Mastering Chiropractic Documentation: An Exploration with Dr. Gregg Friedman

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Welcome to the Activate your Practice podcast.
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I'm Dr Four.
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Data always wins.
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Hello, I'm Dr Arlen Four and welcome to Activate your Practice.
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This morning I have the honor of having a friend of mine here who is an expert in documentation, dr Greg Friedman.
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Welcome, greg, good to be here.
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We have known each other for quite some time and we're friends in the summer.
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We have summer houses in the same area.
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So Greg has been a real good friend and he has so much to offer that I ask him to do a podcast because he did a documentation series 12 Hours of Continuing Education and I want to get this out to more people because the reports that we've gotten back after the people have taken the documentation course have been just fantastic.
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So I ask him to write me a few questions that were important in the documentation area, and so I'm going to start right at the top.
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Greg, people come in and say I have a cash practice.
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I've heard that you don't have to document much.
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What say you.
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So that has been bothering me for decades and it seems to be only chiropractors that have that particular attitude.
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I have never met any other kind of doctor that would even think that, let alone say that out loud.
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So I always like to tell doctors this up front documentation is not an insurance thing, it's not a PI thing, it's not a cash thing, it's a doctor thing.
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There is one way we're required to document period and it absolutely does not matter who is paying for the services.
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So it is.
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That is one thing that it's.
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Every time I hear it, I'm like is there somebody teaching chiropractors this?
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That you don't have to do this if you're a cash practice?
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I've even seen personal injury instructors around the country, one of whom, well, I won't go further into that, but they actually tell doctors that they don't have to do certain things.
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And I reviewed a case one time for a particular state and I'm like, wait a minute, that's not true.
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And I got the statute that they were citing and I passed it by the board and they're like, yeah, that's not true.
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So I don't know where this is coming from, but it is absolutely.
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This is one of those things that transcends every kind of practice Documentation is a doctor thing, not a who's paying for the services thing.
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You know and you mentioned PI and cash and all that, but I hear more people say I'm afraid of being audited by Medicare.
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Right, doctors are so afraid of being audited by Medicare and the reality is, I think maybe your risk of audit by Medicare is so low it's maybe 2% or so.
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It's just that you don't want to be in that 2% and you don't know if you're going to be that random one selected.
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So everybody's nervous about it, and I tell doctors this, and I speak with other people in this space that educate chiropractors that we all joke about it Documentation based on the Medicare requirements and, by the way, cms centers for Medicare and Medicaid services.
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They create the rules for all documentation, thank you.
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And again, it does not matter who's paying for it.
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So this applies to even the non-medicare patients.
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It's everybody.
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So the interesting thing is, when we talk about a Medicare automate, this is so easy.
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If you just understand what the requirements are and how we can do it and how we can do it quickly, you could take care that you will never have another stressful day, another sleepless night.
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And on top of that, if you do the same format for every single patient, you're going to be fine.
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No matter what set of guidelines, no matter what set of rules or requirements or restrictions they throw at you, you're going to be fine, because every one of these is based on these CMS rules.
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What's the number one thing that carpenters miss in their documentation?
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Now, believe it or not?
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This really surprises me.
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The one thing that we should be focusing on is the one thing that's misdramatically, and that is how our patient is improving with our care.
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I mean, you would think that carpenters would be all over that, because we suspect that carpenters get phenomenal outcomes.
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Right, we suspect that, but carpenters are so unbelievably bad at showing that.
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Now there's a couple of things to understand, though.
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There is a few simple requirements on the right way to show that, so it's not just showing it the way that you think you want to show it.
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There's a couple of very simple requirements.
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As long as we do that, we can determine if more treatment is justified or not, if we need to refer out co-manager or whatever.
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But I hear from these carpenters, like in personal injury stuff, they say oh Greg, if I do that, then I'll never get past forward.
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I'm like, are you kidding me?
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I said I see personal injury patients and I'm constantly looking at these specific metrics, and I may see patient for months, but I have every justification for that, because I know exactly what it is that we're looking for.
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You said there were a couple of things.
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Yeah, so there's only three metrics that we're looking for.
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Now, keep in mind, I've reviewed records of carpenters for years and I've done it for insurance companies too, so don't get mad at me.
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But there are three metrics that are required of carpenters, and this again is coming from CMS Centers for Medicare and Medicaid Services.
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So this applies to not just your Medicare patients, it applies to all active patients, and I just use the word active so as not to confuse you with a maintenance or wellness patient.
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That's a little different, but not too much so for the active patient, here are the three metrics you ready.
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Number one we have to assess pain for each condition that we're treating and on every visit.
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Now there's two ways to assess pain.
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One is to assess it was to have the patient rate the intensity of the symptom on every visit.
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But another way that a lot of doctors are missing is to have the patient rate the percentage of time that they're noticing that particular complaint.
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So a lot of carpenters will document the rating the 0 to 10, which is terrible by itself, because carpenters or patients are terrible at this.
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We know it's subjective, and the problem, and what I teach them by 7 hours now, is that, look, don't even bother saying to your patient on a scale from 0 to 10, with 10 being the worst pain imaginable, because nobody gets it.
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Because they look at me.
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They look at me and they say, oh yeah, I'm a 10.
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And I say, no, no, you're not a 10.
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And they go no, no, I'm a 10.
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And I'll say, no, a 10 is the worst pain imaginable.
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And they go yep, that's me Worst pain imaginable.
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I think people don't really understand what worst pain imaginable means, so they just think that's their worth.
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So now I tell it differently.
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I said OK, give me mild, moderate or severe.
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They sort of understand that.
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But before you answer I'll tell them I'm going to eliminate the severe category, sister off the table.
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And they say why.
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I said severe is reserved for those people who are at or on the way to the hospital.
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That's severe.
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So I'll look at the page and they say are you on your way to the hospital?
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They go no, it's not that bad, it's not severe, mild or moderate.
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And then when we get the actual, the correct category, now we could define this scale so mild between a one and a three, moderate, between a four and a seven and for those rare ones that are severe.
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That would be between an eight and a 10.
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But I'm telling you as a reviewer, whenever we see anything that's eight or above, we are rolling our eyes at you and just shaking our head.
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This is not good.
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But the other part of it is the frequency, because if you're only documenting the intensity of each symptom and not the frequency, it is very reasonable to consider that that intensity might not change very much for a little while, maybe for a few weeks.
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So maybe it's a six out of 10.
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And what do you have?
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For two weeks, six, six, six, six, six, six, six.
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Is that showing any improvement?
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No, but the frequency.
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The frequency might be going from 100% on the time to 95%.
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That's not a lot of improvement, but it's some.
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And maybe the next visit to 90%, a little more improvement, and the next visit to 85%, a little more improvement.
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That's a really powerful way of showing improvement, even when the intensity may not be changing.
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But some of the many of the chiropractors that are doing this and a lot of the software programs are actually forcing you into a weak position by having you document occasional, intermittent, frequent and constant, and the problem is, each of those categories is 25 points broad and it could take a couple of months for your patient to go from one category to the next.
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That's not helping you because for those two months you're documenting constant, constant, constant, constant, constant.
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Now those those categories might work okay for doctors who see the patient infrequently, like your primary care doctor.
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They see the patient once they're in the constant category.
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Take this medication, I'll see in three months.
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They came back in three months later.
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Oh, it's frequent.
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Now you're improving.
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That is okay for them.
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But for us, when we see the patient frequently, it's terrible.
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We're just showing that the patient is not getting better, when in actuality they probably are.
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It's a time thing, yeah, yeah, time thing, yeah.
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The third metric only needs to happen on the first visit for each condition and then every 30 days or sooner, and that is a functional outcome assessment.
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Now CMS defines this more specifically as a functional outcome questionnaire.
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You should be happy about this.
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These are so easy If you choose the right ones.
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Some of them are terrible and I tell doctors don't ever use them, ever again.
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And for example, I've been telling doctors for years stop using the oswestry for lower back, stop using the neck disability index for the neck.
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They're awful.
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Why are they awful?
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Because there's only 10 questions for each of them, but there's six options per question.
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That's a total of 60 options that your patient has to sit through and read through.
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And I've got news for you.
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You wouldn't want to do it, and what happens is the patient by the time they get to question number four, they're so frustrated with it they stop reading the questions, they just start checking random boxes and you're getting bad data.
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So there are questionnaires and there are questionnaires.
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Use the ones that are quick and easy, they're valid and they're reliable.
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Move on with your life.
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But those questionnaires are stellar for tracking the patient's progress and they are widely said to buy everyone in healthcare.
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That is exactly what everyone is looking for.
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Sometimes the insurance people that come in and audit and things like that get a bad name.
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I mean, I've heard people give you a bad name just because you do their records, but I come to find out it's the records that are bad and you have no other choice.
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Right.
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I mean, I've been accused when I review some personal injury records.
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Well, you're biased.
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No, I'm not.
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Well, I guess I am.
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I'm biased against bad documentation.
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But if it's good, if you're doing these few things, I would look at that and say, hey, great job.
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Go down the 30 days, show me again.
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All we need to see is is your patient improving with your care?
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If they're not improving with your care, then why would you be justified to continue treating that patient?
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If they are improving with your care, then hey, great job.
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But again, there's a few very specific ways you need to show that and, according to CMS, just documenting pain is not enough.
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They are very big into function, and so is every other set of rules, regulations, requirements and guidelines.
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Every one of them focuses on the function and you don't have to measure range of motion all the time.
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If you want to, you can, but most don't.
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But the functional outcome questionnaires if I could get every chiropractor to give these functional outcome questionnaires the quick and easy ones, not the complicated ones, the quick and easy ones to every active patient on the first visit for each specific condition, and then every 30 days or sooner, I'm telling you we could change the world.
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Why do you need an exam every 30 days?
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Because CMS says they require that it's every 30 days or sooner or sooner.
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So 30 days is the maximum of that, or sooner.
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There are other guidelines that actually say every two weeks.
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If you're not showing measurable functional improvement in any two successive two-week periods, referral is indicated.
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And that's used by Mercy guidelines, that's used by official disability guidelines, that's used by CCGPP, that's used by ACOM guidelines and I've seen workers' COMP guidelines in different states.
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Same exact thing.
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They're using the same thing.
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They look at two weeks, at two weeks.
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If they're not showing measurable functional improvement, change something, alter your treatment, different technique, different modality, different exercise protocol, and then do another two-week trial and you have that flexibility of changing.
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If you look at this every two weeks, now, if you don't do it every two weeks and you do it every 30 days, you have one shot at this and if you don't show measurable functional improvement after 30 days, you're done, because 30 days is equivalent of two successive two-week trials and that's the game.
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Everybody out there listening.
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I hope you just had this quick outline of what to do and what not to do, because it's probably been the most succinct that I've seen or heard forever.
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Now you know, I was old enough in practice to remember when electronic health records came in and they were going to solve all the problems and so forth.
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And I believe that you have an electronic health record that you invented and it's called bulletproof chiropractor.
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Yes, so I actually just developed an EMR electronic medical record which is just for the documentation.
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Yeah, I remember when the EHRs first came out a number of years ago and it was a nightmare.
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It was really designed for Medicare and for hospitals.
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That was the original intent Medicare and the hospitals Because think of it in a hospital setting you would have all these different providers of different specialties seeing the same patient and each one of them were scribbling their own notes in their own jargon and nobody knew what each other was talking about.
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So they created this EHR for the hospital setting so that all the various providers of different specialties could document in the same EHR for that patient.
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That way every doctor on this case could see what the pharmacy records were, what the radiology records were, what the orthopedist said, what the cardiologist said.
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It was all right there and it was really quite a noble thing.
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I thought it made sense.
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Well then they expanded that to medical doctors also.
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Only for it was a Medicare thing, it was a CMS thing, nothing else, it was only for that.
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So medical doctors started doing it and it was hysterical because the medical doctors were like are you kidding me?
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Because it was going to cost them.
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I read an article in Forbes years ago that they said the average medical office was going to cost them about $125,000 between getting the EHR and having staff specific for that and do the whole thing $125,000.
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And that's when the government said, ok, ok, we hear you.
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How about this?
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We will reimburse you up to $42,000 to help offset some of those costs.
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Well, $125,000, 42,000.
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Ok, it's something.
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So they said, all right, we'll try this.
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Well, chiropractors heard this and said wait, hold up a second, we want a piece of this.
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We were in thinking about the absolute, really no need for us being in that.
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But we're like, wait, we could get up to $42,000 back.
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It was like a new profit center for us.
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So all these chiropractors started getting these EHRs.
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I'm like, don't do it yet, because you're going to go on a list.
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You're going to go on a list and guess what?
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They're going to look at that list.
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And then they say, oh well, you got it now let's see if we audit you, what happens.
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And these chiropractors thought, well, if I'm audited, I'm OK because I'm using a certified EHR, but they're not set up to document, right.
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And then all these chiropractors are getting audited and losing and we're like well, wait a minute.
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I thought so.
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I got frustrated, and I because I started looking at all these various EMRs and EHRs to see what I could recommend to other chiropractors.
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But as I looked at them I realized, but that's wrong.
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I mean, I do, I get demos with all these different companies.
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I'm like that's wrong, that's fraudulent, that's just a flat-out lie.
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I'm like you got to be kidding me.
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So I decided I'll just do it.
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So I developed my own, I hired a programmer and it took a while.
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And we're continually just tweaking things and updating things as new information comes out.
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And yeah, because honestly, it could be fantastic.
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If it takes too long and it's too complicated, no, only use it.
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It has to be both excellent and fast.
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That's the key.
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I didn't tell you this, but I had a couple of my instructors look into your program and they ordered it and they, they Loved it and so they said the big thing is it's not expensive Like some of these EHR programs are, you know, very expensive.
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What does that cost per month to run your program.
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Oh, it's ridiculous.
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So it's 59 99 a month.
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That's it 59 99.
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Now there is an upfront cost of about 500 bucks and I waive that if you attend my webinar.
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And the reason I wait?
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I only, I only discount if you attend my webinar because it's so important to Understand the whole concept around this documentation.
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It's not enough to just get a piece of software and Plug away.
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I don't, I don't even want that with my own software.
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I don't want doctors getting my.
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So all Greg did it.
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It must be good.
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You could screw this up too, right, you have to understand how this works.
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Like if somebody used my own program but they didn't do the functional outcome Questionnaires for each condition every 30 days or sooner.
00:18:26.317 --> 00:18:27.884
I'd bury you myself.
00:18:27.884 --> 00:18:30.478
So you have to understand the process.
00:18:30.478 --> 00:18:31.884
That's the only time I give a discount.
00:18:31.964 --> 00:18:36.037
So are you telling me the out-of-pocket cost to start as $500?
00:18:36.037 --> 00:18:41.336
If you don't take the webinar if you don't take the webinar, and how much is it per month then?
00:18:41.355 --> 00:18:42.979
59 59 99.
00:18:43.385 --> 00:18:48.116
Okay, what's your telephone number, because I know we're gonna have people saying how do?
00:18:48.116 --> 00:18:50.671
I find that Please give us your telephone number.
00:18:51.051 --> 00:18:53.219
So the easiest way to get ahold of me is by email.
00:18:53.219 --> 00:19:02.853
Yes, and that is dr Greg Spell, dr gr eg g at the bulletproof Cairo comm.
00:19:02.853 --> 00:19:03.654
So th?
00:19:03.654 --> 00:19:09.585
E bulletproof Cairo, chiro Dot com well, thank you.
00:19:09.965 --> 00:19:30.125
I think you know I took the course because we shot it and then I wanted to go through and and look at it and audit it, and you know it's not easy, the documentation is not an easy subject and so but today the things that you gave out here we're just step-by-step and I really can't thank you enough and listeners, you should be really happy that you tuned in today.
00:19:30.125 --> 00:19:39.268
So thank you, greg, and Thank you listeners, and you heard how to get ahold of the bulletproof chiropractor, and so thank you again, my pleasure.