A few years ago, a new friend introduced me to the board game Go. Go, which means “five” in Chinese, is said to be the oldest-known board game and is the Japanese national game. Go is much less popular in the United States. If you have never heard of it, I am not surprised. I had never heard of it, either. I quickly learned that Go is a tough intellectual game that makes chess look like checkers. The only games I have won were against a computer playing at the most basic level. I have yet to beat my friend.
This brings me to the Wilcox Principle. Bruce Wilcox is a computer programmer and a Go player. While trying to develop a computer version of Go, Wilcox came up with a unique problem-solving principle.
Computers programmed to play chess do so by evaluating and planning several moves ahead. This is possible with chess, as the board is limited to 64 spaces and 32 game pieces. With the exception of the queens, the pieces have limitations, and their numbers decrease as play continues. Go, on the other hand, begins with a clean board that has 361 spaces. Players alternate placing white and black stones (game pieces) on any available space, attempting to capture territory. The stones are more versatile than chess pieces, and their numbers increase with every move. This makes the number of game situations and possible moves in Go much greater than chess.
Wilcox found that the increased number of possibilities in Go prevented even the best computers from playing several moves ahead. The computer had too many choices and could not pick the best move. A very smart Wilcox solved this problem by programming a number of good random moves for each situation and eliminating the moves that would be disastrous. This solution enabled the computer to play at a low-level professional rank. In solving his programming dilemma, Wilcox developed a problem-solving approach that can be applied to multiple aspects of work and life in general – not just board games.
The Wilcox Principle states: It is not always possible to do everything or the best thing. So, do the best you can while avoiding those things that would turn out to be a disaster.
<A href=”http://adtrack.chiroeco.com/cgi-bin/advertpro/blink.pl?name=589&slot=1″ target=”_blank” rel=”nofollow”> <IMG src=”http://adtrack.chiroeco.com/cgi-bin/advertpro/bimg.pl?name=589&slot=1″ alt=”Massage Magazine Subscription Offer http://www.massagemag.com/subscribe” width=”250″ height=”250″ border=”0″ align=”left”></A>
After reading about the Wilcox Principle in the book “Everyday Math for Dummies,” I knew immediately that the principle would apply to chiropractic utilization and insurance claims review. I have been working in this field since 1994 and have taught a few classes on the subject over the years. Applying the Wilcox Principle to utilization review translates into the doctor doing the best job he or she can for the patient while avoiding the five to 10 items that always stimulate a review or result in claims denial.
Just after having this thought, I was contacted by Dr. Frank Hideg about teaching a class on utilization review sponsored by the Kentucky Association of Chiropractors, The Kentucky Chiropractic Society, and Logan College of Chiropractic. I had given the class twice before and thought it would be a good forum to discuss the Wilcox Principle. I decided to make the last hour of the session a workshop where everyone in attendance could give an opinion on the top five to 10 circumstances that stimulate utilization review and claims denial. The list could then be incorporated into an article on the subject.
The seminar occurred on April 18 in Elizabethtown, Ky. The majority of doctors in attendance are involved in utilization and peer review. However, several doctors in attendance where there for continuing education hours or to see how peer reviewers think. Seminar participants are listed at the end of this article.
The list of utilization red flags developed during the seminar does not reflect the position of the Kentucky Association of Chiropractors, The Kentucky Chiropractic Society, or Logan College of Chiropractic. The list simply reflects the consensus of the seminar participants and is provided as advice and not as absolute principles. The initial list included 24 items but has been reduced to seven. Many of the red flags overlapped or were considered to be less common.
Applying the Wilcox Principleto Utilization Review
Doctors wishing to avoid utilization review by using the Wilcox Principle should consider the following information:
• Documentation Errors: Documentation is an area where we must find a happy medium. Problems arise when documentation is deficient, redundant, or excessive. Deficient documentation could be linked to almost every red flag on the initial list. Checklists, illegible handwriting, secret codes, hieroglyphics, and partially completed forms are no longer acceptable. Doctors of chiropractic must describe the procedures they perform, how they were performed, why they were performed, and the results. Descriptions must be readable and easy to interpret.
Redundant and excessive documentation are also unacceptable. Notes that say the same thing visit after visit for weeks on end reflect a lack of clinical progress, not the severity of the condition. Two or more pages of notes for each office visit seem unrealistic for an encounter that only lasted a few minutes.
A multitude of software programs exist today that can help make record-keeping duties more time-efficient, accurate, and affordable. Many of these programs can be customized to some degree to allow for the individual doctor’s preferences and idiosyncrasies.
• Frequency and Duration of Care:
It is a safe bet that from most insurance carriers’ points of view, once a patient has crossed the threshold of a chiropractic office for the first visit, frequency and duration are in question. Chiropractors performing utilization and peer review are a little more lenient.
Care should decrease in frequency and intensity as it continues. Care that begins daily or three visits per week usually tapers to two visits per week. Two visits per week usually taper to one visit per week. One visit per week usually tapers to two visits per month. Two visits per month usually taper to supportive maintenance care, preventive maintenance care, or as-needed care (PRN). Three visits per week for several months are hard to substantiate. As care continues and the patient’s condition improves, the number of treatment procedures utilized should also decrease in frequency and intensity. The exception here occurs when switching from passive therapy modalities to active modalities for rehabilitation.
Daily care that continues for longer than a few weeks sets off an alarm. Care each day of the week with the exception of the doctor’s day off and weekends is not daily care. Intense care that has never decreased in frequency but abruptly ends as insurance benefits expire is not a sudden miracle cure. It is called “maximizing.” Every patient receiving the same number of visits regardless of age, diagnosis, severity of injury, or occupation is unreasonable. Care that continues beyond 12 months without evidence of permanent injury or impairment is difficult to justify.
Beyond this, it is every man or woman for himself or herself. During the seminar, we reviewed frequency and duration guidelines for
adults and children from state boards/associations, textbooks, technique seminars, workers’ compensation boards, insurance companies, utilization review organizations, personal injury seminars, and fee-gathering bureaus, just to name a few. The consensus was, “there are no magic numbers of visits for each condition.” There are too many variables and opinions.
The best advice for doctors being reviewed is to document each patient’s need for care and make a list of the references your typical frequency and duration patterns are based on. The patient’s individual documentation should speak for itself. If not, the list can be provided as documentation to anyone who questions the frequency and duration of care. It is tough to argue against an extensive list of references.
• Unexplained Breaks in Care: Beginning care several months after an accident is an immediate red flag. This is especially true if there has been no previous professional care or a large gap has occurred in professional care. Insurance carriers demand documentation that establishes a direct link between the accident and the symptoms that result in the initiation or reinstatement of care.
The patient’s history must reflect ongoing symptoms, continued homecare, lost work time, problems with activities of daily living or attempts to “tough it out” from near the time of the accident or the end of the last professional care. Documentation of continued symptoms and dysfunction are key here. Without it, payment for care is easily denied. The case either becomes charity, a legal battle, or both.
Patients often return for care after an extended period of time on the advice of their attorney. The attorney has informed the patient that they have a legal right to care within the statute of limitations for certain types of accidents. The patient returns to the doctor’s office as though reinstating care is as simple as changing their shoes. It is that simple for the patient and the attorney. The doctor is the one saddled with the responsibility of establishing the length between the accident and current symptoms.
Having a patient complete additional history forms or document health complaints during a treatment hiatus is reasonable. Personal diaries are helpful here, as they may document the patient’s continued problems. Lists of over-the-counter medications taken on a regular basis, missed or decreased activities, and dates of missed work would also be nice. The patient has to participate in this process. If the patient is unwilling to participate, he or she will probably be unwilling to pay the bill if the claim is denied.
• Upcoding and Unbundling: Upcoding is listing and charging for a higher-level service than was actually performed. The most common example of this in chiropractic occurs during initial examinations of new patients. Many doctors consistently charge for the two highest examination levels, 99204 and 99205. However, the documentation that accompanies the claim usually justifies a 99202 or 99203 at best. It is easy for a reviewer to reduce the code and fees for these claims.
A doctor who has his or her exam codes and fees reduced typically argues that no one does a more thorough patient examination than he or she does. This may be true, but performing the exam and recording it are two different things. It is the documentation of the exam that will determine reimbursement. It’s a good idea to compare examination forms and process to the bullets listed in the CPT® coding manual under each code. It is surprising how many of the required examination elements are missing from the average chiropractor’s examination.
Unbundling is breaking a code into components and billing for each component separately. This also occurs commonly during the evaluation of a new patient. A doctor will charge for a comprehensive exam, muscle-testing, and range-of-motion testing. Then when the patient returns for a report of findings, the doctor will charge for a consultation. Muscle- and range-of-motion testing are included in a comprehensive examination and should not be billed separately. If muscle- and range-of-motion testing are repeated during a full progress evaluation, the procedures are still incorporated into an established patient examination code. If these procedures are performed by themselves, they may be billed independently.
Consultation does not mean talking to the patient. A consultation is an examination requested by a third party, typically another doctor. The same procedures that occur during an examination occur during a consultation. The report however, is generally to the party requesting the examination. Reporting findings to the patient falls under the counseling and/or coordination component of an examination code. Separating the counseling/coordination component of the evaluation process from the examination means the patient is charged for the examination and charged again to learn the results. Using a new patient evaluation and management code and a consultation code can be considered unbundling or double-billing.
• More Than Three Therapies per Visit: Exceeding three therapies per visit usually results in denial based on duplication of service. A variety of modality combinations are deemed duplications, including manual traction with mechanical traction and hot packs with ultrasound. Arguments can be made for multiple modalities based on primary vs. secondary effects of the modalities, depth of penetration, and regions of application. Very specific, thorough documentation outlining these arguments would be required to establish necessity of multiple modalities. Please note that specific, thorough documentation does not equate with excessive, redundant documentation.
The use of old modality codes can also result in claims of duplication. Recent editions of the CPT coding manual have grouped multiple procedures under single codes. If you’re not familiar with these changes, purchase and read a new CPT codebook. You might be using a mixture of old codes that have been combined. The codes may be considered duplicates of each other or the code they are grouped under.
• Nonstandard Procedures: Nonstandard procedures are new techniques and technologies, or old ones applied in a new way. This typically means the procedures are used by a limited number of practitioners, have limited supporting literature, and are usually considered experimental. This does not mean the procedures are without merit. It simply means that the significance and interpretation of the procedures are not widely known or accepted. It is difficult to justify reimbursement for an experimental procedure, especially if the procedure is expensive.
Nonstandard procedures can also be a risk management concern. Malpractice is based on the standard of care. The standard of care is defined as what any reasonable practitioner would do under similar circumstances. If accusations of malpractice arise, it may be difficult to establish that a nonstandard test or treatment met the standard of care, due to its limited use and acceptance.
If a procedure has merit, merit is demonstrated by the procedure affecting the course of care and/or the outcome of the case. Standard or nonstandard procedures that do not affect the diagnosis, plan of care, or prognosis of a case are difficult to establish as necessary.
Spinal ultrasound is the most common example of a nonstandard procedure. The majority of radiologists (chiropractic and medical) and many chiropractic organizations still consider spinal ultrasound an experimental imaging procedure. With continued research and advances in technology, ultrasoun
d may prove to be a reliable imaging modality for the spine. However, current literature does little to substantiate its use.
• Transitions from Passive to Active Care: Passive care is defined as treatment that is performed by the health-care provider for a patient (ultrasound and manipulation). Active care is defined as treatment a patient performs for himself or herself with supervision or limited assistance (stretching, activities of daily living, and other rehabilitative procedures). Transitions from passive to active care usually begin during the latter part of the second stage of soft-tissue healing. Passive modalities utilized for healing and pain control decrease during the transition, while utilization of active modalities for improving function increase.
Rehabilitation (active patient care) is a significant trend in chiropractic. How-ever, it is not universal in the profession. Many doctors do not have the training or equipment necessary to provide a transition between passive and active care. Doctors who do not have the capabilities of initiating active care should at least be aware of the need to decrease passive modalities as care continues.
Many insurance carriers and chiropractic reviewers feel prolonged active care promotes patient dependency or addiction. Some will deny any form of passive care beyond the transition point, including manipulation. Arguments can be made for the eventual discontinuation of some passive therapeutic modalities. However, it was the consensus of our group that there is no active modality or other form of care that can replace the chiropractic adjustment. Thus, the transition between active and passive care is not applied to manipulation.
These guidelines remain true to the Wilcox Principle. They can serve as a framework for doing the best you can while avoiding those things that would turn out to be a disaster.
Dr. Miller is in his 15th year of private practice in Shelbyville, Ky. He is the author of the new text, “Practical Assessment of the Chiropractic Patient.” Dr. Miller is a magna cum laude graduate of Palmer College of Chiropractic; a diplomate of the American Board of Chiropractic Ortho-pedists (DABCO); a fellow of the Academy of Chiropractic Orthopedists (FACO); a certified strength and conditioning specialist (CSCS); and a certified personal trainer (CPT). He can be reached at 502-633-1073.
