All DCs are required to document the same way
On the surface, it might appear that there is not much in common among atherosclerosis, subluxation and Medicare; however, the opposite is true.
Atherosclerosis originated in the early 1900s, which is the same period when doctors of chiropractic (DCs) began to embrace the word “subluxation.” It is important to note that the word did not originate in the chiropractic profession. Subluxation had been around since the late 1600s; the chiropractic profession embraced the word because it seemed to fit the condition/dysfunction being treated with the adjustment.
An examination of the history of atherosclerosis shows how our understanding of the disease has changed since the early 1900s. The current understanding of atherosclerosis is now completely different. The name is the same, but its meaning has changed since 1900. This would be a useful approach for us to apply to subluxation.
Consider that atherosclerosis is far less emotional than subluxation as a topic. Also, there is no internal professional war within medicine regarding the nature of atherosclerosis. For example, medical doctors in one faction do not accuse those in another faction of being anti-medical because they do not believe in atherosclerosis. Unfortunately, our chiropractic profession has such factions. In some circles, if one does not believe in the traditional subluxation model, one is castigated for being anti-chiropractic.
The problem is that one faction embraces traditional subluxation, another faction denies all things subluxation and a third tries to ignore the fighting factions. In my opinion, all three factions are missing an obvious fact. Medicare has operationally defined subluxation for us, which means that all three factions need to change their mindsets and focus on Medicare. It does not matter whether you are a believer, denier or ignorer of subluxation: As a matter of federal law, specific subluxation criteria and other important details must be documented in the record based on specific history and examination findings. And most interesting, the nature of Medicare subluxation is very different from what the believers, deniers and ignorers think it is.
Atherosclerosis was originally thought to be a buildup of plaque on the arterial wall resulting from endothelial cell injury. This view is still embraced today to varying degrees, but began to change in the late 1900s. The evolution of the understanding of atherosclerosis may be useful for chiropractic physicians to apply to their understanding of subluxation. Until about 1970, atherosclerosis was incorrectly perceived as a type of lipid storage disease. Lipid and other plaque components were thought to form on the surface of the arterial wall. Libby states that “this traditional concept viewed atherosclerosis as analogous to the buildup of rust in a water pipe.1
” Then Russell Ross published several papers in the 1970s that changed the perception that atherosclerosis was a “vessel wall reaction to injury.2-5
” Originally, it was thought that endothelial cells were denuded during the injury process, leading to plaque formation.
It was later discovered that atheromas developed beneath uninjured endothelial cells. So in 1986, Ross wrote an update in the New England Journal of Medicine (NEJM) that served to revive his hypothesis.6
He stated that endothelial cells may be injured but remain intact and that the atheroma grows beneath them. Ideally, Ross should have stated, “While I have embraced, promoted and made my living on the reaction to injury hypothesis, perhaps it is wrong.” However, that is tough for humans to do. But Ross did so 13 years later.
In 1999, Ross wrote another article in NEJM, entitled, “Atherosclerosis — an inflammatory disease.” It is important to note that despite this clear title, he still clung a bit to the “reaction to injury” view:7
“Numerous pathophysiologic observations in humans and animals led to the formulation of the response-to-injury hypothesis of atherosclerosis, which initially proposed that endothelial denudation was the first step in atherosclerosis. The most recent version of this hypothesis emphasizes endothelial dysfunction rather than denudation. Whichever process is at work, each characteristic lesion of atherosclerosis represents a different stage in a chronic inflammatory process in the artery; if unabated and excessive, this process will result in an advanced, complicated lesion.”
When he states, “whichever process is at work,” in the context of endothelial dysfunction or a denudation, we see that he is still clinging to hope that a denuding injury might be important. While Ross did not completely give up his reaction-to-injury model, he substantially changed his position over a 25-to-30-year period. Chiropractic physicians should consider making similar concessions regarding subluxation.
Since 1999, it has been established that no denuding injury is needed for atherosclerosis to develop. It develops in areas of turbulence and is known to be a chronic inflammatory process that does not heal.
What was just described is how scientific thinking and the scientific process have led to a more accurate understanding about the nature of atherosclerosis. The related practice of medicine has not been so scientific. The current challenge for medicine is to overcome the dogma surrounding saturated fats and cholesterol, which have been deemed to be the absolute causes of inflammatory atherosclerosis. For a recent critique written by an interventional cardiologist that properly criticized his profession, please read, “Saturated fat is not the major issue,” which was published in the British Medical Journal.8
In short, Malhotra explained that saturated fat and cholesterol are not the cause of heart disease; saturated fat is protective. The real issue is metabolic syndrome. And regarding treatment, adopting the Mediterranean diet after a heart attack is almost three times as powerful as statin therapy in reducing mortality.8
Understanding how metabolic syndrome creates heart disease does involve cholesterol, but not in the way we are taught. We are told that LDL cholesterol rises and HDL cholesterol lowers, and this somehow damages arteries and leads to plaque.
The dietary issue is the consumption of excess foods made of sugar, flour and trans fats. When these chemicals hit the blood-stream, they create low-grade inflammation in many ways. It is very well known that HDL is anti-inflammatory; however, what is not well known is that HDL transforms into a radicalized and inflamed HDL. The consumption of refined carbohydrates and trans fats over time is associated with the expression of metabolic syndrome and the transformation of HDL into a molecule that is no longer capable of participating in proper cholesterol transport and actually promotes atherosclerosis.
The story for LDL cholesterol is similar. Normal LDL is soft and buoyant; however, the consumption of refined carbohydrates and trans fats increases the total amount of LDL and converts it into a molecule that is small and dense (sd-LDL). The continued consumption of pro-inflammatory foods and the development of metabolic syndrome further transform sd-LDL into oxidized sd-LDL (ox-sd- LDL), which is highly inflammatory. The immune system behaves as if ox-sd-LDL is a foreign antigen and wages an all-out attack that is initially silent but will eventually lead to excess plaque formation in the vessel that may result in a vascular event. Oxidized LDL is not yet a commonly available clinical laboratory test. The only indication we have that suggests that LDL is in the transformation process is the identification of elevated LDL.
When we see low HDL and elevated LDL, we need to consider that the patient may have metabolic syndrome. This is an important concern for DCs because patients with metabolic syndrome are at greater risk for developing the most common musculoskeletal pains that have traditionally been perceived as being solely mechanical in nature (e.g. BMI, weight gain, ppm, met syn). Statins and red yeast rice are incorrectly believed to correct the dietary imbalanceinduced inflaming of LDL and HDL.
So, what does the history of atherosclerosis teach us? In my view, we can learn two important lessons. First, we should endeavor to absolutely change our perceptions about the nature of a health condition if the science supports such a change – that is the nature of evidence-based healthcare. Second, we should abandon treatments if they are deemed to be ineffective. Medicine has succeeded in the first lesson, but has in many cases failed miserably in the second. DCs, in my opinion, have failed in the first lesson; we have not adequately advanced the science of subluxation in a professionally beneficial fashion. However, regarding the second lesson, we have succeeded in delivering a primary treatment (the adjustment) that has proven to be very beneficial for many forms of musculoskeletal pain and related symptomatology.9,10
Step back for a moment and consider the subluxation battle that continues to rage within chiropractic, and it seems that the profession has lost focus. The believers continue to call deniers anti-chiropractic, and the deniers scoffat subluxation because it is unscientific and yet to be a proven clinical entity. Each side is firmly entrenched in its positions, and it does appear to be a situation that will not improve or be resolved. I believe subluxation should be viewed similarly to atherosclerosis, and thus, subluxation should be reframed. The believers, deniers and ignorers of subluxation far outnumber people like me who could be called reframers. But my perception, as well as the perceptions of believers, deniers and ignorers is also irrelevant in the context of Medicare. Subluxation does exist in a very specific manner within federal law; this is true whether you are a believer, denier, ignorer or reframer.
To understand the operational definition of subluxation in Medicare, a mind-set change is required. Whether one is a believer, denier, ignorer or reframer, all DCs have to unlearn our preconceptions and do what Medicare directs us to do. In other words, Medicare subluxation is a new reality.
From a mental health perspective, focusing on Medicare would also be beneficial because it would avoid the negative outcomes associated with blaming others for having a contrasting view of subluxation. This would benefit current and future DCs in making them effective at addressing subluxation in the context of Medicare. Space does not permit a detailed analysis of the perceptual shortcomings held by believers and deniers, the groups that, in my opinion, create most of our trouble. I also say with assurance that most believers in subluxation view me as a denier, so I will briefly criticize some of the perceptions of the deniers. In particular, deniers commonly say that “Medicare only pays us to treat subluxation, and it makes no sense that we have to pick a vertebra that is subluxated in order to get paid.”
First, the treatment of Medicare patients is not about subluxation in the traditional sense.
Did you know that you never have to mention the word subluxation in the patient record if you choose not to? Most have no idea that this is the case, yet it is clearly stated in the Medicare Benefit Policy Manual11
(MBPM) and every region’s Local Coverage Determination (LCD). Alternative terms are allowed that refer to musculoskeletal dysfunction, for the purpose of contrasting it with a non-musculoskeletal generator of back pain, such as an abdominal aortic aneurysm.
Second, the notion is foolish that it is problematic to be required to name a painful spinal level to be adjusted. It might be less problematic for the deniers if the word subluxation was not associated with naming the offending vertebral level, and this speaks to the misperceptions held by subluxation deniers. It states very clearly in the MBPM and every region’s LCD that the vertebra to be adjusted must be capable of generating the painful symptoms. In other words, subluxation identification for Medicare is a pain-based approach. Imagine how foolish and scary it would be for spine surgeons to complain about having to identify in the record the spinal level where surgery is to be performed.
In short, the MBPM and LCDs clearly describe what is required for documenting the treatment of a Medicare patient. You only need to read your LCD since each region has minor differences, which do not contradict the MBPM. To facilitate the process of embracing the various requirements put before us by Medicare, Dr. Albert Luce and I developed a chart (See Documentation Requirements and Procedures for Medicare Patients, Page 20) to assist DCs. We first published this in Dynamic Chiropractic.12
My recommendation is to compare the flow-chart we created with your LCD.
After reading the chart of documentation requirements, it should be obvious that most chiropractic physicians harbor misconceptions about Medicare documentation, especially if they have yet to read the MBPM and LCD. Medicare has essentially done to subluxation what science has done to atherosclerosis; Medicare has updated and created an operational definition of subluxation.
In short, it makes no difference what a believer believes, a denier denies, an ignorer ignores or a reframer thinks he or she is reframing, when it comes to Medicare, the requirements are exactly the same for all of us. And if we do not comply, the potential penalties can be swift and painful no matter the subluxation camp in which one may reside. Medicare documentation may be an area on which we can focus and set our differences aside.
1. Libby P. Inflammation and cardiovascular disease mechanisms. Am J Clin Nutr.
2. Ross R. Atherosclerosis: the role of endothelial injury, smooth muscle proliferation and platelet factors. Triangle
3. Ross R, Glomset JA. The pathogenesis of atherosclerosis (first of two parts). N Engl J Med
4. Ross R, Glomset JA. The pathogenesis of atherosclerosis (second of two parts). N Engl J Med
1976 Aug 19;295(8):420-5.
5. Ross R, Glomset J, Harker L. Response to injury and atherosclerosis. Am J Pathol
6. Ross R. The pathogenesis of atherosclerosis— an update. N Engl J Med
7. Ross R. Atherosclerosis—an inflammatory disease. N Engl J Med
8. Malhorta A. Saturated fat is not the major issue: let’s bust the myth of its role in heart disease. Brit Med J
2013;347:f6340 doi: 10.1136/ bmj.f6340 (Published 22 Oct 2013).
9. Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manip Physiol Ther
10. Seaman DR, Winterstein JF. Dysafferentation, a novel term to describe the neuropathophysiological effects of joint complex dysfunction: A look at likely mechanisms of symptom generation. J Manip Physiol Ther
11. Center for Medicare Services. Medicare Benefit Policy Manual. Chapter 15 – Covered Medical and Other Health Services. www.cms.gov/manuals/Downloads/bp102c15.pdf.
12. Seaman DR, Luce AJ, Hamm A. The Medicare hurdle that continues to block our professional progress. Dynamic Chiro
13. Office of Inspector General. Inappropriate Medicare payments for chiropractic services. Dept Health Human Services. May 2009 http://oig.hhs.gov/oei/reports/oei-07-07-00390.pdf
14. Souza TA. Differential diagnosis and management for the chiropractor: protocols and algorithms. 4th ed. Boston: Jones and Bartlett; 2009.
15. Murphy DR. A clinical model for the diagnosis and management of patients with cervical spine syndromes. Australas Chiropr Osteopathy
16. Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord
17. Murphy DR, Hurwitz EL, Nelson CF. A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature. Chiropr Osteopat
18. Murphy DR, Hurwitz EL, McGovern EE. Outcome of pregnancy-related lumbopelvic pain treated according to a diagnosis-based decision rule: a prospective observational cohort study. J Manipulative Physiol Ther
19. Murphy DR, Hurwitz EL, McGovern EE. A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: a prospective observational cohort study with follow-up. J Manipulative Physiol Ther
20. Cleland JA. Koppenhaver S. Netter’s orthopedic clinical examination: an evidence-based approach. 2nd ed. Philadelphia: Saunders Elsevier 2011.