Aetna-Triad Update Foot Levelers Erroneous Use of the –51 Modifier Download

Fall 2012 Volume 8 Number 4
Publication of the Association of New Jersey Chiropractors
Erroneous Use of the –51 Modifier
By David Klein, CPC, CHC
s previously published, the ANJC is at the forefront of another major issue that chiropractors all over the country have been dealing with. The
issue is where carriers are taking liberties with certain coding ambiguities, and corrupting them to better their reimbursement position. One example
of this is the requirement by Optum Health that the -51 modifier must be added
to CPT 98943 when billed with any spinal CMT (CPT 98940-98943). This requirement invokes a MPRR (Multiple Procedure Reimbursement Reduction),
which results in reimbursement to the provider that is being inappropriately
reduced by 50% for the Extraspinal (Adjustment) CMT.
In an effort to combat this erroneous coding requirement and on behalf
of the Association of New Jersey Chiropractors, Coding and Reimbursement
consultant David Klein initiated and coordinated an effort along with five other
Continued on Page 12
Aetna-Triad Update
By Dr. Mike Goione
Announcement: ANJC Appoints New
Chair to Nutrition Education Council
— page 10
s you know, Triad Healthcare, an Organized Delivery System (ODS), expanded its relationship with Aetna beginning on June 1, 2012. However, in the months prior and since
June 1st, ANJC has been actively involved in overseeing this implementation.
It all started in February 2012, when Triad sent certified letters to all their in-network doctors informing them of the upcoming changes. Doctors were told they had to sign the included
addendum to remain an in-network provider for Aetna. The packet was misleading and incomplete in the information that was later to be distributed. Several conference calls between
ANJC/Aetna/Triad took place. The implementation date was delayed from May 1 to June 1 and
Continued on Page 4
ANJC Sports Council Sponsors Kid’s
Triathlon, Provides First Aid Coverage
— page 16
The First 48 Hours
Dr. K. Jeffrey Miller — page 16
Healthcare Credit Cards vs. Cash
Dr. Miles Bodzin — page 17
Electronic Health Records Are
Required by 2014!
Dr. Paul B. Bindell — page 18
What Makes Chiropractic Attractive?
The Political Future of
Chiropractic in New
Jersey is Doubtful
William D. Esteb — page 19
Why Adjust the Extremities?
Dr. Mark N. Charrette — page 19
Self Funded vs. Fully Funded: What is
All the Hype?
Lynette Contreni — page 20
By Dr. Steve Clarke,
– ANJC Legislative Chair
ANJC Sponsors NJ Champion Cyclist
Ryan Pettit
es you heard it here first — the political future of
chiropractic in New Jersey is full of doubt for greater success without a concerted effort from each
and every member of the ANJC.
 Dr. Chris Bump (NEC Chair) at recent NEC seminar
talks about the Challenges & Complexities of Treating
Overweight and Obese Patients
— page 21
Featured Articles
From the President’s Desk.......3
Continued on Page 20
ChiroAssist......................... 6
Platinum Sponsors............. 8
Association of New Jersey Chiropractors
3121 Route 22 East Suite 302
Branchburg, NJ 08876 • U.S.A.
Research Updates........... 10
Foot Loose....................... 13
ANJC Headquarters Update... 13
Legal Ease........................ 14
Sports Short..................... 15
 Dr. Alkie Lapas, medical radiologist presents at
ANJC’s NE/NW Regional meeting on MRI Interpretation
Legal Q&A.........................17
Insurance Q&A................. 18
Risky Business................. 21
Foot Levelers
60 A
See inside for details!
Webinars  Seminars  Newsletters
For more info contact ANJC HQ
Rehab  Sports Chiro  On Field Prep
Join ANJC Sports Council Today
For more info contact ANJC HQ
Fall 2012
By Dr. Joe D’Angiolillo
– President
ANJC Year-in-Review
Best. Biofreeze. ever.
ver the past year the ANJC
has moved into the next
phase of maturity. As Sig has
said many times, the ANJC has become one of the most influential associations, not only politically in the
state of NJ, but also among our peers
nationally. Many of the other states
not only look to the ANJC for direction, many times we are called on to
help solve some of their issues. I’ll
touch a little more on that later.
The ANJC is a stable organization
with a current membership of just
under 2000. While we realize that we
may never get 100% membership,
we are hopeful to break the 2000
member barrier this coming year and
are hopeful to add an additional 250
new members.
The ANJC has implemented new
programs over the past year. The
Nutrition Education Council, NEC,
for those who want to expand their
understanding and utilization of nutrition in their practice, was created
with a special membership fee. This
program has been wildly successful
with the members raving about the
conferences, newsletters and access
to the experts in the field.
Monday Morning Rehab has also
created a lot of buzz. These seminars
take place in all regions of the state
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and are taught by many of our top
docs from the ANJC Sports Council.
The One Thing Series brings to you,
once a week, a tip for your practice.
If the tip of the week doesn’t apply
to you just be certain that different
ideas will be streaming through over
the coming weeks. Should you have
a great practice idea that you would
like to share with your colleagues,
just email Sig and he will make sure
our moderator, Dave Graber, gets it.
One thing you can be guaranteed
as a chiropractor is that you will have
to deal with ongoing insurance issues. Just as you have figured out
the current game, new challenges
will be thrust upon you. In April we
experienced the Horizon BC/BS processing glitch. While it affected all
provider groups and hospitals, DOBI
was unaware of all the issues until
the ANJC presented it to them. What
impressed the Acting commissioner
of insurance and his task force the
most is how detailed the ANJC was in
presenting the case. DOBI was then
able to step in, demanding step by
step corrective actions. While most of
the issues have been rectified some
5010 claims issues still exist for
some national plans. DOBI continues
to stay connected to the ANJC with
resolving these issues.
The Optum Health 98943 Modifier 51 issue, a national issue, was
wholeheartedly handled by the ANJC.
Because of our financial stability
the ANJC is capable of hiring many
experts, coding, legal, and claims
processing to name a few. Optum had
taken the position that whenever an
extremity manipulation is performed
on the same day as a spinal manipulation, there is enough overlap
in the pre-service assessment that
the extremity manipulation should be
paid 50% of its reimbursement when
performed alone. As we all know
the pre-assessment of the spine is
certainly not the same as evaluating an extremity. Without giving you
all of the details, the bottom line is
that the opinions generated by our
experts were presented to Optum the
first week of September. As I write
this article we have yet to receive Optum’s response, but I am hopeful that
Optum will reconsider their position.
TRIAD/Aetna, challenges, challenges, challenges! Whether it is accurate
communications with the chiropractors in NJ, with DOBI, or the prompt
and accurate payments of claims, we
have seen nothing but challenges.
The ANJC has tried to win the cooperation of Triad and Aetna regarding
answering the many questions pre-
sented by our members. Aetna provided a liaison, all to no avail. We were
forced to file a formal complaint with
DOBI, resulting in DOBI requesting
both Aetna and Triad to come in for a
conference. Currently DOBI is monitoring Aetna’s and Triad’s resolution
process. Currently we have received
word that Triad is processing about
half of the claims that were submitted from June through August.
As the ANJC handles more and varied tasks, we need to add specialized
personnel. At the Spring Convention
I had the pleasure of introducing the
ANJC’s Assistant Executive Director,
Diane Philipbar. She is the number
two person in headquarters and has
extensive knowledge in association management. She is a valuable
person who will be helping create
our headquarters processes going
As I had mentioned earlier, many of
our challenges have been insurance
related. Having someone who is able
to keep their fingers on the pulse of
what is taking place, to help create
strategies, and to communicate this
back to the membership is priority
number two. The ANJC board saw
that it was time to make another
Continued on Page 4
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Aetna-Triad Update
ANJC Year-inReview
Continued from page 1
Continued from page 3
Triad agreed to send more detailed
As the months progressed, it
became evident to ANJC Insurance
Committee members that this transition was not progressing smoothly
as conflicting information was being
sent by Aetna and Triad along with
call centers supplying incorrect details of the transition.
There are several key changes to
the claims management and administration that have taken place since
June 1st. First and most importantly,
Triad decided to completely change the
reimbursement schedule. No longer
are in-network doctors reimbursed on
a fee for service basis. Now there are
maximum reimbursements per day. For
example, the reimbursement for treatment without an E/M code is now $50
for HMO and $53 for PPO (note: $3 is
deducted by Triad for administrative
costs). Also, new HMO and all PPO
patients have a 10-visit waiver before
paperwork is submitted. However,
there is a three year look back period
for prior treatment, which quite frankly
is still not completely understood by
ANJC. Also, in order to be in-network
for Aetna, doctors must be in-network
for Triad. These key issues are what
ANJC has been trying to get clearly
explained so that ANJC members could
be properly informed on their decision
to leave or remain in-network.
Almost immediately after June 1st,
the ANJC became aware of major
claims processing problems as claims
were being denied by Aetna and
not processed at all by Triad. ANJC
quickly notified the NJ Department
of Banking and Insurance (DOBI) of
the claims issue as well as several
other inconsistencies of the new arrangement. It became clearly evident
that their claims processing systems
broke down. As of the writing of this
letter, Aetna and Triad are updating
DOBI on a weekly basis on their prog-
ress on overdue claims.
ANJC remains in contact with DOBI
as the situation progresses. Some of
the issues that still need resolution
are the three year look back; the $3
administrative fee charged to doctors; Aetna postcards misstating that
doctors must be in network to treat
Aetna patients; proper addresses for
claims submission; delayed payments;
communication errors from Aetna and
Triad, and; wrongful termination from
networks without proper notice.
The ANJC insurance committee
has a strong team in place that is
monitoring the issue and will continue to update members as more
information is received. Members
are encouraged to email ANJC’s director of insurance, Matt Minnella,
at [email protected] with their concerns as it is the membership that
provides critical information to the
committee as to what is happening
in the trenches.
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critical hire—an in house insurance
expert. This expert is Matt Minella.
Matt comes with years of experience
in the insurance industry, and lends
his perspective from working on the
other side of the fence.
The third priority hire relates to
having an in house Public Relations/
Marketing person. Currently we are
in the initial phases of reviewing resumes and are hopeful about finding
a perfect match within a short period
of time. Not only do we want this
person to proactively make regular
positive chiropractic placements in
all of the various media outlets, but
also be able to respond immediately
to various media pieces that may not
accurately report the chiropractic
As our society matures, grows and
adds new services, so too does our
headquarter’s need to constantly
keep pace. Currently Sig and Diane
are consulting with one of our software vendors to fully update and integrate our computer systems along
with our website. In the very near
future you will be able to register as
well as make online payment for conventions, seminars and products, all
within a safe, protected environment.
This year our board believed it was
time to perform a full audit of our
accounting practices. Our budget exceeded the million dollar mark a couple years ago and we wanted to make
sure that all of our financial practices
and procedures are fully up to the
industry standard. We have full faith
and confidence in our treasurer and
finance committee, and we expect in
a few weeks that the audit will reaffirm our sentiment.
As a means of protecting you, our
members, we were able to receive
full bonding of all of our employees
and contractors who are involved with
handling our finances.
The downturn in the economy
has brought with it many stresses.
In an attempt to ease some of the
sting of running a practice, the ANJC
created a new subsidy—the ANJC
Store—where members may purchase various products and services
at a discounted rate. Services such
as electricity and telephone are available through the ANJC Store and
other products will soon be available.
Looking forward, the coming year
will be just as productive and exciting
as this past year. During the campaign last year Mike Kirk and I spoke
about bringing Work Comp to the
chiropractors of New Jersey, as well
as a paraprofessional/Chiropractic
Assistant certification. Processes
like this are slow, as cooperation is
needed from people outside of the
ANJC, but I can tell you things are
moving positively for both of these
items. I firmly believe this time next
year I will be putting both these items
in the accomplishment column of my
report to you.
I thank you for your confidence in
the ANJC, as well as your support.
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Fall 2012
Your Most Successful FROF
By Kathy Mills Chang, MCS-P
hat the heck does FROF
mean? It is perhaps the
most important meeting
your office will have with a patient:
the critical Financial Report of Findings. Presenting your patient with
an all questions answered report of
financial expectations is the best,
most transparent way to ensure a
comfortable and confusion-free chiropractic experience in your office. Proactively offering this information and
explaining the details of how your office manages patient financial responsibility will save you and your patient
stress and worry over collection of
payments for services rendered. One
of the ways you can ensure this information is relayed to your patient, and
that your patient is on board and understands these processes is through
your FROF.
The initial investment of time
spent with a new patient between
visit one and about visit six, is that
vital core period of indoctrination
into the system of your practice. Patients who clearly understand that
they have a problem, and want to
get it corrected, and understand that
they have a financial stake in the
process, become your best patients.
In KMC University, we call this the
Core Relationship Management System. Imagine two wheels: The first
represents the core clinical steps
necessary for proper indoctrination.
The second represents the core financial steps necessary. Each has a
corresponding counterpart, so that
when the wheels are brought together, from side-by-side then merged
into one, you find the clinical and
then financial steps necessary for
the full Core Relationship Management System.
Here are the steps of both wheels,
in order:
• Initial intake NP phone call: gather both clinical and financial information at this first phone contact;
• First Visit: set the clinical tone
with excellent consultation and
exam skills and set the financial
tone with first visit collections;
• Day 1 ½: (Between initial and
second visit, behind the scenes)
Clinical preparation of diagnosis
and treatment plan and financial
preparation of the recommended
payment plan system;
• ROF/FROF: deliver the clinical and
financial report of findings, face to
face with the patient;
• Embrace Automation: automate
the treatment plan with multiple
appointments and automate the
financial plan with an auto-debit
system of payments;
• Follow up by Visit 6-8: deliver a
clinical Healthy Life Styles Workshop, because a patient can’t
get it all at the ROF, and do a
Financial Touch Base appointment
to recap the payment plan and
finances, since they can’t understand it all at the FROF.
prescribed care is and all the wonderful ways your office works on their
behalf to ease that obligation into
something manageable.
The idea of transitioning the patient from hearing about the clinical
findings to talking about the financial
findings is important, because the
doctor will take what has been a private conversation between the two of
them, and make it public by repeating
it to the financial CA. Now the patient
knows that everyone knows what has
been agreed to behind those closed
doors. When the doctor has reviewed
the ROF with the patient, he has explained all the reasons why care is
necessary as well as what his treatment plan is and what results the patient can expect from this care. The
First Visit: set the
clinical tone with excellent
consultation and exam skills
and set the financial tone
with first visit collections
These 6/12 steps are essential
to properly train a patient in becoming a member of your practice. Your
expectations and theirs are addressed early in the process and your
system is installed, both for you and
your team, and for the patient.
Let’s focus in on one particular
step that is mishandled more often
than the others, Step Four: the proper
transition from the ROF to the FROF.
Should be simple, right? The doctor
calls the CA in to say, “Hey, I’m done!
Come tell this patient about their
insurance!” Or worse, there is no
transition because there is no formal
Financial Report of Findings. This
is one of the most necessary steps
in your office’s new patient procedures. In this educational encounter,
patients get many of their looming
clinical and financial questions answered. This exchange serves as an
opportunity to put your patient’s mind
at ease, letting them know what their
financial obligation for the doctors
patient has agreed to care. This is
the time for a flawless exchange leading into the financial CA’s FROF:
Provider: “Ms. Ouchyback, I am
so glad you are on board with getting
this care you need to help alleviate
your pain and correct your condition.
I am going to ask Rebecca to come
in and discuss more information
about your insurance and such. She
is the expert in our office on those
matters and will be able to answer
any questions you may have as well
as discuss some different financial
options we offer.”
(Provider lets Rebecca know that
Ms. Ouchyback is ready and walks
with her to the room)
Provider: “Okay, Ms. Ouchyback,
this is Rebecca, and she is going to
assist you by going over everything
we found out about your insurance.
And, now that we know what your
treatment plan is, I’m sure you would
like to know how we’re going to be
able to assist you further.”
(Provider addresses Rebecca
directly, while still in front of the
Provider: “Rebecca, I’ve explained
to Ms. Ouchyback her condition and
my recommendations for treatment.
She knows she has a problem, and
she wants to get it corrected. She
has agreed to her treatment plan and
we are going to be seeing her three
times a week for the next four weeks
and at the end of that time there will
be a reevaluation. She has agreed to
schedule those appointments with
you today. She’s agreed to attend the
Healthy Lifestyles Workshop with her
husband, Bubba, next Wednesday, so
please put them on the list. Will you
please go over, with Ms. Ouchyback,
the information you’ve found and review the financials with her and work
it out so she can get whatever care
she needs?”
As easy as it may seem to simply
transition from the Doctor to the CA,
if it’s mishandled, a myriad of problems will befall you later, in the form
of missed appointments, upsets over
finances, and patients who drop out
of care prematurely. When you follow
this script, you set up the encounter
for a successful FROF. No matter
how you allow your patients to pay or
what your office policy is for collecting, this very important conversation
with the patient must begin with
the provider, financial CA, and the
patient all being on the same page
concerning treatment. Taking this
time up front will save the worry and
headache later!
Kathy Mills Chang is a Certified
(MCS-P) and since 1983, has
been providing chiropractors with
training, advice and tools to improve
the financial performance of their
University Reimbursement Specialist
Suzanne Ball for her contributions
to this article. For more information
call (855) TEAMKMC or email [email protected]
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Fall 2012
ANJC Platinum
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Fall 2012
ANJC Platinum Sponsors Directory
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Silver Sponsorship
ANJC Platinum Sponsors are trusted business partners who have supported ANJC for
many years. Their valuable contributions help to achieve ANJC’s goals in serving membership
and their patients. These business partners meet the highest standards regarding quality of
products and services, and they are sensitive and responsive to the personal needs of our
members. ANJC Platinum Sponsors have a proven track record in assisting NJ chiropractors
with reaching their individual practice goals and in staying on the cutting edge of the health
and wellness revolution in their communities. For all they do for ANJC members, you owe it
to them to first take a look at their products and services before going elsewhere. Many offer substantial discounts and value-added services to ANJC members. Remember — when
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help chiropractors leverage their time and grow
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✦ Guardian Life Insurance Company
Anthony Campanile • 609.709.0041
[email protected]
Description: Guardian Life Insurance Company
has been providing doctors with disability and life
insurance and investments for over 150 years. Key
Products and services: Disability Insurance, Life
Insurance, Investments.
✦ Mid Atlantic Resource Group. LLC
Donna Scallo • 732.922.6300 X 167
[email protected]
Lesley Weiner • 973.890.0800 x 329
[email protected]
Description: 2008 ANJC Business Partner of the
Year. ANJC member discount on comprehensive
Disability and Long-Term Care Insurance. Life,
Disability, Long Term Care, Employee Benefits,
Retirement Planning. Independent Insurance and
Investment Services firm since 1975.
✦ The Omar Group, CPA • Salim Omar, CPA
732.566.3660 •
[email protected]
Description: Specializing in providing accounting
and tax services to chiropractic practice owners.
✦ ChiroHCG. • Frank Zoletich
877.377.7636 • [email protected]
Description: ChiroHCG is a professional doctor supervised weight loss company. ChiroHCG uses the
strongest form of US derived and manufactured
homeopathic HCG and includes a complete TurnKey Marketing System containing both print ads
and TV commercials at no cost.
✦ ChiroMatic Sleep Systems • Debbie Carlitz
800.526.5116 •
[email protected]
Description: Developed with help of chiropractors, ChiroMatic mattresses provide ultra premium support and comfort.
✦ Chiropractic Leadership Alliance (CLA)
Jasmine Forsyth • 800.285.2001 ext.130 • [email protected]
Description: CLA is focused on equipping chiropractors around the world with the profession’s
best selling technology, the Insight Subluxation
Station for patient assessment and education.
✦ Erchonia • Melissa Morningstar
214.544.2227 •
[email protected]
Description: Erchonia is the global leader in
low level laser healthcare applications. All
Erchonia lasers are proven safe and effective
through independent clinical trials. Key product
and service: Low level laser therapy.
✦ Foot Levelers • Kent Greenawalt
800.553.4860 •
[email protected]
Description: Exclusive provider of custom-made
Spinal Pelvic Stabilizers and other healthcare
✦ Harlan Health Products, Inc. • Harlan Pyes
800.345.1124 •
[email protected]
Description: We provide leading edge modalities
as well as the training and support so our customers attain the very best clinical outcomes. We
also provide tables, rehab equipment, and all the
supplies you need. Key products: Laser therapy,
Electric Stimulators, Full line of supplies.
✦ K-Med Services, Inc. • Ken Viafora
800.243.2603 •
[email protected]
Description: Full-service chiropractic supply and
equipment company.
✦ Levinson Medical Specialties • Charles Levinson
732.928.4600 •
[email protected]
Description: Suppliers of physical therapy equipment, supplies, chiropractic tables, service, serving the profession for nearly 50 years. Key Products: Physical therapy equipment, Chiropractic
tables and service.
✦ Patient Media, Inc. • Bill Esteb
800.486.2337 • [email protected]
Description: Patient Media, Inc. supplies chiropractic patient education resources created by Bill
Esteb that feature high-impact graphics and short,
patient-relevant text. Key Products: Chiropractic
patient education videos, chiropractic patient
education brochures and chiropractic patient
education posters and charts.
✦ ScripHessco • Heather Zdan
800.747.3488 x7408 • [email protected]
Description: ScripHessco has been a trusted
resource to health care practitioners for over 40
years. ScripHessco features over 10,000 products
and is the largest distributor of reconditioned
tables. Key Products include: Electrotherapy
Equipment, new and used adjusting tables and
traction, and chiropractic supplies.
✦ The Vitality Depot • Mark Mandell
866.941.8867 •
[email protected]
Description: Your #1 chiropractic supplier for
SpiderTech, TENS and electrodes, Lasers, Clinical
Stim Units, Whole Body Vibration, GreensFirst,
Tables, SmartStep Wellness Mats, Back Braces,
Cold Packs, Pillows, Biofreeze, Sombra and the
most innovative equipment at extraordinary value.
Chiropractic Equipment/Supplies & Patient Education
✦ BIOFREEZE®/Performance Health
800.246.3733 • • [email protected]
Description: Performance Health is the maker
of market-leading Biofreeze and Thera-Band
products, as well as other vital clinical brands.
Key Products: Biofreeze and Thera-Band.
✦ Chiro-Squad Enterprises, LLC
Dr. Victor Naumov • 201.265.8688
[email protected]
Description: Creators of the Chiro-Squad Super
Heroes and exclusive products that connect kids
and chiropractic across the globe. Key Products:
Chiro-Squad Kids Club Internal Marketing Kit,
Chiro-Squad Nutritional Supplements and ChiroSquad Super heroes Trading Cards.
X-Ray, Diagnostic Imaging Services & Equipment
✦ Digital Radiographic Equipment, Inc.
Allan J. Rubert • 610.385.0722
[email protected] •
Description: D.R.E.I. has over 60 years of knowledgeable experience servicing the chiropractic
profession. Providing quality and affordable chiropractic equipment, such as X-ray, tables, P.T. Eqpt,
Decompression-Traction units and Chiropractic
supplies and accessories.
✦ LiteCure Medical • Gioacchina Randazzo
302.709.0408 • [email protected]
Description: LiteCure is a medical device company
offering advanced laser products and innovative
technology to healthcare, rehabilitation and training professionals. Drug-free, Surgery-Free, PainFree Relief.
Nutrition & Wellness
✦ Anabolic Laboratories • Bob Rosenberg
Clinical Consultant • 609.239.0358 • [email protected]
Description: Anabolic Laboratories, founded in
1924, is an active pharmaceutical manufacturer
that specializes in the standardization and concentration of natural ingredients to assist with
patient management, healing and pain relief.
Available exclusively through healthcare professionals. Key Products: Nutritional Supplements
for Pain and Inflammation, Nutritional Supplements for general wellness, and condition specific Nutritional Supplements.
✦ Biotics Research • Debra Fish
1.800.231.5777 Ex 140 •
[email protected]
Description: Biotics Research Corporation was
formed in 1975 and from day one the foundation
has been “Innovation and Quality.” Our goals remain unchanged - innovative ideas, carefully researched concepts, and product development with
advanced analytical and manufacturing techniques
to develop and produce nutritional products of
superior quality and effectiveness available exclusively to healthcare professionals.
✦ Health Centers of the Future
Warren Philips Practice Building
888.600.0642 • [email protected]
Description: Our events infuse cutting edge testing
and support protocols for common conditions. The
systems you learn can be applied in your office the
next day.
✦ Metagenics, Inc. • Adam Banning/Maria DiSallvo
800.692.9400 •
[email protected]
Description: Metagenics is a global life sciences
company focused on improving health. Since 1983
Metagenics has helped health care professionals
and their patients throughout the world find solutions to their most pressing health concerns with
high quality, science-based medical foods, nutraceuticals, and lifestyle medicine programs. Visit
us at Key Products:
Professional Quality Nutraceuticals and Medical,
Educational Seminars and FirstLine Therapy foods
and Clinical Services Support.
✦ Nutri West Mid Atantic • Nadine Carrick
302.478.5090 •
[email protected]
Description: Nutri-West provides the highest
quality nutritional supplements formulated and
produced specifically to support your healing arts.
Nutri-West products are sold only through licensed
health care professionals. We are committed to
quality, purity and efficacy of our products. Our
fundamental focus is Patient Well Being.
✦ Nutritional Frontiers • Michael Antonelli
631.767.0945 •
[email protected]
Description: Our Mission is to create, develop and
provide safe, effective therapeutic natural solutions and educational programs to chiropractors
and their patients with excellent quality, integrity
and service.
✦ Science Based Nutrition. • Dr. Van Merkle
937.433.3140 • [email protected]
Description: Our Mission is to set a standard or
objectivity in nutritional healthcare. We strive to
help reach their optimum health so that they in
turn, can reach their fullest potential in life. Key
Products: Discounted blood testing, discounted
hair analysis and detailed test reporting.
✦ Standard Process Inc.® • Bruce Poritzky
800.848.5061 • [email protected]
Description: For more than 80 years, Standard
Process, headquartered in Palmyra, Wis., has provided health care professionals with high-quality,
nutritional whole food supplements. Standard Process offers more than 300 products through three
product lines: Standard Process whole food supplements, Standard Process Veterinary Formulas™,
and MediHerb® herbal supplements. The products
are available only through health care professionals.
✦ VerVita Products, LLC • Dawn Hoezee
616.669.5534 •
[email protected]
Description: VerVita serves to bless communities with a passion to heal and achieve wellness
through Nutritional products and essential oils.
Nutritional simplicity for maximum effectiveness.
✦ XYMOGEN • Richard Malkin
Senior Functional Medicine Consultant
908.310.7333 • [email protected] • 1.800.647.6100
Description: Wellness and Nutrition Integration
Programs-Clinical Research, Education and Product Development- 22 Years Proudly Serving New
Jersey Practitioners
Laboratory Services
✦ NeuroScience • Pat Dorsey
732.766.1884 • [email protected]
Description: NeuroScience, Inc. is a research-driven company committed to improving human health
through a deep understanding of the interconnectedness of the neurological, endocrine, and immune
system. Key products and services: Neuro-EndoImmune Testing, GI Repair System.
✦ Sterling Clinical Laboratories Inc. • Naveed Aschfaq 215.741.6000 • [email protected]
Description: A blood testing lab licensed in New
Jersey and Pennsylvania with 36 employees including pathologist, quality control consultants
and zero deficiency in state inspections. Specializes in blood tests, hormone studies, thematic
evaluations, and all allergy testing available.
Consultants/Practice Management
✦ Breakthrough Coaching • Debbie Olinger
303.451.9123 •
[email protected]
Description: Chiropractic Consulting services.
✦ ChiroHealth USA • Ray Foxworth, DC
888.719.9990 •
[email protected]
Description: Want to practice with peace of mind?
Our network model eliminates worry about dual
fee schedules, improper time of service discounts
and OIG violations for offering discounts on noncovered services.
✦ KMC University • Kathy Mills Chang
888.659.8777 •
[email protected]
Description: KMC University, a chiropractic training and implementation company, specializes in
delivering solutions to a broad array of reimbursement problems and obstacles that DC practices
across the nation face every day. Positioned to
serve as the ultimate DC ally, KMC University
strives to always deliver beyond their clients
expectations always assisting to improve their bottom line. That explains why in average, their clients increase their reimbursement levels by 27%.
✦ Positive Impact Coaching and Consulting Services
Dr. Michelle Turk • 576.921.6116
[email protected]
Description: Positive Impact Coaching is a company focused on helping you grow towards professional success and a balanced personal life. Via
coaching and practice development services, we’ll
help you define and attain YOUR “point of positive
Impact.” We also offer dynamic speaking engagements for groups and organizations on a variety of
practice building and personal growth topics.
✦ Target Coding • Marty Kotlar
800.270.7044 •
[email protected]
Description: Experts in helping chiropractors
document properly, get paid properly and in audit
✦ The Rothenberg Group • Jess Rothenberg, DC
973.694.1981 •
[email protected]
Description: Assist doctors with collection
services and advice for auto accident patients.
Medical/Clinical Services
✦ Advanced Center for Special Surgery –
Montville Health • Dr. David Saint
201.391.8282 •
[email protected]
Description: A freestanding state of the art
licensed multi-specialty ambulatory surgical center offering a wide range of out-patient surgical
Continued on next page
ANJC Disclaimer: The company or persons providing the within goods or services, though an ANJC sponsoring entity or individual, is an independent organization of the ANJC and its structure, views, techniques, materials and methods are not authorized, reviewed for accuracy, or otherwise approved or endorsed by the
A.N.J.C. The content of the materials and services has not been reviewed or approved by the ANJC for accuracy, completeness or compliance with the various governing statues, regulations, ordinances, or other controlling laws and should not be viewed as a direct or indirect endorsement or verification of the accuracy or
legality of the goods, services, or delivery model. The application and impact of laws can vary widely based on the specific facts involved. Given the changing nature of laws, rules and regulations the A.N.J.C. does not engage in rendering legal, accounting, tax, or other professional advice and services. As such, the sponsor’s association with the ANJC should not be used as a substitute for consultation with professional accounting, tax, legal or other competent advisers. Before making any decision or taking any action, you should consult an appropriately trained professional prior to utilizing the sponsor’s goods or services.
✦ Alliance Medical Surgical Group
Sean Hajo • 973.650.4688
[email protected]
Description: Interventional pain management
and Neurodiagnostic services. Key product:
Interventional Pain Management, Neurodiagnostic Services and Orthopedic and Orthodontic Surgery.
✦ Allied Neurology & Interventional
Pain Practice
Jack Koczarski • 201-894-1313
[email protected]
Description: Interventional pain management
is the discipline of medicine devoted to the
diagnosis and treatment of pair related disorders principally with the application of interventional techniques in managing subacute,
chronic, persistent and intractable pain, independently or in connection with other modalities of treatment.
✦ Cancer Treatment Centers of America
Rocco DeCicco • 215.537.7503
[email protected]
Description: Cancer Treatment Centers of
America (CTCA) provides a comprehensive,
patient-centered treatment model that fully
integrates traditional, state-of-the-art medical
treatments with scientifically supported complementary therapies such as nutrition, naturopathic and chiropractic medicine, psychological
counseling, physical therapy and spiritual
support to meet the special, whole-person
needs of advanced-stage cancer patients. With
a network of cancer treatment hospitals and
community oncology programs in Philadelphia,
Phoenix, Suburban Chicago, Tulsa and Seattle,
CTCA encourages patients and their families
to participate in treatment decisions with its
Patient Empowered Care model.
✦ Hackensack Injury & Wellness Center
Damon J. Noto, MD • 201.288.7246
[email protected]
Description: A health clinic focusing on pain
management and minimally invasive procedures
to help patients with orthopedic and spinal
✦ Mountainside Pain Management
Philip Lutz, MD • 973.226.1230
[email protected]
Description: Board Certified physicians specializing in pain management. Working with
chiropractors since 1989 on the management of
patients with pain from spinal disease.
✦ MUA Educators, Inc • Dr. Don Alosio
862.268.3500 • [email protected]
Description: Comprehensive training in MUA
Techniques resulting in the awarding of a Certificate of training in MUA (30 hours).
Legal Services
✦ Davis, Saperstein & Salomon, PC
Garry Salomon • 201.907.5000
[email protected] •
Description: Davis, Saperstein & Salomon is a
plaintiffs personal injury law firm representing
injured clients for over 25 years. It’s twelve
attorneys have built solid relationships with
the Chiropractic community and welcomes
their referrals.
✦ Law Office of E. Vicki Arians, LLC
E. Vicki Arians, Esq. • 973.513.9980
[email protected]
Description: Law firm concentrating in PIP
arbitration, insurance company audits and
✦ Law Offices Of Jeffrey Randolph
Jeff Randolph, Esq.
201.444.1645 • [email protected]
Description: Specialize in healthcare law and
complex litigation.
✦ Law Offices of Sean T. Hagan, LLC
Sean T. Hagan • 732.722.2911
[email protected]
Description: Specializes in NJ PIP Recovery and
Arbitrations at no costs to you, practice management consultation and handles personal
injury cases throughout all of New Jersey.
✦ Pond Lehocky Stern Giordano
Gina Terzolino • 215.568.7550
[email protected]
Description: Pond Lehocky Stern Giordano
dedicates its practice to Workers’ Compensation and Social Security Disability matters.
The attorneys at the law firm of Pond Lehocky
have over 75 years of combined experience
representing injured workers and the disabled.
The Firm has three convenient office locations
in Center City Philadelphia, Northeast Philadelphia and Pennsauken, New Jersey. For more
information, or to set up a free consultation,
please call 215-568-7500 or Toll Free at 866
Injury Law (866-465-8795) or visit us online at
Educational Institutions
✦ Bloomfield College • Dr. Alice Ann Sayler
973.748.9000 • [email protected]
Description: Bloomfield College is an independent liberal arts college offering Bachelor of
Arts and Bachelor of Science degrees. The
college offers a customized Pre-chiropractic
Program leading to a BS Degree in Biology with
preferred admission to chiropractic colleges
around the country.
✦ Union Anesthesia & Pain Management
Julia Kovach • 908.851.7161
[email protected]
Description: Union Anesthesia & Pain Management specializes in Laser Spine surgery- our
physicians cohesively work together to provide
you with effective pain management and comfortable experience.
✦ Collaborans
Dr. Nick Tsaggarelis • 416.750.1500
[email protected]
Description: COLLABORANS provides multimedia education for healthcare providers and
fitness professionals. Our product offerings
include on-line education, webinars, hands-on
courses, DVDs and training manuals.
Insurance Services/Risk Management
Software – Practice Management
✦ Allstate Insurance Company
Bernadette Wanczyk
800.512.9470 •
[email protected]
Description: Allstate offers ANJC members
discounted and enhanced commercial auto,
business owner’s policies and in-home business insurance. Please contact Bernadette
✦ Cash Practice, Inc. • Dr. Margie Smith
877.343.8950 x220 •
[email protected]
Description: Cash Plan Calculator- customized
patient financial plans with compliant discounting options. Auto-Debit System- schedule recurring payments and make one-time payments.
Drip-Education Email Marketing System- systematized patient education.
✦ John C. Crilly Agency • John C. Crilly
732.747.7947 •
[email protected]
Description: Recipient of ANJC ’05 award for
Outstanding Effort and Commitment, we offer
the following insurances: Professional Liability
Malpractice Insurance, business owners, employee benefits, employment practices liability,
life, disability, long term care, workers compensation and Health Insurance.
✦ Digital Data Resources • Dr. Robert Sellari
973.625.3716 •
[email protected]
Description: Profile Deluxe is a complete chiropractic paperless office solution which operates on a “cloud computing” environment.
✦ LTC Global • Joel S. Allen
334.277.6802 • [email protected]
Description: LTC Global has a long term care
insurance program available to all association
members, their employers and their extended
family members.
✦ NCMIC • Mike Whitmer
800.321.7015 • [email protected]
Description: “We Take Care of Our Own” NCMIC has grown to become the largest provider
of Chiropractic malpractice insurance in the
nation, covering more than 37,000 DCs. Key
Products: Chiropractic Malpractice Insurance,
Equipment Financing and Merchant Processing.
✦ OUM Chiropractor Program • Tamara Jackson
888.247.3522 • [email protected]
Description: OUM’s extensive malpractice
insurance policies offer broad protection that
cover the range of professional chiropractic
services you provide within your state’s defined
scope of practice.
Key Products: Malpractice Insurance
✦ Life Systems Software
Paul B. Bindell, DC, or Avi Bindell
973.625.3716 •
[email protected]
Description: Life Systems Software provides
certified EHR that increases income while
providing audit and collection protection. It is
Chiropractic specific designed for your practice. Key Products: Certified ChiroSuiteEHR
electronic health record system, Certified ChiroPadEMR SOAP & narrative software, ChiroOffice management and billing software
✦ PayDC • David Klein
888.306.1256 • [email protected]
Description: PayDC is a fully integrated EHR
solution designed to manage your practice and
the entire course of patient care.
✦ Quick Notes • Ken Schenley
800.899.2468 •
[email protected]
Description: Easy-to-Use solutions for Portable
SOAP Notes and Electronic Medical Records
(EMR). Fully-compliant charting on a PDA or
iPad. Templates and Voice Recognition tools.
Quick Notes has been supporting Chiropractic
in New Jersey for 23 years.
ANJC’s Nutrition Education Council and Silver Sponsors work together to educate members on the latest nutritional research, protocols and nutritional supplements. NEC offers Silver Sponsors a unique opportunity to focus on ANJC
member doctors who have shown a strong interest in incorporating nutrition
into their practices. Dr. Steven Zodkoy, NEC chair states, “NEC is going to serve
as THE leader in nutritional education for the chiropractic profession. The goal
is to educate and promote nutrition to the profession and the public so that NJ
Chiropractors are known as the go-to doctors for all health conditions.”
Anabolic Laboratories
Bob Rosenberg • 609-239-0358
[email protected]
Description: Highest quality manufacturer
of general wellness and condition specific
nutritional supplements. Key Products:
Pain and Inflammation Supplements,
Pharmaceutical GMP’s and Highest Quality Products in the Industry.
Cancer Treatment Centers of America
Rocco DeCicco • 215.537.7503
[email protected]
Description: Cancer Treatment Centers of
America (CTCA) provides a comprehensive, patient-centered treatment model
that fully integrates traditional, state-ofthe-art medical treatments with scientifically supported complementary therapies
such as nutrition, naturopathy, psychological counseling, physical therapy and
spiritual support to meet the special,
whole-person needs of advanced-stage
cancer patients. With a network of cancer treatment hospitals and community
oncology programs in Arizona, Illinois,
Oklahoma, Pennsylvania and Washington,
CTCA encourages patients and their families to participate in treatment decisions
with its Patient Empowerment MedicineSM model.
Chiro-Squad Enterprises, LLC
Dr. Victor Naumov • 201-265-8688
[email protected]
Description: Creators of the Chiro-Squad
Super Heroes and exclusive products that
connect kids and chiropractic across the
globe. Key Products: Chiro-Squad Kids
Club Internal Marketing Kit, Chiro-Squad
Nutritional Supplements and Chiro-Squad
Super heroes Trading Cards.
Health Centers of the Future
Warren Philips • 888-600-0642
[email protected]
Description: Our events infuse cutting
edge testing and support protocols for
common conditions. The systems you
learn can be applied in your office the
next day.
Metagenics, Inc.
Adam Banning/Maria DiSallvo
[email protected]
Description: Metagenics is a global life
sciences company focused on improving health. Since 1983 Metagenics has
helped health care professionals and
their patients throughout the world find
solutions to their most pressing health
concerns with high quality, sciencebased medical foods, nutraceuticals, and
lifestyle medicine programs. Visit us at Key Products: Professional Quality Nutraceuticals
and Medical, Educational Seminars and
FirstLine Therapy foods and Clinical Services Support.
Pat Dorsey • 732-766-1884
[email protected]
Description: NeuroScience, Inc. is a research-driven company committed to improving human health through a deep understanding of the interconnectedness of
the neurological, endocrine, and immune
system. Key products and services: Food
Sensitive Testing, Neuro-Endo-Immune
Nutrition Program, GI Repair System.
Nutritional Frontiers
Michael Antonelli • 631-767-0945
[email protected]
Description: Our Mission is to create,
develop and provide safe, effective therapeutic natural solutions and educational
programs to chiropractors and their patients with excellent quality, integrity and
Science Based Nutrition
Dr. Van Merkle/Tracy Howell
[email protected]
Description: The most advanced computer laboratory analysis incorporating
blood, hair and urine. Providing diet and
vitamin recommendations in an easy to
read color coded report. And all backed
with long term proven results. Key Products: Patented and computerized blood,
hair and urine analysis with specific nutrient recommendations, support for tough
cases and processing and free discount
lab pricing for your patients.
Standard Process
Bruce Poritzsky • 518-226-0197
[email protected]
Description: For more than 80 years, Standard Process headquarters in Palmyra Wi
has provided health care professionals
with high-quality, nutritional whole food
supplements. Key Products and Services:
Supplements-whole food based, Herbal
Supplements, Education.
Sterling Clinical Laboratory
Naveed Ashfaq • 215-741-6000
[email protected]
Description: Sterling Lab provides excellent mobile home draw service for
patients and performs all kinds of diagnostic tests in huge discount prices. Key
products and services: All kinds of blood
tests, urine and stool tests, hormones,
allergy, pneumatic and nutritional tests.
Jennifer Watters • 407-445-0203
[email protected]
Description: Wellness and Nutrition Integration Programs-Clinical Research,
Education and Product Development- 22
Years Proudly Ser ving New Jersey Practitioners
Fall 2012
ANJC Appoints New
Chair to Nutrition
Education Council
ver the past year ANJC
launched a new program, the
Nutrition Education Council
(NEC), under the leadership of Dr.
Steve Zodkoy. NEC has been wildly
successful with their website, seminars and newsletters resulting in ongoing accolades from ANJC membership. Currently ANJC has consultants,
industry experts, and an advisory
board of nutrition practitioners as an
ongoing resource serving ANJC members who joined NEC.
While Dr. Zodkoy had been busy
bringing NEC to fruition, he has also
been busy on the national front creating a program for our returning veterans. This program now demands more
of his attention so he decided to step
down as NEC chair.
As a result, the baton to chair NEC
has been passed on to Dr. Christopher Bump. For those who attended
our spring convention, you heard Dr.
Bump speak and answer many tough
nutrition questions presented during
the nutrition panel discussion.
Dr. Bump has a storied past and
extensive resume. Here are just a few
highlights so you get a snapshot of
the man who now will direct NEC in
the coming years:
• 30 years experience implementing
clinical nutrition into his practice.
• Obtained a Masters in Human
Nutrition at Columbia University;
instructor at Columbia’s Institute
of Human Nutrition.
• Earned diplomat status on the
Chiropractic Board of Clinical Nutrition with certifications in clinical
nutrition from the American College
Dr. Bump has been
an integral part of the
development of NEC
and is committed to
continuing and enhancing the NEC member’s
of Nutrition, and the International
and American Association of Clinical Nutrition.
• Worked to create an integrated
model of healthcare that fuses
chiropractic with clinical nutrition.
• Been active on various committees within the community of Vernon, NJ.
Dr. Bump has been an integral part
of the development of NEC and is
committed to continuing and enhancing the NEC member’s experience.
His background and clinical experience is second to none.
On behalf of ANJC, we welcome Dr.
Bump to his new role as NEC chair
and wish him much success.
Joseph D’Angiolillo, DC - President
Association of New Jersey
Want more new patients? Use
onte ncy!
Manual Therapy and Cervicogenic
Dizziness 1
A comprehensive literature search
in various databases (Scopus, MANTIS, CINAHL, and the Cochrane Library) was conducted to assess the
state of evidence supporting the use
of manual therapy with or without
vestibular rehabilitation in the management of cervicogenic dizziness. A
total of 15 articles from 13 separate
investigations were retrieved. The
results showed that all but one study
reported improvement following unimodal or multimodal treatment. Some
studies reported improvement in postural stability, joint positioning, ROM,
muscle tenderness, neck pain, and
vertebrobasilar artery flow velocity.
The conclusion was that there is moderate evidence to support the use of
manual therapy (spinal manipulation
and/or mobilization). Evidence to
support the combination of manual
therapy with vestibular rehabilitation,
however, is lacking.
1. Lystad RP, Bell G, Bonnevile-Svendsen
M, Carter CV. Manual therapy with and
without vestibular rehabilitation for
cervicogenic dizziness: A systematic
review. Chiropractic & Manual Therapies
2011; 19: 21.
Spinal Manipulation and Chronic
Obstructive Pulmonary Disease 1
A case series involving six residents (average age 79.1 years) with
chronic obstructive pulmonary disease
at a long-term care facility at the
Monroe Community Hospital yielded
encouraging results. The patients
were subjected to a course of twelve
thoracic spinal manipulations over a
four week period, with lung function
measurements recorded by a respiratory therapist at two and four weeks.
In four of the patients, a clinically significant increase in forced expiratory
volume was seen immediately following the treatment and was sustained
at two weeks. It was maintained at
four weeks in only one patient. No
adverse events were observed. It was
proposed that thoracic spinal manipulative therapy increases the functional
Complete, brand new PowerPoint
talks, handouts, surveys, flyers plus
audios with actual closings that
engage your audience!
Investment per talk (all sold separately)
$95 non TLC members $75 TLC members
Call 888–TLC–4488 or order at
Anthony L. Rosner, PhD
– ANJC Research Analyst
mobility of the chest wall by augmenting the mobility of the thoracic spinal
joints and associated rib articulations.
This, in turn, would benefit lung function in the elderly.
1. Doughtery PE, Engel RM, Vemulpad S,
Burke J.. Spinal manipulative therapy for
elderly patients with chronic obstructive
pulmonary disease: a case series. Journal of Manipulative and Physiological
Therapeutics 2011; 34(6): 413-417.
Osteopathic Manipulation and
Chronic Obstructive Pulmonary
Disease 1
Twenty stable patients (five female) with severely impaired chronic
obstructive pulmonary disease were
randomly assigned to receive either
pulmonary rehabilitation plus osteopathic manipulation or pulmonary rehabilitation plus soft manipulation for
five days a week for four weeks. The
patients receiving osteopathic treatment displayed superiority in a walk
test (72.5 m vs 23.7 m), a greater
decrease in residual volume, and an
increase in forced expiratory volume.
The conclusion was that osteopathic
manipulation added to pulmonary
rehabilitation may improve exercise
capacity and reduce the residual
volume in patients with severely impaired chronic obstructive pulmonary
1. Zanotti E, Barandinelli P, Bizzzri C, et al.
Osteopathic manipulative treatment for
effectiveness in severe chronic obstructive pulmonary disease: A pilot study.
Complementary Therapies in Medicine
2012; 20(1-2): 16-22.
Altered Muscular Activation during
Prone Hip Extension1 :
The focus of this investigation was
the activation pattern of lumbopelvic
muscles during prone hip extension
(PHE) in women with chronic lowback pain (cLBP). A convenience
sample of 20 women was categorized into two groups with or without
cLBP. The research team measured
the electromyography (EMG) signal
amplitude of tested muscles during
PHE, after normalization to maximum
voluntary muscle contraction. What
was found was (a) a greater EMG
signal amplitude when cLBP was
present, (b) a significant decrease of
the EMG’s of the ipsilaterial erector
spinae and contralateral erector spinae muscles, and (c) differences in
the gluteus maximus and hamstring
muscles (but statistically nonsignificant). PHE is significant because it
is theorized to simulate the muscle
movement patterns during functional
movement patterns, such as gait.2
It was concluded that these muscle
activation patterns could be useful
either as an evaluation tool or a rehabilitation exercise.
1. Arab AM, Ghamkhar L, Emami M,
Nourbakshsh MR. Altered muscular
activation during prone hip extension in
women with and without low back pain.
Chiropractic & Manual Therapies 2011;
19: 18.
2. Arendt-Nielsen L, Graven-Nielsen T,
Svarrer H, Svensson P. The influence of
low back pain on muscle activity and
coordination during gait: A clinical and
experimental study. Pain 1996; 64:
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Fall 2012
Fall 2012
Erroneous Use of the –51 Modifier
Continued from page 1
coding experts, to create an advisory
detailing the aberrant coding position
held by the Optum and submitted it to
the carrier for review. Subsequently,
representatives of the ANJC took part
in a discussion via conference call,
with representatives of Optum Health,
regarding the issue.
Based on the relevant guidance already provided to Optum, the modifier
-51 was never intended to be applied
to CPT code 98943.
On the surface it is easy to see
where a reasonable person would assume that this would directly apply,
when a spinal CMT and an extra-spinal
CMT are performed on the same patient, at the same visit, by the same
provider. However, it is our contention
that it takes more than a cursory understanding of the use of this modifier,
and a deeper grasp of coding principles
in general, to arrive at the actual appropriate reporting of the CMTs performed
at the same encounter as opposed to
a simple otherwise blanket approach.
The immediate simple counter-explanation is that neither a spinal CMT nor an
extra-spinal CMT is considered a major
primary code to the other; they are in
fact separate, independent and identifiable services whose service values
rarely overlap, if at all.
CPT code 98943 for an extra-spinal
manipulation includes Chiropractic
Manipulative Treatment rendered
to any and all regions identified as
“extra-spinal” including the head,
abdomen, upper extremities, lower
extremities, and rib cage—regardless
of the number of regions addressed
at the encounter. Since there is not
necessarily a contiguous relationship
between these regions and the spine,
CPT code 98943 is established as a
separate code with its own defined
scope different for the spinal CMT
codes. The AMA CPT Guide clearly establishes CPT code 98943 as its own
stand-alone primary procedure.
This separate and distinct nature of
the extra-spinal CMT code 98943 is
further supported and delineated by
the recognized and designated official
CMS coding guidelines, and in the
similarly recognized and designated
CMS reimbursement guidelines, this
guideline is called the National Correct
Coding Initiative (NCCI).
In terms of the work involved with
these services being distinct and of
a certain value, CMS has established
by means of reimbursement policy
a formula called the Relative Value
Unit (RVU) to determine the value of
each CPT code that takes into consideration the relative level of time,
skill, training and intensity to provide
a given service. CMS reimbursement
policies then take into consideration
additional issues including work value
affected by other services reported at
the same encounter to establish final
reimbursement for providers.
It is from this concept that the
association of new Jersey chiropractors (coDe: Va)
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Multiple Procedure Reduction Rule
(MPRR) evolved. MPRR is when two
or more procedures are performed
during the same session by the same
provider, Medicare does not reimburse
all procedures at the full billed or allowable amount. Under the multiple
procedure reduction rule, Medicare
will allow 100 percent of the fee
schedule amount (or billed amount if
it is less) for the first procedure reported, and 50 percent for the second
procedure. It should be noted that
there must realistically be a reduction
of the service to then result in the reduced reimbursement. The mere fact
of there being multiple services does
not automatically determine an MPRR
applies—as one might assume that
from the cursory reading the definition
of modifier -51 as detailed previously.
As the ANJC had already also argued, the work and service attributed
to this code is unaffected by any other
service, including a spinal CMT. The
AMA, CMS, and as we have recently
discovered, both Optum and UnitedHealthcare official published policies
agree with us.
In order to further elaborate on
this explanation, United Healthcare
Multiple Procedure Policy (Policy #
2012R0034D) states:
…When multiple procedures are
performed on the same day, by the
same individual physician or other
healthcare professional, reduction
in reimbursement for secondary and
subsequent procedures will occur…
UnitedHealthcare uses the Centers
for Medicare and Medicaid Services
(CMS) National Physician Fee
Schedule (NPFS) multiple procedure indicators 1, 2, and 3 to determine which procedures are subject
to the multiple procedure concept,
and thereby are subject to multiple
procedure reductions as addressed
in this policy. [Emphasis added]
United Healthcare, and by direct
connection Optum itself, appears to
have already correctly published a formal policy upholding the exact position
put forth by the coding professionals
on behalf of the ANJC—specifically
the argument that CMS clearly establishes that CPT code 98943 should not
be subjected to the MPRR and never
should have been. It appears that inexplicably and quite astonishingly, the
claims adjudication applying the MPRR
to CPT code 98943 has been in direct
opposition to the clearly stated and
published policy, which is at the crux of
the ANJC’s frustration in this matter—
particularly since such a contradiction
has resulted in significant financial
gain by Optum and its affiliated payors,
at the expense of the members of the
ANJC and other doctors nationwide.
“The use of the 51 modifier appended to a code is not a factor in
determining which codes are considered subject to multiple procedure
reductions by United Healthcare…The
reduction list contains all codes that
are subject to the multiple procedure
concept as described above.”
Notably, CPT code 98943 is not on
the list of procedures that are subject
to the MPRR concept—either at CMS,
UnitedHealth or Optum.
We hope Optum is prepared to correct the issue of inappropriately applying an MPRR to CPT code 98943,
particularly in light of the apparent
contradiction with the existing United Healthcare and Optum published
Stabilizing Orthotics:
A “Supplement for
Your Spine”
By Brian D. Jensen, DC
here are moments in life when
you recognize that a profound
nugget of truth has been revealed in a simple, elegant fashion.
One of those moments happened
to me while speaking to a class of
students at Life University, when Dr.
Debra Bisiacchi introduced me and
said that I was going to be talking
about a “supplement for your spine.”
That statement struck me, because
it was a simple and accurate explanation of what stabilizing orthotics are
and what they do.
At first, one might have images
of a bottle of calcium pills or a tall
glass of ice cold milk, because that is
the media’s message that has been
touted as the path to strong, healthy
bones. However, the supplement I
was to be talking about was quite
Why Supplement?
I have often asked this question to
patients: “What is the most important supplement?” The answers I get
run the gamut of nearly every nutrient
they have heard of, including air and
water. The simple truth is that the
most important supplement is the
one that is missing. The missing supplement relating to the spine is often
biomechanical stability. If stability
is missing because of deficiencies
in the foundational structures of the
feet, providing supplemental support
is appropriate.
When it comes to looking at the
concept of a supplement for the
spine, the question has to be raised:
How does one know if the spine
needs supplementation? With nutritional supplementation, we look at
diet, symptoms and even the time
of year to determine how to best accomplish our dietary objectives. With
the spine, there are several evaluation criteria to consider. Symptoms
of pain in the spine and postural
distortion patterns are the first clues
that that we may have a stability
Don’t Miss the Obvious
Any postural distortion you see—
including uneven hips or shoulders,
head tilt, or forward head carriage—
should be a clue that there may be a
fundamental functional failure present, and that it is often hidden in the
asymptomatic structures of the feet.
What do I mean by a fundamental
functional failure? The word “fundamental” literally means “serving
as, or being an essential part of, a
foundation or basis; basic; underlying” (1). The functional structures of
the feet are the basis or foundation
for proper, efficient biomechanical
function of the lower extremity, pelvis and spine. A failure of any of the
three arches of the feet compromise
the functional integrity of the entire
kinetic chain and can contribute to
chronic biomechanical stress, which
can lead to ankle, knee, hip, pelvic
and spinal stress, injuries and degeneration (2).
Additional visual clues of underlying structural deficiencies are
asymmetrical gait patterns. Most
commonly seen is a flaring out of
one foot compared to the other.
Often accompanying this is an asymmetrical valgus distortion of one knee
compared to the other. When you see
these two distortion patterns, you will
often see further evidence in an uneven wear pattern on the shoes. The
area of heel contact during the gait
cycle, the posterior lateral area of the
shoe, will be the most evident area to
observe this.
Get the Full Picture
To get the most accurate assessment of the structural foundation, you
need to be able to evaluate all three
of the arch structures of the foot to
determine if supplementation is appropriate. Digital scanning assessment lets you determine if one, two
or all three of the arches of each foot
are functionally deficient (3). If a deficiency is detected, supplementation
is appropriate. Individually designed,
flexible stabilizing orthotics have a
long history of providing the support
that is missing and contributing to
the structural and neurological stress
that patients seek relief from in chiropractic offices.
How Long Do You Need to
Due to the supportive characteristics of the feet’s arches, lifetime stability supplementation is necessary.
Plastic deformation of the plantar
fascia creates a permanent structural
deficiency, which requires ongoing
support. The good news is that the
consistent use of this time-tested
supplement for the spine will complement chiropractic care, ensuring optimal structural support and neurological function.
2. Hyland JK. Arch stability with spinal
pelvic stabilizers. Practical Res Studies
2007; 21(4):1-4.
3. Foot Levelers. Confirmation of the associate platinum’s reliability. Balanced
Insights 2012; 1(3):1-4.
By Diane Philipbar – ANJC Assistant ED
ANJC staff is working on a number
of projects to better serve members:
• Staffing Up! – In August ANJC
hired a Director of Insurance, Matthew Minnella, to assist members
with their insurance challenges.
HQ is in the process of searching
for its next staff member who can
manage business development,
member services, and public
• ANJC Website Redesign – In
2013, the ANJC website will have
a new look, new functionality
and valuable resources for both
ANJC members and the general
public. The new website will give
members the ability to register for
events, update their membership
profiles, and allow non-members
to join.
• 2013 Calendar of Events - HQ is
in the process of preparing 2013
programs for members. Among
programs in the works include
Spring and Fall conventions; two
Nutrition Education Council (NEC)
seminars; two technique seminars; a series of programs from
the Documentation and Coding
Institute (free to members), and,
of course, monthly webinars for
free CEUs. More information will
be available later this year.
• Membership ID Cards - HQ is
moving forward with providing
Membership ID Cards for all ANJC
members. These cards will be
bar-coded and can be used to
scan in and out of all ANJC CEU
programs. All members will receive their ID cards by the end of
• New Member Packets – Staff is
developing a more robust new
member welcome packet, which
will be mailed to all new ANJC
members. This packet will feature
a membership ID card, list of
member benefits, the latest issue
of the NJ Chiropractor, a Platinum
Sponsor Director, and additional
information to give them a full understanding of the value of their
ANJC membership.
• ANJC Member & Sponsor Logos –
Over the summer, HQ developed
both ANJC member and sponsor
logos. These logos can be used
by members and sponsors on
websites, email signatures, flyers
and other promotional materials.
For more information, contact a
staff member today at [email protected]
Holiday Stress
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These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.
Fall 2012
Fall 2012
By Jeff Randolph, Esq. –
ANJC General Counsel
Unpublished Appellate Case Finds
Chiropractor Competent to Testify
on MRI Findings in Superior Court
he New Jersey Appellate Division issued a decision in the
case of Capasso v. Cavalusso,
A-4040-10T2, on July 26, 2012, which
held that there is no per se ban on
chiropractors testifying as to MRI film
findings in Superior Court actions. This
decision correctly analyzes a chiropractor’s qualifications to provide expert testimony under the Rules of Evidence and the court’s decision should
be adopted by courts throughout the
state. However, it is an unreported
decision and, thus, is merely persuasive authority to other courts and not
absolutely binding.
There has been a long running dispute as to whether chiropractic physicians in the state of New Jersey have
the requisite education, training and
experience to testify regarding MRI
film interpretations in Superior Court
trials. In 2006, the Appellate Division
issued a decision in the matter of Brun
v. Cardoso, 390 N.J.Super. 409 (App.
Div. 2006), which was widely (and
incorrectly) interpreted by both trial
judges and litigants to impose a per
se ban on chiropractors testifying as
to MRI findings in Superior Court matters. The Brun decision, however, did
not impose such an across-the-board
ban though the misinterpretation
of the decision has been perpetuated ever since in many trial courts
throughout the state. The Brun decision concerned the bootstrapping of
inadmissible evidence at trial by a
clearly unqualified chiropractic expert
witness that had not actually reviewed
the MRI films and, instead, relied on
the hearsay radiologist’s MRI report.
Despite the fact that the decision
clearly stated. “[t]o repeat, this determination is not because the witness
was a chiropractor. The same result
would have obtained if the witness
were a medical doctor unqualified to
interpret an MRI,” the decision has
morphed into a per se ban on chiropractors testifying as to MRI findings
at trial. This is so even in situations
Physical Therapy
Massage Therapy
Rehab Modalities
To remedy this situation, the ANJC State Board of Directors authorized its legal counsel to submit a petition to
the Administrative Office of the Courts to publish this
opinion and make it precedential on the basis that it resolves the conflict of authority discussed above and is a
matter of public importance and interest.
where the chiropractor is eminently
qualified in MRI interpretation and actually read the MRI films at issue.
The per se ban on chiropractors
testifying as to MRI findings in court
was perpetuated by further misinterpretation of the New Jersey Supreme
Court decision in Agha v. Feiner, 198
N.J. 50 (2009). Similar to the factual
scenario in Brun, supra, the Agha case
concerned an attempt to permit a
treating doctor (chiropractor and anesthesiologist) to testify at trial regarding MRI findings where the doctors
never reviewed the MRI films and only
relied on the hearsay radiology report.
The Court affirmed the preclusion of
such evidence based on the fact that
the doctors had never independently
reviewed the MRI films and could only
testify as to the hearsay report issued by the radiologist. This decision,
similar to Brun, has been interpreted
to impose an across-the-board ban on
chiropractors testifying at trial as to
MRI film findings.
Fast forward to 2012, the Appellate
Division now has issued its unreported
decision in Capasso v. Cavalusso,
which clears up the confusion and
previous misinterpretation of the
case law by correctly discussing the
actual holdings in the Brun and Agha
decisions and holding that no per se
ban exists precluding chiropractors
from testifying as to MRI findings provided the chiropractor had education,
training, and experience in MRI film
interpretation and had actually read
the MRI films. The court opined that
the prudent approach, based on long-
standing evidentiary precedent, was
to admit the testimony into evidence
and permit the chiropractors’ actual
competency in this regard to be addressed through cross-examination.
It is this author’s opinion that the Appellate Panel in Capasso v. Cavalusso
has reached the correct conclusion.
Provided the chiropractor can establish
experience and training in reading MRI
films and that they have actually read
the films in a particular matter, there is
no legal basis to preclude the chiropractor from testifying as to the MRI results
under the Rules of Evidence or other
legal precedent. However, as mentioned
at the beginning of this article, this decision is an unpublished decision, which
means that it is not binding on any
court or judge in the state.
To remedy this situation, the ANJC
State Board of Directors authorized
its legal counsel to submit a petition
to the Administrative Office of the
Courts to publish this opinion and
make it precedential on the basis that
it resolves the conflict of authority discussed above and is a matter of public
importance and interest. The petition
was submitted on August 29, 2012,
and the ANJC will keep its membership notified as to the status of this
important request and if, and when,
the decision is published and becomes
a binding precedent.
If you would like a copy of the Appellate Division decision in Capasso
v. Cavalusso, please email me at [email protected] with a request for the
decision in the subject line. I will reply
with a pdf copy of the decision.
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At recent NEC meeting, NEC members listen to Dr. Tom Bilella talk about Optimizing
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Concussion: What You Need to Know
By Dr. Andrea J. Sciarrillo
n today’s ever changing landscape
of healthcare, doctors will constantly be pressed to generate a
better understanding of the human
condition. With advancements in
research and technology specific to
healthcare, more detailed analysis
of injuries and diseases will be conducted. Subsequently, diagnoses will
become more accurate, and ultimately
treatments will provide for better outcomes of patients’ conditions. A current topic that has gained significant
media attention is that of concussion.
The current state of one’s ability to
recognize and treat concussed patients is in an upswing and the need
to cultivate our understanding of this
condition is timely.
Our media outlets have brought to
light the urgency and gravity of NFL
players, NHL players and boxers who
have sustained concussions. As chiropractors, it is becoming quite clear
that our patients need us to sharpen
our skills at recognizing potential
mechanisms of injury and the early
signs and symptoms of concussion.
We can all agree that our patient
athletes put themselves at greater
risk of concussion, but we should be
aware of the fact that it is not just the
athletes participating in football and
hockey. Statistically those sports have
a higher incidence of concussion than
soccer and tennis, but all athletes
are susceptible. Recent study has
provided us with statistics indicating
that, for example, female athletes are
at just as much risk of concussion as
their male counterparts in sports like
soccer and lacrosse. In fact, they may
have even more difficulty and take longer to recover from such incidents.
The current standard to which
many of the present concepts on
concussion have manifested is the
Consensus statement on Concussion in Sport—The 3rd International
Conference on Concussion in Sport
held in Zurich, November 2008. This
paper is a conceptual review utilizing
a consensus-based approach compiled from some of the most experienced, scientific minds on the topic
of concussion. This is not specific to
chiropractors, but in fact, its intended
use is for all physicians, therapists,
certified athletic trainers, health
professionals, coaches and anyone
involved in the care of injured athletes,
whether at the recreational, elite or
professional level. From this paper, the
current state of our ability to diagnose
and subsequently treat a concussed
patient has matured.
As chiropractors, we can look to
one of our own certifying bodies for
sports chiropractors, the American
Chiropractic Board of Sports Physicians, for a position on management
of concussion:
1. Concussions may be caused by
a direct blow to the head or elsewhere on the body.
2. Loss of consciousness is a key but
not a required factor in the diagnosis of concussion. An individual
may be concussed without a loss
of consciousness.
3. Individuals with concussion may
present with a wide range of signs
and symptoms such as physical
signs of neurologic impairment, or/
and symptoms of impaired brain
function, which may include abnormal behavior.
4. An athlete suspected of concussion must be removed from play
and immediately assessed.
5. The concussed individual must not
be allowed to return to play the
same day they were concussed.
6. Any individual with signs or symptoms of concussion at rest or with
exertion should not be allowed to
participate in sport until the signs
and symptoms have resolved.
7. Consultation with a qualified
healthcare provider, including a
DACBSP or CCSP, is essential after
suspected concussion.
8. Individuals with concussion should
be directly observed, receive serial
examinations and not be left alone
after the injury until their constellation of symptoms are static.
9. Any increase of symptoms (especially increasing headache, decreasing neurologic deficit, altered
vital signs, or repeated vomiting)
in a concussed individual requires
urgent evaluation of the individual
in a hospital setting.
10.A graded return-to-play protocol
must be followed prior to resumption of full sporting activity.
11.Clearance by a qualified healthcare
provider must be sought prior to
the athlete returning-to-play.
12.An athlete must be symptom-free
at rest and with exercise prior to
The evaluation and management
of concussion is in transition and will
continue to change as more research
is conducted and new advancements
are made in the diagnostic tools used
for evaluation. It is our responsibility as doctors to stay current on this
information. The ACBSP has provided
a vehicle for this in their concussion
registry. Doctors have the opportunity
to study the latest academic materials and test their knowledge on this
subject. Upon successful completion
of the online course, doctors can be
listed on the concussion registry.
With this, chiropractors will be able to
arm themselves with the knowledge
and skill to better diagnose and treat
patients who have sustained a concussion.
Dr. Andrea J. Sciarrillo maintains
a Certified Chiropractic Sports
American Chiropractic Board of
Sports Physicians. She holds a
position on the Board of Directors
for the ACBSP. She is the acting
Vice President for the ANJC Sports
Council and member of the Wellness
& Exercise Science Advisory Board
at Bergen Community College. She
operates her own sports chiropractic
practice in Cranford, NJ.
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Fall 2012
ANJC Sports
Council Sponsors
Kid’s Triathlon,
Provides First Aid
n Sunday, August 26th, ANJC’s
Sports Council sponsored the
third annual Princeton Kid’s
Triathlon both financially and with
manpower. Drs. Veera Gupta and Len
Ershow were co-leaders of an experienced team of sports chiropractors
that included sport DCs from all over
the state. The first aid team of Drs.
Andrea Buccino, Tony DeLuca, Christopher Peterson and John Volpe interfaced with the Princeton First Aid and
EMS Squad to provide coverage for
the triathlon, which had approximately 80 kids from ages 7-14 participate.
The ANJC SC has been involved
with providing sports chiropractors
for the volunteer first aid team and a
significant financial sponsor of Princeton Tri Kids from its inception in
2010. ANJC SC believes in supporting
the concept of raising awareness of
a healthy lifestyle in children through
participation in events like Princeton
Tri Kids.
The triathlon was broken into four
age groups and the swim, bike and
run courses were calibrated to be
challenging but achievable for each
age group. The sports chiropractic
first aid team covered all aspects
of the course and helped ensure
the safety and health of all the
Approximately 80 athletes from
the ages of 7 to 14 competed in
the event. The competition was
broken up into four different groups,
based on age. The ANJC assisted in
sponsoring the event with a donation of event signs, Power bars, and
most importantly, the event’s medical team. The medical team worked
from the wee hours of the morning, starting at 5:45 a.m., until the
final athlete left the course at approximately 12:00 p.m. The medical staff
consisted of Drs Andrea Buccino,
Anthony Delucca, Len Ershow, Veera
Gupta, Christopher Peterson, Peter
Scordilis, and John Volpe. Drs. Ershow and Scordilis provided mobile
medical assistance by riding the
bike course for hours, assisting and
monitoring the health status of the
athletes. Drs. Buccino and DeLucca
were in a key location to observe and
assist athletes in the 2.4 mile run. Drs. Gupta and Volpe provided First
Aid assistance at the medical tent,
as they are both EMTs and chiropractors. Dr. Peterson monitored two of
the greatest points of injury on the
course—the swim-to-bike and biketo-run transition points. The event was extremely successful on many levels. Besides being
a beautiful day, only one athlete
needed extensive care. Due to the
months of the preparation ahead of
time, EMTs, DCs, the police, and the
Princeton Recreation Center had assembled a team that was prepared
for the worst scenarios but had the
very best present itself. For more information on joining
ANJC Sports Council email Dr. Marc
Jenkins at [email protected]
Union Anesthesia Associates
Healthcare Credit Cards vs. Cash Plans
By K. Jeffrey Miller, DC, DABCO
By Dr. Miles Bodzin
he television series The First
48 Hours follows police detectives during the first 48 hours
after a crime, usually a homicide.
The show stresses the fact that the
best chances of solving a crime are
within the first 48 hours. The likelihood of a crime being solved deteriorates steadily beyond this point.
The first 48 hours can also be important in healthcare. For example,
the first 48 hours following a cervical injury sustained as a result of
an automobile accident are critical.
They are critical for proper diagnosis, initiation of appropriate care,
and establishing accurate records.
Proper diagnosis requires thorough history and examination, often
beyond those used for the average chiropractic case. Appropriate
care must begin as soon as possible and correspond to the stages
of soft tissue injury. Records are
crucial as these injuries can take
months to heal, result in permanent
impairment and/or lead to legal
With this said, it is obvious that
an article of this length cannot cover the magnitude of information required to diagnose, treat and document a cervical injury of this nature.
It can however, offer a procedure
the author has found helpful over
the years when dealing with cervical
injuries of traumatic origin.
Cervical trauma results in inflammation and the region expands in
proportion to the degree of inflammation. As a consequence, the
patient may report shirt collars feel
tighter than normal, neck ties or
scarves are uncomfortable to wear
or heavy necklaces create soreness. These signs and symptoms
fade as inflammation decreases
with time.
Reports of this nature warrant
recording in the case history. It also
warrants investigation by measuring
the circumference of the patient’s
neck. This is critical during the first
48 hours to document the initial
inflammation. If more than 48 hours
has lapsed between the trauma and
the doctor’s evaluation, the signs
and symptoms reported by the patient will remain important but the
usefulness of the neck measurement will be diminished.
If a patient’s neck circumference
is 16.5 inches within 48 hours of
the injury and measures 15 inches
four weeks later, the implication is
significant inflammation occurred
from the injury and is resolving.
The measurements provide proof of
injury and positive progress. Further proof is provided if the patient
reports shirt collars, ties or scarves
are once again comfortable.
To further establish neck circumference as an objective clinical
finding, the patient’s body weight
should be recorded. Since weight
loss often reduces neck circumference, the doctor must determine if
a decrease in neck circumference is
related to weight loss.
A reduction in neck circumference in a patient trying to lose
weight, without significant weight
loss, indicates the change can be
attributed to decreasing inflammation. A reduction in neck circumference in a patient trying to lose
weight, with significant weight
loss, indicates the change will be
difficult to attribute to decreasing
Although this article discusses
cervical trauma as a result of automobile accidents, measurement
of neck circumference and body
weight can be instrumental in the
evaluation of cervical trauma of any
etiology. Adding these simple procedures to your examination format
can improve diagnosis, patient care
and case documentation.
K. Jeffrey Miller, DC, DABCO serves
as director of clinical operations for
Tuck Chiropractic Clinics in the New
River and Roanoke Valleys of Virginia.
He has authored over 150 articles in
thirty seven different publications.
He has also authored seven
books. His eighth book, Practical
Assessment of the Chiropractic
Patient 2nd ed., is set for release in
early 2013. Dr. Miller teaches post
graduate seminars in orthopedic and
neurological examination throughout
the country each year for a variety
of chiropractic organizations. He can
be reached through his website www.
Raritan Anesthesia Associates
From Left to Right: Randolph Kahn, D.O., Michael Wilcenski, M.D.,
Wayne Fleischhacker, D.O., Edward Novik, M.D., Steven Shane, D.O.
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Laser Spine Surgery
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654 Broadway, 2 nd Floor, Bayonne, NJ 07002
Somerset County
141 Main St, South Bound Brook, NJ 08880
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40 Union Ave, Irvington, NJ 07111
135 Bloomfield Ave, Suite B, Bloomfield, NJ 07003
Call us for an appointment today: 908-851-7161
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10/12/12 10:02 AM
The First 48 Hours
Board Certified Pain Specialists & Anesthesiologists
Providing the best
treatment for neck
and back pain.
Fall 2012
At NE/NW regional meeting, Dr. Alkie Lapas takes break time to explain to members
intricacies of MRI interpretation.
hink about all the times you
were checking out your favorite
home improvement, department
or super store and before you can
pay the bill and be on your way, the
cashier will politely ask you to open
a credit card. The hook is simple and
straightforward. “Would you like to
save ten percent on your purchase
today by applying for a credit card?”
It is as though the words come out
like a track on a broken record.
However you can’t blame the employees for trying, since they are
more than likely financially rewarded
for the number of credit accounts
they can open. From the superstore’s
perspective it’s an excellent opportunity to make twenty-seven percent
interest on loaned money.
It turns out department stores and
superstores aren’t the only companies looking to cash in on those who
buy now and pay later. Recent news
has reported that doctors, dentists,
and even chiropractors are pushing
healthcare credit cards on patients
who can’t afford the care or have
limited or no insurance benefits. In
fact, there have been a number of
complaints that doctors are pressuring patients while they are in a vulner-
able state—suffering with pain and
desperate for a solution. Even worse,
they are often misled about the credit
card’s high interest rates and its
terms and agreements.
The way it usually works is as
follows: once the patient has been
approved, the credit card companies
forward full payment for the services
to the provider, many times before
the treatment has even been initiated
or completed. For example: Patient A
comes in for a consult and treatment.
They don’t know if their insurance will
cover the care and finances are a little tight so they decide to go with the
By Jeff Randolph, Esq. –
ANJC General Counsel
healthcare credit card that office XYZ
provides. They fill out the credit application and the office obtains instant
approval from the card company.
Office XYZ receives an entire lump
sum payment for care from the credit
card company that normally would be
billed over weeks or months.
It has also been reported that
some of these physicians will recommend more costly treatments and/
or more procedures than necessary
knowing the lending company is
going to pay. What isn’t being disclosed is that if the patient discontinues care, the patient is still liable
for the lump sum payment made to
the doctor.
The negative press and patient
complaints and grievances these
healthcare credit cards can cause
actually harm practices that are
based solely or primarily on cash
plans where patients will pay a
monthly fee for care. It is extremely
important to educate your patients
on the difference between healthcare
credit cards and cash plans. Explain
to them that cash based plans are
not based on any sort of financial
background checks or credit score,
no money is being financed, no interest charges are being incurred, and
no care is being paid for before it is
rendered. Furthermore, the doctor is
not being paid in a costly, upfront,
lump sum payment.
Cash plans versus financed healthcare credit cards are as different as
night and day. No credit applications,
no high interest rates or misleading
tactics to sign patients up. What your
patients can expect is straightforward
honest pricing and convenient care.
Make sure your patients understand
these important differences.
Miles Bodzin, DC founded Cash
Practice ® Systems in 2003 with the
goal of providing an all-in-one webbased application for chiropractors to
get everything they need for running
a cash-based practice. Dr. Bodzin
developed a successful model for
running a profitable, cash-based
wellness practice, and created
software to automate many of these
systems. For more information call
877-343-8950 ext. 101 or visit www.
• Comfortable • Portable • Easy to use • Designed for patient in-home
Q: Do self-funded insurance plans
have to pay claims in accordance
with the time frames required by the
New Jersey prompt pay law (30 days
for electronic claims and 40 days for
paper claims)?
No, federal ERISA law governs selffunded plans and they are not subject to the requirements of the New
Jersey Prompt Pay Law. ERISA regulations generally state that claims
should be paid or denied “within a
reasonable period of time.” The rule
of thumb is that exceeding 90 days
is unreasonable. However, the ERISA
regulations also permit the plan or its
administrator to obtain a 90 day extension by giving notice to you or your
patient, thus, extending the payment
deadline to 180 days.
Q: Is a PIP insurance carrier permitted to delay my PIP reimbursement pending my office sending them
proof that I collected my patient’s
co-pay and deductible amounts?
No. Though you are not permitted to routinely waive co-pay and
deductible amounts as an inducement for a patient to treat with you,
there is nothing in the PIP statutes
or regulations that would authorize a
PIP carrier to withhold payment of a
clean claim from you pending proof
of co-pay/deductible amounts. PIP
carriers, by statute, must investigate
and pay or deny a claim within 60
days of the claim submission though
they can request one 45 day automatic extension in writing. If these
time frames have expired and coverage has been determined, the carrier
must pay the claim and cannot with-
hold payment for arbitrary requests
such as proof of patient cost sharing
payments. It is standard practice in
the industry for a provider to delay
(not waive) collection of co-pay and
deductible payments by asserting a
written lien on the patient’s personal
injury file and waiting until the case
is resolved. There is no authority to
permit the carrier to withhold payment to you until the case is over
if you have agreed to such a delay
as this is contrary to the intent of
our PIP/No-Fault laws that promote
prompt payment of first party medical expense benefits without having
to prove fault in a third party claim.
Q: I received a request for copies
of my patient records related to a
post-payment audit by a major medical insurance carrier. They told me
they would fax me a list of patients
and I would have 24 hours to provide
them all of the copies. Am I required
to provide these copies in such a
short time frame?
The threshold question is whether
you participate with the carrier or
not. If you participate, you must
first review your participating provider agreement to see if there is a
response deadline for providing file
copies following a request from the
carrier. If there is such a provision and
it requires a 24 hour turn around, it is
most likely enforceable as you have
contractually agreed to it by signing
the agreement. On the other hand, if
you do not participate with the carrier,
there is no contractual agreement
Continued on Page 21
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Tel: (604) 270-4263 = Fax: (604) 277-2154 = Toll Free: 1-800-667-7795
Website address:
E-mail address: [email protected]
Proud ANJC Platinum
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Fall 2012
By David Klein, CPC, CHC – ANJC Insurance Consultant
Q. I have a question regarding cervical/lumbar radiculopathy. We have
been using ICD-9 code 722.71 and
722.73 to rule out, pre-cert and bill
for cervical/lumbar radiculopathy,
which we retrieved from the PIP care
path guidelines. Now an automobile
insurance company is stating that is
an inappropriate code to use since
that code is for myelopathy. Can you
advise us of the appropriate code to
use for radiculopathy? A. ICD-9-CM 723.4 is defined as:
Brachial neuritis or radiculitis NOS.
The short description is brachial neuritis NOS. It is the appropriate code
for Cervical Radiculopathy. It should
also be noted that you should never
choose a diagnosis code to rule out
but rather code the diagnoses that
are confirmed.
Q. Do we need to go electronic/
paperless by 2014 for our notes and
A. No. However, Medicare-eligible
professionals who do not successfully demonstrate meaningful use
of a certified EHR software by 2015
will have a payment adjustment to
their Medicare reimbursements. At
this time the payment reduction
starts at one percent and increases
each year that a Medicare-eligible
professional does not demonstrate
meaningful use, to a potential maximum of five percent. However, if
you are considering implementing
EHR now is a good time since you
will be required to make a change
to ICD-10 in October of 2014. This
change to ICD-10 will result in significant changes to how you report
diagnoses and document. An EHR
system will surely help with the
changes and, if you are trying to
learn the new codes and convert to
an EHR system at the same time it
will be a bit overwhelming.
Q. What codes can I use when I
give a patient a cold/warm wrap for
home use?
A. Prior to 2012 providers were
supposed to bill E0238 (hot pack)
and E0230 (cold pack) when issuing
for home use. However in 2011, both
of these codes were deleted and a
new code was created. The new code
for these products is A9273 – Hot
water bottle, ice cap or collar, heat
and/or cold wrap, any type.
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Electronic Health
Records Are
Required by 2014!
By Paul B. Bindell, DC
he choice is no longer whether
or not you will computerize; the
only choice is when, as long as
it is before 2014. In the State of the
Union speech by President George
Bush in January 2004, the President
stated, “by computerizing health
records, we can avoid dangerous
medical mistakes, reduce costs, and
improve care.” In April 2004, he issued an executive order mandating
computerization of health records by
2014. Congress passed legislation
turning the edict into federal law.
President Obama intensified the
pressure with Electronic Health
Records (EHR). He gave speeches
lauding the benefits of EHR and
with Congress enacted an economic
stimulus bill that rewards those using certified EHR and punishes those
not. If you already use a certified
EHR system then you are eligible to
receive bonus payments from Medicare or Medicaid, but not both.
Reward for Certified EHR: The
Medicare stimulus is up to an extra
$44,000, added to Medicare payments over a three year period. The
Medicaid stimulus is up to $64,000
paid over five years.
The Punishment for No Certified EHR
You do not get the up to $44,000
stimulus money, and Medicare payments will be reduced by 1% in
2015, by 2% in 2016, and by 3% in
At this time, there are a few
chiropractic specific EHR systems
that have the proper certification.
However, the certification should
not be the only criteria to select the
software for your office. Make sure
the certified software also includes
the State Board requirements for
documentation, any special features
that you would like to have, and
that its price is in your ballpark. And
verify what the price includes. Some
inexpensive programs do not include
everything and then nickel and dime
you until you have paid more than
the seemingly expensive systems.
Does your purchase include support,
updates, training, etc., and if yes, for
how long?
The insurance industry placed
requirements on health records,
exceeding the timetable set by the
government. Tom Lee, CEO of Partners Health Care System in Massachusetts, reported that for doctors
that did not implement EHR by January 2008, or commit to implementing EHR by January 2009, they are
out of the Partners network. Other
insurance programs are getting on
this bandwagon. The best thing you
can do is computerize today, and not
wait until the government or insurance forces you.
Know the terminology of electronic health records. Recognize that
different entities use the terms differently. We frequently use the terms
of EHR, EMR, and ECR interchangeably. The insurance industry gives
them separate meanings. In the December 2007 issue of Risk Review
Online, Sharon Koob (the Healthcare
Risk Consultant for Princeton Insurance) explained that EHR referred
to the patient’s complete record
including personal data, clinical info,
demographics, insurance material,
phone logs, reminder messages, letters, reports and anything else found
in a patient file. She notes that EHR
spans all the records of doctor offices, labs, nursing and rehab facilities,
all insurance companies and “any
other part of the massively complex
healthcare system.” By contrast, Ms.
Koob identifies EMR or ECR as being
only the clinical record, that is SOAP
notes, exam findings, and narrative
reports about the patient.
EHR provides many benefits.
James B. Couch, MD, Managing
Partner and Chief Medical Officer of
Patient Safety Solutions, LLC noted
in the December 2007 issue of Risk
Review Online that “the healthcare
industry is finally getting swept into
the electronic information age” and
that doctors “who want to continue
practicing …must prepare themselves for the inevitable transition
into this electronic information age.”
He itemized some benefits of EHR
to include
• More thorough knowledge of the
patient’s condition prior to making a diagnosis
• Instant accessibility to test results and consultations, allowing
for a faster and more accurate
• Documentation support for therapeutic decisions
In addition to the items listed,
EHR has many other benefits; EHR
makes your office paperless, so no
one is wasting time in the filing cabinet. EHR enables your staff to be
more productive with building your
practice. Each file is always at your
The mandate for Electronic Health
Records, also referred to as EMR,
EHR, or ECR, is very unusual for
a government program because
EHR gives us very great benefits
including reduced expenses, saved
time, greater staff productivity, and
increased income. Paper filing is
minimal, and in the not too distant
future, even more paper will be
eliminated when patient forms are
completed by the patient using tablet computers. In other words, the
sooner you implement full computerization of your health records, the
better it will be for you.
Dr. Paul Bindell is founder of Life
Systems Software, and as a computer
consultant he assists chiropractors
to improve office efficiencies and
profitability, and to grow successfully.
For more info call 800.543.3001 or
Fall 2012
What Makes Chiropractic Attractive?
By William D. Esteb
any chiropractors forget
what makes chiropractic
care attractive to patients.
Distracted by the challenges of running a small business and deep into
the doing of chiropractic, it’s easy
to forget why chiropractic is so appealing to patients. Here’s a quick
refresher course.
1. Chiropractic is attractive because
it’s different from medicine.
As much as we wish it weren’t so,
chiropractic is often a last resort for
many patients who investigate chiropractic only after exploring medical
That’s why you’d want to create a distinctly different patient
experience than the medical model
they’ve already tried and abandoned. In other words, patients
don’t want same, they want different. That’s good news. It means you
have incredible latitude to show up
truly different. You could even lose
the white lab coat if you wanted to.
2. Chiropractic is attractive
because it’s completely natural.
Perhaps it’s due to the Baby Boom
Generation who avoided polyester
in favor of natural fabrics. It seems
there’s a growing interest in things au
Consider the popularity of organic produce, antibiotic-free poultry, growth hormone-free milk and a
myriad of other all-natural products.
Those who tend to be more highly
educated and attempt to live consciously are inclined to avoid processed foods and artificial just about
When given the choice, most people would prefer natural over artificial,
authentic over phony and the truth
over a lie.
3. Chiropractic is attractive because
it’s safe.
What makes this so ironic is that
many chiropractors are more sensitive to this than patients or perspective patients.
Sure, the bogus stroke thing is paraded out from time to time by chiropractic detractors, but they overlook
the fact that people make decisions
based on how they feel (emotions)
rather than what they know (intellect). In other words, most people
don’t consult actuarial tables before
choosing a treatment option.
Credibility, trustworthiness and
cultural authority are far more influential than some statistical analysis
or comparison with adverse reactions
to drugs or iatrogenic statistics from
medical interventions. This is why patient testimonials can be so powerful,
and financial inducements—“Save
$100 off our regular exam fee”—and
other questionable marketing practices are so damaging.
The real safety patients and prospective patients want is social
safety. Proof that choosing a nonmainstream solution won’t make
them look foolish.
4. Chiropractic is attractive because
it trusts the wisdom of the body.
Many chiropractors overlook this
when explaining chiropractic to patients. Perhaps this is because the
allure of showing up as the hero,
mimicking the attitude of traditional
doctors, is more gratifying than telling the truth about the nature of
healing. In other words, doctors, of
any ilk, don’t heal. Nor do drugs. Or
Recovering one’s health is a shedding process not an acquiring process. Which is to say, we each have
within us the ability to heal. Usually,
health can manifest by reducing
obstructions or interferences rather
than filling a void because something
is missing.
We’re not flawed, we’re merely
blocked. We’re not deficient, we’re
merely constrained from our fullest
expression. We’re not suffering a
drug shortage, we’re merely exceeding our ability to accommodate one
or more stressors.
5. Chiropractic is attractive because
its side effects are largely positive
Virtually every intervention can
have an unintended consequence or
adverse reaction.
Even chiropractic.
Fortunately, these are overwhelming positive, even if unintended.
Such as the patient whose allergies
improve after receiving chiropractic
care for headaches. Or the patient
whose indigestion disappears after
receiving chiropractic care for back
pain. Or the expectant mother whose
restored fertility seems to have coincided with her chiropractic care for
low back pain. You know the list.
The danger when seeing these
frequent associations is to make the
leap that chiropractic treats allergies,
indigestion and fertility. Of course
chiropractic doesn’t treat anything.
However with a revived nervous system, just about anything is possible.
Even the relief of headaches and
back pain.
6. Chiropractic is attractive because
it can help anyone regardless of age.
Chiropractic care helps people who
have assumed a defensive posture
we call subluxation in an attempt to
accommodate physical, emotional or
chemical stress. That’s no guarantee
of cure since countless other factors can impair the healing response.
However, all things being equal, if the
stressor is no longer present, people
tend to function better without subluxations than with subluxations.
Naturally, anyone who expects to
benefit from chiropractic care must
meet one important condition: they
must be alive. Granted, this is the
same criteria that medical interventions require, however, the important
distinction afforded chiropractic is
that it focuses on the person with
the condition, not the condition in the
7. Chiropractic is attractive because
it’s simple.
By the second quarter in chiropractic college, many chiropractors have lost the simple elegance
and minimalism of chiropractic.
Obfuscated by technique, practice
procedures, physiology and beneath
layers of dogma and seminar rhetoric, many chiropractors emerge later
as spinal therapists, medical doctor
wannabes, patient pleasers or just
The principles of chiropractic often
take a backseat to the practice of
chiropractic and the how of practice
often eclipses the why. In the process, patients rarely learn that their
nervous system controls the whole
show and reviving their ability to self
heal, mediated by the nervous system
is the focus of chiropractic care—not
pain relief, posture restoration or
even treating subluxations.
William D. Esteb is the Creative
Director of Patient Media, Inc. and
co-founder of the Perfect Patients
website service. The above is
excerpted from his weekly broadcasts
of Monday Morning Motivation during
the summer of 2012. Subscribe at
Why Adjust the Extremities?
By Dr. Mark N. Charrette
eurological research has presented us with a model that
gives an explanation to why
chiropractors achieve positive clinical
results when patients’ extravertebral
articulations are examined and appropriately adjusted. The model known
as dysafferentation gives an explanation why a variety of symptom complexes not usually associated with
altered joint function are reduced or
The first chiropractor, D.D. Palmer,
was well aware of the clinical significance of adjusting extravertebral
articulations, particularly the feet.
In his 1910 book, The Chiropractor’s Adjustor, the Science, Art, and
Philosophy of Chiropractic, D.D.
states, “Why adjust in the lumbar
for displacements in the joints of the
foot?” (1). In 1906 both B.J. Palmer
and D.D. Palmer wrote in The Science of Chiropractic, “Were we to
know of a dislocated shoulder, hip
or any one of the fifty-two articulations of the vertebral column being
luxated...and did not replace the would show our patients
and students that we were not doing
our duty...” (2).
Though the explanations given by
D.D. Palmer are considered crude
by today’s standards, the clinical
significance of extremity/extravertebral adjusting cannot be understated. A deeper look at the model
of dysafferentation gives some
insight as to why I recommend the
examination of extravertebral articulations and the appropriate adjustments based on indicators, not
This explanation deals with the
two main types of sensory receptors,
nociceptors and mechanoreceptors
that innervate the joint structures.
Depolarization of nociceptors occurs
via noxious mechanical stimuli and
the chemical mediators released in
response to injured tissue. The depolarization of mechanoreceptors occurs only via mechanical stimuli such
as that associated with touch and
normal body movements. Examples
of mechanoreceptors are Pacinian
Continued on Page 23
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Fall 2012
Self Funded vs. Fully Funded: What is
All the Hype?
y now you must be hearing the
terms ‘self funded’ and ‘fully
funded’ thrown around a lot!
So…..what’s the big deal? What is the
difference between the two and why
is it so important? This is a subject
that chiropractors need to get a handle
on—sooner rather than later! It’s evident that there is still need for clarification based on some of the emails that
come into the ANJC. So let me help!
Fully Funded Policies:
Small employers are typically fully
funded or fully insured. An employer
group or individual contacts a broker or an insurance carrier and is
provided with a schematic of plan
options (usually a spreadsheet with
the monthly premium and the various
plan specifications such as in and
out of network benefits, hospitalization coverage, chiropractic coverage, etc.). There is no altering those
plans. What you see is what you get.
You cannot combine or make changes
to create your own plan.
Once the policy is purchased, the
insured receives a Certificate of Coverage (COC). From then on a monthly
premium will be paid to keep the
policy active. These polices are under
the jurisdiction of the Dept of Banking & Insurance (DOBI).
Self Funded Policies
Most mid to large employer groups
are self funded or self insured. As
the number of employees an employer group has increases, it often
By Lynette Contreni – ANJC Insurance Consultant
becomes less and less cost effective
to pay those monthly premiums for
a fully funded policy. Instead, an employer group may choose to become
self insured or self funded. Once the
model is established, the employer
group needs to hire an administrator for the plan. They may choose
to hire an insurance carrier (such
as BC/BS or Cigna) or they can hire
a managed care company (such as
Qualcare or First Health, etc.). Basically, the employer group hires the
insurance carrier or managed care
company to function as a TPA (Third
Party Administrator) for use of a provider network, claims processing, fee
schedule, etc., etc.
In this self funded model, the employer group provides the TPA with a
Summary Plan Document (SPD). This
tells the TPA exactly how to administer the benefits for the covered members under that employer group. In
the SPD, the employer dictates all the
benefit information. In addition, the
employer group actually funds the TPA
with the money to pay the claims.
These policies are not under the
jurisdiction of DOBI, but are rather under ERISA law and the administration
of the benefits need to follow ERISA
guidelines. ERISA is the Employee Retirement Income Security Act. This is
a federal law that sets minimum standards for most voluntarily established
pension and health plans in private
industry to provide protection for individuals in these plans. (
Now you have clarification on self
funded vs. fully funded. But how
does that affect your practice? Well,
truth be told, whether the policy is
self funded or fully funded affects so
many areas of a provider’s office. Just
to name a few:
**Who’s getting paid—the provider
or the patient?
**Complaints you may have regarding a particular carrier
**EOB follow-up
**If you are entitled to interest on
claims not paid timely
**Copay Maximums
For example, many providers are
confused about why some BC/BS
checks continue to go to the patient.
Well, the assignment law that was
passed a few years back was a DOBI
decision. Remember that DOBI only
has authority over fully funded policies, so if BC/BS is administering
a self funded plan (like the NJX prefixes), the assignment law does not
apply and the payments can still go
to the patients. It is the same with
the copay maximums. Again, that decision to put a cap on the maximum
amount a copay can be is a DOBI
decision; so therefore, self funded
accounts do not have to honor such
limitations under ERISA.
Appeals have different processes
for self funded policies and fully funded
policies, and EOB follow-up and time
frames are slightly different from a fully
funded plan to a self funded plan.
There are so many reasons why
making sure you obtain this information at the time of verification is
imperative. If you have not already
done so, add it to your insurance
verification immediately. If you obtain
this information at the beginning of
the patient’s treatment, you would be
prepared for the checks to go to the
patient and act accordingly before it
becomes a problem. You can anticipate that the copay maximum will
not apply. You can prepare your staff
to watch for runout periods that go
along with changes of TPAs, you can
be educated as to what appeal process you may have to follow if there
is a medical necessity dispute, etc.
My point is that knowing this information is another very important way to
set yourself up for success.
Unfortunately, gone are the days
that you could just love the patients
and get paid for it unconditionally.
We find ourselves in an industry now
where it is imperative that you always
stay one step ahead of the payer to
ensure a proper payment for your services. I strongly encourage providers
to continue to educate themselves.
It is true when they say knowledge is
power and power is money!
Lynette Contreni is founder of CB&C,
Inc. and an ANJC Insurance Consultant.
As an ANJC Platinum Sponsor. CB&C,
Inc. offers insurance patient billing
& collection services, consulting
services, insurance verifications,
webinars, managed care contracting,
and more. For information visit www. or call 973-827-3544.
The Political Future of Chiropractic in New Jersey is Doubtful
Continued from page 1
For the past several years, just a
handful of ANJC chiropractors (15%)
throughout the state have donated
to the ANJC Political Action Committee (ANJC-PAC) to help support
those legislators that support chi-
ropractic patients and the concerns
of the chiropractic physician here in
New Jersey.
Just think about how politics and
the laws that were created by politicians affect virtually every aspect of
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chiropractic. Taxes, licensure registration, insurance regulations, chiropractic law; it goes on and on. Whether
you know it or not, you’re in the middle
of the political world by having to comply with each and every one.
You do not have to even like politics to understand that politics affects every day of your life whether
you are a bystander or a participant.
As a bystander you’re controlled by
these outside voices with absolutely
no input. The MDs could put in laws
designed to stymie other professions
from advancing. PTs have always
looked to dismantle chiropractic and
if you have not been negatively affected by an insurance carrier, consider
yourself in the minority.
Choosing to be a participant as a
PAC contributor can make incredible
changes in your profession and your
life so that you and your patients
might have a better future ahead.
Someone once said “We can either
do politics or politics will do us.”
PAC fundraising is vital to protecting as well as advancing our profession by 1) participating in legislators’
functions throughout the state; 2)
discussing and debating the issues,
and 3) demonstrating that we will
support legislators who support our
profession and the rights of our patients. Yet very few in our profession
take ANJC’s PAC seriously enough
to make voluntary donations, even a
small amount of $25/month.
Put simply, donating monthly
to ANJC-PAC builds power for your
profession and your patients, and
makes a dramatic impact on legislators who have stood up and taken
notice that the chiropractic profession is on the map like never before.
ObamaCare, Triad, PIP changes,
and Optum are just a few of the uncertainties our profession faces, and
without building a strong PAC it is very
easy to see our future as doubtful, or
even slipping and sliding backwards.
I urge you to join us as an ANJCPAC supporter with a simple $25/
month credit card donation. This way
ANJC can continue to do all the necessary work required.
Whether a PAC participant or bystander, you talk to your patients
about maintenance being important
for their health and prevention of
future problems. Think of ANJC-PAC
as your profession’s maintenance
program, not only working to prevent
problems, but also working to improve your overall health.
For more information please contact ANJC HQ at 908.722.5678 or
email [email protected]
Thanks in advance for your consideration.
Dr. Steve Clarke
ANJC Legislative Chair
Fall 2012
ANJC Sponsors NJ
Champion Cyclist
Ryan Pettit:
Answers to Your
Important Malpractice
Chiropractic Has Helped
His Performance
By Keith Henaman, NCMIC Assistant Vice President-Claims
Q: A couple of weeks ago, my CA
informed me that one of our elderly
patients made a sexual comment to
her. I told the patient it couldn’t happen again, and he agreed. But today
my CA said she heard the patient
making innuendos under his breath
when he walked by. She threatened
to quit if she has to continue to deal
with him. Should I dismiss the patient from the practice?
A: As the employer, one of your
primary duties is to protect your employees. A patient like this one not
only causes strife among staff members and disrupts the flow of the
practice, he exposes you and your
practice to a complaint to your state
board or even an employee lawsuit.
That’s why you may have to dismiss him from your practice. Obviously, dismissing a patient who still
needs healthcare attention is not
to be done hastily or without good
cause. What’s more, it should only
be done if there are no other viable
alternatives. Be aware that the dismissal itself could become grounds
for an allegation of abandonment if
not handled carefully. Here are a few
ways to help protect yourself:
• Document thoroughly. If a patient’s dismissal ends up in
litigation or in a complaint to
your state licensing board, good
documentation will help you justify your decision. The records
should show that you discussed
the behavior and told the patient
it must stop, and yet the patient
failed to comply. Your documentation should paint a clear
picture of the patient’s behavior
and noncompliance, and that
you had little choice other than
to terminate the doctor/patient
relationship. It may also be advisable to document the situation in a separate incident report
outside the chart.
• Verify dismissal steps with thirdparty payers. If the patient is a
member of a PPO or HMO or other
third-party payer, it’s wise to check
to see what steps are required
to dismiss one of their covered
• Communicate the reasons for ending the doctor/patient relationship
at the patient’s next appointment.
Explain any need for continued
healthcare, document this in the
patient’s record, and follow up with
a letter. The letter should be on
practice letterhead, include the
doctor’s signature and be sent
via certified mail, return-receipt
requested. It should clearly explain
your rationale for terminating the
relationship, any need for continued healthcare and the possible
consequences of noncompliance.
A copy of the letter should be kept
in the patient’s chart.
• Offer to provide patient care for a
limited time to allow the patient to
find another doctor. The timeframe
will depend on the specific healthcare needs of the patient and the
availability of other healthcare
in the area. Many practices give
patients 30 days to find another
doctor. If appropriate, your letter
can provide information on finding
a new doctor. Also, make arrangements so the staff member does
not have to deal with the patient in
the meantime.
NCMIC is a company trusted by
more than 37,000 DCs and growing.
Policyholders know our strength
is summarized by our motto, “We
Take Care of Our Own®.” For more
information call 1-800-769-2000, ext.
3809. ©2010 NCMIC Group, Inc. All
rights reserved.
Legal Q & A
Continued from page 17
wherein you must provide copies of
records within a certain time frame. In
the absence of a participating provider
agreement, the carrier is requesting
copies of the patient records as an
authorized representative of the patient. N.J.A.C. 13:44E-2.2(e), which
governs chiropractic record keeping in
New Jersey, only requires a chiropractor to provide copies within thirty days
of a receipt of a written request from a
patient or their authorized representative. Accordingly, if you are non-par,
you have up to 30 days to provide the
copies to the carrier.
The author of this article is an
independent person of the ANJC
and his views are not authorized,
sponsored, or otherwise approved by
the ANJC. The information provided
is for general guidance on matters of
interest only and may not take into
account particular facts relevant
to your individual situation. The
application and impact of laws and
healthcare can vary widely based on
Continued on Page 25
yan Petitt of Hammonton, NJ
is a three-time New Jersey
Category 1 State Cycling
champion. However, earlier this
summer, the 30-year-old Petitt was
not experiencing the success he
had in the past as his body started
showing the effects that grueling
competitions can have. Looking
for a competitive edge and knowing how chiropractic care helped
him years earlier when he played
club lacrosse in high school, Petitt
returned to the care of Medford
chiropractor Dr. Brett Wartenberg a
few weeks ago, and since then has
returned to his winning ways, including winning four consecutive events
this summer.
Pettit, a member of the Heart
House Cycling Team and CC Evesham Elite Racing Team, now has
the entire chiropractic industry in
New Jersey supporting him. ANJC
has agreed to become a sponsor of
Petitt, who will serve as a showcase
to the benefits of chiropractic care.
An ANJC banner will be on-site at his
cycling events and Petitt will wear
the ANJC logo this fall in all of his
“I was in shape before going
back to Dr. Wartenberg, but like any
athlete, I was looking for that 1-2%
extra,” noted Petitt. “I had been doing well, but not winning and I was
looking to find an edge. After three
weeks of treatment, I won a race
and have now won four in a row.”
The physical toll on a cyclist’s
body can lead to lower back pain,
elbow, shoulder and problems with
the feet.
“When I compete with my road
bike, there is no suspension,” Petitt notes. “Your wrists, elbows
and shoulders are all affected. Dr.
Wartenberg has been adjusting my
right shoulder and it has made a big
“Riding a time trial bike, which
is all geared for aerodynamics and
keeps the body in an aggressive
position, also causes physical problems. Prior to being adjusted I could
not ride back-to-back days in time
trial competitions. My chiropractic adjustments have enabled my
body to recover and I have won two
straight time trial events.”
“When Ryan came in to see me
and I examined him, his feet and
ankles were a mess,” commented
Dr. Wartenberg, the ANJC Chiropractor of the Year in 2010 and the past
1st Vice President of the ANJC. “We
did a digital scan of his feet and began treating his feet as well as his
back and shoulders. Ryan is experiencing the benefits of chiropractic
care as have hundreds of athletes
ranging from Olympians to weekend
Those watching Ryan compete will
easily find him in the crowd of cyclists. He rides a pink bike, with pink
accented wheels and wears pink
shoes and socks as a tribute to his
late daughter Brianna, who passed
away three years ago from a heart
Fall 2012
Despite a Recommendation for Surgery, A C6-7
Disc Herniation Causing Arm Pain into the
Fingers and Upper Back, an Inability to Sleep,
and Emotional Upset, Relieved with Cox® Technic
By Dr. Joseph C. D’Angiolillo
This is a case study of a Patient
with a congenitally narrow central
spinal canal with a large right paracentral disc herniation at C6-C7.
On December 21, 2011 an obese
47 year old Caucasian male presented himself for examination and
treatment. He was cooperative, alert
to time and place and in obvious
discomfort presenting with a right
Bakody Sign. He related that approximately one month before, while traveling in an airplane to Spain, his neck
began to feel uncomfortable and
stiff. He described his neck pain as
a constant pressure sensation. Then
five days prior to coming into the office the pain spread out to his right
shoulder, right upper back, between
his shoulder blades and into his right
arm. The pain shoots into his right
arm causing the muscles in his forearm to spasm. He has numbness into
his right hand which comes and goes.
His right hand feels weaker than his
left hand. Moving his head in certain
directions, like rotation, increases the
intensity of his pain. The patient is
emotionally upset because he claims
to have not slept in the past few days
as he cannot find a comfortable position. He also relates that over the
past few months’ side sleeping has
caused his hands to fall asleep.
Prior to seeking care in my office the patient saw his primary
care physician who prescribed a
muscle relaxor and a non steroidal
anti-inflammatory. The patient has
also self treated with a heating pad,
therma-care patch, Ben Gay, and hot
The patient’s past history includes
an episode of left sided sciatica in
1999 leaving him with a permanent
loss of his left Achilles reflex. He
had the surgical removal of a benign
growth from the roof of his mouth.
He currently takes over the counter
medications for acid reflux.
His family history reveals that
his father has a history of back
problems and his mother has
Examination revealed that the patient carries his head in an anterior
antalgic lean. While the Foramina
Compression Test was essentially
negative, the RT/LT Shoulder Depressor Tests and RT/LT Maximal
Cervical Compression Tests produced right sided cervical spine
pain. The seated Dorsolumbar Circumduction Test bilaterally produced
pain in the upper thoracic spine. Using a goniometer the cervical ranges
of motion were:
Anterior bending: 30 degrees with
Posterior bending: 20 degrees with
Left lateral bending: 35 degrees.
Right lateral bending: 10 degrees
with pain.
Left rotation: 50 degrees with pain.
Right rotation: 15 degrees with pain.
The deep tendon reflexes of the
Biceps, Triceps, Brachioradialis,
and Patella were +2 bilaterally. The
left Achilles was 0 the right Achilles was +2. Using a Whartenberg
Pinwheel the right C7 and C8 dermatome levels were reduced, all
other dermatome levels of the upper
Are you being investigated by the nJ Board
of ChiropraCtiC examiners or audited
by an insuranCe Company?
extremities were noted to be within
normal limits. Using a dynamometer the left hand grip strength was
105/105/105 lbs per square inch;
the right hand was 85/90/85 lbs
per square inch. The patient reports
to be right handed. Paravertebral
muscles spasms were present from
the sub-occipital region to the midthoracic spine, the trapezius muscles and SCM muscles. Tenderness
on digital pressure extended from
the sub-occipital region to the mithoracic spine.
On December 21, 2011 the patient had two cervical films taken.
Analysis of these films reveals the
following: essentially negative for
evidence of recent fracture as visualized. Spondylosis is noted at the
C5-C6 joint level with Lushka Joint
hypertrophy, anterior and posterior
spur formations. The C5-C6 disc
space is thinned. There is a bilateral elongation of the C7 transverse
processes. The lateral film reveals a
loss of the normal cervical lordosis.
The A-P film reveals a lower right
shoulder along with a right lateral
lean to the upper thoracic and cervical spine.
I referred the patient for an MRI of
the cervical spine as my suspicions
were of a HNP of the cervical spine,
which was performed on December
23, 2011. The MRI reveals the following significant findings (See the
axial and sagittal MRI images.):
Figure 1
Axial Image 10/40 T2W FFE 3D shows the
large right sided C6-C7 disc herniation (See
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Figure 2
Sagittal T2 TSE section 10/15 showing the
large C6-C7 disc herniation (See arrow.)
“There is a mild to moderate diffuse
congenital narrowing of the cervical
spinal canal.”
“At C5-6, there is a small left paracentral disc protrusion and uncovertebral degenerative change
especially on the left. There is
mild to moderate narrowing of the
central spinal canal and left lateral recess. The left neural foramen
is mildly narrowed.”
“C6-7, there is a moderate to large
right paracentral disc herniation
that fills the right side of the
spinal canal and causes severe
narrowing of the right lateral
recess and proximal right neural
foramen. The central spinal canal
is moderately narrowed. There is
potential for impingement on the
right C7 nerve roots.”
“T1-2, there is a small to moderate
right paracentral disc protrusion
that causes mild to moderate narrowing of the central spinal canal
on the right. Tiny disc protrusions
are seen at the T2-3 and T3-T4
levels as well.”
HNP of C6-C7 resulting in a right
sided cervicoradiculopathy, hypoesthesia, paravertebral muscle
spasms, and weakness of the right
upper extremity, complicated by a
congenitally narrowed central spinal
Cox Decompression Spinal Adjustments, along with trigger point ultrasound, electrical muscle stimulation,
ice packs/hot packs as needed.
Initial course of care three times per
week for four weeks or until pain
reduction of 50% is achieved, with
a re-evaluation at the conclusion of
this trial of care to determine the
patient’s future needs.
To reduce the patient pain level by
50% within one month of care. If the
patient does not improve during this
trial of care I may consider referring
the patient for a consultation with a
This patient presented himself
in obvious distress and emotionally
upset. My initial impression of a
herniated nucleus pulposus of the
cervical spine compressing the C7,
C8 nerve root levels, was confirmed
by MRI two days later. I explained to
the patient that our goal is to first
reduce the pain and that I expected
to achieve at least a 50% reduction within the first month of care. I
informed him that the cervical headpiece on the Cox 7 table is designed
to accomplish decompression of the
spinal nerve roots as well as the spinal canal, that his feedback during
the testing and treatment phase is
needed to test his tolerance of the
Continued on Page 25
Fall 2012
The Corporate Athlete: How to Avoid
Injury in the Modern Workplace
By Dr. Clifford Daub
ho is the corporate athlete
in your office? Is it the former football player who always gets volunteered to change the
heavy five gallon bottle on the water
cooler? Is it the MVP of the company
softball team? Is it the person who
goes for a five mile run every day
on their lunch hour? Yes, they certainly are athletes in the traditional
sense, but in order to avoid some of
the physical dangers of the modern
workplace everyone needs to look at
themselves as a corporate athlete.
Anyone who works in an office environment and spends time sitting at a
computer is at risk for disability associated with tension headaches, neck
and back pain, rotator cuff injuries and
carpal tunnel syndrome. These are all
classified as musculoskeletal conditions, which are the number one cause
of missed work days and decreased
productivity in the United States.
The human body is designed for
varied movement and the prolonged
periods of sitting at a computer or
the small repetitive movements with
our hands, wrists and shoulders associated with using a smartphone can
cause big problems. These physical
ailments are becoming so prevalent that terms like “text neck” and
“Blackberry thumb” have been added
to the lexicon of workplace postural
and overuse syndromes. Fortunately,
with a little training, you can improve your fitness so that your body
can withstand these biomechanical
stresses without breaking down.
If you spend a good part of your day
using this modern technology, you are
probably developing a posture that
is overly stressing certain muscles,
ligaments and joints that can put you
at risk for one of these workplace
ailments. Your head probably sits
forward from your upper back, your
chin probably protrudes forward, your
shoulders are rotated inward, your
forearms are pronated (palms face
downward), your fingers always flexed
and your low back is slumped forward.
Try this simple test: Stand with
your back against a wall. Try to keep
your heels, buttock, lower back, upper back, shoulders and head flat
against the wall at the same time
without tilting your head backward.
Then raise your hands above your
head with elbows at shoulder height
and keep your elbows and backs of
your hands flat against the wall while
still keeping the rest of your body
against the wall.
If you have difficulty holding this
position, then you have already developed some postural faults and lost
flexibility that puts you at risk for the
pain and disability associated with
the above noted injuries of the modern workplace.
The good news is that you can decrease your risk if your start thinking
and training like a corporate athlete.
A simple way to improve your workplace fitness and start limiting the
physical stresses on your body is to
take frequent micro-breaks to change
position, stretch and undo some of
the cumulative stress on your muscles, ligaments and joints that develops from sedentary posture.
1. It has been said that the only
good chair is one that you get out
of frequently; every 30 minutes
stand up and take a short 2-3 minute break to move around.
2. Perform the following stretches
every hour throughout the
• Neck: looking straight ahead,
relax your shoulders and gently
pull your head backward as far
as possible; hold for five seconds and repeat three times
• Shoulders: with your arms at
your sides, turn your palms outward and squeeze your shoulder
blades together and downward;
hold for five seconds and repeat
three times
• Back: stand up, place your
hands on the back of your
waist and gently press downward as you slowly bend backward; repeat three times
• Wrists: place a rubber band
around all five fingers and extend your fingers as you open
your hand as far as possible
against the resistance of the
rubber band; repeat three
times with each hand
If you incorporate these stretches
into your workday, you will begin
improving your workplace fitness
from that of an average desk jockey
to that of a true corporate athlete.
Dr. Clifford Daub is a Diplomate of the
American Chiropractic Rehabilitation
Board and practices in Morristown,
New Jersey.
Why Adjust the Extremities?
Continued from page 19
corpuscles, Meissner’s corpuscles,
Ruffini corpuscles, Merkel’s receptors, muscle spindles and Golgi tendon organs (3).
It appears that with joint subluxation/misalignment/hypomobility,
nociceptors will excessively fire while
the mechanoreceptors will decrease
their firing rate. Research of Hooshmand demonstrates how restricted
joint motion causes an increase in
firing of nociceptive axons (A-delta
and C fibers) and a decrease firing of
large diameter mechanoreceptor axons (A-beta fibers) (4).
Remember that an important function of mechanoreceptor input is to
inhibit nociception at the level of the
spinal cord. So, it would be reasonable to think that reduced mechanoreception (decreased firing rate
due to subluxation) may magnify the
symptoms generated by excessive
nociceptor input.
Dysafferent input can and does
produce a variety of symptoms that
one would not usually associate with
dysfunctional joints. In research written by Nansel and Szlazak, it explains
that nociceptive input from dysfunctional joints can cause symptoms
such as sweating, pallor, nausea,
vomiting, abdominal pain, sinus congestion, dyspnea, cardiac palpitations, and chest pain that mimics
heart disease (5). Cabell authored
research that states, “nociceptor activity reflexively activates the sympathetic nervous system...” (6).
In addition to relieving symptoms
classically associated with joint
subluxation/misalignment, most chiropractors experience their patients
leaving their offices with a much
more relaxed and lighter feeling. In a
paper written by a chiropractor, Dr.
Patterson, it states, “Adjustments
to decrease nociceptor input to the
spinal cord seem to be an effective
way to decrease the hyper-excitable
central state” (7). Based on my clinical experience and this research, it
is my opinion that examination of extremity/extravertebral articulations
and their appropriate adjustment
and rehabilitation be considered an
integral part of proper chiropractic
procedure. Extremity examination
and adjusting should be performed
on a routine basis and not only when
a patient complains of extremity
In my opinion another important
aspect of proper chiropractic procedure is stabilization and rehabilitation. This is where taping, orthotics,
pillows, rehabilitative exercise and
a variety of other procedures fit into
comprehensive chiropractic care. All
of the aforementioned will enhance
the proprioceptive response and
ultimately stabilize the patient to a
greater degree.
I do not believe that extremity/
extravertebral adjusting is a specialty or add-on technique. I also
believe that extremity adjusting and
stabilization should be based on
indicators, not symptomatology. All
chiropractors are aware that an asymptomatic joint is not necessarily a
non-subluxated joint.
In closing I would like to stress
the importance of including extremity and extravertebral adjusting
procedures in the chiropractic care
of patients. Like D.D. Palmer said
in 1910,”When we as chiropractors,
have adjusted all displaced bones of
the skeletal frame...what more can
we do?” (1).
1. Palmer DD: The Chiropractor’s Adjustor, The Science, Art, and Philosophy
of Chiropractic. 1910, Portland Printing
House, Portland, Oregon.
2. Palmer DD, Palmer BJ: The Science of
Chiropractic. 1906, Palmer School of
Chiropractic, Davenport, Iowa.
3. Guyton A. Basic neuroscience. 2nd ed.
Philadelphia: w.B. Saunders,1991.
4. Hooshmand H. Chronic pain: reflex
sympathy dystrophy, prevention and
management. Boca Raton,FL: CRS
Press:1993. p.33-35.
5. Nansel D, Szlazak M. Somatic dysfunction and the phenonena of viscral
disease simulation: a probale explanation for the apparent effectiveness
of somatic therapy in patients presumed to be suffering from visceral
disease. J Manipulative Physiol Ther
6. Cabell J. Sympathetically maintained
pain. In: Willis W. ed. Hyperalgesia and
allodynia. Raven Press. NY: 1992.
7. Patterson M. The spinal cord: participant in disorder. J Manipulative Physiol
Ther: 1993:9(3)2-11.
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Fall 2012
Despite a Recommendation for Surgery, A C6-7 Disc
Herniation Causing Arm Pain into the Fingers and
Upper Back, an Inability to Sleep, and Emotional Upset,
Relieved with Cox® Technic
Adjustments, Strokes and Errors
in Medicine
Continued from page 22
By Christopher Kent, DC, JD
or decades, in both Canada
and the United Stares, reports
have appeared in the popular
media suggesting that chiropractic
manipulation of the cervical spine is
associated with strokes. Some writers have suggested that such procedures be banned, or that patients
be informed of the possibility that
a stroke may follow an adjustment.
These allegations require a swift and
vigorous response.
A common error in logic is equating correlation with cause and effect. The fact that a temporal relationship exists between two events
does not mean that one caused the
other. As Keating (2) explained, “To
mistake temporal contiguity of two
phenomena for causation is a classic
fallacy of reasoning known as ‘post
hoc, ergo propter hoc,’ from the
Latin meaning ‘after this, therefore
caused by this.”
Consider the application of this
fallacy in the case of chiropractic
adjustments and strokes. Lee (3)
attempted to obtain an estimate of
how often practicing neurologists in
California encountered unexpected
strokes, myelopathies, or radiculopathies following chiropractic
manipulation. Neurologists were
asked the number of patients evaluated over the preceding two years
who suffered a neurologic complication within 24 hours of receiving a
chiropractic manipulation. Fifty-five
strokes were reported. The author
stated, “Patients, physicians, and
chiropractors should be aware of
the risk of neurologic complications associated with chiropractic
What’s wrong with this? Let’s
change “neurological complications”
to “automobile accidents.” Would
it be reasonable to suggest that if
55 patients over the last two years
had car accidents within 24 hours of
seeing a chiropractor that the D.C.
caused the accidents? Want to see
how absurd this can get? Change
neurologic complications to ice
cream consumption. Or sleep.
Is there anything that would either
strengthen or weaken a case of alleged causality? Yes.
We can compare the number of
times the event in question (in this
case, stroke) occurs as a random
event to the number of times the
event occurs following the putative
causative event (in this case, a chiropractic manipulation). In a letter to
the editor of JMPT, Myler (4) posed
an interesting question: “I was curious how the risk of fatal stroke after
cervical manipulation, placed at
0.00025% compared with the risk of
(fatal) stroke in the general population of the United States.” According
to data obtained from the National
Center for Health Statistics, the
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mortality rate from stroke was calculated to be 0.00057% If Myler’s data
is accurate, the risk of death from
stroke after cervical manipulation is
less than half the risk of fatal stroke
in the general population.
But is Myler’s data accurate? His
0.00025% figure is from a paper by
Dabbs and Lauretti (5). Their estimate is probably as good as any,
since the basis for it was a reasonably comprehensive review of literature. Jaskoviak (6) reported that
not a single case of vertebral artery
stroke occurred in approximately
five million cervical manipulations at
The National College of Chiropractic
Clinic from 1965 to 1980. Not one.
A study by Cassidy et al (6) was
described in the Canadian newspaper The Globe and Mail (7). The article, titled, “Chiropractors don’t raise
stroke risk, study says” reported
that “Researchers say patients are
no more likely to suffer a stroke following a visit to a chiropractor than
they would after stepping into their
family doctor’s office.”
The illusory concept of chiropractic manipulation and stroke should
be considered in the context of the
de facto standard for healthcare
safety—allopathic medicine. In an
article in the Journal of the American Medical Association, Kilo and
Larson (8) describe the real issues
surrounding our current healthcare
crisis. “On balance, the data remain
imprecise, and the benefits that US
health care currently deliver may
not outweigh the aggregate health
harm it imparts…it is time to address possibility of net health harm
by elucidating more fully aggregate
health benefits and harms of current
health care.” In a review of errors in
medicine, Leape (9) reported that if
the results of the papers reviewed
were applied to the U.S. as a whole,
“180,000 die each year partly as a
result of iatrogenic injury, the equivalent of three jumbo-jet crashes every
2 days.”
Even apparently innocuous diagnostic procedures can be lethal.
Myocardial infarction occurs in 1
out of 2,800 persons undergoing
treadmill exercise testing. One out
of 20,000 individuals will die as a
result of treadmill exercise testing
(10). Those with suspicious results
may undergo cardiac angiography,
a procedure with a mortality rate of
0.10% to 0.25%. This translates to 1
in 1,000 to 1 in 250 (11).
There is no scientific evidence
establishing a causal relationship
between stroke and chiropractic
1. Any attempt to mandate a disclosure of such a putative relationship constitutes consumer fraud.
2. While it is human nature to attempt to attribute a catastrophic
health event to a specific cause,
it must be remembered that the
mere fact that one event follows
another does not mean that one
caused the other.
3. Things more likely to occur than
a stroke following a chiropractic
• Being killed in a car accident
• Asteroid impact
Being struck by lightning
Drowning in a bathtub
Assault by a firearm See:
If chiropractors are to be required
to communicate to patients that a
cervical adjustment may cause a
stroke, then physicians, dentists, podiatrists, optometrists, beauticians,
barbers and plumbers should be
compelled to disclose to their clients
that visiting them may be followed
by a stroke, car accident, electrocution, a lightning strike, or asteroid
Despite this, attorneys continue to
file stroke-related lawsuits against
chiropractors, and muckrakers masquerading as journalists stir the
emotions of the populace. It is time
to replace yellow journalism with scientific investigation. Chiropractors
should respond swiftly and vigorously to these allegations.
1. Keating JC Jr: “Toward a Philosophy of
the Science of Chiropractic.” Stockton
Foundation for Chiropractic Research,
1992. Page 189.
2. Lee K: “Neurologic complications following chiropractic manipulation: a
survey of California neurologists.” Neurology 1995;45:1213.
3. Myler L: Letter to the editor. JMPT
4. Dabbs V, Lauretti WJ: “A risk assessment of cervical manipulation vs.
NSAIDS for the treatment of neck
pain.” JMPT 1995;18:530.
5. Jaskoviac P: “Complications arising from manipulation of the cervical
spine.” JMPT 1980;3:213.
6. Cassidy JD, Boyle E, Cote P, et al: of
Vertebrobasilar Stroke and Chiropractic
Care. Spine 2008;33(45):S176-S183.
7. Chiropractors don’t raise stroke risk,
study says”
8. Kilo CM, Larson EB: Exploring the
Harmful Effects or Health Care. JAMA
9. Leape L: “Error in medicine.” JAMA
10.Mildenberger VD, Kaltenbach M: “Lifethreatening complications of ergometry.” Fortschr Med 1989;107(27):569.
11.Jansson K, Fransson SG: “Mortality
related to coronary angiography.” Clin
Radiol 1996;51(12):85 8.
Dr. Christopher Kent is president
of the Foundation for Vertebral
Subluxation, co-founder of the
(CLA), and owner of On Purpose
Dr. Kent was named the ICA
“Chiropractic Researcher of the Year”
in 1991 and selected ICA “Chiropractor
of the Year” in 1998. He received Life
University’s first Lifetime Achievement
Award in 2007. He is former chair
of the United Nations NGO Health
Committee, the first chiropractor
elected to that office.
On December 21, 2011 the patient received his first Cox Decompression Adjustment of the cervical
spine, Protocol 1, along with electrical muscle stimulation and ice packs
at the cervicothoracic junction. The
patient tolerated the procedure well.
The patient had not been able to
obtain a full night sleep for a week.
In order to properly heal the patient
must also be able to rest and sleep.
He therefore was directed back to his
medical physician to seek some assistance so he can sleep. His physician
prescribed Tylenol with codeine on December 24, 2012, which allowed him
the ability to get a few hours of rest.
On this day I also changed the physiotherapy modalities to trigger point
ultrasound to the posterior cervical
spine and trapezius muscles.
On December 27, 2011 the patient had his fourth visit and related
that he was beginning to feel better.
The MRI report was received this
day and I discussed its findings with
the patient. Since the disc herniated
at C6-C7 was so large, compromising the central spinal canal and
right neuroforamen, I referred the
patient for a neurosurgical consult.
The patient was adamant that he
did not want surgery, and I informed
him that this was a prudent decision
in the event conservative care was
By January 3, 2012 the patient
described that he primarily had an
ache under his right shoulderblade
and slight numbness at the tips of
his right thumb, index finger and middle finger of his right hand. He was
now being adjusted using protocol 2
for the cervical spine on the Cox 7
Table head piece.
On January 9, 2012 the numbness
in the fingertips of his right hand was
easing up, he primarily felt a “deep
pain” into his right elbow.
On January 18, 2012 I performed
a re-examination, which revealed
that the LT/RT Shoulder Depressor
Tests and LT Maximal Cervical Compresion Tests were now negative.
The RT Maximal Cervical Compression Test was positive for cervicothoracic junction pain. The Seated
Dorsolumbar Circumduction Test was
essentially negative bilaterally. Using
a goniometer the cervical ranges of
motion were:
Anterior bending: 50 degrees.
Posterior bending: 45 degrees.
Left lateral bending: 35 degrees.
Right lateral bending: 30 degrees.
Left rotation: 50 degrees.
Right rotation: 50 degrees.
The deep tendon reflexes of the
Biceps, Triceps, Brachioradialis, and
Patella were +2 bilaterally. The left
Achilles was 0 the right Achilles was
+2. Using a Whartenberg Pinwheel
the right C7 and C8 dermatome
levels were reduced, all other derersary
nnivextremimatome levels of theth A
ties were noted to be within normal
The patient also noted that his
pain level was now a 4/10, describing that he felt 70% improved.
The patient saw the neurosurgeon
on January 20, 2012, who recommended surgical decompression
of C6-C7. The patient related that
he declined this suggestion and he
wanted to see if he would continue
to improve without surgical intervention. The neurosurgeon then recommended that he return in six weeks
for a follow-up visit.
Over the course of the next six
weeks I saw the patient 10 additional times with the patient making
continued positive progress. On February 24, 2012 he had his last visit
in my office with him stating that he
primarily has a tight sensation in his
neck, which is noticed primarily if he
sits poorly. He has no pain in his upper extremity and “no numbness in
his right hand to speak of.”
I present this case to highlight that
spinal decompression using the Cox
7 Table cervical spine headpiece may
be an effective tool in dealing with a
significant HNP. It is also important
to note that while the chiropractic approach to care is non drug and non
surgical, at times the appropriate use
of pain medication is essential in order
for the chiropractor to have the opportunity to care for the patient. This patient was in such extreme pain initially
that he was not sleeping, which ultimately inhibited the healing process,
and the patient’s ability to function.
With the assistance of the patient’s
primary care physician, a pain medication was prescribed allowing the
patient the opportunity to sleep and
undergo a non surgical decompression
protocol, thereby avoiding surgery.
Respectfully submitted,
Joseph C. D’Angiolillo, D.C.
Legal Q & A
Continued from page 21
the specific facts involved. Given the
changing nature of laws, rules and
regulations, there may be omissions or
inaccuracies in information contained
in these materials. Accordingly, the
information you receive is provided
with the understanding that the
author and the A.N.J.C. are not
herein engaged in rendering legal,
accounting, tax, healthcare or other
professional advice and services nor
are they providing specific advice
with regard to your practice, the
treatment of any specific illness,
disease, deformity or condition, or
any other matter that affects trade,
commerce, or legal rights of others.
As such, this article should not be
used as a substitute for consultation
with professional accounting, tax,
legal, healthcare, or other competent
advisers. Before making any decision
or taking any action, you should
consult an appropriately trained
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References for the published peer-reviewed scientific research papers:
1. National Board of Chiropractic Examiners. 2005. 5. Cambron, JA. JMPT May 2011 (Vol. 34, Issue 4, Pages 254-260)
2. Stude DE. JMPT 23 (3) April 2000
6. Zhang, J. J of Chiropractic Medicine June 2007 6:2, 56-65
3. Stude DE. JMPT 1997; 20(9):590-601.
7. Jensen B. J Chiro Ed 2007; 21(1):109
4. Stude DE. JMPT 2001; 24(4):279-287
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Fall 2012
When It Comes to Over-Utilization,
What Do Carriers Expect?
By David Klein, CPC, CHC – ANJC Insurance Consultant
assive care, or care where
the patient passively receives
treatment, is something that
all chiropractic offices provide to their
patients. Electric muscle stimulation, ultrasound, manual therapy, and
mechanical traction are examples of
this type of care. It has become more
common, however, that much of this
type of treatment is being denied
by third party payers as inclusive to
another therapy or entirely denied as
a non-covered service. This trend is
beginning to frustrate and concern
many providers all over the country.
Why are they denying this type of
care for patients? In many cases the
CPT codes in question are not mutually exclusive or component codes
and should be separately reimbursable. The most obvious answer is that
the insurance companies are looking
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The New Jersey Chiropractor is a bimonthly publication of the Association of New Jersey Chiropractors.
To assist with the many challenges of everyday practice, it is filled with updates and extraordinary
ideas from our profession’s best and brightest minds and serves as a leading information resource for
the more than 3000 chiropractors located throughout the Garden State. We hope you enjoy ANJC’s
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ANJC Leadership
ANJC Elected Officials
• Dr. Joseph D’Angiolillo
• Dr. Michael Kirk
Vice President
• Dr. Jim Campbell
2nd Vice President
Executive Director
• Dr. Sigmund Miller
ANJC Appointed Officials
• Dr. Richard Healy
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Editorial Assistant
Immediate Past President
• Dr. Steven Clarke
ANJC State Board Members
Dr. Bob Blozen
Dr. James Campbell
Dr. Joseph D’Angilillo
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Dr. Barry Coniglio
Dr. Michael Kirk
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Legal Advisory
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Sports Council
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Joe Garolis
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Research Consultant
for ways to cut costs and removing a
benefit for a particular service from
a specific health plan offered to its
clients is an easy cost saving measure. While I believe that this is a significant contributing factor, there are
most certainly other issues involved,
the most likely being over-utilization.
I have performed hundreds of audits over the last 20 years, and have
found that over-utilization of services,
especially when it comes to passive
modalities, without supporting documentation, is one of the most common negative findings.
So ask yourself, how often and
when can I perform these services
on my patient? How do I justify my
care? Many payers stress that treatment consisting of passive care for
extended periods of time is palliative and thought to foster chronicity.
Generally, a transition to active care
is expected within 1-4 weeks. Using Landmark’s medical policy as an
example, providers can get a feeling
for what payers may view as within
normal guidelines, as follows:
“Passive Care - Application of
treatment/care modalities by
the practitioner to a patient, who
“passively” receives care. The
patient receives treatment from
the caregiver rather than actively
participating in the treatment process (see active care).”
The policies comments on Active
Therapeutic Treatment:
“Only medically necessary care
that is active and therapeutic,
with the expectation of symptom
resolution and/or maximum therapeutic benefit within a reasonable
period of time is eligible for acupuncture and chiropractic coverage. All other forms of care are
considered palliative and/or are
given to promote optimal function
and are not considered medically
Aetna’s clinical policies get even
more specific when it comes to services provided, for example:
“Massage therapy is not considered medically necessary for
prolonged periods and should
be limited to the initial or acute
phase of an injury or illness (i.e.,
an initial 2-week period).”
And another example:
“Ultrasound — Deep heat by high
frequency sound waves to relieve
pain, improve healing — constant
attendance. This modality is considered medically necessary to
treat arthritis, inflammation of periarticular structures, neuromas, and
to soften adhesive scars. Standard
treatment is 3-4 treatments per
week for one month.”
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Based on the above examples,
providers can get a glimpse into what
many insurance companies adopt as
acceptable treatment parameters.
If care consistently falls outside
of these norms, then the provider
should know that their profile could
be affected. They must be sure to
clearly document the rationale supporting the necessity of treatment or
provide some sort of clinical research
backing up treatment that falls outside the norms.
Denials from third party payers
may be a fact of life. However, there
are a few ways to help limit the denials, and if they occur, help you to effectively appeal the denial:
1. Create an effective treatment
plan and follow it; update as
2. Know the coding rules, and when
to properly use modifiers.
3. Limit passive care for extended
periods of time without proper
4. Document everything and make
sure to tell the story.
5. Make sure to show functional
improvement and outcomes
6. When maximum improvement (MI)
is reached discharge the patient
or transition to wellness care.
In summary, over-utilization of services is a common but easily avoidable problem. By following the above
guidelines, chiropractors can effectively avoid over-utilization and limit
costly denials. When providers have
a better understanding of what insurance companies are looking for, they
can begin to combat unnecessary denials and audits and still provide the
care that their patients need.
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