Download Summer 2012

Summer 2012
Publication of the Association of New Jersey Chiropractors
www.anjc.info
Volume 8 Number 3
Coding Advisory Regarding
Modifier -51 and Proper
Use with CMT Codes
By David Klein, CPC, CHC – ANJC Insurance Consultant
On June 12 th, 2012, under the leadership of David Klein, CPC, CHC, ANJC’s Insurance
Consultant and founder of DK Coding & Compliance, along with five other national coding
experts composed this letter to OptumHealth regarding the -51 Modifier issue.
Introduction:
This Medical Coding Advisory has been collectively produced by Certified
Professional Coders with combined decades of experience specifically in reporting chiropractic and physical medicine services. The issue at hand is that
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Re: TRIAD/AETNA Update
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Big Changes Already in Place…
ANJC’s Medicare Consultant, Dr. Richard Healy, just
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Become an ANJC Member to receive
links to recordings.
ANJC Launching Dept. of Transportation
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On the Sidelines No More!
Dr. Steve Clarke — page 4
Dear ANJC Colleagues:
Several months ago, AETNA sent chiropractic practitioners throughout New Jersey
a letter stating that TRIAD Healthcare would
have greater involvement in the handling of
chiropractic medical necessity issues for AETNA policyholders. The letter was vague, not
specific with full details and gave a limited
understanding of exactly what steps AETNA/
TRIAD were implementing so doctors could
decide whether it was in the best interests of
their patients or themselves to stay in or out
of network.
As the volume of angry calls made by members to ANJC headquarters steadily increased,
ANJC leadership requested a conference call
with TRIAD and AETNA to gather additional information on the specifics of the program and
how it would impact patients as well as practitioners. When many doctors read TRIAD’s
letters and then called AETNA directly, they
reported receiving conflicting and inaccurate
information causing many to become even
more angered and confused.
We have received information that this
confusion has led to many doctors fleeing the
Continued on Page 21
For more info contact HQ…
Association of New Jersey Chiropractors
3121 Route 22 East Suite 302
Branchburg, NJ 08876 • U.S.A.
Continued on Page 4
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ANJC Fall Convention
Hilton East Brunswick
Oct. 27 & 28
See page 12
for more info
ANJC Executive Director Addresses
Disabled Vets Convention
— page 12
Association of NJ Chiropractors Hosts
Successful Spring Convention
— page 13
Inflammation: Friend and Foe
Dr. Van Merkle — page 17
Letter on Supreme Court Decision
Dr. Joseph D’Angiolillo — page 17
Easy Way to Add Nutrition to Treat
Patient’s Pain
Dr. David R. Seaman — page 18
Patient Centered Care: Clarification and
Application
Dr. Jeffrey Sklar — page 20
Featured Articles
From the President’s Desk.. 3
ChiroAssist......................... 6
Sports Shorts................... 10
Risky Business................. 15
Foot Loose....................... 16
Research Updates........... 19
PR Update.......................... 19
Q & A Legal...................... 20
Q & A PIP.......................... 22
Q & A Medicare................ 22
Q & A Insurance............... 23
Legal Ease........................ 23
With the New Doctor in Mind....
☛
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Page 16
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Summer 2012 www.anjc.info
www.njchiropractors.com
NeW
By Dr. Joe D’Angiolillo
Strictly by the Numbers
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A
s a physician you make many
decisions. Some relate to patient care. Do I take an x-ray?
Order an MRI? Refer the patient out?
Adjust the patient’s cervical spine?
Some decisions relate to basic office protocols and procedures. Is the
wall color appealing to my patient
base, are the chairs comfortable, are
the CAs courteous on the phone, do
we need to order more supplies, etc.
These decisions are made within a
short period of time, some within seconds, and others within days. Rarely
do you second guess your decisions,
you generally feel comfortable with
the choices you’ve made.
At times some decisions feel like
you have no control. You fret and
fume wondering for weeks and in
some instances for months if you
have arrived at the right conclusion.
Some do nothing thinking that you
can’t make a choice, when in reality
doing nothing is a decision.
I give this little run down as a
means to frame one of the most
common requests we get from the
membership. It goes like this: an insurance company sets an extremely
low in-network rate, you feel like you
have no option but to accept it, and
you contact the ANJC for an opinion.
While neither the ANJC or I can tell
you to accept a contract or reject
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information for you so you can make
an educated decision. A decision in
this regard will determine not only
the health of your business, but also
the health of your employees. For if
you have stress relating to reimbursement it will spill over to how you interact with your employees, patients
and family.
Let’s get one thing straight: while
you are a doctor caring for the health
and welfare of your patients, you are
also a business owner who needs
to care for the health and welfare
of your business. While this may be
uncomfortable for many of you to accept, the purpose of a business is
to make a profit. You cannot make a
profit if the reimbursement level of
an insurance company’s fee schedule
is at or close to your cost of doing
business.
I am sorry if I am boring our more
seasoned providers, but there seems
to be a real need to go through this
simple exercise.
A basic way to calculate what it
costs you to see a patient is to take
all of your expenses, salaries, rent,
taxes, utilities, insurance, supplies,
loan payments, etc. This should be
relatively easy as you have just filed
your income taxes a few months ago
for 2011. Take this number and di-
vide it by the number of patient visits
you had for the entire year. What you
are left with is what it costs you to
have a patient walk through the door
and lay down on an adjusting table.
The difference between this number
and what an insurance company fee
schedule pays is the amount of profit
you are making per visit. Now is this
profit enough to give you the lifestyle
you deserve? If it is, great! If not, the
answer is obvious.
Once you look at the numbers you
will be able to make a sound business decision.
During our fall convention the
ANJC will be having a session on
how to read a contract as part of
our business development series of
programs. I look forward to seeing all
of you in October in East Brunswick.
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4
Summer 2012 www.anjc.info
www.njchiropractors.com
Dr. Steve Clarke,
ANJC Legislative Chair
On the Sidelines No More!
F
or years the chiropractic profession looked to the legislators
for assistance to protect and
advance the profession and for years,
we received nothing but lip service
with virtually no legislative victories.
A chiropractor in one area of the
state would have a legislative contact
and attend a few fundraisers. Another
DC in a different area of the state
would buy a ticket to another legislator friend, yet there never was a cohesive effort to meld together all the
contacts for the benefit of the entire
profession—until recently.
More and more in Trenton, our
presence has changed from being
mere spectators on the sidelines to
becoming game players on the field.
Legislators now come up to us, ask
what our thoughts are on a particular
bill and work closely with the chiropractic profession both out front as
well as behind the scenes. Sometimes we need to move offensively
on a bill while at other times we need
to work defensively. Strategically, we
sometimes take a neutral position
and just observe closely and monitor
a situation.
The foundation of our profession’s
surprising rise and success has come
from straightforward honest debate,
negotiations and compromise with
other professions as well as the legislators. They know when we come
in we are prepared with our facts, we
do not act emotionally but thoughtfully and rationally. In a political world
known for half-truths and spin, we
always stay focused and truthful and
for many in Trenton, it is a welcome
breath of fresh air.
There is a saying in politics that
two things you never want to see
made are sausage and legislation and
that may very well be true, but staying on top of legislation is vitally important to protecting what rightfully
belongs to our profession, as well as
advancing the profession to keep up
with modern day changes.
As we track the multitude of bills
that might impact our profession in
some way, you can be assured that
ANJC will work to keep the profession strong here in New Jersey and
protect the interests of all of our patients and doctors.
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Coding Advisory
Regarding
Modifier -51
and Proper Use
with CMT Codes
Continued from page 1
OptumHealth has been denying the
reimbursement of claims with CPT
code 98943 for Extraspinal CMT,
when 98943 was reported with a
CPT code for Spinal CMT (9894042) at the same encounter. They
are denying the reimbursement for
the extraspinal service and requiring
providers to now affix modifier -51 to
indicate “multiple procedures”. When
a provider complies, the carrier then
reduces the reimbursement of the
extraspinal service by 50%, invoking
the CMS standard payment adjustment rule for multiple procedures.
Optum has also published this policy
online, and is now applying this
policy to all claim submissions, both
in and out of network.
We know that the CPT codes are
organized and listed by the AMA in
a particular fashion so that, when
deemed significant, they indicate a
relationship between similar procedures. The CPT modifiers have been
created to report certain specific
conditions or extenuating circumstances to certain services and
procedures. According to the AMA
CPT Manual, modifier -51 for Multiple Procedures was established as
a designation for providers to report,
when more than one service was
performed, and performing multiple
services had some significant affect
or modifying factor on any one (or
more) of the services in question.
Overview of Our Rationale:
The AMA intentionally publishes
the CPT Manual in an abbreviated
format as a tool for efficient coding.
For further clarification, the AMA
publishes more detailed guides for a
variety of topics in order to further
explain and instruct on proper coding,
often including examples, history, and
vignettes. These publications include
the AMA CPT Assistant, E/M Documentation Guidelines, and similar
more detailed coding guides. Notably,
the AMA publishes a guide specifically for modifiers entitled “Coding
with Modifiers: A Guide to Correct
CPT and HCPCS Level II Modifier Usage (2011 Fourth Edition).”
In this specific guide for correct
and proper use of modifiers published
by the AMA, there is a reasonable
explanation of the intention behind
the modifier -51. The AMA discusses
the concept of some primary procedures or services taking precedence
in terms of work, and more specifically in terms of Relative Value Units
(RVU). A certain value is placed on a
variety of circumstances and factors
surrounding a service or procedure,
and a specific formula is used to arrive at that service or procedure’s
financial worth, or RVU. The concept of the -51 modifier evolved to
address the fact that a number of
significant circumstances or factors
may overlap or be notably reduced
when multiple services or procedures
are performed at the same patient
encounter. When this occurs, one
procedure can be determined to be
a primary procedure while any one
or more of the other services may be
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6
Summer 2012 www.anjc.info
www.njchiropractors.com
By Kathy Mills Chang, MCS-P
A Policy a Day Keeps the
Uncollectable Balances Away!
I
deally, we will collect all monies
due from patients and third party
carriers without any stragglers—
those patients that elude making payments and EOBs that arrive without
the anticipated checks attached. But
welcome to the real world! We render
services in good faith and establish
that covenant of the doctor patient
relationship based on the ethical
foundations of respect and trust,
but sometimes a patient takes all of
your services and leaves you without
paying or with a balance on their account. Likewise, it’s disconcerting
when a carrier questions the services
you provide, restricts your treatment
plans, and then reduces payment
assuming you’ll agree to the lesser
amounts. This conundrum occurs in
nearly every office, but what sets the
most advanced offices apart is how
they deal with these issues by referencing policies in place to mitigate
the frequency of occurrences.
Why is it that some patients will
promptly pay after receiving a statement while others will ignore repeated
requests or become defensive and
argumentative when a past due balance is brought to their attention?
We’ve all heard the familiar phrases:
1) I was told my insurance was going
to cover everything; 2) When I called
the insurance company they told me
you billed the wrong codes, can you
send it in again?; 3) I left my checkbook at home; 4) Can I pay you next
month?; 5) Can you send the bill to my
husband’s office, to my mother, father,
etc.? In the meantime, many practices continue to book appointments
for these patients, provide them with
services and supplies, comply with
their requests to fill out paperwork
and forms, all the while watching as
their balances continue to increase.
These types of scenarios will continue
unabated until you establish firm collection policies in your practice.
Activation of your office financial
procedures should begin prior to the
first patient appointment. Gather all
patient and insurance information
and obtain benefit details before the
patient arrives to see the doctor. Explain your office financial policies on
the first appointment, helping the patient to know how we do it here. An
effective office financial policy should
also explain your collection policies
and how your office will handle past
due accounts. If your office has yet to
create a system to handle delinquent
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accounts, it is time to establish collection guidelines.
Here are some important considerations that should be explained in
your office financial policy:
• The amount of time elapsed from
an initial patient statement until it
is turned over for in-house collection procedures (e.g., phone calls
requesting payment, payment
plans, etc.)
• If you will access finance charges
to past due balances
• If you are able to add administrative fees (note: some insurance
contracts do not allow a physician
to charge administrative fees)
• If you offer a discount plan, like
ChiroHealthUSA
• If you offer a hardship program
• When to use an outside collection
agency
• When to use small claims court
• If and when to discontinue services when the patient has not paid
If you find yourself behind the eight
ball with an outstanding balance for a
patient, although you are not technically going to deny a patient’s needed
care, you may elect to offer them a
choice of paying the balance, or a large
portion thereof, or the option of finding
another doctor. Note: denying care to
someone with a true medical emergency could warrant a malpractice suit.
In addition, make sure any office
collection policies you establish are
in compliance with federal and state
collection laws. The Fair Debt Collection Practices dictates:
• Collection calls to patients cannot
be made before 8:00 A.M. or after
9:00 P.M.
• Never make any threats
• Do not use any form of deception
• Do not discuss the patient’s debt
with anyone else
The Telephone Consumer Protection Act prohibits:
• The use of an automated dialing
device for calls to patients
Because a patient’s insurance is
also a part of TPO (treatment, payment, or healthcare operations),
there are some offices who elect to
notify the patient’s insurance carrier
when the patient has failed to pay
their deductibles, co-pays and coinsurance amounts. The patient has
signed a health insurance contract
with their carrier and is therefore
obliged to meet their financial responsibilities toward healthcare costs.
Although there is little if anything a
carrier will do, a copy of the below
letter sent to both the carrier and the
patient will sometimes motivate the
patient to pay the balance due.
Date
ABC Insurance
PO Box 123
Jacksonville, FL 123456
■
www.kmedsupplies.com 800.243.2603
■
RE: Patient Name
ID #: 123456789
DOS: June 4, 2012
Dear ABC Insurance:
Be Confident Your
Nutritional Protocols are
This Complete
The above referenced claim required the patient to pay their deductible and/or co-insurance in the
amount of $120.00, per the terms
of your health insurance contract
with the policy holder. After sending
numerous statements and letters to
your policy holder, they have failed to
pay that amount on the above referenced claim for the dates of service
from _____ to _______.
Nutrients within foods work synergistically
to support the complexity of the body.
It is our understanding that failure
to pay the co-insurance and/or the
deductible amounts, as in this case,
can result in the cancellation of the
policy, per the terms of the policy.
Please feel free to contact this office should you wish to confirm the
non-payment of your policy holder.
Over 200 Known Nutrients and Phytonutrients are Found in Carrot Root,
Just One of the 15 Whole Food Ingredients in Catalyn
Sincerely,
Office Manager
Office/Doctor Name
Cc: Patient Name
Keep in mind also that a patient’s
financial situation may change during a
course of care (e.g., the loss of a job, divorce, etc.), and payment arrangements
might need to be altered for the continuation of treatment. When documenting financial hardship, be sure to obtain
from the patient their tax returns, W2s,
1099s, as well as assets and household expenses, and keep a record of
any fees (co-pays, co-insurance and
deductibles) that are waived.
It makes no sense to continually
send patient statements out month
after month without collection policies in place on how to handle delinquent accounts. As insurance carriers
shift more of the costs of healthcare
onto patients in the form of higher copays, higher co-insurance and higher
deductible amounts, these payments
in turn become a higher percentage
of your annual income. If you want
to succeed in your collection efforts,
make sure your patients understand
and know their financial obligations
and that your office is serious about
the collection process.
Reference:
Fair Debt Collection Practices
http://www.ftc.gov/os/statutes/fdcpa/
fdcpact.shtm
The Telephone Consumer Protection Act
http://transition.fcc.gov/cgb/policy/
TCPA-Rules.pdf
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ALPHA-PINENE
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ALPHA-TERPINEOL
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ANILINE
ARABINOSIDE
ARGININE
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BENZYLAMINE
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BETA-AMYRIN
BETA-BISABOLENE
BETA-CAROTENE
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BETA-FARNESENE
BETA-PINENE
BETA-SITOSTEROL
BETAINE
BIPHENYL
BORNEOL
–––––––
Kathy Mills Chang is a Certified
Medical Compliance Specialist and
provides chiropractors with training,
reimbursement and compliance advice
and tools to improve the financial
performance of their practices. In
2007, KMC University was created to
streamline, develop and offer a broader
range of chiropractic solutions in the
areas of coding, insurance, patient
financial procedures, Medicare and
compliance. For more info call 888-6598777 or email [email protected].
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LYSINE
MAGNESIUM
MALIC-ACID
MALTOSE
MALVIDIN-3,5-DIGLUCOSIDE
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METHIONINE
METHYLAMINE
MEVALONIC-ACID
MOLYBDENUM
MUFA
MYRISTIC-ACID
MYRISTICIN
N-METHYL-ANILINE
N-METHYL-BENZYLAMINE
N-METHYL-PHENETHYLAMINE
NEUROSPORENE
NIACIN (B)
NICKEL
NITROGEN
NON-2-EN-1-AL
NONAN-1-AL
NOPOL
OCTAN-1-AL
OLEIC-ACID
OSTHOLE
OXALIC-ACID
OXYPEUCEDANIN
P-COUMARIC-ACID
P-CYMENE
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PUFA
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RHAMNOSE
RIBOFLAVIN (B)
RUBIDIUM
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SELENIUM
SERINE
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SHIKIMIC-ACID
SILICON
SODIUM
STARCH
STEARIC-ACID
STIGMASTEROL
STRONTIUM
SUBERIN
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THREONINE
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TYROSINE
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VITAMIN K
WATER
XANTHOPHYLLS
XANTHOTOXIN
XYLITOL
XYLOSE
ZINC
ZIRCONIUM
Visit standardprocess.com/wholefoods
or call 800-558-8740 and ask for our
Why Whole Food Supplements Kit.
Whole Food Supplements Since 1929
w w w. s ta n d a rd p ro c e s s.c o m
*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.
WWF 9.75” x 15.75.indd 1
©2010 Standard Process Inc. All rights reserved.
6/8/10 11:01 AM
8
Summer 2012 www.anjc.info
www.njchiropractors.com
ANJC Platinum
Sponsors Directory
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
buying from ANJC Platinum Sponsors, you are supporting ANJC, it’s that simple!
Billing/Coding & Collections
✦ LiteCure Medical • Gioacchina Randazzo
302.709.0408 • [email protected]
www.litecuremedical.com
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.
Summer 2012 www.anjc.info
www.njchiropractors.com
ANJC Platinum Sponsors Directory
Continued from page 8
✦ The Rothenberg Group • Jess Rothenberg, DC
973.694.1981 • www.jrapip.com
[email protected]
Description: Assist doctors with collection services and advice for auto accident
patients.
Medical/Clinical Services
✦ CB&C Inc. • Lynette Contreni
973.827.3544 • [email protected]
Description: Specializing in Chiropractic, CB&C offers consulting, training and a full range of Billing/
Collections services, which are tailored to your
needs. Also, we offer a verifications department
which assists your office in obtaining maximum
reimbursement, & handling contracts.
✦ EClaims, Inc. • Kristi Andarews
888.576.0800 • www.zyantus.com
[email protected]
Description: With EClaims OS from Zyantus, you
will experience electronic insurance claims processing that is easy, efficient and economical.
With firsthand experience in electronic claims we
have created a solution to claims processing that
is compatible with many forms of technology and
current with today’s government requirements.
✦ MD On-Line • Tom Schweizer
888.499.5465 • www.mdon-line.com
[email protected]
Description: Provide clearinghouse services to
facilitate the electronic transfer of healthcare
transactions and information between providers
and payers.
Business/Financial Services
✦ C&A Financial Group • Robert Pendergist V.P.
732.528.4800 • [email protected]
www.CA-Strategy.com
Description: A full service financial firm focused
on cash flow and quality of life. Key products and
services: Business succession planning, disability
overhead, life insurance, stock and bonds, mutual
funds, commercial mortgages long term care etc.
We also provide exit strategies in and around business ownership.
✦ Chiro Finishing School • Ashleigh Mooney
214.954.0302 • [email protected]
www.chirofinishingschool.com
Description: Chiro Business Finishing School
teaches chiropractors to implement “The 12 Foundational Principles of Business.” These principles
help chiropractors leverage their time and grow
their revenue.
✦ Cooperative Communications, Inc • Lou Lombardi
800.833.2700 • [email protected]
www.cooperativenet.com
Description: Cooperative provides Telecommunication and internet services to businesses. We
specialize in competitively-prices voice, data, equipment, telephone systems (hosted and non-hosted)
and cellular services.
✦ David Lerner Associates • Bill Stolow
609.806.2734 • www.davidlerner.com
[email protected]
Description: Building and preserving assets for 35
years with a conservative investment philosophy
offering income producing securities and avoiding
the money pitfalls of the stock market. Key Products: Municipal Bonds, Real Estate Investment
Trusts, and Insurance Products.
✦ Guardian Life Insurance Company
Anthony Campanile • 609.709.0041
www.planningalliance.com
[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. www.margfinancial.com.
✦ The Omar Group, CPA • Salim Omar, CPA
732.566.3660 • www.omargroupcpa.com
[email protected]
Description: Specializing in providing accounting
and tax services to chiropractic practice owners.
Chiropractic Equipment/Supplies & Patient Education
✦ Bio Posture • Thomas Williams
888.642.4800 • [email protected]
www.bioposture.com
Description: Comprehensive green Bio Memory
foam mattresses pillows available exclusively thru
DC’s and related healthcare professionals.
✦ BIOFREEZE®/Performance Health
800.246.3733 • www.biofreeze.com
www.thera-band.com • health@ biofreeze.com
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]
www.chirosquad.com
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.
✦ ChiroHCG. • Frank Zoletich
877.377.7636 • [email protected]
www.chirohcg.com
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 • www.chiromatic.com
[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
www.subluxation.com • [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 • www.erchonia.com
[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 • www.footlevelers.com
[email protected]
Description: Exclusive provider of custom-made
Spinal Pelvic Stabilizers and other healthcare
products.
✦ Harlan Health Products, Inc. • Harlan Pyes
800.345.1124 • www.harlanhealth.com
[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 • www.kmedsupplies.com
[email protected]
Description: Full-service chiropractic supply and
equipment company.
✦ Levinson Medical Specialties • Charles Levinson
732.928.4600 • www.charleslevinson.com
[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]
www.patientmedia.com
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]
www.scriphessco.com
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 • www.thevitalitydepot.com
[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.
X-Ray, Diagnostic Imaging Services & Equipment
✦ Digital Radiographic Equipment, Inc.
Allan J. Rubert • 610.385.0722
[email protected] • www.drei.xray.com
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.
✦ Spinal Kinetics, LLC
Dr. Bill Puglisi • 908.687.2552
[email protected]
www.spinal-kinetics.com
Description: The most advanced Computerized
Radiographic Mensuration Analysis that helps
prove subluxation, objectively and accurately.
Key Products: C.R.M.A., DMX, and Free Lectures
and education
✦ Stat Imaging @ RiverWinds • Joseph Jarrett
856.251.9100 • www.statimaging.com
[email protected]
Description: We offer High Field Open MRI and XRay Services. 24 turn around time for reports and
Same Day Appointments and STAT Reads.
✦ Tilton Dynamic Imaging • Norm Brettler
609.383.2400 • www.tiltondynamicimaging.com
[email protected]
Description: Our company features the Upright
MRI. 2nd location: Ocean Upright MRI 864 Rt. 37
West Toms River, NJ 732-240-2772
✦ Upright MRI of Cherry Hill • Marge Beck
856.486.9000 • www.uprightmriofcherryhill.com
[email protected]
Description: At Upright MRI of Cherry Hill, patients can be scanned weight bearing, seated,
standing, bending or lying down to permit the
best visualization possible of their problem.
Key Products: MRI Scans
Nutrition & Wellness
✦ Anabolic Laboratories • Bob Rosenberg
Clinical Consultant • 609.239.0358
www.anaboliclabs.com • [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 • www.bioticsresearch.com
[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.
✦ Future of Health Care, Inc. • Rick Ercolano
609.978.7890 • www.fohcwater.com and
www.fohcwater1.com
Description: Wellness workshops designed to specifically increase your patient base. Key product:
Kangen Restructured Alkalized Ionized Water.
✦ Health Centers of the Future
Warren Philips Practice Building
888.600.0642 • [email protected]
www.healthcentersofthefuture.com
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 • www.metagenics.com
[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 http://www.metagenics.com. 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 • www.nutriwest.com
[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.
✦ Science Based Nutrition. • Dr. Van Merkle
937.433.3140 • [email protected]
www.nutritionpracticebuilder.com
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]
www.standardprocess.com
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 • www.vervitaproducts.com
[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]
www.xymogen.com • 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
888.744.9494 • [email protected]
www.sterlinglaboratory.com
Description: NeuroScience, Inc. is a researchdriven company committed to improving human
health through a deep understanding of the interconnectedness of the neurological, endocrine, and
immune system. Key products and services: Neurotransmitter Testing, Neuro-Endo-Immune related
products, Immunological testing, Adrenal and sex
hormone testing.
✦ Sterling Clinical Laboratories Inc. • Naveed Aschfaq 215.741.6000 • [email protected]
www.sterlinglaboratory.com
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 • www.mybreakthrough.com
[email protected]
Description: Chiropractic Consulting services.
✦ ChiroHealth USA • Ray Foxworth, DC
888.719.9990 • www.chirohealthusa.com
[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 • www.kmcuniversity.com
[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 • www.positiveimpactcoaching.com
[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 • www.targetcoding.com
[email protected]
Description: Experts in helping chiropractors
document properly, get paid properly and in audit
prevention.
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.
9
✦ Advanced Center for Special Surgery –
Montville Health • Dr. David Saint
201.391.8282 • www.montvalehealth.com
[email protected]
Description: A freestanding state of the art
licensed multi-specialty ambulatory surgical
center offering a wide range of out-patient
surgical procedures
✦ 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.
✦ Cancer Treatment Centers of America
Rocco DeCicco • 215.537.7503
www.cancercenter.com
[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
www.spineandjointcenter.com.com
[email protected]
Description: A health clinic focusing on pain
management and minimally invasive procedures to help patients with orthopedic and
spinal disorders.
✦ Mountainside Pain Management
Philip Lutz, MD • 973.226.1230
www.montclairanesthesia.com
[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).
✦ Union Anesthesia & Pain Management
Julia Kovach • 908.851.7161
www.unionspinepain.com
[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.
Insurance Services/Risk Management
✦ Allstate Insurance Company
Bernadette Wanczyk • 800.512.9470
www.allstate.com
[email protected]
Description: Allstate offers ANJC members
discounted and enhanced commercial auto,
business owner’s policies and in-home business
insurance. Please contact Bernadette Wanczyk.
✦ John C. Crilly Agency • John C. Crilly
732.747.7947 • www.crilly.biz
[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.
✦ OUM Chiropractor Program • Tamara Jackson
888.247.3522 • [email protected]
www.oumchiropractor.com
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
Legal Services
✦ Davis, Saperstein & Salomon, PC
Garry Salomon • 201.907.5000
[email protected] • www.dsslaw.com
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
healthcare.
✦ 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]
www.njpiprecovery.com
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]
www.pondlehocky.com
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
Pondlehocky.com.
Educational Institutions
✦ Bloomfield College • Dr. Alice Ann Sayler
973.748.9000 • [email protected]
www.bloomfield.edu
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.
Software – Practice Management
✦ Cash Practice, Inc. • Dr. Margie Smith
877.343.8950 x220 • www.cashpractice.com
[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.
✦ Digital Data Resources • Dr. Robert Sellari
973.625.3716 • www.DDRProfile.com
[email protected]
Description: Profile Deluxe is a complete chiropractic paperless office solution which operates on a “cloud computing” environment.
✦ Life Systems Software
Paul B. Bindell, DC, or Avi Bindell
973.625.3716 • www.LifeSystemsSoftware.com
[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
✦ 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.
✦ PayDC • David Klein
888.306.1256 • [email protected]
www.paydc.com
Description: PayDC is a fully integrated EHR
solution designed to manage your practice and
the entire course of patient care.
✦ NCMIC • Mike Whitmer
800.321.7015 • [email protected]
www.ncmic.com
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.
✦ Quick Notes • Ken Schenley
800.899.2468 • www.qnotes.com
[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.
Silver
Sponsorship
Directory
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]
www.anaboliclabs.com
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]
www.cancercenter.com
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, naturopathy, psychological counseling, physical
therapy and spiritual support to meet the
special, whole-person needs of advancedstage 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]
www.chirosquad.com
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]
www.healthcentersofthefuture.com
Description: Our events infuse cutting
edge testing and support protocols for
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system. Key products and services: Food
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Bruce Poritzsky • 518-226-0197
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based, Herbal Supplements, Education.
Sterling Clinical Laboratory
Naveed Ashfaq • 215-741-6000
[email protected]
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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.
XYMOGEN
Jennifer Watters • 407-445-0203
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Description: Wellness and Nutrition Integration Programs-Clinical Research,
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Summer 2012 www.anjc.info
www.njchiropractors.com
TIME
JUST IN
10
Subacromial Bursitis: Causes,
Treatment and Prevention
By Dr. Christine A. Foss
R
ecent research shows that
shoulder pain constitutes
roughly 16% of all musculoskeletal injuries. This makes it the
third most common musculoskeletal
disorder next only to low back and
neck pain. Because of this fact, it is
imperative for the practitioner to be
well equipped to handle etiologies
of the shoulder and have an acute
awareness of the success and failures of rehabilitation protocols.
In the shoulder there are a number
of bursa that can be causative agents
of shoulder pain (see diagram).
We know that the function of the
bursa is to reduce friction, whether
it be between two bony structures or
between tendon or bone. We can also
say then that inflammation of a tendon
or repetitive friction over the bursa will
cause it to be inflamed. Understanding
this very basic concept will make your
diagnosis as well as treatment regime
much more appropriate.
Due to its anatomical location, the
subacromial bursa is most commonly
affected with repetitive motion activities. Considering this during examination will help delineate causative
activities, motions or glenohumeral
inadequacies. The subacromial bursa
is located between the acromion
process and the humeral head and is
intimately involved with the normal
function of the rotator cuff. Diagnosis of shoulder bursitis is done using
Dawburn’s test, which is basically palpating the subacromial bursa for pain
and a painful arch of motion in the
first and last third of shoulder flexion.
However, a thorough evaluation of all
the shoulder structures is imperative.
You need to know why this bursa is
inflamed. Possible causative factors
are: bicipital tendonitis, impingement
syndrome, torn rotator cuff, shoulder
inflexibility, and lastly, repetitive motion with poor ergonomics.
Treatment of an athlete with bursitis consists first of decreasing the
activity in practice that is causing the
irritation. Remember cross training is
the key for any athlete so be creative.
Electrical muscle stimulation, laser
and cryotherapy treatment three times
per day is also imperative. Although
some of the literature does point to
heat application as a good treatment,
I have found that ice is the quickest
way to heal these patients. The most
important aspect of treatment howev-
Summer/Fall 2012
er, is to address the biomechanical insufficiency that is causing the bursitis.
This will begin slowly during the acute
phase but really take full action once
the acute phase has passed, which
should be no longer than 5-7 days.
As you correct the biomechanical or
structural inadequacies of the shoulder the athlete will begin a slow return
to sport within the limits of pain.
Treatment with non-steroidal injections has shown in clinical trials to
be effective in the acute phase of
care, however, after four weeks post
injection these patients had a greater
reoccurrence rate as compared to
those that rehabilitated the shoulder
properly. Not to mention the long
term changes in the integrity of the
tendon with repeated injections. For
an athlete this can be career limiting.
Lastly, subacromial bursitis if managed well in the acute phase and
adequately rehabilitated as to the
causative agent can be an injury that
should not offer the athlete long term
limitations and pain. Good patient
education as to proper technique, ergonomics and stretching of the glenohumeral joint will greatly reduce the
reoccurrence rate.
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Summer 2012 www.anjc.info
www.njchiropractors.com
ANJC Executive Director Addresses
Disabled Vets Convention
A
NJC Executive Director Dr. Sig
Miller gave a talk about chiropractic care services available to veterans of our state when he
spoke on June 13 at the NJ Disabled
Veterans Convention at the Resorts
International Hotel and Casino in Atlantic City.
Speaking before a group of approximately 60 state commanders and
regional directors of the NJ Disabled
Veterans Association from throughout
the state, Dr. Miller used the opportunity to discuss the mission of the
ANJC and to outline some of the programs available to veterans from the
ANJC and how the group could assist
the ANJC in helping with ongoing legislative efforts.
Dr. Miller discussed the ANJC’s ongoing commitment to “Healing Hands
for Heroes,” with Army OneSource,
a U.S. Army Community outreach
program and the Army Community
Covenant to raise awareness of the
unique challenges of military life on
our service members and their families and to address the growing need
for accessible health services. Participating ANJC doctors committing to
the program agree to treat veterans
of the Afghanistan and Iraq wars for
disorders and related maladies).
Unfortunately, Congress has not yet
acted to ensure that the services delivered by doctors of chiropractic are
available to retirees, dependents,
and survivor beneficiaries in the military TRICARE system.
The ANJC will be following up with
the newly-elected leadership of the
NJ Disabled Veterans to distribute
pertinent information to their membership and to engage them further
in assisting with educating veterans
and their families about the benefits
available through chiropractic care.
Sign-up for Fall Convention TODAY!
Correction
This article, The Glycemic Index: A Closer
Look, originally published in the January/
Winter edition of the NJ
Chiropractor was authored by Dr. Julianne
Monica and not Dr.
Steven Zodkoy.
ANJC apologizes
this error.
free for a minimum of 60 days.
Dr. Miller expressed his hope that
the members of the NJ Disabled Veterans would help spread the word
about Healing Hands for Heroes in
their communities.
Ongoing legislation affecting chiropractic care for veterans and their
families was also discussed. One
was the TRICARE bill, HR 409, bipartisan legislation to provide TRICARE
recipients with a benefit that is now
available to many in the private
sector (access to doctors of chiropractic and services to address pain
management, neuromusculoskeletal
for
Please complete and fax to ANJC HQ: 908.722.5677. More info call 908.722.5678 or email [email protected]:
Name
Must be an ANJC member to attend. For more info call 908.722.5678 .
Staff Name #1:
Staff Name #2:
Address
City
State
Email
Phone
Doctor (ANJC Members can attend):




Zip
$295 – Aug 1 through Sept. 14 , 2012
$345 – Sept. 15th through Oct. 25, 2012
At the Door – To be announced
$95 - additional attendees for Sat. Night dinner/entertainment
Fax
CA/Staff per person):



$175 – Aug 1 through Sept. 14 , 2012
$225 – Sept. 15th through Oct. 25, 2012
At the Door – To Be Announced
Hotel: ANJC reserved limited # of rooms at special price – $118/night + tax. Call Hilton @ 732.828.2000. Tell them you’re with ANJC.
Continuing Education Credits – You should have already paid your 1x annual fee of $75 to NYCC that covers processing of all CEUs from
Sept. 1, 2012 to Aug. 31, 2013. For more info contact NYCC Post Grad. Dept at [email protected].
Payment Total Amount: $___________ q Checks (Full Payment Only) - Payable to ANJC
q Visa q MC q AMX q Discover
Card# _____________________________________________________ Exp Date _____________ Signature _________________________________________
Cancellation Policy: Includes refunds less 25% admin. charge if request received 14+ days prior to event. No refunds after that time.
FALL CoNveNtioN
oCtober 27 & 28, 2012
Plus, Saturday Night Dinner & entertainment!
Convention AgendA*
r nutritional Problems that Complicate Patient
Care (2 CEUs - Nutrition)/dr. david Seaman
r Concussion: it’s not Just for Football,
Anymore (1 CEU)/dr. eric nelson
r Proper Coding and documentation for Rehab
& nutrition (1 CEU)/david Klein, CPC, CHC
r eRiSA Claims – What it is; Self vs. Fully
Funded; Medical necessity issues; Appeal &
get Paid (2 CEUs)/dr. Mike Kirk & Lynette Contreni
r Role of Platelet Rich Plasma injections/
Regenerative treatments in Musculoskeletal
Medicine/damon noto, Md
interventional Pain Management: Complex
Spinal issues/Phil Lutz, Md (1 CEU)
r Kids in Chiropractic (2 CEUs)/dr. Michelle
Binkowski
r Functional nutritional examination: easy
Assessment for nutritional needs in the
every day Patient (1 CEU - Nutrition)/
dr. Christopher Bump
r the neurology of Spinal Manipulation
SAt., oCtoBeR 27tH
7:30 - 11:30 pm
Dinner & Entertainment Featuring:
The Duprees & Kevin Lepine/ Hypnotist
(Las Vegas Headliner)
(1 CEU)/dr. david graber
r Understanding Your Managed Care
Contracts (1 CEU)/Jeff Randolph, esq.
& dr. Mike goione
r Understanding new Medicare Policy &
Regulations (2 CEUs - Documentation)/
dr. Rich Healy
PrePare to b
e
thoroughly
entertained
!
r Cervical Spine – An evidenced-Based
Approach to Management (2 CEUs)/
dr. William Lauretti
r Headaches: diagnosis & Management
(2 CEUs)/dr. Charles Hemsey
*rECEivE Up to 11 CEUs
CHiRoPRACtiC ASSiStAntS/StAFF tRACK
r overview of Patient Care & Practice Mgmt. (Sat. only)
dr. Ron Wellikoff & dr. tom ventimiglia
For more info call ANJC
at (908) 722-5678 or
email [email protected]
SAt., oCtoBeR 27th (8:00 am – 6:00 pm)
SUn., oCtoBeR 28th (8:15 am-1:00 pm)
Hilton E. Brunswick Hotel • 732.828.2000
3 Tower Center Boulevard • E. Brunswick
Summer 2012 www.anjc.info
www.njchiropractors.com
13
Association of NJ Chiropractors Hosts Successful
Spring Convention and Looks Ahead to Fall Event
on October 26-27 at the Hilton East Brunswick
ANJC Event Highlighted by over 500 Attendees, Great Panel of Speakers and
ANJC Student Scholarship Presentation
W
ith over 500 ANJC members attending, a wealth
of exhibitors, a special
presentation to chiropractic students
and a dynamic panel of speakers and
presentations, last weekend’s ANJC
Spring Convention at the Sheraton
Hotel in Parsippany provided an informative platform for helping members
improve their business and professional development.
Highlights of the two-day event included a State-of-the-Association address by Dr. Joseph D’Angiolillo, ANJC
President, updating membership on
ANJC insurance, legal, legislative and
PR issues. The convention also allowed the ANJC to officially introduce
Diane Philipbar, ANJC’s new Assistant
Executive Director.
“Once again, ANJC members benefitted by joining with colleagues in
the profession and having at their disposal a convention featuring a vast
array of informative and educational
presentations,” said Dr. D’Angiolillo.
“We thank all of our vendors and
sponsors for their support and we
look forward to an even bigger event
this fall in East Brunswick.”
Presentations at the event covered
all of the main topics for doctors to
run a successful practice. Sessions
included:
• Bill Esteb – Explaining Chiropractic So People Get It
• Rick Sapio & Patrick Gentempo
– Foundational Principles for Business Growth & Leverage
• Dan Murphy – Science of Subluxation Neurology
• Dave Klein – Introduction to
ICD-10
• Rich Healy – Medicare Updates
and Hot Topics
• Mark Charrette – The Noisy Joint
and Adjusting the Typical Foot
and Wrist
• Michelle Turk – Educating Your
Patients for Lifetime Care and
Communication Excellence
• Jeffrey Sklar – Chiropractic Applied in a Medical Oncology Care
Setting
• Jeff Randolph, Esq. – Chiropractic
Informed Consent
A highlight of the weekend event
was the ANJC Student Scholarship
presentation to students selected
by the ANJC’s Senior Advisory Committee, which rewarded five $1,000
scholarships to students from New
Jersey that are returning from chiropractic colleges to begin their practice in the state.
The ANJC Scholarships were
awarded to:
• Yevgeniya Boyko – University of
Bridgeport
• Michael Vito Spadafino – Palmer
College
• Dominique Cyran – Southern California University
• Hailey Coonrad – Life University
• John Ripley – Palmer College
The students received a certificate
and their checks. The ANJC’s Senior
Advisory Committee conducted the
oversight, application, review and
scoring for the scholarship program.
The ANJC’s Senior Advisory Committee, which meets on a quarterly
basis, was created by ANJC Executive Director, Dr. Sigmund Miller, as
a committee with vast experience in
the profession to serve in an advisory capacity.
association of new Jersey chiropractors (coDe: Va)
it pays to belong!
Help support our fundraising efforts by joining TD Bank’s
Affinity Membership Program. Your participation earns
us an annual contribution based upon the number
of members enrolled.
Eligible accounts include:
• Checking • Money Market
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Existing TD Bank Customers are eligible, too! Just give them
our organization’s name and they’ll take care of the rest.
to open an account, visit your nearest
tD bank or call 1-888-751-9000.
14
Summer 2012 www.anjc.info
www.njchiropractors.com
Summer 2012 www.anjc.info
www.njchiropractors.com
Coding Advisory Regarding Modifier -51 and Proper Use with CMT Codes
ANJC Launches Store
Continued from page 4
determined to be separate and distinct, additional, secondary, or even
incidental. Modifier -51 was created
to report procedures that are secondary or lesser procedures or services,
since the factors and circumstances
significantly overlap; the RVU of the
secondary or lesser procedure is significantly reduced accordingly.
In “Coding with Modifiers,” according to the AMA, “To understand Modifier 51, it is important to understand
when not to use Modifier 51.”
Extraspinal CMT is a separate
and distinct stand-alone procedure,
which can often be performed to a
completely unrelated anatomic site
or region than a Spinal CMT. It is
uncommon that any notable contrib-
uting factors or circumstances of Extraspinal CMT would be significantly
reduced or overlapped with the contributing factors from a Spinal CMT.
The E/M, pre-manipulative work, and
intra-manipulative work of an ankle or
knee condition has very little redundancy to the same effort and clinical
decision making for a cervical condition. Suggesting that evaluating and
treating the cervical condition could
somehow reduce the RVU for the effort and clinical decision making of
the evaluation and treatment of the
knee or ankle condition, by any real
discernible amount, is absurd – even
to a non-clinician.
The AMA goes as far as suggesting the vast majority of the services
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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.
intended to be determined as secondary are surgical procedures.
On page 98 of “Coding with Modifiers," the AMA states:
Modifier -51 has three applications, namely, to identify:
• Multiple, related surgical procedures performed at the same
session
• Surgical procedures performed in
combination, whether through the
same or another incision or involving the same or different anatomy
• A combination of medical and surgical procedures performed at the
same session
The modifier therefore has a common sense application, with reasonable exceptions.
By attempting to maintain that the
Extraspinal CMT is secondary, and
that its RVU should be reduced by
50%, these carriers are essentially
saying that the work is duplicated.
They would have us believe that the
same film and diagnostic tests would
have covered and evaluated both
sites and therefore be overlapping.
However it is our contention that
different sites require completely different additional pre and post work.
For example: how can a provider
use a cervical x-ray to evaluate a
patient’s knee or the argument that
palpation of the neck would overlap
with the palpation of the knee. With
the exception of very minor things
like pulse, temperature, BP, and mental orientation or mood, every other
part of the pre-service work, and all
of the intra-service work (such as
the adjustment technique) would be
completely unique and not overlap
between spinal and extra-spinal manipulations. Even the post manipulation work is unique, with the exception of having the documentation
source, paper or computer, prepared
and in progress.
Fortunately, based on the AMA
“Coding with Modifiers,” one need
not simply rely on pure reason to establish the correct usage of the modifier. Even beyond the detailed reasoning provided above, the AMA takes
the guidance on proper coding with
the modifier 51 even further when
they declare “The CMS designates
which procedure codes are eligible
for Modifier 51 and subject to multiple procedure fee reductions.”
CMS has a series of correct coding
policies as well as mutually exclusive
coding pairs, highly unlikely coding
pairs, bundling rules and more. Built
into the Medicare Physician Fee
Schedule (MPFS) are some rules
regarding how certain services are
to be reimbursed and most carriers
use these very rules like global surgical fees and time period rule. There
is actually a multiple procedure rule
that indicates when the modifier -51
should be used, and if and how payment should be reimbursed when
appropriate.
I have included the link to the official CMS transmittal explaining how
to read the indicators used in the
MPFS data base, including the number indicators 1-9 for multiple procedures (see page 10 box labeled “21
- Multiple Procedures (Modifier -51)”).
http://www.cms.hhs.gov/transmittals/downloads/R1632CP.pdf
Additionally Medicare has created
an excel spreadsheet that lists all the
MPFS data, including the indicators for
multiple procedures. If you scroll down
to CPT 98943 you see the column
titled Mult Proc (column Y). The indicator listed by CMS is 9, which according
to the transmittal explaining the indicators means: concept does not apply.
Carriers that require the -51 modifier are inappropriately choosing to
apply what would be indicator 1 or 2
requiring the modifier – much to their
benefit and to chiropractors detriment. Medicare’s rules on this have
existed since at least 2008.
Based on the above, the concept
does not apply when it comes to
affixing the -51 modifier to the Extraspinal CMT (CPT 98943) when
performed with Spinal CMT (CPT
98940-98942). It should also be
noted that while Medicare does
not recognize this code for actual
reimbursement purposes they obviously recognize it by including it in
the NCCI. The carriers in question
have apparently indicated that they
do not necessarily follow Medicare’s
rules for processing their claims. The
absurdity of that statement barely
dignifies a response, but instead
elicits another question. If they are
indicating that a modifier 51 should
be used for what they deem multiple
procedures just as CMS does, and
then they reduce the reimbursement
for the Extraspinal CMT by exactly
50% just as CMS does, do they consider those similarities to be coincidental? It is plainly obvious that they
are inappropriately attempting to
apply a CMS rule erroneously simply
for their own financial gain.
In conclusion, there are three
main reasons as to why modifier
-51 should not be affixed to the Extraspinal CMT (CPT 98943) when
performed with Spinal CMT (CPT
98940-98942).
1. The intra service work and preservice work is completely separate for the two procedures, and
the AMA’s own reasoning dictates
that Extraspinal CMT is not a secondary procedure to Spinal CMT
with redundant or overlapping
work significant enough to reduce
its RVU.
2. By specific guidance in the AMA’s
“Coding with Modifiers” publication, Modifier 51 does not apply
to CMT services.
3. The AMA recognizes the specific
rules in CMS published guidelines
which specifically states that, for
CPT code 98943, the multiple
procedure reduction rule concept
does not apply
Sincerely,
David Klein, CPC, CHC
John M. Kelly, Former AHFI, CPC
Bharon Hoag
Ted Arkfeld, DC, CPC
Jeff Brown, DC, CPC, CCPC
Amy Prentice, BS, ASCT, CPC
15
Save on Home/Office Gas & Electric; Other
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Contact HQ for More Info.
Q: I need to dispose of some old Xrays to free up space. What steps are
needed to do this properly? Also, is it
advisable to sell old films to a vendor
for the silver in them?
A: You need to take into account not
only state and federal requirements
and licensing standards, but also the
needs and wishes of your patients.
Most state laws require adult
patient X-rays be kept on file for
seven years after the last date of
treatment—the same requirement
as for patient records. It may not be
acceptable to destroy films if you
are keeping the other medical records. Minor patient X-rays generally
need to be retained until the patient
reaches age 25.
Most state laws require
adult patient X-rays be kept
on file for seven years after
the last date of treatment—
the same requirement as
for patient records.
After that timeframe, you can
dispose of the films, as long as you
do it properly from a patient privacy
perspective and in accordance with
EPA regulations. Due to HIPAA privacy requirements, you cannot simply
throw X-rays in the trash. Films must
be destroyed. Some states even require the notification and response
of patients before the destruction of
records, including X-rays.
In general, proper disposal methods
include shredding, burning, pulping or
pulverizing the records so that patient
health information is rendered essentially unreadable and cannot be reconstructed. The challenge is that home
and office shredders are not sturdy
enough to destroy X-rays and the films
have hazardous material that cannot
be legally disposed of in landfills.
If you enlist a company to destroy
your X-rays, work through a professional document shredding company
and make sure the company prepares
a HIPAA Business Associate agreement and provides a certificate of
destruction. To protect patient confidentiality and avoid the potential for
identity theft, make sure to:
• Know the difference between
recycling and destroying. Simply
recycling X-rays may not comply
with patient confidentiality laws.
• Have a written policy on document
destruction before contacting vendors for bids.
(908) 722-5678
• Examine a company’s written policy for managing the destruction.
• Require the company to do background checks of its employees.
• Conduct periodic, unannounced
audits of the destruction facility if
the destruction is done off-site.
While these steps may seem burdensome, the consequences of not
taking the necessary precautions
may include litigation, privacy violations, and a general loss of reputation
and confidence in the office.
Another issue to keep in mind
when disposing of films is patient perception. This is especially true if you
sell the X-rays to a third party. Some
companies will pay you for the silver
contained in the films.
Not only do patients trust you to
maintain the confidentiality of their
health information, they may think
they own the films since they, or
their health insurance company, paid
for them. Although what they really
paid for is to have the X-rays taken,
processed and read, it is important
to be aware of this frequent patient
misconception.
With these factors in mind, some
authorities recommend retaining
X-rays indefinitely. This may not be
practical, however, as films must
be stored in a safe location with adequate temperature and humidity.
However, it might be worth keeping
the X-rays longer than legally required
if you have the space and the right
facility. If not, make sure to dispose
of them properly and maintain patient
confidentiality.
–––––––
About NCMIC: NCMIC is a company
trusted by more than 37,000 DCs
and growing. Policyholders know our
strength is summarized by our motto,
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information call 1-800-769-2000, ext.
3809. ©2010 NCMIC Group, Inc. All
rights reserved.
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16
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Summer 2012 www.anjc.info
www.njchiropractors.com
17
Inflammation: Friend and Foe
By Dr. Van Merkle
By Brian D. Jensen, DC
A
Orthotic Support Helps
Prevent Athletic Injuries
F
oot position and alignment are
important factors that must be
considered in our active population. As we encourage more of our
patients to walk, jog, and exercise,
we need to be prepared for the side
effects of our recommendations if
any foot problems exist.
For example, a study of runners
found that those who pronated more
while running had a much greater
likelihood of developing a sportrelated injury (1). While this isn’t surprising to most of us who have been
treating athletes, it helps us explain
why individually designed, stabilizing
orthotics can be so helpful in preventing athletic injuries.
This retrospective study looked
back at the characteristics of athletes who reported recent foot and
leg overuse problems and compared
them with a control group. The researchers were interested in finding
whether excessive pronation (using a
method of measuring pronation while
weightbearing) correlated with the
possibility of developing various types
of overload sports injuries.
When the Body Can’t Rebuild The clinical conditions evaluated in
this study are known as “overuse,”
or “overload” injuries. These injuries
develop when the body is unable to
strengthen and rebuild in response to
strenuous and repetitive athletic or
work activities. In this study, 66 injured athletes who ran at least once
a week—and who had no history of
traumatic or metabolic factors to
their overuse injury—were the study
group. Another control group of 216
athletes were matched who had no
symptoms of overuse injuries.
The amount of pronation during
standing and while running at regular
speed was determined by measuring
the angles of their footprints. This
inexpensive method of determining
the amount of pronation during functional activities, plantar prints, had
been previously investigated (2). One
of the advantages of this method of
measuring pronation is that it can be
done without radiation exposure from
x-rays and is not time consuming.
The investigators found that athletes with more pronation had a much
greater likelihood of having sustained
an overuse athletic injury. They also
established that the amount of pronation seen in the standing, weightbearing footprint was the more predictive
of developing an overuse injury. This
study reminds us that it is very important to athletic performance and for
injury prevention to check the alignment of patients’ feet in the standing
position.
Knee Pain and Foot Alignment
- The researchers in another study
performed a visual assessment of
the feet of 77 athletes while they
were standing (3). After classifying
the feet as obviously pronated, obviously supinated, or neutral (based on
agreed-upon mandatory criteria), the
investigators inquired into the history
of knee pain. Those athletes who
answered yes to the question of knee
pain were more than twice as likely
to have an abnormal foot alignment.
This study found that “athletes with
excessively pronated or supinated
foot types may be more susceptible
to knee pain than athletes with neutral foot types.” Since knee injuries
can often ruin athletic aspirations,
controlling pronation and absorbing
the shock of supination could be crucial for many athletic patients.
Some Injuries Preventable - Knee
injuries often seem so sudden and
unpredictable that prevention would
appear to be impossible. This may
not actually be the case with many
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acute injuries to the anterior cruciate ligament (ACL). One study looked
at pronation in athletes and found
a higher risk of injury to the ACL in
those with hyperpronation (4). These
researchers looked at the amount of
arch collapse to determine the tendency to excessive pronation. They
used the navicular drop test, which is
another easy method to assess a patient’s foot and can be done quickly
in the office.
When the researchers compared
50 subjects who had sustained an
arthroscopically diagnosed rupture of
their ACL with 50 uninjured matched
controls, they found that higher
scores on the navicular drop test correlated with a history of ACL injury.
Since the score on the navicular drop
test increases with greater amounts
of pronation, and especially with collapse of the medial arch, they were
able to conclude that abnormal foot
alignment predisposed an athlete to
knee injury. In fact, they stated that
“hyperpronation of the foot and ankle
complex may increase the risk of injury to the ACL.”
Share What You Know - These
retrospective studies clearly demonstrate the correlation between foot
position and function, and various
biomechanical problems and injuries.
Talk to your patients about these factors, and explain why they should be
evaluated for stabilizing orthotics. I
have found that most patients, and
athletes in particular, appreciate it
when their doctors demonstrate their
expertise by discussing research findings, which can help improve performance and prevent future problems
and injuries.
References:
Busseuil C, Freychat P, Guedj EB, Lacour JR.
Rearfoot-forefoot orientation and traumatic risk for runners. Foot & Ankle Intl
1998; 19(1):32-37.
Freychat P, Belli A, Carret JP, Lacour JR. Relationship between rearfoot and forefoot
orientation and ground reaction forces
during running. Med Sci Sports Exerc
1996; 28(2):225-232.
Dahle LK et al. Visual assessment of foot
type and relationship of foot type to
lower extremity injury. J Orthop Sports
Phys Ther 1991; 14:70-74.
Beckett ME et al. Incidence of hyperpronation in the ACL injured knee: a
clinical perspective. J Athl Train 1992;
27:58-62.
–––––––
Dr. Brian Jensen is currently the
Associate Director of Professional
Education at Foot Levelers. He speaks
on a wide variety of topics, including
orthotic therapy, posture, structural
preservation, breaking free of the
medical model of healthcare, and
innovations in nutrition. Dr. Jensen
can be reached at 800.553.4860.
What’s New at HQ?
Diane Philipbar – Assistant Executive
Director
• Staffing up: ANJC is growing! We
will be hiring an Insurance Director this summer to assist members with their insurance challenges, along with additional staff
in the near future.
• ANJC Members & Sponsors will
soon be provided an opportunity
to use ANJC logos.
• ANJC is soon adding additional
Affinity Partners to more easily
access their services at additional
savings (see TD Bank ad on page
13).
• Platinum Sponsors: Staff is working towards adding additional
sponsors with focus on MRI/Diagnostic Facilities.
• ANJC Trade Show Booth/Signage:
We are designing a professional
booth and signs for ANJC events,
and other events outside of ANJC.
• Member ID Cards are being designed, in part, for easier scanning during ANJC CEU programs.
Nicole Bachman, Administrative
Assistant
• HQ just completed Phase I, upgrading membership software to
streamline all procedures.
• Phase II allows ANJC members to
sign up for programs, pay dues,
and update contact info. Christine Otto, Administrative
Assistant
• HQ is currently working on upgrading the ANJC Website to better
serve member doctors and sponsors. Improvements include a
search feature, more organized
navigation and easier access to
valuable resources.
s chiropractors we deal with
protective inflammation from
injury and pain on a daily
basis. But what about the inflammation we can’t see or feel. Systemic,
low-grade infections can keep the immune system on the attack for years
with virtually no symptoms.
While short term inflammation is
essential for healing, chronic inflammation—whether the result of an overreactive immune system or an underlying problem the body is attempting
to heal—creates a damaging environment for your body. Researchers
continue to uncover one illness after
another that is affected or initiated
by chronic inflammation such as allergies, increased cholesterol, atherosclerosis, Alzheimer’s, auto-immune
disorders, arthritis and more.1
The bad news is that instead of
seeking out underlying causes of inflammation, medical doctors prescribe
anti-inflammatory drugs like NSAIDs or
immuno-suppressive drugs like Prednisone as preventive measures. Statins
are being used to lower inflammation
in patients with normal cholesterol
levels to reduce the risk of developing
heart disease.2 This puts patients at
risk for drug side effects and leaves
them susceptible to problems created
by the untreated underlying condition.
The good news is that natural options exist to help battle chronic inflammatory conditions and you can provide
this for your patients. The first step is
to test. Certain blood tests will tell you
if a patient has chronic inflammation.
Note: “Clinical range” is the medical
community standard. “Healthy range”
is a stricter guideline for optimal health.
Unfortunately, the clinical ranges continue to expand, reflecting a society of
declining health. Twenty years ago, the
clinical cut-off for the Erythrocyte Sedimentation Rate was 9, now it is 20.
C-Reactive Protein (CRP) - Clinical Range: 0.00-4.90 mg/L; Healthy
Range: 0.00 – 1.50 mg/L
Produced in the liver by pro-inflammatory cytokines, chronic inflammatory
processes are typically <8 mg/dL while
acute infections can jump as high as
30-35 mg/dL. Researchers have show
that a high sensitivity-CRP >3 mg/L
can triple your risk of heart disease.3 4
Erythrocyte Sedimentation Rate
(ESR) - Clinical Range: 0.00-20.00
mm/HR; Healthy Range: 0.00-6.00
mm/HR
ESR indicates the presence and
intensity of inflammation. More important than an abnormal measurement is its change over a period of
time, however, the lower the number
the better.5
High Platelets - Clinical Range:
150-450k/cumm; Healthy Range:
175-250k/cumm
Infections and inflammation can
cause the platelets to rise. When
platelets run high, clotting factors
can increase the risk of blocked
arteries.6
One patient came to my office with
the following inflammatory markers:
CRP high at 16.40; ESR high at 32;
platelets elevated at 255. With these
numbers, could we determine what’s
causing the inflammation? No.
You must locate the root of the
problem to be of help to your pa-
tients. A baseline comprehensive test
including complete metabolic profile,
liver panel, kidney panel, lipid panel,
iron & ferritin check, hemoglobin
A1C, LDH, CRP, ESR, Vitamin D 25-hydroxy, creatine kinase, thyroid panel
and a CBC is essential. Table on page
22 are the most important abnormal
results from my patient’s comprehensive test.
Thanks to the comprehensive analysis, we have a clearer picture of the
problem at hand.
• High uric acid—Gout (an arthritic condition that produces
inflammation)
• Low AST, ALT & GGT—liver dysfunction (likely the result of the
liver being overworked to remove
excess uric acid from the body)
• High cholesterol, LDL cholesterol
and diabetic markers with low
triglycerides—unhealthy diet/lack
of exercise (high LDL with chronic
inflammation is a risk factor for
coronary artery disease 7)
Continued on Page 22
Supreme Court Ruling on Health Care Law
To: ANJC Members
From: Dr. Joe D’Angiolillo,
ANJC President
Y
esterday, the Supreme Court
upheld the healthcare law with
a split, complex opinion. The
important point made by the Justices
is that the individual mandate — the
requirement that most Americans buy
health insurance or pay a fine — is
constitutional as a tax.
Our local legislators wasted no
time responding to the Supreme
Court decision. While Governor Christie stated that he disagrees with the
decision and does not believe one
size fits all regarding health insurance, others such as Senator Nia Gill
reintroduced her legislation to create
a New Jersey healthcare exchange.
While it is very early in the process
and there are many variables that
will surely play out, the chiropractic
profession needs to be involved making sure we have a place at the table.
This will be a process that requires
not only involvement at the national
level, but at the state level, as well.
The establishment of Health Care
Exchanges is one part of the puzzle
providing a marketplace to purchase
health insurance. Another piece is the
creation of Accountable Care Organizations (ACOs) to provide coordinated
patient care in a cost effective manner.
Be assured that ANJC is monitoring every aspect of this issue and will
update you with concrete information
as it becomes available.
The first step in the process is
legislative. Bills have already been
introduced in both the Senate (S2135, Senators Gill and Vitale) and
the Assembly (A-3186, Assemblymen
Conaway and Singleton).
ANJC will be actively involved as the
legislature considers these bills, making sure your voice is heard in Trenton.
Next Action Step – Please Assist:
It is important in times like these
that we continue to support those
legislators that have supported our
profession in the past and will continue to do so into the future. ANJC
has established itself as the voice of
the profession and as a major player
on healthcare issues in Trenton. It is
important that as the future of healthcare evolves that we continue our
strategy.
One pillar of that strategy has
been ANJC’s Political Action Committee (PAC). We couldn’t have arrived
where we are without it; and won’t
accomplish what we need to without
further PAC support.
In the past, your participation has
been vital in giving us a stronger
voice in Trenton. Your continued support of the PAC will provide ANJC the
means to support those who support
our profession as the future of healthcare is determined.
What I am asking of each of you
is to become a monthly contributor
to ANJC’s PAC. Please fill out the attached form and email back to sig@
anjc.info or fax HQ at 908.722.5677.
If you’re unable to make a monthly
contribution we would gladly accept a
single contribution.
Thank you in advance for your
consideration in this most important
issue.
Sincerely
Joseph D’Angiolillo, D.C.
ANJC respectfully requests your non-tax deductible voluntary contribution. q $25/mo q Other $________­­­______
q Credit Card
q Check
q Visa q MC q AMX q Discover
Card # _____________________________________________ Exp. Date _______________
Please make payable to ANJC : Mail to ANJC PAC, 3121 Rte. 22 East, Branchburg, NJ 08876
The undersigned authorizes ANJC to charge the credit card/debit card specified in the amount indicated above for ANJC PAC.
Print Name________________________________________________________
Signature _______________________________________________­­­­­­­­­­__________ Date ___________________
18
Summer 2012 www.anjc.info
www.njchiropractors.com
Summer 2012 www.anjc.info
www.njchiropractors.com
Easy Way to Add Nutrition
to Treat Patient’s Pain
Research
Updates
L
ow back pain is one the most
common reasons patients visit
all physicians in the United
States and it represents a substantial financial burden on society (1).
The most common treatments are
pharmaceuticals, which are either
prescribed or self administered, and
manual care, which is delivered largely by chiropractors.
Nutrition is not generally considered in the treatment of low back
pain and in fact, there are few trials
that have specifically studied the
effect of diet and/or supplements.
This leads some to incorrectly view
that nutrition may not be useful. The
problem with this view is that no matter where the pain may be, the same
peripheral and central nervous mechanisms are involved, which includes
the release of chemical mediators,
such as prostaglandins and cytokines
(2), which are known to be modulated
by diet and supplementation (3).
In this article, three different
types of common pain patients will
be discussed. Those whose back
pain begins without obvious injury;
those who suffered an obvious strain
that led to pain; and individuals with
chronic aches and pains that vary
in intensity and generally make life
miserable.
Reduced Caloric Intake - In human
and animal studies, caloric restriction has been associated with the
reduction of pain and inflammation
(4-6). The precise mechanisms are
not known for sure; however, it is
clear that overeating nutrient-free
and calorie dense foods will lead to
postprandial elevations in glucose
and triglycerides, which is associated
with inflammation and is referred to
as postprandial dysmetabolism (7).
Americans spend most of their
waking hours in the postprandial dysmetabolic state (7). While postprandial dysmetabolism is largely studied in
the context of heart disease and diabetes, this can be applied to all conditions associated with inflammation.
In other words, it makes no sense for
patients with pain to live their lives in
the postprandial inflammatory state.
Who are these patients? Individuals
who are overweight and sedentary,
which is the majority of patients.
These patients overeat sugar, flour,
and excessively fatty foods at the expense of vegetables and fruit, leading
to excessive systemic inflammation.
Perhaps a chronic postprandial
dysmetabolic inflammatory state is
why patients are less responsive to
spinal adjustments today, compared
to yesteryear? This has been suggested to me as a possible reason
by numerous DCs in the past twenty
years who had been in practice for at
least 40 years.
Modest caloric restriction immediately reduces postprandial inflammation (7), a practice that should be
adopted by all patients in pain. Simply cut out the high calorie dessert
foods and snacks and increase the
consumption of whole foods, particularly vegetables and fruit.
Back Pain Develops without
Obvious Injury
Many patients present with back
pain that slowly develops without an
obvious inciting injury. Many of these
patients have tried anti-inflammatory
medications without success and so
decide to give chiropractic a try. It
is important to remember that many
of these patients enter your office
in the postprandial dysmetabolic
inflammatory state. They likely need
mechanical and chemical care as
outlined in Table 1.
Table 1. Back Pain; Obvious injury
Spinal manipulation
Reduced caloric intake
White willow bark extract
White willow bark is a good choice
for this category of back pain patient
and should be taken as needed to
help modulate the pain. Back pain
guidelines and review articles have
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identified that white willow is no less
effective than medications and is
associated with fewer side effects
(1,8). Important to note is that white
willow bark should not be viewed as a
natural aspirin. The beneficial effects
of white willow are thought to be due
to its unique flavonoid profile that offers a novel analgesic effect (9).
Back Pain that Develops Due to
Obvious Injury
When patients state that a specific
mechanism of trauma was responsible for their back or other pain,
the key term to be thinking about is
acute inflammation. Clearly, these
patients need to avoid the postprandial dysmetabolic inflammatory state.
Care should be given to delivery of
manual care as the tissues are acutely inflamed and can be further injured.
Table 2 also includes the use of proteolytic enzymes as a component of
the treatment approach.
Table 2. Back Pain: Obvious strain
Spinal manipulation
Reduced caloric intake
Proteolytic enzymes
Proteolytic enzymes include bromelain, trypsin, chymotrypsin and
papain. Research has identified
multiple mechanisms of action. The
most notable in the context of acute
inflammation is that proteolytic enzymes help to activate plasmin, which
degrades fibrin and can help control
tissue fibrosis after acute injury (10).
Proteolytic enzymes should be taken
on an empty stomach, at least three
times per day. A very safe dose ranges from 600-2000 mg per day (10),
for about a week.
In a study on ankle sprains, subjects that took enzymes were back to
work in less than 2 days compared to
over 4 days for those taking the placebo. And those taking enzymes were
back to exercising again in under 10
days versus almost 16 days for the
placebo group (11).
Chronic Aches and Pain
As people age, they become accepting of aches and pains as if they
are normal. This view is not accurate.
In most cases, their musculoskeletal
pains can be effectively modulated
with manual treatments and nutritional interventions. The majority of these
patients do not realize that they
have lived in a postprandial dysmetabolic inflammatory state for perhaps
decades. Reducing caloric intake
is important as a lifestyle. I would
suggest making their college or high
school body weight as the goal to be
achieved.
Table 3. Chronic Back Pain
Spinal manipulation
Reduced caloric intake
Ginger, turmeric, boswellia, etc.
Table 3 includes various botanicals
in addition to manipulation and caloric reduction. Ginger and turmeric are
two of the most studied botanicals
(12,13). Typically about 1-2 grams
per day are recommended and should
be taken on a continuous basis. Substantial pain reduction has occurred
for patients with rheumatoid arthritis,
osteoarthritis, and general musculoskeletal pain (12).
Summary
A substantial number of musculoskeletal pain patients need a natural
combination of manual care and proper nutrition. While the supplement
applications have been divided into
specific patient categories, it should
be understood that combinations of
the three supplements can be used in
the same patient, which I refer to as
a natural dose pack.
References
1. Chou R et al. Diagnosis and treatment
of low back pain: a joint guideline from
the American College of Physicians and
the American Pain Society. Ann Intern
Med. 2007;147:478-91.
2. Marchand S. The physiology of pain
mechanisms: from the periphery
to the brain. Rheum Dis Clin N Am.
2008;34:285-309.
3. Seaman DR. Nutritional considerations
in the treatment of soft tissue injuries.
In Hammer WI. Editor. Functional softtissue examination and treatment by
manual methods. Boston: Jones &
Bartlett; 2007: p.717-734.
4. Kjeldsen-Kragh J et al. Controlled
trial of fasting and one-year vegetarian
diet in rheumatoid arthritis. Lancet.
1991;338:899-902.
5. Hargraves WA, Hentall ID. Analgesic
effects of dietary caloric restriction in
adult mice. Pain. 2005;114:455-61.
6. Fontan-Lozano A et al. Molecular bases
of caloric restriction regulation of neuronal synaptic plasticity. Mol Neurobiol.
2008;38:167-77.
7. O’Keefe JH, Bell DS. Postprandial hyperglycemia/hyperlipidemia (postprandial
dysmetabolism) is a cardiovascular risk
factor. Am J Cardiol. 2007;100:899 –904.
8. Bogduk N. Pharmacological alternatives for the alleviation of back
pain. Expert Opin Pharmacother.
2004;5(10):2091-98.
9. Nahrstedt A, Schmidt M, Jäggi R, Metz
J, Khayyal MT. Willow bark extract:
the contribution of polyphenols to the
overall effect. Wien Med Wochenschr.
2007;157(13-14):348-51.
10.Maurer HR. Bromelain: biochemistry,
pharmacology, and medical use. Cell
Mol Life Sci. 2001; 58:1234-45.
11.Bucci LR. Nutrition applied to injury rehabilitation and sports medicine. Boca
Raton, FL: CRC Press; 1995: p.
12.Srivastava KC, Mustafa T. Ginger
(Zingiber officinale) in rheumatism and
musculoskeletal disorders. Med Hypotheses. 1992; 39:342-8.
13.Goel A, Kunnumakkara AB, Aggarwal
BB. Curcumin as “curecumin”: from
kitchen to clinic. Biochem Pharmacol.
2008; 75:787-809.
–––––––
Dr. David Seaman is a Professor
of Clinical Sciences at the NUHS
branch campus at St Petersburg
College in Florida. He is also a Clinical
Consultant for Anabolic Laboratories.
He has written numerous articles on
the treatment options for chronic pain
patients, with a focus on nutritional
management. He can be reached at
deflame@deflame.com.
1. Effect of Hydration on Effectiveness of SMT for Low Back Pain
This investigation sought to assess
ways in which the efficacy of osteopathic manipulative therapy (OMT)
might be improved; in this case,
focusing on hydration status of the
patient prior to treatment. This randomized, single-blind crossover study
conducted from March-December
2010 at an outpatient academic center drafted 19 patients with low-back
pain (LBP) of 1-12 months’ duration.
Participants received 2 sessions of
OMT, each in a different hydration
condition (by modifying water consumption for 36 hours prior to OMT
sessions) and with a 1-week washout
period in between. Outcome measures pre- and post-treatment included: (1) visual analog scales for pain,
(2) number and severity of somatic
dysfunction as scored on the somatic
dysfunction severity scale, and (3)
number of asymmetric landmarks
found on the osteopathic standing
structure examination.
In the euhydrated condition, improvements in total and severe number of lumbar somatic dysfunction and
number of asymmetric landmarks on
the standing osteopathic structure examination was found as compared to
the hypohydrated state. Furthermore,
participants had a mean of two fewer
areas of post-treatment somatic dysfunction when euhydrated than when
hypohydrated. Self-reported pain on
the visual analog scale improved immediately after OMT, regardless of the
patient’s hydration status.
With the greater improvement seen
in the euhydrated condition, it was
deemed reasonable for clinicians to
recommend that patients increase
their hydration to optimize treatment.
Interestingly, this finding is consistent with those reported in applied
kinesiology, in which hydration status
has been reported to affect the results of manual muscle testing.2
1
Parker J, Henking KP, Kappler RE. Efficacy
of osteopathic manipulative treatment
for low back pain in euhydrated and
hypohydrated conditions: A randomized
crossover trial. Journal of the American
Osteopathic Association 2012; 112(5):
276-284.
Walther DS. Applied Kinesiology,
2 Edition. Shawnee Mission, Kansas: International College of Applied
Kinesiology, 2000, p. 144.
2
nd
2. Upper Cervical/Thoracic SMT vs.
Mobilization for Neck Pain
A total of 107 patients with mechanical neck pain presenting at
seven outpatient physical therapy
clinics were randomized into (A) highvelocity, low-amplitude (HVLA) thrust
manipulation or (B) nonthrust mobilization cohorts in the C1-C2 and T1-T2
regions. The neck disability index
yielded a 50.5% reduction in group
A and 12.8% reduction in Group B.
Furthermore, Group A yielded greater
improvements in the passive C1-C2
range of motion and greater motor
performance of the deep cervical
flexor muscles. The conclusion was
that HVLA thrust manipulations
were more effective than nonthrust
mobilizations over the short term for
relieving mechanical neck pain in this
investigation.
PR Update
By Anthony L. Rosner,
Ph.D., LL.D.[Hon.], LLC
– ANJC Insurance Consultant
By David R. Seaman, DC, MS, DABCN
Dunning JR, Cleland JA, Waldrop MA, Arnot
A, Young Y, Turner M, Sigurdsson G.
Upper cervical and upper thoracic thrust
manipulations versus nonthrust mobilization in patients with mechanical neck
pan: A multicenter randomized clinical
trial. Journal of Orthopaedic and Sports
Therapy 2012; 42(1): 5-18.
3. Critical Review and Distinctions of
Applied Kinesiology in the Literature:
Modification of the motor system
in assessing and treating as well
as understanding one of the causes
of musculoskeletal dysfunctions is
a topic of growing importance in
healthcare. Applied kinesiology (AK)
addresses this interest in that it is a
system that attempts to evaluate numerous aspects of health (structural,
chemical, and mental) by the manual
testing of muscles combined with
other standard methods of diagnosis.
It leads to a variety of conservative,
non-invasive treatments that involve
joint manipulations or mobilizations,
myofascial therapies, cranial techniques, meridian and acupuncture
skills, clinical nutrition and dietary
management, counseling skills,
evaluating environmental irritants,
and various reflex techniques. The
effectiveness of these ancillary treatments is believed to be consistent
with the expanded construct validity
of the manual muscle test (MMT),
as described, although this assertion
has primarily been tested in outcome
studies.
AK and its adjunctive procedures
(challenge and therapy localization)
are highlighted in this review providing details of its implementation as
prescribed by an International College of Applied Kinesiology’s Board
of Examiners, cited for its scholarly
and scientific activities. Because
these procedures are believed to
identify specific articular, soft-tissue,
biochemical, or emotional issues underlying muscle function, the applicability of this diagnostic method for all
clinicians treating muscle imbalance
disorders is described. As of yet,
MMT efficacy in therapy localization
and challenge techniques has not
been established in published, peerreviewed research.
A variety of challenges likewise
remain for professional AK to establish itself as an emerging science,
with numerous gaps in the literature
and testable hypotheses enumerated. Of particular concern are a
multiplicity of derivatives of AK that
have been described in the literature,
which should be greeted with caution
in light of the fact that they lack one
or more of the essential attributes of
AK as described in this report. The
validity of these studies, which have
been critical of applied kinesiology,
appears in many instances to be no
greater than several of the randomized controlled trials, cohort studies,
case control studies, and case studies found in this communication to
support various aspects of applied
kinesiology.
Rosner AL, Cuthbert SC. Applied kinesiology: Distinctions in its definition and
interpretation. Journal of Bodywork
and Movement Therapies 2012; doi:
10.1016/j.jbmt.2012.04.008.
19
New Jersey Education
Association Update
By Tom Cosentino – ANJC PR Consultant
A
s we outlined in the last issue
of NJ Chiropractor, the ANJC
has launched a major public
relations initiative with the NJEA,
the New Jersey Education Association. The first element of this new
relationship was the publishing of an
ANJC Health column in an issue of
the NJREA Newsletter sent to retired
members.
This will be a major initiative that
will require multiple editorial stories
in NJEA publications over the next
year. Thus, the ANJC public relations
team will be in need of pertinent editorial content that can be used for
these NJEA publications as well as a
host of other content providers that
the ANJC is now working with.
There are multiple platforms now
available for the distribution of ANJCproduced content. Editors of these
sites value the content delivered to
them and are looking for more.
Last year, the ANJC entered into a
relationship with NJ.com, the largest
website in New Jersey and the online
home of the Newark Star Ledger. As
part of the agreement, ANJC was
given a sponsored blog on the NJ.com
site. We have renewed the agreement with NJ.com and will be seeking
contributors that would like to submit
content to the site.
Additionally, we have also launched
a blog on the micro-local website
Patch.com, owned by AOL. Each blog
requires new content to be published
each week. We have also begun providing editorial content to regional
publications such as Lifestyles Magazine in Monmouth County and Today’s
Senior in Burlington County.
What is needed is the help of ANJC
member doctors to supply content,
health tips and suggestions to the
public relations team. We realize your
day is overloaded as it is in dealing
What is needed is the help
of ANJC member doctors
to supply content, health
tips and suggestions to the
public relations team.
with patients. However, any ideas,
positive stories or tips are greatly
appreciated. Our team is available
to take these suggestions and topics and convert them into published
content. Any ANJC doctor submitting
content would receive a by-line for
the story.
You will soon receive an outline
from our team at headquarters with
an editorial calendar for the next
year. This calendar will highlight specific editorial themes we will pursue
with our local news partners. A separate editorial calendar will be developed with the editors of the NJEA
publications.
For example, August would revolve
around back-to-school issues; the fall
for concussions, ergonomics and winter health tips, etc.
We feel by giving you an editorial
calendar you will get a feel for what
we are looking for, which may even
spark specific story ideas and give
you an opportunity to garner local
publicity by tailoring content to your
own local media.
This editorial calendar will extend
to the ANJC’s public Facebook page
that will be launched shortly.
As always, if you would like to
make editorial recommendations,
feel you have a good story to tell,
and would like to have ANJC frame
this up for you for distribution, please
contact ANJC HQ at [email protected].
20
Summer 2012 www.anjc.info
www.njchiropractors.com
Legal
By Jeff Randolph, Esq. –
ANJC General Counsel
Q: My employees sometimes discuss their jobs and patients at our
practice on social networking sites
such as Facebook or Twitter. Is this a
problem?
Yes, it could very well be a HIPAA
violation if the posts contain protected health information (PHI) of the
patient. The definition of PHI under
HIPAA is very broad and is defined
to extend beyond just patient clinical records to include the identity
of patients as well as other identifying information that would disclose
to third parties any aspect of their
medical condition or use of medical
services. The HIPAA rule defines
private health information as information, including demographic data,
that relates to: the individual’s past,
present or future physical or mental
health or condition, the provision of
healthcare to the individual, or the
past, present, or future payment for
the provision of healthcare to the
individual, and that identifies the
individual or for which there is a reasonable basis to believe can be used
to identify the individual. See, 45
C.F.R. §160.103. Such information
includes many common identifiers
(e.g., name, address, birth date, social security number). Every healthcare provider, regardless of size, who
electronically transmits health information in connection with certain
transactions, is a covered entity, and
must comply with the HIPAA privacy
rules. Thus, if the posts contain PHI,
they most likely violate the HIPAA
privacy rules.
Q: How can I make sure my practice and employees don’t violate
HIPAA when posting on social network sites?
You should implement a written policy at the practice, either
standalone or as part of your overall
Employee Policy Handbook, which
governs HIPAA and electronic communications. The policy, at a minimum, should mandate that all uses
and disclosures of patient identifying
health information should be carried out in a manner compliant with
applicable patient privacy policies,
regulations, and standards. It should
also require that, prior to sharing
patient identifying health information
or images through any social media
forums, the individual responsible for
the project involving the sharing of
that information shall obtain a written authorization for the use and
disclosure of the information from the
patient/patient’s legal representative.
The policy should further require that,
when discussing in any social media
venue any work-related issues, doctors or other employees must not talk
about patients, even in general terms
or in anonymous postings. They are
permitted to discuss conditions, treatment options, research or other topics
in general terms but with no specific
identifying information. Follow the rule
of thumb: “If you wouldn’t say it in a
crowded elevator, do not put it online.”
Q: My practice sometimes transmits patient protected health information via email. Do I need to have
some type of encryption or other protection to be HIPAA compliant?
Yes, if you are transmitting any
protected health information (PHI)
via email, the email should be encrypted so that third parties cannot intercept or view the PHI. The
National Institute of Standards and
Technology (NIST) and the AMA recommend using Advanced Encryption
Standard (AES) encryption with a
minimum of a 128 bit key. See, NIST
Special Publication – “An Introductory Resource Guide to Implementing the HIPAA Security Rule.” For
additional up-to-date information
on HIPAA and encryption, you can
visit the U.S. Health and Human Services website at: www.hhs.gov/ocr/
privacy. If you are like me and don’t
understand the technical aspects
of encryption, you should refer your
IT specialist to the NIST Resource
Guide and HHS website or hire an IT
specialist who is conversant in the
HIPAA Security Rules.
Patient Centered
Care: Clarification
and Application
By Jeffrey Sklar, DC
P
atient centered care is not
a unique concept to chiropractors. Moreover, patient
centered care is the tenet of most
practicing DCs. But, what defines patient centered care? If given a podium
or an opportunity for a two minute
elevator speech, how many chiropractors could easily summarize the core
values that make up a physician who
embraces a quality of care with unfettered focus on the patient?
Furthermore, what if the patient
was not just a typical chiropractic
case, but someone with a complexity of musculoskeletal issues combined with a cancer diagnosis. In
this scenario, the infirmed’s need
for a patient centered practitioner
could not be greater. As consumers
become driven toward a better paradigm of healthcare and more educated through the internet via blogs,
social media and physician review
sites, etc., physicians who are committed and convicted to empowering
patients in healthcare choices and
focusing on the whole person when
developing treatment plans will find
a very satisfied group of patients and
a very satisfying day of work month
after month and year after year.
Some of the key qualities that help
define a physician’s care paradigm
are (1):
1. Takes all symptoms into account
to formulate a diagnosis
2. Takes a thorough history of past
and current health conditions
3. Shows knowledge about latest treatments, medication and
research
4. Welcomes family members and
caregivers to play an active role in
patient care
5. Helps find solutions for complications or obstacles during
treatment
6. Offers advice to help patients and
care givers to become engaged in
the treatment
7. Collaborates and cooperates with
other practitioners that play a role
in the patient’s care
8. Makes information about agencies
that provide additional services
easily accessible and guides patients in utilizing those services
9. Speaks in a language that is nonscientific and easy to understand;
looks for patient facial expressions to make sure the patient understand the information; repeats
key aspects to make sure they are
understood
10.Presents as though he has all the
time in the world; in that moment,
the patient in front of them is the
only patient they have that day
11.Demonstrates consistency with
follow up care
In recognizing the special needs
of cancer patients, there should be a
focused effort of quality of life issues
that frequently challenge this patient
population almost daily. Moreover,
addressing areas that can affect optimal wellness may offer an effective
way of an enhancing performance
status with ADLs.
In a report titled “Patient Centered
Care and Breast Cancer Survivors
Satisfaction with Information,” Malinger, Griggs, and Shields found patient
satisfaction is improved when physicians incorporate patient-centered
behaviors into their care (1).
Additionally, in researching
evidence base for patient-centered
cancer care, Venetis and Turkiewicz
found that there is an evidence base
for the efficacy of patient-centered
care and that cancer specialists need
to train to improve their patient-centered communication (2).
Furthermore, when considering
how patient satisfaction factors into
Continued on Page 26
ANJC Webinar
Series Update
Free CEUs
ANJC posted a new series of webinars scheduled
July – Dec, 2012, provided as an ongoing member
benefit which includes free CEUs.
For more info contact HQ.
Dr. Mark Charrette’s webinar on Adjusting the Pronated
Foot was one of the best. He repeated important concepts
and his visuals made it very simple to understand. Thanks
for having him present.
Dr. Shar Dreicer – Red Bank
Summer 2012 www.anjc.info
www.njchiropractors.com
21
How to Get 100% Patient Compliance
By William D. Esteb
F
inally, what every chiropractor
wants: a new practice management tool. When used as
instructed it produces perfect patient
follow through.
Present a complete relief, rehabilitative and wellness care package spanning years and costing thousands and
get instant acceptance and compliance. Not only do patients comply, but
they’re on time for their appointments
and never object to rush hour waiting.
Implement this practice enhancer and
when you ask patients to bring in their
spouse and children they immediately
do so. Referrals? Ask and you automatically receive. Need more income?
Simply increase the recommended
visit frequency and every patient dutifully complies.
Finally the practice of your dreams!
Slow down. I don’t think this is what
you really want. In fact, upon further reflection you wouldn’t wish this scenario
on your worst enemy. Consider this:
Let’s say you’re a tennis player.
Several times a week you find a court
and play as many games as you can.
In fact, it’s the cornerstone of your
exercise program. As you watch your
game improve and become an increasingly better player, winning the
game becomes your primary focus.
It’s practically your preoccupation.
Over drinks at the juice bar where
you frequently play, a friend asks you
if you’ve heard about the latest sure
fire winning strategy. You perk up. “It
guarantees that you win every time,”
your friend explains.
“What is it?” you ask. “How much
does it cost? Does it really work?”
“Oh sure,” your friend reassures.
“When you use this technique you win
every time. You become a winning
machine.”
“Sounds great. How do I get one?”
You brighten, unable to hide your
enthusiasm.
“Well, it’s really quite simple,” your
friend smiles, “you just play seven
year-olds. You win every time! They
hardly ever return your serves. It’s a
slam dunk.”
Turns out 100% patient compliance
only sounds interesting because it
appears so elusive. You would quickly
become bored, reduced to nothing
more than a meat computer. The
joy and fulfillment of practice would
quickly disappear.
No, it’s the uncertainty of the
dance and creativity required to inspire patients that is what stirs your
heart and gives you the soul-satisfying sense of accomplishment.
Far too many chiropractors see
practice as a destination rather than a
process. As in, “I’ll be happy when...”
“I’ll be successful when...” “If I could
just...” Those who are having the most
fun realize that you never get there.
TRIAD/AETNA Update Letter
Continued from page 1
Instead, the objective is to keep the
game going. Because when you win,
you actually lose. You lose your excitement. You lose your vision. You lose
the need to rise to your best and practice degenerates into mediocrity.
If you’re not having fun or you’re
not enjoying the process of educating and caring for patients, inspiring
them to bring in others, take action:
Change careers. Does the grass
look greener somewhere else? If
your heart isn’t in chiropractic and
you think you can serve others in a
different capacity, go for it. If you’re
just going through the motions,
you’re shortchanging patients. In
fact, you’re stealing from them. If
you feel obligated only because of
your education or out of duty to your
mortgage payments, stop killing
yourself. Unless of course your idea
of a great tombstone is, “He never
missed a payment.”
Start over. This is a common approach among the more entrepreneurial minded. Sell the practice and
move somewhere else and start over.
For those who enjoy the adrenalinpumping days of start up and dislike
the maintenance of a business, this
may be a viable solution. Do remember though, you’ll take the problem
patients, the problem procedures and
the problem insurance carriers with
you wherever you go.
Sabotage the practice. This is a
favorite among those who find starting over too risky. Instead, they test
their practice. They saddle themselves
with a self-imposed handicap to make
things interesting. They try it without
patient education. They try it without
staff. They try it by practicing only two
days a week. They try it while dividing
their interest between their run for city
council or some other aspiration.
The juice of chiropractic comes from
the challenges and opportunities created by your relationships with patients
and your support team. It’s the people
part, not the clinical part that feeds
your soul. Oh, I’m sure the clinical part
is interesting, especially for the first
six or seven years. But at some point,
when you’re finally convinced that reducing nerve interference revives the
healing response, you can transcend
to the higher calling of attending to
people, not merely spines.
–––––––
William Esteb is the creative
director of Patient Media, Inc., a
patient communication resource for
chiropractors. He is a frequent guest
lecturer at chiropractic gatherings,
regularly makes blog posts at www.
patietmedia.com and has broadcast
his weekly Monday Morning Motivation
e-newsletter continuously since 1999.
Nutrition & Blood Chemistry:
Keeping it Simple & Effective to Improve Outcomes
May 10: Brooklyn, NY- 6 hr CEU
For more syllabus information please visit our website.
TRIAD/AETNA networks. We also
continue to receive information that
AETNA and TRIAD customer service
representatives continue to give doctors conflicting information with regard
to the program.
Realizing TRIAD’s long history of
complaints/appeals by patients and
their doctors, ANJC officials and consultants attempted to have a dialogue
with AETNA and Triad so that we could
provide clear and concise information
to its membership.
Further confusion and disorganization on TRIAD’s end caused their implementation to be delayed from May 1 to
June 1, 2012. Triad sent a FAX broadcast on April 24, 2012 (#188) that
stated, “The notice provided by Triad
did not contain sufficient detail from
which to make an informed decision.”
They also stated “Triad will begin
collecting and providing information
to providers by broadcast fax on a
regular basis over the next few weeks,
continuing through the implementation
date of June 1st.”
ANJC has polled various in/out of
network doctors throughout the state
and found that not one has received
any follow-up information from TRIAD
that they are “collecting and providing
information to providers.” Last week
AETNA sent a card suggesting providers call TRIAD for more questions
about the program. TRIAD representatives then provide conflicting informa-
tion to providers.
It is obvious that after several
attempts to get clarification from
TRIAD this program continues to be
confusing, unreliable, not fully explained and potentially destined to
cause additional problems and delays for patients seeking chiropractic
care and for the chiropractors treating these patients.
Providers throughout the state have
dropped from participating with TRIAD.
ANJC cannot tell you whether to stay
in or out of their network. That is a
personal practice decision that only
you can make.
We can tell you to examine this
potential relationship very thoroughly
and decide for yourself whether you
have been provided complete information and are completely satisfied as
to what is being offered with regard to
reimbursement, office visits, etc. before you make the important decision
of staying in or dropping out of their
network.
That said, we can tell you that
it has been a frustrating several
months attempting to work with TRIAD and although we had hoped they
would be more forthcoming with a
full explanation of the program, they
simply have not.
Should you receive any additional
comments orl information from AETNA
or TRIAD, please contact ANJC HQ immediately or email [email protected].
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22
Summer 2012 www.anjc.info
www.njchiropractors.com
Inflammation: Friend and Foe
PIP
Test Name
Q: Can an insurance company deny
an MRI ordered within the first 10
days post accident?
Although any treatment/testing
does not need pre-certification within
the first 10 days of an accident, medi-
cal necessity does apply. If the PIP
carrier deems the MRI not medically
necessary, they can deny it. Normally
for the typical chiropractic patient,
MRI’s are not done within the first 10
days. Exceptions do occur and there
are certainly times when the MRI
is necessary. It is recommended to
document in detail the need for the
study and be prepared to defend your
decision.
I
and 30 treatments per 365 days.
I received an EOB back from Medicare denying my claims based on
the documentation reviewed; what
are some of the reasons I could be
denied?
The more common reasons would
be:
Do the records show a neuromusculoskeletal condition/symptoms for
the regions documented?
Is there a precise subluxation
documented?
Does the exam on the initial visit
and subsequent visits substantiate
the condition and the subluxation?
Is there a primary and secondary
diagnosis that show a direct relationship to the level of subluxation?
Do you have a treatment plan with
frequency and duration of care and an
objectively measurable goal?
Do the records show that with continued care, one could reasonably expect significant clinical improvement
in the overall function of the patient?
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Outcome
Healthy Range
Clinical Range
98.00
Hi
80.00 – 95.00
65.00 – 99.00
6.00
C. Hi
4.60 – 5.40
4.80 – 5.90
Uric Acid
8.30
C. Hi
4.10 – 6.00
2.40 – 8.20
SGOT (AST)
14.00
Lo
15.00 – 26.00
6.00 – 40.00
SGPT (ALT)
14.00
Lo
15.00 – 26.00
6.00 – 40.00
GGT
22.00
Lo
23.00 – 39.00
6.00 – 65.00
Total Cholesterol
211.00
C. Hi
140.00 – 170.00
100.00 – 199.00
Triglyceride
71.00
Lo
80.00 – 115.00
10.00 – 149.00
HDL Cholesterol
52.00
Opt
50.00 – 55.00
40.00 – 59.00
VLDL Cholesterol
14.00
Opt
5.00 – 20.00
4.00 – 40.00
LDL Cholesterol
145.00
C. Hi
50.00 – 75.00
6.00 – 99.00
4.10
Hi
0.00 – 4.00
0.00 – 5.00
255.00
High
175.00 – 250.00
140.00 – 415.00
C-Reactive Protein
16.40
Critical
0.00 – 1.50
0.00 – 4.90
ESR
32.00
Critical
0.00 – 6.00
0.00 – 20.00
Vitamin D 25 Hydroxy
16.80
Critical
50.00 – 90.00
32.00 – 100.00
Platelets
Opt – Current result is optimal.
Hi/Low– Current result is higher/lower than the healthy range, but still within clinical ranges.
C. Hi/C. Low– Clinically high/low.
Critical – Critically high/low; is greatly outside the clinical range
• Low vitamin D—impaired ability
for the body to heal and repair
(creates an environment for chronic inflammation; low levels also
increase insulin resistance8)
By Dr. Richard Healy, ANJC Medicare Consultant
E-mail address: [email protected]
LEGAL
Hemoglobin A1C
Total Cholesterol/HDL
Q: If a patient has auto insurance
from NY and is treated in NJ, must I
follow NJ Decision Point Review?
If it is a NY policy, you do not have
to follow NJ DPR requirements. However, the NJ PIP fee schedule does
apply to billing and reimbursement.
Medicare
was told that in the new policy a
recurrence is now after 90 days,
not 30, when there is a return
of a condition or symptoms. Is this
accurate?
Yes, there was a revision to the
definition of recurrence and it is now
extended to 90 days. If there is a
flare-up of symptoms or a condition
being treated and it happens prior to
the 90 days, it would be considered
an exacerbation.
I understand there is a change in
the number of allowed treatments
based on the diagnosis reported; is
this in the new policy?
Yes, the new Medicare policy from
Novitas separates the ICD-9 diagnoses into four categories. These are
itemized in the policy and the number
of allowed treatments based on medical necessity ranges from 12 treatments in Group A to 30 treatments in
Group D.
In addition, the number of allowed
chiropractic adjustments/manipulations is 12 treatments per 30 days
Glucose
Blood Test
By identifying the underlying
causes of inflammation we can produce a more effective list of recommendations for the patient:
• DIET - certain foods can cause
inflammation such as processed
meats with MSG or nitrates (hot
dogs, sausages, etc.), sugar,
excess carbohydrates, dairy,
fried foods, high sodium foods,
coffee, etc. Other foods containing purines (alcohol, peanuts,
organ meats, soda, etc) will
increase uric acid levels making
the gout and inflammation worse.
A diet high in clean protein and
vegetables will help reduce
inflammation.
• EXERCISE - exercising at least
30 minutes, three times a week
will help reduce fat cells. Fat cells
produce cytokines, which create
inflammation. Studies have also
linked excess fat and inflammation with insulin resistance. 9
• NUTRIENTS - fish oil, vitamin D
and chromium to help with diabetes and insulin resistance
› ginger, vitamin C, vitamin
E, resveratrol and bromelain to naturally reduce the
inflammation
› multi-vitamin/mineral to replenish his body with nutrients
depleted by his poor diet
With the help of these recommendations, the patient was able to
make a great recovery. Within a few
months, his CRP dropped to 0.30,
ESR to 4.00 and Platelets to 188.
While chronic inflammation can be
damaging, the most important recommendation you can make for your
patients is to get a comprehensive
analysis. Combating the inflammation is a good start, but locating the
underlying source is the only way for
your patients to truly be healthy.
Endnotes
1
Gorman C, Park A, Dell K. Health: The
Fires Within. Time [Internet]. 2004 Feb
23 [cited 2012 Mar 10]; 5p. Available
from: http://www.time.com/time/
magazine/article/0,9171,993419,00.
html#ixzz1oY06ZkjK
2
Ross H. Statins and Inflammation.
LifeWire [Internet]. 2008 Oct 5 [cited
2010 Mar 10]; 1 p. Available from:
http://cholesterol.about.com/lw/
Health-Medicine/Conditions-and-diseases/Statins-and-Inflammation.htm
3
Gorman C, Park A, Dell K. Health: The
Fires Within. Time [Internet]. 2004 Feb
23 [cited 2012 Mar 10]; 5p. Available
from: http://www.time.com/time/
magazine/article/0,9171,993419,00.
html#ixzz1oY06ZkjK
4
Yeh E, Anderson H, Pasceri V, Willerson
J. C-Reactive Protein: Linking Inflammation to Cardiovascular Complications Circulation. 2001 [cited2012
Mar 10];104:974-975. Available from:
http://circ.ahajournals.org/content/104/9/974.full
5
6
7
8
9
23
Jeffrey Randolph, Esq.
– ANJC Insurance Consultant
Continued from page 17
By Dr. Michael Goione – ANJC Insurance Consultant
By Dr. Jeffrey Savitt – ANJC Insurance Advisor
Q: After being released from care,
a PIP patient returns one year later
with an exacerbation of the initial
injury. Is this still covered under the
PIP policy?
A patient has two years from the
date of last treatment to return to
care with coverage from the initial
accident. However, the provider may
need to prove the correlation to the
orginal injury. Also, there cannot be
correlation of the symptoms/diagnosis to a different or new injury.
Summer 2012 www.anjc.info
www.njchiropractors.com
Medline Plus. ESR [Internet]. 2011
June 1 [cited 2012 Mar 10]; 1p. Available from: http://www.nlm.nih.gov/
medlineplus/ency/article/003638.htm
George M. Platelets. Department of
Biostatistics & Epidemiology, College of
Public Health, OUHSC [Internet]. 2011
Feb 18 [cited 2012 Mar 10]. 1p. Available from: http://www.ouhsc.edu/platelets/Platelets/platelets%20intro.html
Winfried M. The Ludwigshafen Risk
and Cardiovascular Health Study. Circulation [Internet]. 2004 Oct 25 [cited
2012 Mar 10]; 110: 3068-3074. Available from: http://circ.ahajournals.org/
content/110/19/3068
Chiu KC, Chu A, Go VL, Saad MF. Am
J Clin Nutr [Internet]. 2004 May [cited
2012 Mar 10];79(5):820-5. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/15113720
Gorman C, Park A, Dell K. Health: The
Fires Within. Time [Internet]. 2004 Feb
23 [cited 2012 Mar 10]; 5p. Available
from: http://www.time.com/time/
magazine/article/0,9171,993419,00.
html#ixzz1oY06ZkjK
---------------------------------------Dr. Van D. Merkle is president of
Science Based Nutrition, is a certified
clinical nutritionist, and has been in
chiropractic practice for 25 years. He
serves as a Diplomat on the American
Chiropractic Board of Nutrition, a
Diplomat on the Chiropractic Board
of Internists, and is also a member
of The International and American
Association of Clinical Nutritionists.
For more information visit www.
nutritionpracticebuilder.com.
EASE
Reviewing Your Managed Care
Participating Provider Contracts
S
urprisingly, many doctors have
signed participating provider
agreements with healthcare
insurers to become in-network providers without ever having read the
contract. Later, when their bills are
denied or paid at levels well below
what they expected, they find themselves contractually bound to accept the carrier’s reimbursement or
lack thereof. The following are some
general topics to keep in mind when
you are reviewing a managed care
participating provider contract and
deciding whether to sign the agreement. The ultimate decision will be
your own based on your own specific
situation. However, at least read
the agreement before signing it and
know what you are getting yourself
into. These topics will be addressed
in more detail at the ANJC Fall Convention, which you would be remiss
in not attending.
The rationale behind becoming a
participating provider with a healthcare network is that you agree to
accept reduced fees in return for a
volume of patient referrals by “being
in the book.” However, the volume
of referrals must justify the reduction in your fees to make becoming
a participating provider economically
feasible. You must do this analysis
based on your own practice structure
and revenues to make an informed
determination as to whether it is
economically feasible for you to go
in network or be an out-of-network
provider.
First and foremost, find out what
the size is of the discount you are
agreeing to. Obtain a copy of the
network fee schedule and compare
to the rates you are receiving out of
network and from other insurance
payors such as PIP, Medicare, etc.
Determine how much it costs you
in both fixed and variable expenses
to treat a patient (your Relative
Value Unit or RVU) and compare it
to the fee schedule reimbursement.
If the fee schedule reimbursement
is higher than your RVUs, it may be
economically feasible for you to participate. If not, it may not be.
Next, calculate the other values of
being in network such as: i) adver-
tising by the network; ii) financially
incentivized patients who have less
cost sharing obligations such as copay (vs. out-of-network coinsurance)
and deductible amounts; iii) an
improved authorization process; iv)
reduction in collection costs, and v)
direct payment by carrier, which will
avoid the time and cost of having
to chase your patients to obtain the
insurance reimbursement checks the
carrier sends directly to them. Include these savings in your analysis
to see if it is economically feasible
to participate.
You must also undertake an analysis as to what your expected volume
of referrals will be from being in
the book and add these increased
projected revenues to your calculations. On the other hand, you must
also take into account whether patients will discontinue care if you are
out-of-network or if they will remain
patients in the face of higher outof-network cost sharing obligations.
This is your patient attrition rate.
Poll a sampling of your patients to
estimate your attrition rate and see
Insurance
PIP COLLECTION SPECIALISTS
Family owned and operated for 18 years
Over 75 million dollars collected
Serving over 100 medical providers
By Dave Klein, CPC, CHC – ANJC Insurance Consultant
1. What codes can I use when I give
a patient a cold/warm wrap for
home use?
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. 2. Do we need to go electronic/paperless by 2014 for our notes and
documentation?
No. However for 2015 and later,
Medicare-eligible professionals who
do not successfully demonstrate
meaningful use of a certified EHR
software will have a payment adjustment to their Medicare reimbursements. The payment reduction starts
at one percent and increases each
year that a Medicare-eligible professional does not demonstrate meaningful use, to a 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.
3. What is the New Jersey state law
regarding the use of ultrasound
in the chiropractic setting? Does
this modality have to be used by a
licensed person, such as doctor,
physical therapist, medical assistant, nurse etc.? Or can it now be
used by a non-licensed individual
as long as a licensed doctor or
individual is on site and present?
According to N.J.A.C. 13:44E – 2.7
the answer is simply no. The regulation actually states the following:
(c) A licensee shall not permit an
unlicensed assistant to:
5. Administer the following physical
modalities:
i. Ultraviolet (B and C Bands) or
electromagnetic rays including,
but not limited to, deep heating
agents, microwave diathermy,
short-wave diathermy and
ultrasound
ii. Electro-therapy devices powered
by an alternating current or any
interferential devices as set
forth in NJAC 13:44E 2.7A; or
iii. Decompression therapy devices or mechanical traction,
except non-fulcrum mechanical
traction without restraints;
6. Administer therapeutic, rehabilitative or strengthening exercises; or
7. Perform any task or function for
which the skill, training and judgment of a licensed chiropractor
is required to safely and competently perform such task function.
if it is something your practice can
absorb if it occurs. Add this factor to
your overall analysis.
In the end, you will have to make
a practice-specific decision as to
whether to participate or not. There
is no easy black and white answer
and the analysis is, unfortunately,
based on many assumptions and
best guess projections—not an exact science. If you decide to participate, most participating agreements
permit the doctor to terminate the
contract if it turns out to be a bad
business decision. However, many
of these contracts have extended
notice of termination and wind down
provisions that could result in it taking up to one full year to completely
terminate your participation. Thus,
this is an important decision that
you should make with the assistance
of trusted advisors, such as an accountant who specializes in representing healthcare, and a healthcare
attorney.
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24
Summer 2012 www.anjc.info
www.njchiropractors.com
Brother, Can You Paradigm?
With the New
Doctor in Mind...
By Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC – ANJC Research Advisor
H
aving barely avoided an economic meltdown—a repeat
of the Great Depression—it’s
worth reflecting on the research
accomplishments and directives in
both mainstream and alternative
medicine and, like the classic lyrics of the 1931 mantra of the Depression (“Brother, Can You Spare
a Dime?”), to wonder if all have
been rightfully given their due of
recognition.
The Institute of Medicine tells us
that it typically takes 17 years for
a new, validated, efficacious, and
safe discovery to find its way into
standard clinical practice.1 Typically,
but not always. You have to scratch
your head in bewilderment over such
instances as the following:
1. Minimally invasive technologies for the treatment of benign
prostatic hyperplasia are in widespread use, yet no clinical trials
have been performed to compare
the risks and benefits of these
treatments with standard surgical
interventions.2
2. The Medicare program has spent
millions of dollars each year for
the home use of special beds for
patients with pressure ulcers,
despite the fact that no well-designed study demonstrates that
they improve the healing of these
ulcers.3
I mean really? Besides this double
standard which regrettably shows up
all too often in medical practice, there
is simply the basic problem in healthcare where rigor, so often assumed
to be the gold standard in research,
bypasses the equally importance
concept of relevance. Simply put by
Tanenbaum 17 years ago, “Unfortunately for the applied-science model
of medicine, rigour and relevance not
only compete but are fundamentally
irreconcilable. Patients are complex
and particular...[and] are routinely
rejected from RCTs when complicating conditions threaten statistical
relationships, no matter how much
more physicians see complicated than
uncomplicated cases.”4
Put in concrete terms, to assume
that the entire range of clinical treatment to any modality has been captured by the precision of analytical
methods in the scientific literature
“would be like saying that a medical
librarian who has access to systematic reviews, meta-analyses, Medline, and practice guidelines provides
the same quality of healthcare as an
experienced physician.”5
But does all this mean that the
science jocks, research wonks, and
policy freakazoids have no place in
designing healthcare research? Absolutely not. It is more a matter of
admitting what actually takes place
in both the sciences and clinical
practice and build a meaningful paradigm from there. It’s not as if clinical
practice has all the answers, either.
For, as NC David has suggested,
clinical practice seems to consist of
(1) a few things we know, (2) a few
things we think we know [but probably don’t], and (3) lots of things we
don’t know at all.6 Obviously, help is
needed here.
This sets the stage for realizing
that, for a truly meaningful delivery
of healthcare services to take place
in which the patient really does matter, we should consider that there
are basically two clinical reasoning
strategies that work in parallel fashion. The first, which is the standard
for all classical medical services, is
diagnostic, which is the formation
of a diagnosis related to a physical
disability and impairment with the
consideration of associated pain
mechanisms, tissue pathology, and
the broad scope of contributing
factors. This is called procedural
management. The second, for the
first time considering context, is
the apprehension and understanding
of a patient’s illness experiences,
“stories,” contests, beliefs, and cultures. It requires both the organiza-
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tion of biopsychosocial knowledge
with communication skills, as well
as the understanding of a patient’s
meaning and perspective. Known as
narrative [communicative] management, it is acquired, having evolved
from a combination of personal,
societal, and cultural experiences.
Both conscious and unconscious interpretations and emotions coalesce
to make up views and feelings.7 It is
this second strategy that so often
characterizes the objectives of so
many branches of alternative medicine, the latter thankfully becoming
more widely recognized—with a long,
long ways to go.
Tracking this thesis-antithesissynthesis dialectic further, Jeremy
Swayne presents a more balanced
view in which one is not to argue for
less science, but rather for more and
better science—better in the sense
of being better attuned to the rest of
life. Essentially, there seems to be
an unfortunate preoccupation with
learning to control the processes
that go wrong rather than learning
more about enabling the processes
to put things right 8 In other words,
wellness has been overlooked.
In his book Remodeling Medicine,
Jeremy Swayne has argued in conformity with my own viewpoints in
that traditional medicine imparts
a degree of untruthfulness when it
presents a diagnosis (a description
of what is going on) rather than the
explanation of why something is
what it is.9 Ignored is the therapeutic effect of the doctor as well as the
self-healing powers of the patient.10
Rather, new paradigms of research
and evidence-based medicine that
admit (1) modifications of the traditional RCT design, (2) the basic sciences, (3) whole systems research,
(4) comparative effectiveness research, (5) qualitative research, (6)
cost-effectiveness issues, and (7)
observational studies including case
studies and case series, all need
to be admitted into the pantheon of
medical evidence. Fortunately, I have
had the opportunity to explore in
some detail this reconstruction of evidence-based medicine elsewhere.11
It comes down to making a distinction between canonical vs.
conceptual thinking. The danger, according to Champion, is that in traditional approaches to evidence-based
medicine, which are solely based on
randomized controlled trials and systematic reviews, they create a situation in which the rationale behind
decisions is not explained. Critical
appraisal is discouraged. And clinical
pathways end up resembling instruction manuals, in which users may develop technical proficiency but lose
their conceptual reasoning skills.12
Put into daily use, canonical thinking regrettably manifests itself every
time you see a cashier struggling to
make change, incapable of applying
simple manual arithmetic since he
or she has become fully dependent
on an electronic calculator. In civil
aviation, it gets worse. Here there
are instances in which pilots have
been found to revert to autopilots
or flight manuals instead of deriving
creative solutions to unanticipated
emergency situations.13 Indeed, the
lack of manual flight proficiency is
believed to have contributed to the
horrific crash of Air France Flight
447 on June 1, 2009 en route from
Summer 2012 www.anjc.info
www.njchiropractors.com
Rio de Janeiro to Paris with the loss
of 228 lives.14,15
The take-home moral of this story
is never to discount the experiential
component of both the sciences
and clinical expertise. It is precisely
where both schools of thought originated and where they harbor the
most creativity—to say nothing of
vitality.
References:
1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the
21st Century Washington, DC: National
Academy Press, 2001.
2. National Institutes of Health-OER
Home Page. Minimally invasive surgical therapies treatment consortium for
benign prostatic hyperplasia. Available
at http://grants.nih.gov/grants/guide/
rfa-files/RFA-DK-01-024-html. Accessed
July 5, 2002.
3. Centers for Medicare and Medicaid Coverage. Air-fluidized beds for pressure ulcers. Available at http://www.cms.hhs.
gov/coverage/8b3-q6.asp. Accessed
July 5, 2002.
4. Tanenbeaum S. Getting there from here:
Evidentiary quandaries of the US outcomes movement. Journal of Evaluation
in Clinical Practice 1995. 1(2): 97-103.
5. Horwitz RI. The dark side of evidencebased medicine. Cleveland Clinic Journal
of Medicine 1996; 63: 320-323.
6. David NC. Grey zones of clinical practice: Some limits to evidence-based
medicine. Lancet 2995; 345: 840-845.
7. Jones M, Grimmer K, Edwards I, Higgs
J, Trede F. Challenges in applying best
evidence to physiotherapy practice: Part
2: Health and clinical reasoning models
to facilitate evidence-based practice. Internet Journal of Allied Health Sciences
and Practice 2006; 4(4): http://ijahsp.
nova.edu.
8. Horrobin D. Medical Hubris: A Reply to
Ivan Illich. Edinburgh: Churchill Livingstone, 1978.
9. Swayne J. The problem with science:
The context and process of care. An
excerpt from Remodelling Medicine.
Global Advances in Health and Medicine
2012; 1(1): 76-85.
10.Dixon M, Sweeny K. The Human Effect
in Medicine. Oxford: Radcliffe, 2000.
11.Rosner A. Evidence-based medicine: Revisiting the pyramid of priorities. Journal
of Bodywork and Movement Therapies
2012; 16(1): 42-49.
12.Champion B. Clinical pathways: A departure from medicine. Medical Journal of
Australia 2012; 196(2): 96.
13.Scott M, Sampson J, Crowch T. Automation pilots as machine-minders or as
professional aviators? Aviation Today
2005; 25 Apr.
14.Interim report No. 3 on the accident on
1 June 1009 to the Airbus A330-203
registered F-GZCP operated by Air France
Flight AF 447 Rio de Janeiro-Paris. Bureau d’Enquetes et d’Analyses pour la
securite de l’aviation civile 29 July 2011.
http://www.bea.aero.docspac/2009/fcp90601e3.en/p/df/f-cp090601e3.
en.pdf. Retrieved 17 December 2011.
15.Clark N. Report on Air France Crash
Points to Pilot Training Issues. The New
York Times 29 July 2011. http://www.
nytimes.com/2011/07/30-world/europe/air-france-flight-447-crash-reportjuly 2011.html.
25
By Dr. Jim Campbell
Triad of Patient Compliance
A
s chiropractors, we are all
befuddled by the patient. For
years I’ve said: “Getting people better is the easy part..getting
them to let me help them is the tough
part!” After 24 years of practice,
I’ve seen just about everything—I
hope! For example, the patient who
has been everywhere else and finally
comes in to see you and gets great
results!! And then quits after two
weeks when he was just starting to
really make progress. Or the patient
who couldn’t hear out of his right ear
until you started adjusting him!! Then
his insurance plan changes and, well
you know the story.
So why do patients treat, pay, and
refer in your office? Why do they follow through or quit too early? The
answer, unfortunately, can be quite
complex. For instance: was the patient referred in, or did they come
to you simply because you were on
their insurance list? Are you doing a
perfect report of your findings? Is it
short, to the point, and in a language
the patient can understand?
Remember, they only want to
know:
1. What’s wrong with me? 2. Can
you help me? 3. Is it going to hurt? 4.
How long will it take? 5. How much
will it cost?
Answer these questions and you will
greatly improve compliance. Do it perfectly and succinctly and you will really improve compliance. You need to
practice your ROF, constantly improve
it, and rehearse it with your staff.
Assuming that you have everything
else in place, what motivates the patient to be compliant with their treatment plan? Over the years, I’ve come
up with a concept that I call the Triad
of Patient Compliance. It’s broken
down into three components:
Time – Symptoms – Money
To illustrate how this works, let’s
say a new patient comes in and he
or she is in a lot of pain. Do you have
to call them the next day to remind
them of their appointment? Is their
$50.00 co-pay an issue? Do they
say, “I just can’t make it in today because I have a hair and nail appointment?” Of course not. When, may
I ask, do patients start to miss appointments, grouse about their fees,
or ask when they’ll be done with
your care? When they begin to see
improvement of course. So let’s see
what we can do to try to mitigate or
even avoid these issues.
First in the Triad of Compliance is
the issue of time. Quite simply, when
patients are in their cars driving to
or near your office they are doing
a quick calculation in their heads:
“How long will I have to wait in the
office, and how long is the treatment?” They then decide whether
the amount of discomfort
iversare
th Annthey
ary
in is worth the amount of time that
it takes to be seen. Whether we like
it or not, this calculus occurs prior
to each visit to your office. So what
can be done? As I’ve said in previous
articles, the number one use of time
on a visit is needless conversations
from the doctor. Simple fix: never talk
about anything other than the patient’s health—never about yourself.
60
Another issue is treatment time. If it
only takes you 30 seconds to adjust
your spouse, then why does it take
10 minutes to adjust your patient. We
have complete control over the time
spent in our offices by our patients:
be efficient!
Money: If a patient has to pay at
each and every visit for your care
than this will dissuade them from
completing their care plan. Find a
way to avoid this by getting their permission to have a credit card on file
to bill for their visits on a weekly or
monthly basis, or find some other way
to make it more convenient for them.
If you can remove the first two of
the three Patient Compliance Triad
issues from the equation, then all you
have to do is deal with the third issue.
Symptoms: Many doctors have
and enjoy acute care practices.
They are available seven days per
week for emergencies. While chiropractic works great for acute
pain, I think that it works even better for correcting, supporting, and
maintaining our patient’s health.
Over the years I have built a large
supportive care type of practice
for patients who, for the most part,
are doing well and wish to stay that
way. I also have an army of symptomatic treaters who can walk in or
call in anytime, during my normal
office hours, when they feel they
need my care.
The bad news about building this
type of practice is that it takes time,
and you build it one patient at a time.
You will need to be humble, grateful,
and practice with caring and love in
your heart. The great news about this
type of practice is that it is not based
on symptoms only, and over time
you can build the practice of your
dreams!
–––––––
Dr. Campbell has been in practice
in East Brunswick for 22 years.
He is a Diplomate in Chiropractic
Acupuncture, and serves on the ABCA
board as their treasurer. He also
currently serves on the ANJC Board
as 2nd VP. For more info email drc@
campbellchiro.com.
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References for the published peer-reviewed scientific research papers:
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2. Stude DE. JMPT 23 (3) April 2000
6. Zhang, J. J of Chiropractic Medicine June 2007 6:2, 56-65
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7. Jensen B. J Chiro Ed 2007; 21(1):109
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Summer 2012 www.anjc.info
www.njchiropractors.com
We’ve Made PRACTICING Chiropractic EASIER
ANJC Announces Hiring of
Diane Philipbar as Assistant
Executive Director
A
NJC announced the hiring of
Diane Philipbar as Assistant
Executive Director. She will
report to Dr. Sigmund Miller, ANJC
Executive Director, and the ANJC Executive Board.
Diane was chosen for her extensive experience in working with professional associations over the past
17 years, working with volunteer
leaders, developing career services
and chapter/component relations
programs and human resources
management. She joins the ANJC
from a position at Sovereign Bank in
Bethlehem, PA where she served as
a Human Resources Recruiter III, re-
sponsible for sourcing, recruiting and
placing corporate banking personnel for positions at all organization
levels.
“The ANJC Board is extremely
pleased to add someone with the
extensive attributes and career experience of Diane Philipbar to our
growing Association,” said Dr. Joseph
D’Angiolillo, President of the ANJC.
“Her expertise in working with Associations will be a tremendous asset to our Executive Director Dr. Sig
Miller, allowing the ANJC to continue
to provide solid educational and career advancement programs for our
member doctors.”
Welcome New Members!
Dr. Dan Altman
Dr. Sherin Bourne
Dr. John Brow
Dr. Donna Cantalupo
Dr. Beau Casey
Dr. Matthew Corbo
Dr. Sean English
Dr. Karim Faris
Dr. Thomas Federico
Dr. Robert Gleason
Dr. Robin Linster
Dr. David Maffei
Dr. John O’Conner
Dr. Brian O’Mullan
Dr. James O’Rourke
Dr. William Puglisi
Dr. John Puleo
Dr. Todd Schragen
Dr. Andrew Sokol
Dr. Carl Spinelli
Dr. David Stephens
Dr. Robert Wood
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
latest effort to keep you updated and informed. The Association of New Jersey Chiropractors - The kind
of association you’ve been aching for!
ANJC Leadership
ANJC Elected Officials
• Dr. Joseph D’Angiolillo
President
• Dr. Michael Kirk
Vice President
• Dr. Jim Campbell
2nd Vice President
Executive Director
• Dr. Sigmund Miller
ANJC Appointed Officials
• Dr. Richard Healy
Treasurer
• Katherine Lusk
Editorial Assistant
Immediate Past President
• Dr. Steven Clarke
ANJC State Board Members
Central
Dr. Bob Blozen
Dr. James Campbell
Dr. Joseph D’Angilillo
Dr. Kostantinos Linardakis (Alt.)
South
Dr. Barry Coniglio
Dr. Michael Kirk
Dr. Blaise Glodowski
Dr. Brett Wartenberg (Alt.)
Northwest
Dr. Don DeFabio
Dr. James Fedich
Dr. James Santiago
Dr. David Graber (Alt.)
Northeast
Dr. Steven Clarke
Dr. Tom D’Elia
Dr. Joseph Garolis
Dr. Robert Haley (Alt.)
Council
Dr. Larry Marchese
Dr. Alan Vargas
Dr. Lenny Siskin (Alt.)
Committee Chairs

• Dr. Joe D’Angilillio
Legal Advisory
• Dr. Robert Blozen
COCSA Rep
• Dr. Richard Healy
Medicare Consultant
• Dr. Steven Clarke
Legislative
• Dr. John Cerf
Hospital Protocol
• Dr. Marc Jenkins
Sports Council
• Drs. Mark Spratford
Joe Garolis
Communications
• Dr. Tom D’Elia
Insurance
• Dr. Barry Coniglio
Rules and Regulations
• Dr. Joseph Garolis
NJ Board of Examiners
• Dr. Steve Zodkoy
Nutrition
• Dr. Frank Zaccaria
College Liason
• Dr. Mark Magos
Senior Advisory
Advisors

Consultants
• Dr. Richard Healy
Finance
• Dr. Joseph D’Angiolillo
Executive Committee
• Dr. James Fedich
HQ Committee
• Dr. Mike Kirk
PR Committee
• Dr. Richard Fellows
PAC Committee
• Dr. John Hamada
Work Comp Committee
• Jon Bombardieri
Lobbyist
• Lyndette Contreni
Insurance Consultant
• Dave Klein, CPC, CHC
Insurance Consultant
• Chip Dutcher
Regulation
• Tom Cosentino
PR Consultant
• Dr. Mike Goione
Insurance Consultant
• Anthony Rosner, PhD
Research Consultant
ANJC Vision & Mission
Vision: To position Doctors of Chiropractic as providers of first choice for New Jersey families to obtain
optimal health and wellness, while improving the quality of their lives.
Mission: To improve the health of patients, families and communities by promoting high standards of
professionalism and patient care through chiropractic methods, education, advocacy and accountability.
Association of New Jersey Chiropractors
3121 Route 22 East, Suite 302 • Branchburg, New Jersey 08876
908.722.5678 • 908.722.5677 – fax
www.anjc.info • [email protected]
Prior to her role at Sovereign Bank,
she was VP, Career Services and Human Resources with Financial Executives International in Morristown, NJ,
a non-profit professional membership
association for senior-level financial
executives with 15,000 members.
She joined the firm in 1994. She
also served as Interim VP/Director of
Membership & Chapter Relations, with
direct oversight of all membership recruiting/retention activities, chapter/
component relations for 75+ chapters
across the US, and revenue generating programs, as well as serving as
Director, Career Services and Human
resources from 2001–2007.
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Diane has also held positions as
Recruiter with Analysts International
Corporation in Livingston, NJ, Recruitment Sales Representative &
Coordinator with Cahners Publishing
(now Reed Elsevier) in Roseland, NJ
and Alumni Coordinator for the County College of Morris in Randolph, NJ.
Diane holds a Bachelors of Arts in
Communication Management from
the College of Saint Elizabeth in Morristown, NJ and an Associate of Arts
in Journalism/Communication from
the County College of Morris. She is
a member of the Society of Human
Resource Management (SHRM). She
resides in Bethlehem, PA.
Patient Centered Care:
Clarification and Application
Continued from page 20
Makes information about agencies that provide
additional services easily accessible and guides
patients in utilizing those services
QOL, it is important to remember that
some key aspects of optimal wellness
such as social, spiritual and physical
factors play an important role with
QOL. A Japanese study that utilized
the commonly administered European
Organization for Research and Treatment of Cancer Core Questionnaire
(EORTC QLQ-C30) looked at socioeconomic, physical and spiritual concerns of cancer survivors and found
that QOL was negatively impacted at
significant levels (3).
With a spotlight on patient satisfaction and how it relates to economic growth by way of patient referrals,
a German study revealed that when
areas of shared decision, improved
doctor-patient communication, and
organization of care are substandard,
QOL can be significantly impaired. It
is pointed out that patient-provider
relationship, facility setting, and information on diagnosis and treatment
options are major determinants of a
patient’s willingness to recommend a
facility to a friend or relative if needed (4). This is valuable take away
information.
It could be argued that many chiropractors treat beyond the physical
aches and pains of the neuro-musculo-skeletal system, and that by the
physical touch chiropractors provide,
a window of intimacy between doctor and patient opens. This provides
an opportunity to facilitate an optimization of health through engaging
patients. By listening and offering
education, doctors help patients
internalize the concept of patient
centered care. This ultimately can improve QOL whether a patient suffers
from a sports injury, an auto accident
or something as severe as cancer.
In simple language, patient centered care focuses on the patient
not only 100% of the time during
the clinical encounter, but in follow
up and collaboration with other providers. Whether the case is one of
prevention or intervention, the more
physicians practice with this model
of care, the more effective healing
will occur.
References:
1. Adapted from Jeppson, E. Thomas, J.
(1994). Essential Allies: Families as Advisors, Patient-centered care and breast
cancer survivors’ satisfaction with information. Mallinger JB. Griggs JJ. Shields
CG. Patient Education & Counseling.
57(3):342-9, 2005 Jun. [Journal Article.
Research Support, Non-U.S. Gov’t]
2. An evidence base for patient-centered
cancer care: a meta-analysis of studies
of observed communication between
cancer specialists and their patients.
[Review] [78 refs] Venetis MK. Robinson JD. Turkiewicz KL. Allen M. Patient
Education & Counseling. 77(3):379-83,
2009 Dec. [Journal Article. Meta-Analysis. Review] UI: 19836920
3. Effects of socioeconomic factors and
cancer survivors’ worries on their quality of life (QOL) in Japan. Kobayashi K.
Morita S. Shimonagayoshi M. Kobayashi
M. Fujiki Y. Uchida Y. Yamaguchi K.
Psycho-Oncology. 17(6):606-11, 2008
Jun. [Journal Article. Research Support,
Non-U.S. Gov’t] UI: 17972358
4. Patient satisfaction and quality of life
in cancer outpatients: results of the
PASQOC study. Kleeberg UR. Tews
JT. Ruprecht T. Hoing M. Kuhlmann A.
Runge C. Supportive Care in Cancer.
13(5):303-10, 2005 May. [Clinical Trial.
Journal Article. Randomized Controlled
Trial. Research Support, Non-U.S. Gov’t]
–––––––
Jeffrey Sklar, DC is Regional Director
of Chiropractic Services at Cancer
Treatment Centers of America in
Philadelphia. He serves on the ACA
Health Promotion and Wellness
Committee. He is also a district
board member for the Pennsylvania
Chiropractic Association. For more
information email [email protected].
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