taking an x-ray of that spine before putting a force into it, I’m not so sure that's a smart practice. The PART exam should be for maybe a patient after a month of care, you're not going to re-x-ray but I would say please don’t impart a force to a potential fragile spine without an x-ray. That being said, I think the things that doctors missed the most, I'll just give you a list that Medicare has just published with their comparative billing report. The first thing that's missing, believe it or not and this will seem shocking to you, is that doctors will lack putting the space patient-specific subjective complaint. That almost seemed like, "How is that possible?" Believe it or not when I review a file, you'd be surprised to see what the doctor just goes right into the objectives. Don’t talk about what the patient is stating. The other factor that's missing is a lack of functional status. What Medicare does for payment is just show that we can make the patient better and better is a difficult thing is it just less pain. What Medicare says is that they want to see a functional change. We better make sure that there is a functional change in the file that the patient is showing improvement whether you're doing it by physical exams such as an orthopedic test or range of motion or as simple as [inaudible 00:20:26]. The other factor that really probably hurts the doctors the most is not having the objective documentation of subluxation. If you're using an x-ray, you must specifically point out where you have found C2 had subluxated x-ray. Has it gone PR, has it gone POS, whatever your nomenclature would be? The other factor that's always missing from the file or often missing, Medicare requires that on each visit, you indicate the specific vertebrae. With other insurance is you can get away with saying, "I adjusted cervical spine." Medicare is going to want to see in the notes that you adjusted C2, C5 and T2. If you do not put that information, again, it invalidates the entire notes. You have to be in the habit of always making sure that you indicate I've adjusted specific vertebrae. The other and this is something Dr. Ken pointed out is, doctors need to have a treatment plan. Now treatment plan is what you think it is. I want to see this patient 2 times week, for 3 weeks but beyond the plan, you have to give a short-term and long-term goal. Now, it doesn’t have to be as fancy as you might think. Short term generally is always going to be a reduction of pain but it should be goal-oriented. Don’t just say, "I want to reduce pain, but I would like to reduce the pain level from level 5 or level 7 to level 4." Some difference there, even 50%. In addition, you want to maybe indicate that you want to increase the patient's ability to do activities of daily living. In other words, what is Medicare really looking at? They want to see that the patient is getting better. We have to document factors that show that. A reduction of subluxation from our point of view as a chiropractor is an improvement but Medicare says, "We want to see something tangible when there's that reduction of subluxation" show the patient getting better in a functional way. Making sure that there's good subjective history of how are you better. I always say, "Don’t just ask what's the pain level, but ask what is the pain level and how does it affect you from doing certain things." Then on the next visit or
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