Part four: The fortune wheel of documentation

By Kathy Mills Chang

Wikipedia defines a differential diagnosis as a systematic method used to identify unknowns.

This method, essentially a process of elimination, is used by physicians and other qualified healthcare professionals to diagnose a specific disease in a patient. Not all medical diagnoses are differential ones. Some diagnoses merely name a set of signs and symptoms that may have more than one possible cause, and some diagnoses are based on intuition or estimations of likelihood.

Careful differential diagnosis involves first making a list of possible diagnoses, then attempting to remove diagnoses from the list until — at most — one diagnosis remains. Removing diagnoses is done by making observations and using tests that should have different results, depending on which diagnosis is correct.

Differential diagnosis is the process whereby a given condition or circumstance (called the presenting problem or chief complaint) is examined in terms of underlying causal factors and concurrent phenomena, and is then compared to known categories of pathology or exceptionality.

Differential diagnosis allows the physician to:

• More clearly understand the condition or circumstance,

• Assess reasonable prognosis, and

• Plan treatment or intervention for the condition or circumstance.

The diagnosis is a synthesis of your test results. The findings that differentiate one diagnosis from another are referred to as clinical pearls.

As a physician, you are expected to make “the diagnosis to your highest level of understanding,” says Manuel Duarte, DC, full-time faculty member at National University of Health Sciences.

It is OK to have intersegmental dysfunction as a diagnosis, but this is a part of the bigger clinical conundrum. A higher level of diagnosis could be something such as lumbar disc herniation with concomitant sciatica and associated segmental dysfunction as a descriptor.

Your review of the patient’s historical information, physical examination, and x-ray findings are the building blocks to your diagnosis. What makes a great physician is the ability to synthesize this information and interpret it. The end result is an identification of the injured tissue and the extent of the injury. With application of this process, the treatment should be intuitive.

One of the biggest mistakes doctors make in proving medical necessity is they don’t go through this process. Or if they do, it’s not well documented in

the findings. Without this process, it’s difficult to write a treatment plan and be able to justify why that treatment is necessary based on the findings.

The diagnostic process requires adequately linking the diagnosis to your treatment. In the billing process, on the 1500 billing form, this is accomplished in box 24E. Many practice management software programs automatically insert the numbers one to four in this box, representing all four diagnoses assigned in box 21.

If you look at the form, you’ll find an arrow descends from box 21, which is the diagnosis reporting box of the 1500 billing form, down into box 24E. In theory, when reporting your services on this form, everything should be connected.

This should also be clearly expressed in your treatment plan. Each component of the treatment process should be clear as to why you chose that treatment for the given diagnosis.

Your decision-making process should be evident to you and any interested third party.

For example: Examination findings may reveal overlapping symptoms for a diagnosis of spinal stenosis and a herniated disc. Both indicate nerve compression, with one more acute in nature and one more degenerative. Both share similar symptomatology, yet require drastically different treatment plans. Both conditions will benefit from chiropractic manipulative treatment and possibly electrical stimulation for the modulation of pain. But, if you want to assign stretching and strengthening exercises to these patients, the treatment must be different.

The treatment protocol for the disc might include distraction and extension protocols. Stenosis might benefit from distraction, but flexion rehabilitation protocols rather than extension would yield a better outcome.

Remember, as chiropractors, you are integrated into the existing healthcare system and must follow a standard of care in order to make a diagnosis that is supported and to maintain adequate records.

The end result is better outcomes, smoother billing and reimbursement, and fewer hassles. By doing it right the first time, you save time, money, and you protect yourself from unnecessary scrutiny from third-party payers, regulators, and patients.

Kathy Mills Chang is the founder of her own consulting firm, assisting doctors with finding financial and reimbursement ease in practice. She also serves as Foot Levelers’ insurance advisor. She can be reached Kathy@kathymillschang.com or through www.kathymillschang.com.