prep for the ccca ca 101: anatomy, exam later physiology ... ca-101 parker-notes.pdf · •provides...

www.KMCUniversity.com 10/9/2017

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CA 101: Anatomy, Physiology, Medical

TerminologyPresented by:

Kathy Mills Chang, MCS-P, CCPC, CCCA

Prep for the CCCA Exam Later

•Not taking the test? No problem!• Still want to take the test?•Use this as a refresher for some of the questions about terminology

Topics Covered

•Chiropractic terminology for CAs•Boundaries and Ethics•Patient Safety•Documentation

Chiropractic Terminology

•Anatomy

•Physiology

•Therapies and Modalities

•Conditions

Anatomy BasicsSkeletal System: 206 bones, cartilage and ligaments

Axial Division: Trunk

Appendicular Division: Appendages

Condyle: Rounded end of bone

Tendons: Anchor Muscle to Bone

Ligaments: Anchor Bones to Bones

Understanding the Roots

• It’s Greek to me! Or Latin!

• Terminology

• Root Words

• Suffixes

• Prefixes

• There’s a method to the madness


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Core Chiro Terms

• -algia = pain

• -itis = inflammation

• -pathy – disease of, usually non-inflammatory

• -osis = state or condition of

• Cervicalgia

• Lumbalgia

• Scoliosis

• Cephalgia

• Myalgia

• Myofascitis

• Spondylopathy

Very Common Prefix/Combining Forms for DX

Basic Anatomy-Directional TermsAnterior: In front of, front

Posterior: After, behind, following, toward the rearDistal: Away from, farther from the originProximal: Near, closer to the originDorsal: Near the upper surface, toward the backVentral: Toward the bottom, toward the bellySuperior: Above, overInferior: Below, underLateral: Toward the side, away from the mid-lineMedial: Toward the mid-line, middle, away from the side

Common Anatomical Terms

•Prone: Lying face down

•Supine: Lying on the back, face up (also dorsal)

•Antalgic: Any physical attitude assumed to gain relief of pain

Spinal Anatomy Cervical Spine• 7 vertebra: C1-C7• Occiput• Atlas = C1• Axis = C2• Atlanto-Axial = C1-C2• Cervical Lordosis: refers to the curve of the spinal: could be hypo or hyper


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Thoracic Spine

• 12 Vertebra: T1-T12

• Also called the dorsal spine

• Kyphotic Curve• From the Greek: hump•AKA hunchback

Lumbar Spine

• 5 Lumbar Vertebra: L1-L5• Pelvic• Sacrum• Coccyx• Lumbar lordodic curve• Many areas to understand below the belt

Extra-Spinal Joint Anatomy

Joints outside of the spine:• Mostly Synovial (filled

with Synovial Fluid)• Have different functional

limitation and pathologies based on body’s use

• Are ALL adjustable (98943)

• Dysfunction effects function of the spine

Muscles

Different types of muscle•Skeletal (moves bone and other structure)•Smooth (organs)•Cardiac (Heart)

Chiropractors mostly treat Skeletal Muscles

Muscle Anatomy

• Like Rope:•Made of multiple strands of myofibrils that are bound together to form the muscle• Each myofibril has multiple sarcomeres that are bound together as well

Fascia •All muscles and organs are wrapped in fascia

•Injury or repetitive activities cause binding up of tissue

•Causes groups of muscles to be effected


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Nerves•Enclosed, cable-like bundle of nerve fibers in the nervous system•Provides a pathway for the electrochemical nerve impulses•Made of mostly Fats (Omega 3’s)•If the nerve is impaired, impeded, or damaged, pain or other pathologies present

Physiology

Physiology is the study of movement of the body

Terms of Motion•Flexion: The joint angle becomes smaller• A bent elbow is flexed• Cervical flexion is when the head is bowed forward•Bicep flexion is familiar•Lateral flexion is ear to shoulder

•Hyper/hypo-flexion: Too Much/Too Little Flexion

Terms of Motion

•Extension: The joint angle becomes larger•Cervical extension-head goes backward•Positive for pain when joint pinching occurs

•Hyper/Hypo-Extension: Too far, as in hyperextended knee

Terms of Motion

• AB-duction: Moving farther away from the mid-line

•AD-duction: Moving toward the midline

•Usually in the shoulder, hip, fingers, toes

Lordosis/Kyphosis

•Lordis – Bent to front

•Osis – state of

•Kypho – bent to back

•Hypo- not enough

•Hyper – too much


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Cervicothoracic Junction

•Sit at a desk much?

•Text much?

•Look at your phone much?

•Patients have more and more challenges with forward head carriage

Upper Cross Syndrome

Very Common in DC Offices

Subluxation/Segmental Dysfunction DXA vertebral subluxation is the result of spinal bones with improper motion or position affecting nerve communications between your brain and your body.sub = less than | luxation = dislocation

A vertebral subluxation is a stress response. Muscles go into spasm. Spinal bones lock up. And adjacent nerves are choked or chafed. This interferes with the control and regulation of your body. This garbles communications between the brain and parts of your body.

Some chiropractors are passionate in favor or against using this as a DX

Facet Joint Syndrome•The zygapophysial

joints account for between 5% and 15% of cases of chronic, axial low back pain•Facetogenic pain is the result of repetitive stress and or cumulative low-level trauma leading to inflammation and stretching of the joint capsule


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Facet Syndrome

• The patient often presents with well- localized LBP with some hip/buttock or leg pain above the knee

•Onset is sudden often related to a misjudged movement or arising from a flexed position

• Facet or capsule is the source of pain

• Lumbar paravertebral tenderness is indicative of facetogenic pain

Disc ConditionsChanges to the disc space or condition effect:

•Nerve communication•Organ dysfunction•Muscle spasms• Burning/numbness

feeling•Muscle atrophy

•Normal joint function• Recruiting of muscles• Increase wear on

adjacent joints

Disc ConditionsDegeneration

• Spinal arthritis• Three phases (increasing in severity)• Chronic

Bulging disc• Part of the disc presses on the nerve root• Can cause radicular symptoms• Commonly caused by trauma

Herniated disc• More severe version of bulging disc• MRI often needed to confirm• Very severe can require surgery

Thinning disc• Dehydration/desiccation of the disc

Osteophyte formation• Sandpaper-like bone spurs where the body

naturally starts to fuse vertebrae together• Wolfe’s Law (Bones grows according to imposed

demand)• Compresses and limits the discs’ normal ROM

Muscle Spasm

Commonly called a “charley horse” but it can occur in any muscle

Spasms of skeletal muscles are often due to:• Overuse • Dehydration• Electrolyte abnormalities

Presents:• Abruptly• Painful• Usually short-lived• Often the pain comes and goes• Secondary to larger condition

Trigger points (“muscle knots”) are found in spastic muscles – these may cause radicular symptoms

Arthritic Conditions

• Over 100 types of arthritis• Common arthritis joint symptoms include

swelling, pain, stiffness and decreased range of motion

• Can cause permanent joint changes• Osteoarthritis is the most common type of

arthritis• When the cartilage – the slick, cushioning

surface on the ends of bones – wears away, bone rubs against bone, causing pain, swelling and stiffness

• Over time, joints can lose strength and pain may become chronic

• Risk factors include excess weight, family history, age and previous injury

Osteoporosis

•The bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D•Becoming very common in youth due to poor diet

Large amounts of soda cause the body to build bone from phosphorus instead of calcium Contraindicated for some chiropractic techniques


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Therapies and ModalitiesSupervised Modalities

• 97010-97028 DO NOT require one-on-one contact by the provider

• Billed only once per encounter

• Are not time based for billing purposes

• Expected 2-12 visits

• However documentation should include the time spent on the modality

Why so few visits?

•Research shows that these tend to be effective for a short time•Overall Non-active care is less effect as Active•Overutilization by peers

97010 Hot/Cold Packs

•Application of Ice packs or cryotherapy

• Application of hot packs, ex. hydrocollater packs or moist towels

Often a non-covered service

• Does NOT include applying Biofreeze or any other type of topical analgesic

Use of Ice-Cold Therapy

• Causes vasoconstriction (shrinkage of blood vessels), decreasing blood flow to an area, and slowing the body’s metabolism and its demand for oxygen.

• The therapeutic goals include reducing edema, easing inflammation, and blocking pain receptors.

• Cold application is more effective than heat for sprains or other soft tissue injuries and is the preferred treatment within the first 48 hours after injury.

Use of Heat

•Heat causes vasodilation increasing blood flow to a specific area. • Increases the oxygen,

nutrients, and various blood cells delivered to body tissues•Relieve local pain,

stiffness, or aching, particularly of muscles and joints•Aids in removal of wastes

from injured tissues, such as debris from phagocytosis


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97012 Mechanical Traction

• Force used to create tension of soft tissue or to separate joints•Untimed & billed only

once a visit• Intersegmental or Roller

tables meet criteria, BUT check with 3rd party payer guidelines• Flexion Distraction

technique is a CMT & should be coded as an adjustment

Mechanical Traction• Manual or mechanical pull on

extremities or spine to relieve spasm and pain

• Considered medically necessary for chronic back or neck pain

• Typically used in conjunction with therapeutic procedures, not as an isolated treatment

• Standard treatment is to provide supervised mechanical traction up to 4 sessions per week

• For cervical radiculopathy, treatment beyond 1 month can usually be accomplished by self-administered mechanical traction in the home.

97014 Electrical Stimulation (EMS)

• Application of Electric stimulation to a specific area for nerve or muscle disorders• Billed only once per visit• Some payers allow 2-4 visits• Sometimes you must use

G0283 instead of 97014 for unattended EMS

Presently United Health Care & Medicare are the only carriers that require G0283

Interferential Therapy (IFT) / Premodulated

• A treatment modality that is proposed to relieve musculoskeletal pain and increase healing in soft tissue injuries and bone fractures

• Two medium-frequency, pulsed currents are delivered via electrodes placed on the skin over the targeted area producing a low-frequency current

• IFT delivers a crisscross current resulting in deeper muscle penetration

• Theorized that IFT prompts the body to secrete endorphins and other natural painkillers and stimulates parasympathetic nerve fibers to increase blood flow and reduce edema UHC MN 2016

Other WaveformsTranscutaneous electrical nerve stimulation (TENS) Stimulate the nerves for therapeutic purposes•Used to block pain•Often given for home use

Russian• Effective in increasing muscle strength

and torque generationHigh Voltage Pulsed•Used for pain and edema reduction

•Microcurrent• Speeds healing process• Increases circulation•Used in dermatological practices to

tighten skin on face

Constant Attendance Modalities

•97032-97039 require direct one-on-one patient contact by provider.

•These are timed based codes for billing

•Documentation should include total time spent


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One on One means “One on One”•One-on-one attendance

is defined as “maintaining visual, verbal, and/or manual contact with the patient during the provision of the service”. One-on-one attendance is achieved when the provider is attending to one patient individually for each minute counted toward the required minutes in order to bill the CPT code for that particular therapy service

97035 Ultrasound

•Ultrasound, each 15 mins. One or more areas

•Great for adhesive scars, spasm, soft tissue

Ultrasound

•Benefits of ultrasound: • Speeding up of the

healing process from the increase in blood flow in the treated area• Pain decrease from the

reduction of swelling and edema•Gentle massage of

muscles tendons and/or ligaments in the treated area because no strain is added and any scar tissue is softened

Laser Therapy

• Low-level laser therapy is a non-invasive light-source treatment that has no heat, sound or vibration

• By reducing the duration of inflammation as well as enhancing specific repair and healing process, laser therapy has been proven to provide pain relief, reduce damage due to the injury and loss of function

Coding is either 97039 or S8948Both are each billed in 15 min. increments

• Indications for laser therapy to promote healing• Inflammation• Pain• Edema• Muscle strains• Ligament sprains• Nerve injuries/irritations

Patient Safety

• Comes down to noticing potential risks in patient interaction and treatment and responding to the unique needs

• All offices have risks

• Having well documented policy and procedures of how your office will handle possible safety issues is key

OSHA

• Occupational Safety and Health Administration (OSHA) governs workplace safety

• Many states have their own version that may have stricter rules and/or resources

• They will do a free onsite audit to help you get to legal


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Blood Born Pathogens• Even if your doctor does not do

acupuncture or venipuncture this area must be addressed

• OSHA has direct minimum guidelines

• Your policy should address:• Handling blood or other body fluid

spills• Patient treatment with open wounds

or lacerations• Hepatitis B vaccinations and/or

declination of employees who might come in contact with body fluids (even if your doctor is anti-vaccine)

• How the office will handle the event of a needle stick and/or coming in contact with body fluids for patients and/or team members

• “If it is wet and not yours, DON’T TOUCH IT”

Radiology Considerations

• X-rays do contain risks and contraindications

• CA an alert the doctor so they can weigh the risks of the testing

• Potential risks• Pregnancy or possible

pregnancy• Active or recent radiation

treatment• Metal in the body (MRI)• Possible or confirmed

fracture (positioning)• Others

Therapies Some therapies have counterindications which could harm the patient:

• Pacemaker for EMS or ultrasound

• Open wounds

• Active Cancer

• Heart conditions with rigorous exercises

• Balance issues

• Pregnancy

• Current flu/cold

• Medications (blood thinners and others)

If the patient has these or others, it does not mean they cannot have the treatment.

Alert your doctor and they will assess the risks of the therapy vs. the rewards of treatment

Responding to Health Emergencies

How will your office respond to :• Heart Attack/stroke• Patient/team member

fall or injury• Loss of conscience• Active labor • Others

Have policies in place and train annually on how they are to be handled

Ethics/Boundaries/ Managing Risk

• Most Common Causes of Malpractice

• Harassment and Patients

• Cultural Sensitivity and Diversity

• Inappropriate Patient contact

Harassment and the Work Place

No matter the office size, possible harassment must be addressed

• Comments or actions effect the tenor of the workplace

• Does not have to be sexual to cause harm

• Even if team members leaves, they can cause problems with 3rd

party payers and legal authorities

• Lawsuits or audits keep you from treating patients

• Guilty until proven innocent situation – policy can protect!

• Set up:• How potential allegations should

be filed internally• How potential allegations will be

addressed


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Cultural Sensitivity and Diversity• Not everybody is the same

religion, race, sexual orientation, and/or gender

• Not treating a patient or patient population is a business decision that should not be taken lightly

• Casual comments can offend or cause the patient more harm than the doctor’s treatment at times

• Be aware of what you say

• Don’t say or write it unless you are willing to pay the consequence!

Inappropriate Patient Contact

Consider:• Proper draping/gown

usage of exposed skin• Comments about

wardrobe or other physical attributes

• Women do this too!• How will the office

handle inappropriate patients

• Ethics of patient/team member dating

Documentation

Why Is Documentation So Important?• Ensures quality patient

care• Meets licensure

requirements to protect the public

• Guards against malpractice action

• Secures appropriate reimbursement

• Because…if it wasn’t written down, it didn’t happen!

Know your Audience

• Another health care provider

• Your board

• A malpractice attorney

• Third party payer's medical necessity auditor

Good Documentation Tells a Story


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CA’s Play a Huge Part in Documentation• Patients will tell you

things they don’t tell the doctor

• You likely spend more time with the patient than the doctor

• They give you LOTS of subjective data that effects their care

• Write it down!

Help Your Doctor to Be a Good Documentarian

• Elaborate on subtleties

• Dig deeper

• Evaluate all the systems that apply to chiropractic care

• Elaborate on those that may not apply

• Document the “good doctoring”

Most Important Communication Tool

• Improves communication with other providers

• Records are a legal document

• Inadequate documentation impacts both patient care and outcomes

• The “other” provider can be the “future you”

Documentation in History• Best to record a mechanism of

trauma for every new patient or new episode• Patients may tell you about a

recent injury which they “forgot to tell the doctor”

• Ask leading questions of your patient to elicit a specific incident that precipitated the pain that the patient is experiencing

• Ask about ADL’s • How are they doing in normal life • What can they do now that they

could not before treatment

• Record any incident that the patient can relate that ties to the pain that brought them into the office

Medicare Specifics

• Claims can be denied without documented mechanisms of injury

• Per Medicare: patient can’t just come in with a headache and expect Medicare to pay for the care of that headache

• Some Medicare contractors are even going so far as to say that the injury can’t be incurred during activities of daily living

• For example, patient wakes up in the morning with bad neck pain; denial says that the claim is denied because sleeping is an activity of daily living

Minimum Documentation Standards

• Each state has written or implied documentation rules

• Sometimes one is not aware until it’s too late

• Find out whether your state has specific rules

• Don’t find out the hard way


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State Specific RulesGood Documentation Protects

• Provides an accurate timeline of treatment

• Confirms compliance

• Ensures consistency of patient care

• Enhances quality of the care given

• Clarifies the actual happenings in the visit

• Is a chronological record of your experiences with the patient

• Should include phone calls and other “orders”

Bad Documentation Disregards

• Altered records

• Missing dates, patient names, provider signatures

• Obliterated entries

• Illegible and many blanks

• Failure to document patient non-compliance

• Lack of documenting phone calls

• Charting only abnormal findings

• Testing without clinical rationale

• Sloppy charting of activities and patient remarks

• Lack of attention to detail to record everything that takes place in a visit

Your Best Defense is a Good Offense

• A well-documented patient record may actually prevent a lawsuit from being filed

• Patient record documentation should accurately reflect the care and treatment provided to a patient and that the standard of care was rendered.

• Objectivity is critical

• Poor documentation or alterations in the patient record can render an otherwise defensible case indefensible

Signature and Patient Name Issues

Why Authenticate?

• To verify provider who treated

• Prove services were provided

• Indicate and verify who provided them

• Validates the entry and legally binds the physician for the included info


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Can we Identify Provider? Review Signature RequirementsFamiliarize providers and office staff with signature requirements to ensure

more complete compliance with

signature authentication policies

How do we authenticate signatures?

Signature Log

Update Signature Log

• Every year have each provider sign again, even if it hasn’t been a year since the last signature

• Add new providers to the log as they join the group

• Replace previous logs with most recent signatures, however save old copies

• Make sure every log has a start and end date

Patient Identifiers

• Patient name must appear on every item or piece of paper

• Electronic name is ok

• Front and back both

• Especially important when sending records

• Patient number can identify as well

What is Timely Documentation?

In plain English:

• Write down what happen

• Support why your did it

• Sign that it happened

• Do all of the above right away or by the end of the day!


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Scribe Use

• Consider using a scribe to speed up data entry during a visit

• Specific guidelines on who can write certain things in the medical file

Amending Completed Records

CMS has direct guidance on amending a patient's record:

• The medical record cannot be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, and legibly signed or initialed.

Either Way

• Test or no test….this information makes you more valuable than ever to your doctor and your practice

• Rock on, CA!!

Need help? [email protected]

prep for the ccca ca 101: anatomy, exam later physiology ... ca-101 parker-notes.pdf · •provides...

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