Thank You to Our New. Continued on Page UPCOMING SEMINARS MAR 12 MAR 26. The Rehab Infrastructure MAY 14. Lower Extremity Adjusting

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1 Publication of the Association of New Jersey Chiropractors Winter 2015 Volume 11 Number 1 Thank You to Our New Accuthotix ( Anabolic Laboratories ( Andrew Blair, Attorney at Law ( Cancer Treatment Centers of America ( East Brunswick Open Upright MRI ( ILHWA NA, Inc. ( Infinity Practice Management ( Law Offices of Jeffrey Randolph ( Levinson Medical ( LiteCure Medical ( LunaAmerica LLC ( Medical Protective ( NCMIC ( PAY DC ( Prevention Pharmaceuticals Specialties ( Take Shape For Life ( Target Coding ( The Orthotics Group ( Are you interested in learning more about the benefits of being an ANJC Diamond Sponsor? Contact ANJC HQ at for details. Senate Commerce Committee Approves Chiropractic Assistants Legislation On Monday, December 8, 2014, Senate Bill S 2333, which provides for licensure of chiropractic assistants, passed favorably 5-0 from the Senate Commerce Committee and will now move forward to the entire New Jersey Senate for a vote in the near future. Dr. Steven Clarke, ANJC Legislative Chairman, along with ANJC s lobbying team traveled to the Statehouse yesterday in support of the legislation that subsequently was voted favorably to forward. Not Just for CE Alone By Julie Cox-Cid & James M. Cox, DC, DACBR Cervical Spine: A Common Case of Neck Pain and Extremity Pain A72-year-old white, married female, accompanied by her husband, is seen at referral of her orthopedic surgeon for the chief complaint of left neck pain extending into the left shoulder with occasional Continued on Page 26 Continued on Page UPCOMING SEMINARS MAR 12 MAR 26 The Rehab Infrastructure Part 1: Beyond Gluten Sensitivity: Part 2: Case Studies: How to Apply Clinical Nutrition in a Chiropractic Practice Inside: The Power of Community Dr. Michael Kirk page 3 A Tribute to a Wonderful Term! Dr. Joseph D Angiolillo page 4 ANJC Goes International Donald C. DeFabio page 5 Looking at Injury Trends: A Case Study Dr. Christine Foss page 6 Magnesium: Miraculous Mineral Christopher J. Bump page 14 Answers to Your Important Malpractice Questions Keith Henaman page 15 Three Key Steps to Ensure Proper Coding and Documentation David Klein page 16 Big Brother and His Siblings: Social Media Creates a Society of Watchers Dr. Ray Foxworth page 18 If It Doesn t Hurt, Nothing Is Wrong Dr. Mark N. Charrette page 20 Rehab Made Easy Donald C. DeFabio page 21 Protect Your Business from Snow and Ice Garry R. Salomon page 22 Starting with Your Next New Patient William D. Esteb page 22 Cash Practice Alternatives: Considerations for Chiropractors Mark Sanna page 23 Featured Articles Association of New Jersey Chiropractors 3121 Route 22 East Suite 302 Branchburg, NJ U.S.A. PRSRT STD U.S. POSTAGE PAID PLATTEVILLE, WI PERMIT NO.124 MAY 14 Lower Extremity Adjusting Spring Summit APRIL SIGN-UP TODAY! Visit for more info. Insurance... 6, 12, 20 Research Updates... 9 ChiroAssist Q & A Legal...17 Q & A Insurance...17 Legal Ease Insurance Update Promoting Your Chiropractic Practice on Facebook in the New Year? Read This. See Page 25

2 Winter THE RIGHT STRETCH. The Power of Community By Dr. Michael Kirk President, ANJC EVERY TIME. XactStretch Indicators Make Specific Kinesiology Tape Elongation Easy NEW On behalf of Don DeFabio and myself I would like to thank you for allowing us to serve you as the vice president and president of our great chiropractic COM- MUNITY known as the ANJC. Would you agree that it is our sense of community that has and will continue to make us successful? Think about it. Ten plus years ago our chiropractic community was fragmented. In New Jersey, we lacked a unified voice and a unified mission, which at the very best only helped to keep us afloat. Fast forward ten years and look at some of the results that the efforts of our COMMUNITY has accomplished. Our COMMUNITY consists of approximately 1900 member doctors. We have a stellar headquarters team. We have the support of 75 sponsors and retain a number of knowledgeable consultants. We have a unified voice. We have a new scope of practice. We have positive relationships with legislators, policy makers and statewide organizations like the NJEA. We have a voice that allows us to stand up against the wrongdoings of the insurance companies. We have member benefits (FREE CEUs, Summits/Conventions, specialized councils, DOT training, ChiroAssist program, etc.) that have chiropractic associations across the nation looking to us for direction. We have chiropractic assistant legislation making its way through the legislature that will allow you to better serve your patients through the help of a licensed assistant. We are ramping up our public website with social media outreach that is designed to educate the public about the numerous benefits of chiropractic care and to have them pick up the phone to call a COMMUNITY member close to them. How has the ANJC become so successful and accomplished so much in so little time? It s not the result of any one person or small group of persons. Rather, it s a result of our joint COMMUNITY efforts. It s a unique combination of our rock solid membership, headquarters staff, sponsors, board of directors, consultants, and others that all contribute in their own special way to the greater good of our COMMUNITY known as the ANJC. By putting our COMMUNITY first we will be able to serve more New Jersey residents that need our care and as a result we all rise to new heights together. A COMMUNITY is successful because of its members and their unique contributions. Contributions to our COMMUNITY come in three basic forms: time, money, and a combination of time and money. All three forms of contribution are necessary to help our COMMUNITY continue to thrive. Monetary contributions come in the form of membership dues, By putting our COMMUNITY first we will be able to serve more New Jersey residents that need our care and as a result we all rise to new heights together. political action committee (PAC) contributions, and sponsorships. Time contributions come in the form of participating on state/regional boards, committees (such as insurance, legislative, and public relations), or volunteering your time as special needs arise. Or we have a unique combination of both time and money. My question to you is how will you continue to support the greater good of our COMMUNITY? All COMMUNITIES, including the ANJC, are in need of individuals with SEE AD ON PAGE 18 unique talents, knowledge, and skills to step up and participate in order to take their COMMUNITY to new heights. Are you willing to contribute your unique talents, knowledge, or skills to a COMMUNITY that has served all of us so well over the past ten years? If so, please contact headquarters or me and let us know how you would like to get more involved on a state/ regional level or with a particular committee of interest. As Helen Keller once said, Alone we can do so little; together [as an ANJC COMMUNITY] we can do so much. Please let me know how I can better serve you and how you can help better serve our COMMUNITY. Thank you for all that you do as well as your ongoing support and together we will continue to THRIVE! Best in Class Adhesion 8 Designs from Subtle to Bold Available in bulk, individual, and pre-cut rolls Contact your authorized TheraBand distributor to purchase Visit Thank You, Doctors, for Helping Make NCMIC the One and Only Malpractice Insurance Company to Return a Premium Dividend to its Chiropractic Policyholders We can t say thank you enough. You ve made possible our stellar record 19 consecutive years of giving back to our chiropractic malpractice insurance policyholders through a premium dividend. Our doctors effective risk management, along with NCMIC s solid business decisions and experience managing claims, makes it happen. FREE Videos Over 200 Research Abstracts FREE Samples For more information about NCMIC and our premium dividend, visit Or, call us at , ext TheraBand, XactStretch, Cramer, the Color Pyramid and Associated Colors trademarks are property of Performance Health and/or its subsidiaries and may be registered in the United States and other countries. Unauthorized use is strictly prohibited. All rights reserved P07117 Rev 0 Premium dividends are not guaranteed. We Take Care of Our Own is a registered service mark of NCMIC Group, Inc. and NCMIC Risk Retention Group, Inc NCMIC NFL 3693 P07117 KTAPE ad ANJC.indd 1 12/9/14 7:14 PM

3 4 Winter A Tribute to a Wonderful Term! Winter ANJC Goes International By Donald C. DeFabio, DC, DABSCP, FACO By Dr. Joseph D Angiolillo, Immediate Past President, ANJC S itting here writing my final president s message, I truly cannot believe it has been three years. As the saying goes: time flies when you re having fun! Yes we had some stressful points, but overall the experience has been positive with many fantastic accomplishments. Many of you have stopped me to give me a pat on the back for the success of the society. I can tell you that the success is the result of a fabulous team. I am honored to work with some of the most dedicated board members, whose primary concern is the advancement of the profession and to ensure our members expectations are met or exceeded. This team is also composed of a highly skilled headquarters staff who handle the daily operations of the society. Last but not least kudos have to be given to our creative ED, Sig Miller, and our highly efficient Assistant ED, Diane Fetzer. The board and I set the course and approve the SEE AD ON PAGE 17 direction. It is headquarters that is focused on executing the daily tasks of serving you. As I alluded to in my opening remarks at the spring convention in 2011, my goal was to create the framework that would sustain this society moving into the future. I truly believe we have accomplished this goal. Diane Fetzer was hired as the Assistant ED to oversee the operations of headquarters. She has systematized and streamlined our processes and procedures as well as been instrumental with the hiring of a very talented staff. Many of your questions, complaints, and challenges come under the broad heading of insurance. The board realized there was no way we could serve your needs without having an in-house insurance specialist. Matt Minnella was our next hire to fill this role and he is doing an outstanding job. Why Upright MRI of Cherry Hill? G. Tom Morea, MD, our Board-Certified Radiologist, is one of the most experienced MRI physicians in the world with over 25 years providing unparalleled MRI expertise. Dedicated, highly trained, friendly staff and convenient hours. Most reports are sent to your physician s office within 24 hours of your study. Accredited by American College of Radiology. The Fonar Upright MRI, at 0.6 Tesla, is twice as powerful as most other open MRI scanners and yields high-quality, routine MRI and MRA studies as well as our unique positional studies. Most insurances accepted including workers comp and MVA cases. Accommodates patients up to 500 lbs. Scans done in your position of pain: seated, standing, lying down or bending. Claustrophobic? No worries. At Upright MRI of Cherry Hill, you won t lie in a tube for your scan. NO MORE TUBE. Instead, you ll be able to sit and relax while watching a 42 inch flat screen TV during your scan. Conveniently located at 701 Route 38 East, Cherry Hill, NJ phone se habla español fax Visit us on the web! I am honored to work with some of the most dedicated board members, whose primary concern is the advancement of the profession and to ensure our members expectations are met or exceeded. We have triumphed in several legal battles. Class action lawsuits against some of the biggest carriers have been won, which has not only put some dollars into our association s coffers, but also in the pockets of you, our members. Challenges like the modifier 51 issue with Optum have been won and the issue with Aetna is currently progressing. Both are national issues, taken on by your society. It is because of your support that we are able to hire the necessary expert coding and legal advice to make our points. I, along with a team from the ANJC, have met several times with the Commissioner of Banking and Insurance, as well as the Director of Consumer Affairs to bring your concerns to them, as well as to offer the ANJC as a source of information. We are very happy with the relationships we have developed with both departments. We have created partnerships with several unions including the NJEA. We not only provide their members with information on the cost effectiveness of chiropractic, but also direct them to seek the services of an ANJC member. Our members have varied interests and levels of expertise. As such we began to serve these interests by creating and providing new programs, councils, and committees. We introduced the Nutrition Education Council, The Department of Transportation Program, we have recently launched the Council on Technique and Clinical Excellence, as well as the Rehabilitation Council. ChiroAssist was begun to support our staff members. This past summer the Assembly approved the Chiropractic Assistants Bill, which will create a class of assistants that will be able to assist the chiropractic physician with some of the clinical activities in the office. I expect that by the time you read this, the Senate will have passed their version of the bill and have sent it to Governor Christie for his signature. We are able to move legislation because the ANJC is a credible, unified voice for chiropractic. I can honestly say that the board and I are proud of these accomplishments. It has been my pleasure to serve you. I thank you for your support and entrusting me with this honorable position. As I pass the torch on to Mike Kirk, I know that our society is in good hands. Please afford him the same support that you have given me. A major benefit of chiropractic as a career is that we can never be outsourced offshore! Yes, webinars and long distance learning have become the norm today, but the chiropractic adjustment will always need to be done by hand from one person to another. Although a uniquely American discipline, chiropractic is legally recognized in over 45 countries with a strong and stable presence in New Zealand. New Zealand has approximately 350 registered chiropractors and most are members of the New Zealand Chiropractor s Association NZCA. Originally founded in 1922, the NZCA s purpose is to maintain professional standards, liaise with various government and health bodies, and to be a professional voice for chiropractic. According to NZCA board member, Dr. Hayden Thomas, the high level of membership NZCA enjoys is attributed to a unified identity for chiropractic in the country as well as a place within the national healthcare system. We have a broad scope of practice and a good relationship with the other professional associations. Right now everything is quite stable, which is fine with us. Recognized as primary healthcare professionals, NZ chiropractors are focused on promoting health and wellness through the chiropractic adjustment. Areas of specialization beyond general practice include animal chiropractic, pediatrics, sports chiropractic, and chiropractic research. In fact, strong research has been coming out of New Zealand for decades. To support the growing need for chiropractic in NZ, in 1994 the NZCA decided it was time to start training doctors locally and formed the NZ Chiropractic College. The school is located in Auckland and has an efficient and welcoming campus. Matriculating 75 doctors annually, NZCC is near capacity for its four year program. The academics are rigorous: NZCC is accredited by the International and Australasian accrediting councils CCEI and CCEA respectfully and accepts both domestic and international students. Furthermore, it is recognized by the NZ Qualifications Authority. President, Dr. Phil McMaster, was there from the beginning and is extremely proud of his school and students. Our standards for hands-on learning are high, our students are taught sound chiropractic philosophy, and our research department is well recognized. It is a great place to become a chiropractor. Interestingly, the degree conferred down under is a Bachelor of Chiropractic (BChiro), and is recognized beyond Australasia as well. This is comparative to other health fields that are conferred degrees such as Bachelor of Dentistry or Bachelor of Medicine. Even several states in the US allow chiropractors from NZCA to apply for licensure. On a post graduate level, NZCC has partnered with Sherman College to provide a certification program in chiropractic philosophy and also has a Radiology Diplomate program. NZCA is the only private chiropractic training institution within Australasia and has a clear mission: To provide an inspired educational program that graduates chiropractic leaders committed to the highest standards of professional excellence in the philosophy, science, and art of chiropractic. Research coming from NZCA has is researching the cortical changes been consistently strong: Chiropracthat occur after an adjustment. Very tic benefits during pregnancy Diakow, cutting edge and worth a PubMed PRP, et al. JMPT Vol. 14, No. 2 Feb. search More recently, The role of New Zealand has taken a focused spinal manipulation in addressing and thoughtful approach to chiropracdisordered sensorimotor integration tic over the years and it shows. A and altered motor control Haavik H, stable national organization, solid edmurphy B. J Electromyogr Kinesiol ucation for upcoming chiropractors, (2012), is an excellent study to suband leading edge research from its stantiate that adjustments improve chiropractic college with a vision for performance and reduce sports re A world of people expressing optimal lated injuries. Currently Dr. Haavik potential. NAPA NJ Chiropractic Ad x FINAL_Layout 1 12/30/14 9:33 PM Page 1 your partner in healing. To learn how we can work together to help your patients, please call Dr. Phil McMaster, president of New Zealand Chiropractic College, with Dr Don DeFabio at a recent site visit and campus tour. Monmouth Pain Care A DIVISION OF North American Partners in Pain Management 279 third avenue, Suite 601 long Branch, nj tel: Fax:

4 6 Winter Pre-Participation Examination Update By Michael W. Goione, DC In a past issue of New Jersey Chiropractor, published by the ANJC, we discussed some of the challenges facing NJ chiropractors and school related physical exams and return to play issues. A recent law passed by the NJ Legislature called the Scholastic Student Athlete Safety Act has in some ways clouded the pre-participation examination situation even more. The Act was designed to update the Pre-Participation Physical Evaluation (PPE) form, Health History Update Questionnaire, Sudden Cardiac Death in Young Athletes pamphlet, and sign-off sheets for parents, guardians, and student athletes. The PPE form was developed jointly by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. This form is now mandatory for all student physical examinations prior to participation in any school sponsored intramural or interscholastic sport. This form can be found at education/students/safety/health/ records/athleticphysicalsform.pdf. The most significant change in the form is the requirement that the healthcare provider signing the form must have completed a Professional Development Module called the Student-Athlete Cardiac Assessment Professional Development Module. This module is being developed in collaboration by the NJ Department of Education, NJ Department of Health, and several state and national cardiac associations. However, as of the writing of this article, the module is still not completed and unavailable on any state websites. Until the module is completed, the forms are acceptable without the healthcare provider attestation of completion. The PPE form has a signature line that states Name of physician, advanced practice nurse (APN), physician assistant (PA). Below that line is another area where the healthcare provider will attest to completion of the PD module. The Department of Education released a Frequently Asked Questions and Answers document with respect to the Act. education/students/safety/health/ services/athlete/faq.pdf. The critical issue to chiropractors is question #8: 8. Does the term physician only mean MDs and DOs or are other individuals such as chiropractors allowed to complete physicals now? According to N.J.S.A. 18A:40-1, physician refers to physicians licensed to practice medicine and surgery within the state. The law allows physicians, advanced practice nurses, and physician assistants to conduct the student-athlete s preparticipation physical evaluation. This has not changed. Since chiropractors are not licensed to practice medicine or surgery, (emphasis added), nor are they specifically named in the law, they are not allowed to complete the physicals. As has been stated in the past articles, the ANJC opinion is that chiropractors do fit the definition of physician in that statute. There is case law in NJ attesting to this subject. The ANJC ad hoc committee is currently working with our in house counsel and a leading Education Law attorney to present this issue to the NJ Departments of Education and Health. We will keep membership informed on any and all developments on this topic. In the meantime, any chiropractor interested in performing pre-participation exams should contact their local board of education and request the policy on physical examinations. Those policies should be reviewed by an attorney and investigated as to whether the school district policy is following statute. The problem that many chiropractors face on this issue is a significant level of confusion by the local school administrators. An example is a local district s Athletic Director stated that he would accept a pre-participation examination by a chiropractor. Yet the school physician said no, and the school policy is so vague, that it doesn t clearly allow or deny a chiropractic physician exam. Hopefully, the new statute although currently problematic, will actually clarify this issue once the definition of physician is clearly defined to the NJ Department of Education. Dr. Michael W. Goione currently practices in Red Bank, NJ. He is the Official Team Chiropractor to the Monmouth University Hawks and the Georgian Court University Lions. Dr. Goione is also an insurance consultant to the ANJC and he sits on the Optum Health Chiropractic Physician Advisory Panel. Start Here for Daily Nutrition The Simple Way to Support Wellness Looking at Injury Trends: A Case Study By Dr. Christine Foss In working with athletes of all calibers daily, it is important to keep an eye on injury trends. I understand that sometimes in our practices we see more of a particular condition on a given week than the previous week or month, but injury trends among athletes are very different. They can give you a wealth of knowledge about the training, recovery, phase of season, and nutrition of the athlete. It is our job to keep an eye on these factors so we can effectively treat and facilitate healing in the athlete. Working with a particular group of athletes this year, I noticed that we were getting an increasing amount of injuries. Because of this, it is important to always keep track of how the athletes get injured. For example, were the injuries incurred during warm up, the middle of practice, doing a particular exercise, or even with a certain coach? How the injuries occurred is usually where you can find the answer to your trend questions. Keeping track of types of injuries is also imperative. Are we seeing mostly ankles, hamstrings, or low backs? This year, although there were more injuries than previous years, there was no trend that I could find at first. I spent time with coaches asking about training regimes, changes in equipment, times of training, or even sets and reps. Nothing was changed that anyone could point out. The coaches even decreased the daily assignments for the athletes due to the injuries. Taking time to talk to the athletes is also very important in evaluating injury trends. Ask them about training changes or equipment changes. Again, knowing the athlete s daily routine and being acutely aware of the requirements of the sport for performance is important. Once again the athletes attested that the practices were not as demanding but the injuries were mounting up. Clinically, it was interesting that not only were there an increased number of injuries, but that the most common injuries were stress related injuries. Examples of these are prestress fractures of the pars, stress fractures of wrists, occult fractures of cuboid, and distal tibial pre-stress fractures to name a few. It was also evident that most of these athletes were experiencing fatigue and delayed healing times as well. Putting all these facts together led me to think of environmental factors to injury. The athletes in this case were very high level. They trained all day and schooled between and after training. Stress related injuries and delayed healing times sounded like it could be a possible vitamin D deficiency to me. We had just come off a long, cold, grey winter. This added to my theory. I began testing the athletes with stress related injuries for vitamin D levels, and found them to be below normal in each case tested. The only athlete that was not low in vitamin D was the one that was put on the supplement two months earlier post surgical intervention. Because of evaluating injury trends, these athletes were effectively diagnosed, treated, and educated. They can avoid future injuries due to this knowledge as well. Evaluating injury trends is a simple and effective means to help keep our athletes healthy and in play. Any questions regarding this or treating athletes can be directed to H e a Sold Through lth C are P rofe s sio n als Make your patients lives a little easier with these convenient grab-and-go packs. Visit or call to place your order today. Whole Food Supplements Since 1929 2014 Standard Process Inc. All rights reserved. 07/14 These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease. Daily Fundamentals-New Jersey Chiropractor.indd 1 9/29/14 2:58 PM

5 8 Winter Winter ANJC PLATINUM SPONSORS DIRECTORY ANJC PLATINUM SPONSORS Continued from page 8 Research UPDATES By Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC ANJC Platinum Sponsors are trusted business partners who have supported ANJC for many years. Their valuable contributions help to achieve ANJC s goals in serving membership and their patients. These business partners meet the highest standards regarding quality of products and services, and they are sensitive and responsive to the personal needs of our members. ANJC Platinum Sponsors have a proven track record in assisting NJ chiropractors Billing/Coding & Collections CB&C Inc. Lynette Contreni Description: Specializing in Chiropractic, CB&C offers consulting, training and a full range of Billing/Collections services, which are tailored to your needs. Also, we offer a verifications department which assists your office in obtaining maximum reimbursement, & handling contracts. MD On-Line Tom Schweizer Description: Provide clearinghouse services to facilitate the electronic transfer of healthcare transactions and information between providers and payers. NJ PIP Pay Associates Lori Blair Description: Our company bills and collects exclusively for Personal Injury Claims. Our costs are extremely competitive and are based upon our recovery. Business/Financial Services Emerald Financial Michael A. DeVizio Michael Manginelli Description: We are focused on developing and delivering the exact combination of financial tools that Chiropractors require for today s comprehensive practice and their particular situation. Guardian Life Insurance Company Anthony Campanile Description: Guardian Life Insurance Company has been providing doctors with disability and life insurance and investments for over 150 years. Key Products and services: Disability Insurance, Life Insurance, Investments. M&T Bank Jerome Baier Description: We understand the importance of building long-term relationships and community involvement. It s what we ve been doing for over 155 years. When your practice succeeds, we all succeed. Mid Atlantic Resource Group. LLC Donna Scallo X 167 Lesley Weiner x 329 Description: 2008 ANJC Business Partner of the Year. ANJC member discount on comprehensive Disability and Long-Term Care Insurance. Life, Disability, Long Term Care, Employee Benefits, Retirement Planning. Independent Insurance and Investment Services firm since The Omar Group, CPA Salim Omar, CPA Description: Specializing in providing accounting and tax services to chiropractic practice owners. T.M Vitale Associates Shannon Smyth Description: We are Certified Public Accountants with extensive experience in the Chiropractic Industry. We work closely with business owners as their trusted advisors. In addition to tax and accounting services, our firm also offers profitability analysis, budgeting & forecasting, retirement planning advice and other consulting solutions. Chiropractic Equipment/Supplies & Patient Education Back App Todd D. Comer, DC Description: We would like to introduce a new Scandinavian chair technology which is changing the ways we think about sitting in our home and office work space. The chair was invented out of necessity following two failed low back surgeries by a Norwegian research scientist, Freddy Johnson. Dr. Johnson needed a solution to his ongoing pain he experienced while sitting at work. The result of his motivation was the Back App Ergonomic Chair, a unique way of sitting. BIOFREEZE /Performance Health Description: Performance Health is the maker of market-leading Biofreeze and Thera-Band products, as well as other vital clinical brands. Key Products: Biofreeze and Thera-Band. ChiroMatic Sleep Systems Debbie Carlitz Description: Developed with help of chiropractors, ChiroMatic mattresses provide ultra premium support and comfort. Chiropractic Leadership Alliance (CLA) Sabrina Pelech ext.130 Description: CLA is focused on equipping chiropractors around the world with the profession s best selling technology, the Insight Subluxation Station for patient assessment and education. Description: Since 1997 Elite medical Specializes in Providing Chiropractors and Surgeons with quality spinal bracing, traction, electrotherapy products assisting their patients on the road to recovery. Erchonia Melissa Morningstar Description: Erchonia is the global leader in low level laser healthcare applications. All Erchonia lasers are proven safe and effective through independent clinical trials. Key product and service: Low level laser therapy. Haven Innovation Sharon Swain Description: Haven Innovation is the manufacturer of the Cox Table. The best just got better; introducing the Cox Model 8, the latest generation Cox Table and the ultimate instrument for the hands on professional. The re-engineered Model 8 is extremely robust and features enhancements for better caudal and cervical section balance, improved tactile performance, expanded software and control options, and general aesthetic upgrades. Human Scale Paul Levy Description: The premier designer and manufacturer of award-winning ergonomic products, including seating, monitor arms, keyboard supports, height-adjustable tables and more. Levinson Medical Specialties Charles Levinson Description: Suppliers of physical therapy equipment, supplies, chiropractic tables, service, serving the profession for nearly 50 years. Key Products: Physical therapy equipment, Chiropractic tables and service. Mally Enterprises PJ Cook Description: Mally Enterprises founded by Dr. Mitch Mally supports informational and diagnostic extremity manipulation techniques, case and practice management, biomechanics, radiology, physiotherapy and rehabilitation programs with state-of-the-art DVD s and books plus hands on seminars! ScripHessco Kevin Baltzer Description: ScripHessco has been a trusted resource to health care practitioners for over 40 years. ScripHessco features over 10,000 products and is the largest distributor of reconditioned tables. Key Products include: Electrotherapy Equipment, new and used adjusting tables and traction, and chiropractic supplies. Troluna Christina Troha Description: TrolunaMedical has the superior edge when it comes to the latest, high quality chiropractic products and proven practice marketing techniques. MOVING YOU FORWARD. X-Ray, Diagnostic Imaging Services & Equipment LiteCure Medical Gioacchina Randazzo Description: LiteCure is a medical device company offering advanced laser products and innovative technology to healthcare, rehabilitation and training professionals. Drug-free, Surgery-Free, Pain-Free Relief. with reaching their individual practice goals and in staying on the cutting edge of the health and wellness revolution in their communities. For all they do for ANJC members, you owe it to them to first take a look at their products and services before going elsewhere. Many offer substantial discounts and value-added services to ANJC members. Remember when buying from ANJC Platinum Sponsors, you are supporting ANJC, it s that simple! Spinal Kinetics, LLC Dr. Bill Puglisi Description: The most advanced Computerized Radiographic Mensuration Analysis that helps prove subluxation, objectively and accurately. Key Products: C.R.M.A., DMX, and Free Lectures and education Stat RiverWinds Joseph Jarrett Description: We offer High Field Open MRI and X-Ray Services. 24 turn around time for reports and Same Day Appointments and STAT Reads. Upright MRI of Cherry Hill Marge Beck Description: At Upright MRI of Cherry Hill, patients can be scanned weight bearing, seated, standing, bending or lying down to permit the best visualization possible of their problem. Key Products: MRI Scans Nutrition & Wellness Biotics Research Debra Fish Ex 140 Description: Biotics Research Corporation was formed in 1975 and from day one the foundation has been Innovation and Quality. Our goals remain unchanged - innovative ideas, carefully researched concepts, and product development with advanced analytical and manufacturing techniques to develop and produce nutritional products of superior quality and effectiveness available exclusively to healthcare professionals. Health Centers of the Future Warren Philips Practice Building Description: Our events infuse cutting edge testing and support protocols for common conditions. The systems you learn can be applied in your office the next day. Nordic Naturals Judi Jones Senior Sales Consultant P: x30 M: Description: Omega oils have become an essential component of every health protocol. Because they are in high demand, many professional brands have added omega-3 fish oil products as a line extension. That s where Nordic Naturals differs. Since 1995, omega-3 nutrition has remained the passion and focus of Nordic Naturals. As a brand that specializes in one thing, we are uniquely positioned to partner with you in sharing the power of omega-3s with your patients and community. Nutritional Frontiers Jamie Dorley Description: Our Mission is to create, develop and provide safe, effective therapeutic natural solutions and educational programs to chiropractors and their patients with excellent quality, integrity and service. Prezacor, Inc. James Pachence & Description: Prezacor, Inc. is a medical products company focused on developing and marketing an innovative pain management technology. The initial Prezacor Energeze product is a simple to use extended wear pain relief patch. Standard Process Inc. Bruce Poritzky Description: For more than 80 years, Standard Process, headquartered in Palmyra, Wis., has provided health care professionals with highquality, nutritional whole food supplements. Standard Process offers more than 300 products through three product lines: Standard Process whole food supplements, Standard Process Veterinary Formulas, and MediHerb herbal supplements. The products are available only through health care professionals. XYMOGEN Richard Malkin Senior Functional Medicine Consultant Description: Wellness and Nutrition Integration Programs-Clinical Research, Education and Product Development- 22 Years Proudly Serving New Jersey Practitioners Laboratory Services Healthlink Diagnostic Laboratories Mike Toader Description: Healthlink Diagnostic Laboratories is a state of the art CLIA certified diagnostic laboratory offering a broad spectrum of lab tests. HLD utilizes the most advanced technologies to help healthcare providers and patients detect hormonal and nutritional imbalances, cardiometabolic risks, vitamin D deficiency, fertility and thyroid disorders through accurate, convenient and innovative laboratory testing. HLD is a preferred ANJC platinum sponsor offering very competitive prices. Parkway Clinical Laboratories Inc. Carolyn Bonner Description: Parkway Clinical Laboratories (PCL) is an emerging national CLIA-certified clinical reference laboratory performing routine and esoteric diagnostic testing, with a focus on supporting anti-aging and wellness providers in the initial diagnosis and ongoing care of patients suffering from complex chronic diseases, nutritional deficiencies and advanced cardiovascular risk. PCL is proud to be the preferred reference lab and platinum sponsor of ANJC. Through our broad menu of services, we provide personalized and customized solutions to ANJC members, including around the clock ambulatory specimen collection, home draw service and a discounted fee schedule. Consultants/Practice Management Beshert Michelle Simon Description: Beshert is a unique case management company that caters to patients involved in no-fault, worker s compensation, and slipand-fall accidents as well as patients with sport s injuries, out-of-network insurances, and lien/cash cases. Beshert is a scheduling service that is equivalent to a medical concierge for patients, attorneys and doctors. Beshert s motto: your network is your net worth. Breakthrough Coaching Debbie Olinger Description: Chiropractic Consulting services. ChiroHealth USA Ray Foxworth, DC Description: Want to practice with peace of mind? Our network model eliminates worry about dual fee schedules, improper time of service discounts and OIG violations for offering discounts on non-covered services. KMC University Kathy Mills Chang, MCS-P TEAM KMC Description: KMC University provides Chiropractors with tools and solutions to improve and maintain the reimbursement and compliance performance of their practice, delivered with maximum effectiveness, innovation, and ease of implementation. Positive Impact Coaching and Consulting Services Dr. Michelle Turk Description: Positive Impact Coaching is a company focused on helping you grow towards professional success and a balanced personal life. Via coaching and practice development services, we ll help you define and attain YOUR point of positive Impact. We also offer dynamic speaking engagements for groups and organizations on a variety of practice building and personal growth topics. Target Coding Marty Kotlar Description: Experts in helping chiropractors document properly, get paid properly and in audit prevention. The Rothenberg Group Jess Rothenberg, DC Description: Assist doctors with collection services and advice for auto accident patients. Continued on next page ANJC Disclaimer: The company or persons providing the within goods or services, though an ANJC sponsoring entity or individual, is an independent organization of the ANJC and its structure, views, techniques, materials and methods are not authorized, reviewed for accuracy, or otherwise approved or endorsed by the A.N.J.C. The content of the materials and services has not been reviewed or approved by the ANJC for accuracy, completeness or compliance with the various governing statues, regulations, ordinances, or other controlling laws and should not be viewed as a direct or indirect endorsement or verification of the accuracy or legality of the goods, services, or delivery model. The application and impact of laws can vary widely based on the specific facts involved. Given the changing nature of laws, rules and regulations the A.N.J.C. does not engage in rendering legal, accounting, tax, or other professional advice and services. As such, the sponsor s association with the ANJC should not be used as a substitute for consultation with professional accounting, tax, legal or other competent advisers. Before making any decision or taking any action, you should consult an appropriately trained professional prior to utilizing the sponsor s goods or services. TLC 4 Superteams Phyllis Bliem Description: TLC is the coaching company where everyone s voice matters. A community standing strong for chiropractic, shared experiences and hopes raising servant leaders for future generations. Medical/Clinical Services Advanced Center for Special Surgery Montville Health Dr. David Saint Description: A freestanding state of the art licensed multi-specialty ambulatory surgical center offering a wide range of out-patient surgical procedures Allied Neurology & Interventional Pain Practice Jack Koczarski Description: Interventional pain management is the discipline of medicine devoted to the diagnosis and treatment of pair related disorders principally with the application of interventional techniques in managing subacute, chronic, persistent and intractable pain, independently or in connection with other modalities of treatment. Cancer Treatment Centers of America Rocco DeCicco Description: Cancer Treatment Centers of America (CTCA) provides a comprehensive, patient-centered treatment model that fully integrates traditional, state-of-the-art medical treatments with scientifically supported complementary therapies such as nutrition, naturopathic and chiropractic medicine, psychological counseling, physical therapy and spiritual support to meet the special, whole-person needs of advanced-stage cancer patients. With a network of cancer treatment hospitals and community oncology programs in Philadelphia, Phoenix, Suburban Chicago, Tulsa and Seattle, CTCA encourages patients and their families to participate in treatment decisions with its Patient Empowered Care model. Union & Raritan Anesthesia Associates and Pain Management Maria Sanagustin Description: Union Anesthesia & Pain Management specializes in Laser Spine surgeryour physicians cohesively work together to provide you with effective pain management and comfortable experience. Insurance Services/Risk Management ChiroHealth USA Ray Foxworth, FICC, MCS-P Description: ChiroHealthUSA is a Discount Medical Plan Organization that provides a simple solution when it comes to offering legal network based discounts for cash, underinsured and out of network patients. John C. Crilly Agency John C. Crilly Description: Recipient of ANJC 05 award for Outstanding Effort and Commitment, we offer the following insurances: Professional Liability Malpractice Insurance, business owners, employee benefits, employment practices liability, life, disability, long term care, workers compensation and Health Insurance. Medical Protective Company Julie Nycum Description: MedPro s unmatched A++ A.M. Best rating and 114 years of experience defending 100,000+ malpractice claims make it the clear choice for chiropractic professional liability insurance. NCMIC Mike Whitmer Description: We Take Care of Our Own NCMIC has grown to become the largest provider of Chiropractic malpractice insurance in the nation, covering more than 37,000 DCs. Key Products: Chiropractic Malpractice Insurance, Equipment Financing and Merchant Processing. OUM Chiropractor Program Tamara Jackson Description: OUM s extensive malpractice insurance policies offer broad protection that cover the range of professional chiropractic services you provide within your state s defined scope of practice. Key Products: Malpractice Insurance Legal Services Brach Eichler Description: Brach Eichler LLC is a full-service law firm with offices in Roseland, N.J. and New York City. The firm s core practice groups are health law, real estate, litigation and trusts & estate, and through these groups they cover many key practice areas such as criminal defense & government investigations, employment law, business & transactions, family law and intellectual property. With more than 60 attorneys, the Firm has frequently been recognized by clients and peers alike in Chambers USA, Best Lawyers in America, and New Jersey Super Lawyers. Visit Davis, Saperstein & Salomon, PC Garry Salomon Description: Davis, Saperstein & Salomon is a plaintiffs personal injury law firm representing injured clients for over 25 years. Its twelve attorneys have built solid relationships with the Chiropractic community and welcomes their referrals. Law Office of E. Vicki Arians, LLC E. Vicki Arians, Esq Description: Law firm concentrating in PIP arbitration, insurance company audits and healthcare. Law Offices of James C. DeZao, P.A. Jim DeZao, Jr Description: DeZao Law is a full service plaintiff s firm that is committed to excellence and 100% client satisfaction. Law Offices Of Jeffrey Randolph Jeff Randolph, Esq Description: Specialize in healthcare law and complex litigation. Law Offices of Sean T. Hagan, LLC Sean T. Hagan Description: Specializes in NJ PIP Recovery and Arbitrations at no costs to you, practice management consultation and handles personal injury cases throughout all of New Jersey. Software Practice Management PayDC David Klein Description: PayDC is a fully integrated EHR solution designed to manage your practice and the entire course of patient care. Quick Notes Ken Schenley Description: Easy-to-Use solutions for Portable SOAP Notes and Electronic Medical Records (EMR). Fully-compliant charting on a PDA or ipad. Templates and Voice Recognition tools. Quick Notes has been supporting Chiropractic in New Jersey for 23 years. Simple Chiro Software Kurt Strecker, DC Description: Simple Chiro Software allows you to quickly create concise patient records including history and physical examinations, SOAP notes, and more. Gather demographics and medical history using a kiosk to expedite patient flow while keeping complete and accurate charts. Drastically reduce labor costs. Customize the system for the way you practice. Automatically track and restock inventory. Effectively market and grow your business. Compliance HIPAA Secure Now! Patrick Felicetta x801 Description: Provides products and services to help healthcare entities comply with HIPAA. Includes the required Security Risk Assessment, 18 Policies and Procedures and Training delivered via Compliance Portal. An annual Subscription provides an updated Risk Assessment and $100,000 Financial Protection from HIPAA fines and breach-related expenses. 1. ASSESSMENT OF NECK PAIN TREATMENTS 1 In a comprehensive assessment of neck pain and related disorders, a task force convened by the Bone and Joint Decade reviewed available noninvasive treatments for neck pain, Grades 1 and 2 (most common without radiculopathy or serious pathology). The panel concluded that the treatments with similar levels of safety and effectiveness and worth consideration were: education, exercise, mobilization, manipulation, acupuncture, analgesics, massage, and low level laser therapy. The focus of these treatments was on regaining function. On the other hand, treatments deemed unlikely to help and not supported by evidence included: surgery, collars, ultrasound, electrical muscle stimulation, transcutaneous nerve stimulation (TENS), and most injection therapies including corticosteroid injections in cervical facet joints or use of radiofrequency neurotoxins. The panel found that therapies involving manual therapies and exercise were more effective than alternative strategies. 1 Hurwitz EL, Carragee EJ, van der Velde G et al. Treatment of neck pain: Nonivasive interventions: Results of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4S): S123-S SELECTIVE ADVANTAGES OF CHI- ROPRACTIC USE IN THE MEDICARE POPULATION 1 The goal of this investigation was to determine how chiropractic care compares to medical treatments with regard to one year changes in selfreported function, health, and satisfaction in a representative sample of Medicare beneficiaries. A sample of 12,170 fee-for-service such individuals aged 65 and over was recruited with two interviews, the results being tabulated in five functional measures and two measures of self-rated health. A logistic regression using generalized estimated equations modeled the results to reveal that, in the unadjusted model, the chiropractic cohort as compared to the medical-only treated groups experienced proportionately and significantly less functional decline as shown by limitations in activities of daily living and difficulties in lifting, reaching, and walking for several blocks. In terms of satisfaction, participants in the chiropractic group were more satisfied with care quality, out-of-pocket costs, follow-up after the initial visit, and with information provided as to what was wrong with them. The specific protective effect experienced by the chiropractic care inviduals was buttressed by the finding that their average Medicare spending after 2000 grew at a slower rate than that of the medical group, remaining flat between 1999 and 2006 and decreasing from 71% of total Medicare Part B spending on spine conditions in 1999 to 2000 to 48% of total spending in 2005 to Weigel PAM, Hockenberry JM, Wolinsky FD. Chiropractic use in the Medicare population: Prevalence, patterns, and associations with 1-year changes in health and satisfaction with care. Journal of Manipulative and Physiological Therapeutics 2014; 37(8): RELIABILITY OF SURFACE ELEC- TROMYOGRAPHY IN ASSESSING PARASPINAL MUSCLE FATIGUE: AN UPDATED SYSTEMATIC REVIEW 1 A review of the literature in this study sought to determine whether surface electromyography (semg) is a reliable method for assessing paraspinal muscle fatigue in both healthy subjects and in patients with low back pain (LBP). Numerous databases (PubMed, Pro- Quest, Science Direct, EMBASE, OVID, CINAHL, and MEDLINE) were consulted from the period , yielding 178 articles of which 12 articles were selected based on inclusion criteria. Seven of the twelve chosen articles involved healthy subjects with the remaining five applying to patients with LBP or a comparison with a control. In all studies, median frequency was shown to be a reliable semg parameter to assess paraspinal muscle fatigue, suggesting that there appears to be a convincing body of evidence to support the merit of semg in assessing paraspinal muscle fatigue in both healthy subjects and in patients with LBP. 1 Bandpei MAM, Rahmani N, Majdoleslam B, Abdollahi I, Ali SS, Ahmad A. Reliability of surface electromyography in the assessment of paraspinal muscle fatigue: An updated systematic review. Journal of Manipulative and Physiological Therapeutics 2014; 37(7): COST-EFFECTIVENESS OF MAN- UAL THERAPY IN MANAGING MUS- CULOSKELETAL CONDITIONS: SYS- TEMATIC REVIEW AND NARRATIVE SYNTHESIS 1 A systematic review of trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions was undertaken in this study. Using major medical, health-related, science and health economic electronic databases, the authors extracted 25 publications geared toward comparing cost-effectivenesses with regard to reducing pain (spinal, shoulder, and ankle). Manual therapy techniques included osteopathic, spinal manipulation, physiotherapy, manipulation, mobilization, and chiropractic manipulation with or without other treatments. All these were found to be more costeffective than usual general practitioner (GP) care alone or with exercise, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic intervention was shown to be less costly and more effective than alternative treatments compared with other physiotherapy or GP care in improving neck pain. Caution was expressed in that the evidence concerning the costs of manual therapy Continued on Page 26

6 10 Winter Winter View from the Back: Importance of Active Therapy Audit Your Coding for Better Compliance and Reimbursement By Amber Wichmann, CA By Abbie Miller, MSC-P During the course of your tenure, it s likely that some patients will want to know more about the importance of an active lifestyle. It can be fun and rewarding to encourage patients to increase their activity levels, especially if that starts in your office with an active therapy treatment plan. Your doctor will prescribe the treatment methods and their duration according to the patient s symptoms and desired outcomes, but you can also play an active role in helping the patient work through their exercises. Here are a few starting points for your discussions with your doctor and patients. New studies emerge on a frequent basis that support the positive effect of exercise on general health. While we work with patients and watch them progress from hurting to healing, we know that spinal conditions tend to heal better when active care is combined with other forms of treatment, including regular spinal adjustments. Active care, like therapeutic exercises, involves active patient participation, something you As you reflect on the year that has passed, did you accomplish what you had hoped to in 2014? What do you hope to achieve in 2015 and what will you have to do, and who will you have to be, to make that happen? The following is a list of musts to start 2015 off on the right foot: Create a marketing plan for the entire year! Of course you cannot finalize every date, but make the commitment now to yourself and can support by encouraging patients to find motivation from both external sources and internal drive. Varying Degrees of Passivity Donald Murphy, DC, CCSP, DACAN, proposes a continuum of therapies with varying degrees of passivity or activity. Progressing from the most passive to the most active treatment, we would identify bed rest as the most passive, progressing from there to medication, physical therapy modalities, traction, chiropractic adjustments, increased activities of daily living, exercise, and finally to broad-based fitness. While chiropractic may not be as active as broad-based fitness, it does set the patient s ability to tolerate active care in motion. Chiropractic is not passive care; it is activating care, allowing patients to progress to higher levels of activity. Not only are chiropractic adjustments useful in removing barriers to active care, but they also work well in combination with active care. Several studies point to a synergistic effect when your practice. Put in the marketing actions that occur on a continued basis, such as healthcare classes, asking for referrals and networking, and then commit to some different actions each month. These can include lectures, sponsorships, or special events in your community. Remember to focus your marketing efforts on your ideal patients. Recalls! Make sure that any patient that began care in 2014 manipulation and exercise are combined.* Progression to More Active Care To facilitate the progression of a patient from passive to active care within a chiropractic practice, consider the use of the following paradigm of six progressive components of chiropractic rehabilitation: educating the patient about what caused his or her condition and how to prevent further injury adjustments, osseous, and soft tissue stretching tight muscles strengthening weak or inhibited muscles functional rehabilitation, which may include proprioceptive/balance training restoration or introduction of a broad-based fitness program Start the Year Off Strong! By Dr. Michelle Turk that is no longer under active care gets a recall. Let your patients know that you care about them and their health. Don t delegate these all to your team make some of these calls yourself! Train your staff! Plan some training or empowerment to be included in each weekly staff meeting and sign your staff up for ANJC s ChiroAssist program. Review each month with your team what A phased progression of active therapy and care provides the doctor and patient with a clear plan of treatment for successfully reaching their goals. This model of chiropractic rehabilitation is inherently understandable and measurable. It also moves the patient s function through increasingly better action. *adapted from ACA Amber Wichmann has been a chiropractic assistant for five years and loves taking care of patients. She is a certified CA and is a credentialed x-ray technician. She lives near Rapid City, South Dakota and is an avid runner and certified Pilates instructor. Amber is enthusiastic about teaching others about active and passive care in the chiropractic clinic. She or any of the other Reimbursement Specialists at KMC University can be reached by ing they have learned and how to incorporate it into practice. Clean up, spruce up, freshen up, and de-clutter your office! Does your office appearance make you proud? Allocate CEO time each week to plan for and execute the actions of success. You must work on your practice at a different time than you are working in your practice. Read your goals every day! Don t have goals? Then write them now! Make them specific, with a timeframe and with actions steps to help you achieve them. Meet with a financial planner to make sure you are on the right path financially, saving each month for taxes, retirement, and your other goals. Be congruent! You cannot sell what you do not own. Make sure to take great care of yourself, physically, mentally, emotionally, and spiritually. Of course this includes regular chiropractic care for you! Dr. Michelle Turk has been coaching chiropractors and CAs for over a decade on personal and practice development with particular emphasis on helping doctors develop their ideal practice while maintaining a fulfilled and balanced personal life. For more information visit Keeping track of your code usage is critical for compliance. It can be easy to fall into a dangerous routine of using the same code over and over again even though it really might not be the most appropriate code to use. Remember that the codes you submit to third-party payers for reimbursement represent you as a provider. Be assured that even if you re not looking at your code usage for red flags and outliers, the insurance companies are. You ll want to be sure that your billing is telling a good story. There are several guidelines you can use to see what your ratios look like compared to the national averages. But it s important to remember that these guidelines are just that not recommendations of ways to game the insurance companies or to increase reimbursement. Your computer system should be able to provide you with a list of codes and their usage. In order to gather the data from your practice management software, ask for a report that will outline the codes entered for the given period of time you wish to audit. The report should reflect the total occurrences of each code entered into the system for each month. If you don t use computer software, you may need to rely on paper reports. Even just monitoring the code usage from the past 30 days can give you an indication of where you stand. Once you have these numbers, you need to know how to analyze the results. When analyzing Evaluation and Management (E/M) codes, there are at least two areas to consider: For each New Patient E&M code (9920X), you might expect at least one x-ray code. This will apply to you if x-rays are done within your practice as part of your protocol. You ll take the number of New Patient codes performed within a given period of time and compare it to the x-ray code usage for the same time period. The rationale for this is that most new patients will have at least one x-ray series. Some will have more; some won t have any. In addition, for each New Patient E&M code (9920X), you should see at least two times that number of Established Patient E&M codes (9921X). The rationale is that each patient you see should have at least two re-evaluations, even with short-term treatment and the second one is a discharge examination. Practices should strive for the ratio of at least two to one with established patient exam codes being at least double the new patient exam codes. This does not take into consideration reactivating patients, those returning with new conditions, and other reasons you may have for established patient E/M codes. Therefore, two times is a conservative estimate. When looking for Active and Passive Therapy Procedure codes, the total of active therapy codes (97530, 97112, and 97110) should be approximately twice the total of passive modality codes if you have an active care component to your practice. This is because passive And the Giant Said, Fee, Fi, Fo, Fum! By Becky Walter, MCS-P 2015 brings what can seem like truly gigantic challenges for the chiropractic profession. Healthcare regulations are increasingly complex. Many states are pressing legislation that will require chiropractic assistants to pass examinations or receive certifications. The Affordable Care Act is still in play, but its effect pales against that of HIPAA, electronic health records, attestation, and PQRS reporting. All of this is coming together to create a perfect storm of fee impacts that will be gathering mass and momentum until 2017 at the very least. In this new environment, it s critical that chiropractic assistants be able to understand the differences in fees. The Medicare giant demands that fees be tied to the quality you produce. Changing Medicare fee amounts are no longer just about budget approval in Washington, but about which fee for Medicare you really have to charge or collect. If you re a participating office, it s a bit easier but nonetheless impactful. The coinsurance amount for the patient doesn t change, but your actual reimbursement can. If you re a non-participating office, you have an array of limiting charges to choose from based on your participation in quality programs in All of this Fee, Fi, Fo, and Fum is not really out of the blue. The giant that is Medicare has been climbing slowly down the beanstalk for some years. Some providers realized that Medicare was seriously talking about quality, but many didn t take it seriously. As the 2015 fee schedules were posted, questioning providers were asking, Why so many columns this year? All of these doctors are going to be relying on their CAs to help sort this out. While you won t be able to change 2013 s data (2015 fees are based on your participation with two CMS reporting programs in 2013), you can still make an impact on what happens in This is the year your office must master PQRS, limiting charges, Medicare regulations, and what quality benchmarks are all about affects 2017 where value-based modifiers will apply to your Medicare fee schedules. The giant has landed on the ground, but you modalities are expected to drop off after the first month of treatment, due to the goals of those treatments being achieved relatively quickly. At this point, patients are expected to transition to active therapy. The total number of 97110s should be equal to at least 50% of total of CMT codes. The reason for this is that in today s functional model of care, it s important to deliver active care in your practice so that you can show you are delivering care aimed at functional restoration. If you have a high usage of combined with a high usage of 98941, check the documentation to make sure the manual therapy was not performed on one of the regions adjusted on that day. The code must be done on a separate region when performed and billed on the same day as a CMT code. This combination of codes billed on the same day has been a hot topic with several carriers recently, as it tends to be misused and sometimes abused. Use this coding audit to double check your accuracy with these codes. The CMT code usage among the three spinal codes will vary with your practice style, your adjusting techniques, and other factors. Typically, we d see from 40%-60% of your code usage for each and with a very low percentage of usually 8% or less. For example, it may be 55% used for 98940, 40% used for 98941, and 5% used for Or, 35% used for 98940, 63% used for 98941, and 2% used for These are estimates based on CMS data for relative usage by chiropractors. The total number of codes should be approx % of the number of spinal CMT codes, depending on your likelihood of treating extra spinal regions. The rationale is that approximately that many patients in a given population will require additional care for extra spinal regions. Perform these coding audits on a regular basis and record the findings into your OIG compliance manual. Be sure to document areas of concern, create strategies to correct these problems, and detail any training that will take place to assist practitioners with corrections that are needed. This will allow you to stay on top of any potential problems with overuse of certain codes when coding ratios are out of balance with expected norms. Abbie Miller, MCS-P has her Bachelor s Degree in Business Administration and is a Medical Compliance Specialist as well as working for KMC University as a consultant, analyst, and Medicare Enrollment Specialist. Abbie s extensive chiropractic coaching and training experience has its roots in running her husband s chiropractic office and fighting for every collectible dime. She can be reached at or by phone 855-TEAM-KMC. can keep him at bay and away from your door if you know what to do. Be careful, because there are those who could lead you astray. Choose a trusted source for your information. The true golden egg could be a positive upswing in your 2017 Medicare fees. Really it can happen! But it depends on what you do now. It s too late to just chop down the beanstalk and run, but it s the right time to get on board with quality outcomes. Oh, and what about the patient choosing their care provider? They are going to have a new tool to help them figure out which Medicare provider to choose in the form of a physician comparison website. That s just what it sounds like, so you should get curious about what this website will contain. Will we be ranked against each other? What will be the categories? Good news: properly trained and knowledgeable CAs will be invaluable to finding a happy ending. Providers are and will continue to spend more time on documentation, and they need help with this. The savvy assistant has always been a valuable part of this profession and that s now more true than ever. This true story is more than a fairy tale parody. It s a call to action for all chiropractic assistants. Realize your value in the office. Learn, train, study, and support your doctor. When you re doing your part, you give your practice s provider the time to actually provide that wonderful care that is the real reason we re in the chiropractic profession. Becky Walter, MCS-P, has a Bachelor s Degree in Organizational Management as well as certification and licensure as a Certified Chiropractic Assistant, Licensed Radiology Technician, and Certified Medical Compliance Specialist, and she uses that knowledge as well as more than 30 years in the profession to train and guide KMC University s client teams to maximum success. She can be reached at 855-TEAM- KMC or

7 12 Winter Winter CA, Interrupted By Kathy Mills Chang, MCS-P Keeping Your Finger on the Pulse of Your Practice Online Verifications: What You Need to Know By Lynette Contreni Bernier ANJC Insurance Consultant As many of us are aware verification of benefits is leaning more and more toward online tools like Navinet and other carrier specific websites. This is a shift from the old way of doing verifications by getting on the phone with the carrier to using alternative methods is due to a few things. First, often the hold times to get through to the insurance carrier representatives are unreasonable and even unmanageable so offices opt to skip it altogether. And second, the carriers themselves are more and more pressing providers to go in that direction and in some cases have made that the only avenue to get information. Well in theory this should be great and make our lives easier if it was reliable. Unfortunately, it s often not reliable at all! It seems there are more and more cases of misquoted benefit issues. Provider complaints stating that the information they obtained on Navinet did not match how the claim paid has increased dramatically over the last year. Although I can probably write an entire book on the current problems with online tools especially when used for verification of benefits, I thought I would focus on a few key ones here that seem to be causing the biggest problems. The first problem worth mentioning is the fact that chiropractors may only go to the chiropractic tab when accessing the online tools. Now, let me say that I agree that it should be easy enough to go to the tab that directly correlates to the specialty you are in. Unfortunately, the online tools are not necessarily set up that way. For example, you may go to the chiropractic tab and it may list a $30 copay. However, it may or may not also reference a deductible. You may have to search under the office tab or the general tab to access that information. The chiropractic tab may not divulge that there is a deductible and coinsurance for x-rays. It may not divulge that there is a higher copay if the provider performs and bills for a NP exam or RE exam on the same day. We have even seen instances (especially for an out of state BCBS carriers) where there is a separate or additional copay for the 97 codes when performed by a chiropractor. Remember that as a NJ provider you may be accessing Navinet (using your Horizon BCBS login) and then following steps for Blue Card eligibility to obtain information on your out of state BCBS members. Therefore, often the depth of information is limited. Another important piece of information that may be hard to decipher is whether physical therapy services, when performed by a chiropractor, are listed properly. For example, when you click on the physical therapy tab it may list one benefit, but then you receive an EOB that does not match what you saw on Navinet. Or you may speak with a rep and get conflicting information from what is listed on the carrier s site. That s because in some cases the carrier says that the physical therapy benefit listed is for services performed by a licensed physical therapist, not when performed by the chiropractor. I have actually seen this problem both ways. I have had situations where a provider did not pay attention to the physical therapy benefit (which was 90/10 for example) because they felt that as a chiropractor they should go to the chiropractic tab (which showed a $40 copay) and they figured that anything they did would process as per the chiropractic benefit. However, when the claims processed, the 98 codes were processed with the $40 copay and the 97 codes processed at the 90/10. Of course this increased the amount of patient responsibility. That particular carrier s position was they process based on the CPT code type regardless of who the provider is. Therefore, there is a split benefit when a chiropractor performs physical therapy services. And I have also seen the opposite where a provider expected the benefit to process in the split scenario, but then the claims all processed under the chiropractic copay because the carrier processed based on the provider of service regardless of the CPT code type. Complaints are also increasing regarding the fact that information on Navinet or on other online tools is just plain wrong. Yes, we have had many instances where we call to address something that is not clear or something that doesn t match the EOB and we are told that the information posted is just not correct. Or even more common is the carrier stating the information in the online tool is not updated. When pressing the carrier s representatives to view what we are viewing, the response is often that they don t access Navinet themselves because they use another tool to provide information to callers. So why is it that the representatives would not access and analyze the same information they are requiring the provider and the patient to use? And if they have better or more complete data why isn t that what we can all access and use? Also, keep in mind that online tools are often missing important information like: 1. Self funded vs. fully funded (important for claim processing guidelines, follow-up, and appeal processes) 2. Policy period (does the chiropractic limit or deductible run from Jan-Dec or from another period?) 3. Referral and pre-cert requirements are often either not listed or not specific to the discipline you re researching 4. The correct address by specialty may not be listed, for example, for a chiropractor looking at Cigna s online tool it may not tell you whether your claims need to go to ASHN or to Cigna Further complicating the process is that even if you become an expert in one carrier, meaning you perfect the gathering of info when using Navinet for Aetna patients, it s not necessarily the same for using Navinet for HBCBS patients. I know this is very frustrating! As I said, this is a small sampling of problems providers are experiencing in the current environment and enough to make this article longer than one would like. You may be thinking: what is the point of the verification then if it is so difficult to get the right information? Again, I would agree with you if you could count on the carrier processing the claims correctly! Unfortunately, we often call the carrier after the EOB comes in and did not match the way we thought the claim should pay and it is determined that the EOB was processed wrong and then the carriers will reprocess the claims. So what is the answer here? To be honest, I am really not sure yet! For us at CB&C we access the online tool and open all tabs that may be relevant and then compare it to the ID card. Then we still get on the phone with the reps and do the old time verification. We then compare all information provided. Any discrepancies are noted and we push the representative to explain those inconsistencies. We note all information in reference numbers and also print the Navinet benefit sheets to PDFs and keep them with our verifications. This way if the claim does not process the way expected we have the Navinet printouts and reference numbers of the calls to hold the carrier responsible. While probably not the most cost effective approach right now, let s remember this is still evolving technology. My hopes for you after reading this article is that you will at least be more aware of the problems and what to look for to try to bridge those gaps to make things just a little smoother. Hopefully! Lynette Contreni Bernier is the founder and President of CB&C, Inc., a billing, collection and consulting company specializing in chiropractic and multidisciplinary practices. She can be reached at or Anew patient stands before you, intake paperwork in hand. The phone is ringing. Your DC has a question. Another patient s child is crying in the waiting room. Your stomach rumbles you didn t have time for breakfast. You wonder when you re going to get to those reach-outs to patients with outstanding balances. The UPS guy walks in. And so it goes, day after day, for most chiropractic assistants. Because it s not uncommon for CAs to wear more than one hat, tasks and responsibilities overlap, sometimes crashing together in a perfect storm of distraction. Gloria Mark, a professor in the Department of Informatics at the University of California, Irvine, says that when an interruption matches the topic of the current task at hand, it can actually be helpful. If you re working on task A and somebody comes in and interrupts you about exactly that task, people report that s very positive and helps them think about task A. Even off-task interruptions can feel okay if they re short. Say you re working on a patient s insurance information and someone comes up to you and asks you to sign an unrelated form. You sign it, and it s no big deal because it takes little thought or effort away from the task at hand. But what about when you re on task and something larger and more distracting comes winging out of nowhere? Here s where interruptions not only stress us out, they also eat up a surprising amount of time. Mark and her researchers found that it takes an average of 23 minutes and 15 seconds to get back on task after being interrupted. That adds up to a big chunk of time over the course of a day! So what s a multitasking CA to do? One place to start is by performing your own informal time study, by tracking the amount of time it takes, uninterrupted, to do each of your tasks. Sometimes, our doctors might not be aware of how long each of your tasks actually take especially if they haven t done them themselves. They re Introducing the Most Bio-available Ginseng in the World The most prescribed fermented ginseng by Health Care Professionals Receive a FREE SAMPLE Call (mention ANJC) or visit World leader in Ginseng Science Since 1971 Stress Management as Nature Intended also likely not to have figured in the toll interruptions take, and may have unrealistic expectations of how much you can get done in a day. Once you know how long each task takes, it s time to plan your work day, interruptions included. Timemanagement experts recommend that you plan out 60% of your time, leaving 40% of your day for the inevitable interruptions and emergencies. This could be as high-tech as scheduling software that includes task lists or as simple as an index card system with cards for each day of the month. As you prioritize your task list, consider getting the ones you like doing the least up front, as well as high priority tasks such as phone calls to third-party payers and patients with outstanding balances so you have Standard Process, maker of dietary supplements with whole food ingredients, and MediHerb, maker of professional-strength herbal products, have more than 100 years of combined clinical experience. We recognize the importance of partnerships and are proud to support ANJC. We value the dedication of chiropractors, their high standards of patient care, and are proud to support them by contributing to the well-being of their patients. 2014 Standard Process Inc. All rights reserved. the rest of the day to hear back from them. When we get the things we don t love doing out of the way, we feel more accomplished and have more enthusiasm to do the other stuff. Finally, don t forget to go over your task lists with your doctor. That way, you both have agreed-upon expectations for what you can reasonably get done in any given day. As for the initial scenario? Take the paperwork and kindly ask the patient to take a seat until you can go over it with them. Answer the phone while signing for the UPS delivery. Tune out the crying child assuming there s a parent on hand who s on the job and smile at your doctor as you finish your phone call and turn to answer their question. Oh, and for goodness sake, eat some breakfast We believe that nutrients derived from whole foods can help rebalance the scales of nutrition. Whole food nutrition begins with sun, water, and fertile soil. Dr. Royal Lee Many raw materials are harvested from our certified-organic farm in Palmyra, Wisconsin. next time. You ve got important work to do! Kathy Mills Chang is a Certified Medical Compliance Specialist(MCS-P) and, since 1983, has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 14 at KMC University, and is known as one of our profession s foremost experts on Medicare. She or any of her team members can be reached at (855) TEAM KMC or In 1929 our founder, Dr. Royal Lee, began the tradition of independent inquiry and innovation that continues at Standard Process to this day. Standard Process products are manufactured at our state-of-the-art facility following Food and Drug Administration good manufacturing practices. ANJC Ad 7.25x indd 1 3/25/14 9:51 AM

8 14 Winter Winter Magnesium: Miraculous Mineral By Christopher J. Bump, DC, MS, DCBCN, CNS, CCN Answers to Your Important Malpractice Questions By Keith Henaman NCMIC Assistant Vice President-Claims It is ambitious for me to write an article about magnesium in a short piece such as this because it is such an incredibly important and often miraculous nutrient, I will only come off sounding full of hyperbole. But I will try anyway, and hopefully I can peak your interest in considering magnesium for your clinical nutrition armamentarium. Magnesium is the most important mineral in your body, and that is not my opinion, it is a consensus of hundreds of researchers who offer their findings in thousands of peer review papers (last PubMed count > 92,000). Magnesium is involved in over 350 physiologic processes with major involvement in the following: Energy transfer, storage, and use Systemic detoxification Muscle relaxation including arteries and heart (calcium stimulates contraction) Synthesis of nucleic acids, RNA, and DNA Nervous tissue conduction and neuromuscular excitability Metabolism of macronutrients protein, fat, and carbohydrate All enzymes involved in ATP utilization (every cell in the body) Regulation of body thermodynamics Reduced inflammation Regulation of parathyroid hormone (key importance to bone remodeling and health) Blood pressure control and peripheral vascular resistance Maintenance of cellular membrane function and cellular mineral balance Steroid hormone secretion Academic Excellence. Professional Success. We have evolved over 3.5 million years with our diet having a calcium to magnesium of 1:1 but things changed rapidly about 100 years ago. In the early 20th century synthetic fertilizers became widely used, which replaced only phosphorous, nitrogen, and potassium back into the soil. At the same time the food industry began refining grains, which removed many essential nutrients including magnesium. So currently nearly 70% of the US population does not consume the RDA of 500 mg of magnesium per day. And if we consider the RDA is simply that dose required to prevent deficiency syndromes, then the levels of deficiency increase to over 90%. Not only do we not consume enough magnesium each day because the foods we eat don t supply it, but we consume foods and drugs that antagonize magnesium causing its loss. Dairy, soda, alcohol, and coffee (especially Starbucks) all upset the magnesium/calcium balance or cause loss of magnesium. Also every major drug group prescribed comes with warnings about magnesium deficiency and some of the worst are the proton pump inhibitors, antacids, ACE inhibitors, diuretics, HRTs, antibiotics, corticosteroids, and aromatase inhibitors. Magnesium and calcium as mentioned above have had a close relation throughout human evolution, a 1:1 relation. In fact magnesium regulates calcium s function and availability in many processes. Muscle contraction and relaxation is a perfect example; without a healthy level of intracellular magnesium available muscle fibers cannot relax. Therefore not only will our striated muscle suffer tension and cramping, but so will our vascular system. And when the cardiac muscle can t relax, or goes into spasm, we run into some dire consequences. Calcium is regulated by two hormones calcitonin (CT) and parathyroid hormone (PTH); they work to regulate skeletal turnover of calcium and availability of cytoplasmic calcium. PTH s major effect is to increase bone resorption by stimulating osteoclasts. This causes an increase mobilization of calcium from bone (think bone loss). PTH also enhances uptake of serum calcium by soft tissue and phosphate excretion by the kidneys. CT on the other hand has the opposite effect by blocking calcium uptake by soft tissue and increasing deposition in bone. Magnesium suppresses PTH and stimulates CT, which favors bone remodeling and release of calcium from soft tissue. One other interesting yin/yang relation between these two minerals is magnesium enhances calcium absorption and retention, while increasing calcium intake suppresses magnesium absorption. It should not surprise you then to learn that it is western countries where vast amounts of dairy are consumed that osteoporosis is a problem, and that in Asian countries where more plants, seeds, nuts, and whole grains are consumed do not suffer from bone wasting. In my opinion osteoporosis offers an example of a disease process that is based on poor science, lack of physiological understanding, and expensive pharmaceuticals that further contribute to the problem. Testing for magnesium deficiency is not necessary, but if you do wish to evaluate your patient s mg levels test RBC intracellular levels. Do not test serum levels, remembering that Mg is an intracellular ion. The current reference range is mg/dl, but know that in 1962 (before every third person was obese or diabetic) the Reference Range was mg/dL. Based on this latter range, any score below 6.0 mg/dl is a clear signal of Dedicated to: Academic Excellence Quality Patient Care Professional Leadership Degree Programs include: Doctor of Chiropractic Master of Science in Acupuncture Master of Science in Acupuncture and Oriental Medicine Master of Science in Applied Clinical Nutrition (online delivery) Master of Science in Human Anatomy & Physiology Instruction (online delivery) For more information call NYCC at or visit Finger Lakes School of Acupuncture & Oriental Medicine of New York Chiropractic College School of Applied Clinical Nutrition 2360 Route 89 Seneca Falls, NY magnesium deficiency. You can also use a symptom survey to evaluate your patient s Mg status, but based on exam and history you can make very easy and accurate assessment. If your patients have tight muscles, hypertension, insomnia, low energy, constipation, hypoglycemia, headaches and migraines or any of the other symptoms associated with Mg deficiency, it will be safe to prescribe. A good starting dose is five times the patient s weight in milligrams. (e.g. 125 female: 5 x 125 = 625 mg/ day). We need to supplement with magnesium as we simply cannot obtain enough magnesium from our diets, as our lives are so riddled with stress that we have exceedingly high magnesium burn rates (MBR). The best type of magnesium supplement will depend on what you are attempting to help fortify. Malate-Citrate is good for muscle metabolism, and excess myofascial lactic acid build up. Glycinate, which well tolerated is good all around and magnesium orotate passes the blood brain barrier easily. Lactate and citrate will help sluggish bowel, and in extreme cases of fecal impaction, mag oxide is good...though rough on the gut in too high a dose. Milk of Magnesia is still a good option for gastric distress as this magnesium helps relax the pyloric sphincter, which is much needed in times of stress. Also simple epsom salt baths is a wonderful way to both destress and absorb magnesium. As far as diet is concerned: start eating more magnesium-rich foods like seafood, especially kelp and oysters. Also whole grains, especially buckwheat, millet and wild rice. Leafy greens, especially collards, beet greens, mustard greens, spinach, and kale. Nuts and seeds, especially cashews, almonds, and pistachio nuts, as well as pumpkin seeds. And chocolate, dark, cacao rich chocolate has more magnesium than any other food you will be happy to know. But make sure it is at least 70% cacao and dark. As Dr. Sid Baker, who is one of my mentors, said; Magnesium is the Shepard of Light for our bodies. So my advice then is to eat high magnesium rich foods, reduce your calcium rich foods, take your magnesium supplements and sport a green mustache. Q: One of my regular patients is a 52-year-old male with back pain and hypertension who was referred to me by his internal medicine physician. Diet, exercise, and chiropractic care all failed to improve his hypertension. At a recent appointment, I checked his blood pressure, and it was at critical level, 195/106. I immediately contacted the patient s internist who wanted to see the patient right away. On the drive to the internist, the patient fainted, drove onto a busy sidewalk and nearly struck a 10-year-old girl. Would I have been liable if the patient injured her? A: In general, healthcare malpractice suits are based on negligence, and the plaintiff has the burden of proving the doctor was negligent. The four elements required to show negligence are: Duty or standard of care owed to the patient by the doctor Breach of that duty or standard of care Causal connection between the breach and the injury Damages sustained by the patient In the situation you described, the issue is that the injured party is not the patient. However, if the patient would have hit the girl, you could still be found negligent since you allowed the patient to drive in an impaired condition, which in turn led to the patient s fainting, an accident, and the girl s resultant injuries. You might have limited your potential liability in this situation if you would have: Educated the patient early that he shouldn t operate a vehicle or equipment if his blood pressure reaches a critical level. With the patient s permission, you could have brought family members into this discussion. Documented your discussion and instructions carefully, especially any short- or long-term driving restrictions once you deemed the patient unsafe to drive. Complied with your state laws and regulations about mandatory reporting. Contact your state s department of transportation as required by law anytime a patient s ability to safely operate a motor SUPPORTS DISC AND CONNECTIVE TISSUE HEALTH A SPECIAL BLEND OF INGREDIENTS DESIGNED TO NATURALLY REDUCE INFLAMMATION PROMOTES THE PRODUCTION OF COLLAGEN SUPPORTS THE REBUILDING OF CARTILAGE To order please call Customer Service at or visit us at Educated the patient early that he shouldn t operate a vehicle or equipment if his blood pressure reaches a critical level. With the patient s permission, you could have brought family members into this discussion. vehicle is jeopardized. Taken the conservative approach erring on the side of caution rarely gets a doctor in trouble. Ideally, a family member of the patient would have driven him to the internist s office. Cases of third-party liability allegations of healthcare negligence that result when a patient causes injury are becoming more frequent across How It Works various healthcare settings. Even conscious sedation from a colonoscopy requires someone to drive a patient home. An eye examination requiring dilation of the pupils requires a patient either to have a driver or to wait until they are reexamined and cleared for driving. A doctor of chiropractic must exercise sound clinical judgment, espe- Association of New Jersey Chiropractors TD Bank will make an annual contribution to your organization based on the activity of all participating members TD Bank accounts. Eligible accounts 1 include: Checking - Business & Consumer Savings Money Market Certificate of Deposit Retirement Fundraising Potential Checking Accounts $50 for every new checking account 2 $10 for every existing checking account Savings Accounts or CDs 1/10 of 1% contribution based upon your participants annual average balances 3 If you are already a TD Bank Customer, visit any one of our locations and ask to have your balances included as part of your organization s Affinity Membership Program. cially when there is a serious health situation. In this case, perhaps you should have restricted the patient s driving when his blood pressure reached the level that could lead to a loss of consciousness. NCMIC was founded in 1946 for the express purpose of providing the chiropractic profession with malpractice coverage. Today, we are the company trusted by more than 40,000 DCs and growing and chiropractic colleges and universities across the U.S. For more information about NCMIC, call , ext NCMIC Group, Inc. All rights reserved. Get $25 (code: VA) when you open a new non-interest bearing checking account 4 Coupon code: Open your account today! Please contact our Bridgewater Regional to become a member of the program 1 Refer to the program Summary of Terms for a complete list of eligible accounts. 2 Account must be new to TD Bank and have been opened and maintained at least three months prior to the Program enrollment anniversary date. Any closed participant checking accounts will offset the calculation of the $50 new checking account incentive. Number of participating checking accounts must be maintained or grown each year for contribution eligibility. 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9 16 Winter Winter Three Key Steps to Ensure Proper Coding and Documentation David Klein, CPC, CHC ANJC - Insurance Consultant Healthcare professionals almost universally agree that rules, regulations and laws surrounding coding, documentation, and reimbursement are becoming more and more confusing and difficult to understand. Coupled with the fact that record requests, audits, and board inquiries appear to be significantly on the rise, providers are left confused and frustrated, and this ends up affecting their bottom line. If you throw in the upcoming changes to ICD-10, add a little PQRS reporting, and top it off with some Meaningful Use, it s no wonder that I am hearing more and more providers say they are ready to retire or get out of the profession. Every day I receive calls and s from providers and staff asking me a large array of questions on how to code or document something. How much they should charge for an item, whether the service they want to provide is reasonable and many other questions are asked. Recently, I had a provider start off his question by saying, I hear you are the authority on coding and documentation. While I do know a lot about coding, documentation, and reimbursement, I can assure you I am not the authority. The law is the authority, your chiropractic board is the authority, and your provider agreements are the authority. Misinformation is one of the easiest ways to get yourself into trouble. I can t tell you how many times I hear a provider say, My buddy down the street said he is coding it this way and he is getting paid. Payment is not an indicator that you are doing something correct the law is. So where do you go to get accurate information? There is a saying in the coding and compliance industry, Quote early and often, and knowing who to quote is imperative to getting the right answer. As a professional coder, in order to answer a coding/compliance question I must go through a process to obtain accurate information. While it takes a good deal of education and training to become a skilled medical coder, there are three key steps providers can take to help ensure that they are getting the correct answer. Step 1 The first and most important step is not to take anyone s word that something is correct. With every answer or piece of guidance you receive, you must ask the question, Where did this information come from? Recognizing accurate information and understanding who the authorities are is paramount to getting the right answer. When trying to determine the proper code, the first place to look is in an up-to-date code book. Many providers don t realize that as a result of the HIPAA Transactions Rule in 2002 (see 45 CFR (a), ), the codes we use to bill, Current Procedural Terminology (CPT) and the International Classification of Diseases (ICD-9), became federal law. This means that every time you report a diagnosis code or a procedure code you are reporting the law. Having up-to-date code books is critical to correct coding. It is estimated that on average, there are over 800 changes to the codes and their definitions every year, so make sure your coding books are up-to-date. The code books that every practice should have are: AMA s CPT, Professional Edition HCPCS Level II (for DME and other items) ICD-9-CM, Volumes I and II Step 2 The second step providers should understand is that Medicare is the gold standard. Not only do you need to know what Medicare rules are when treating a Medicare patient, you should know Medicare rules for any patient. There is a saying in the profession, As Medicare goes, so goes the rest of the industry. Most carriers base their own guidelines on NAPA NJ Chiropractic Ad x 4.75-FINAL_NAPA NJ Chiropractic Ad x /30/14 9:29 PM Page 1 Monmouth Pain Care A DIVISION OF North American Partners in Pain Management The fastest way To a pain-free life: Teamwork Chiropractic can do a great deal to alleviate patient pain. But working together, we can do even more. at monmouth pain Care, we re board-certified physicians who specialize in pain management. we ll team with you to help restore your patients good health. we specialize in non-surgical and minimally invasive techniques, including joint injections, nerve blocks and epidural steroid injections. and we do it in a compassionate, patient-centered way that respects your relationship with your patients. we ll even provide periodic reports on your patient s progress. all in all, we offer an individualized, multi-modal approach to care. To learn how we can work together to end your patients pain, please call we accept most major insurance plans. Medicare standards and many of the larger carriers administer Medicare benefits. Medicare carriers have the discretion to establish which services are reasonable and necessary, and therefore, which services are covered as a Medicare benefit. These coverage policies are all written out and issued in documents called Local Coverage Determinations or LCDs. Local Coverage Determinations provide guidance that assists providers in submitting correct claims for payment. LCDs also outline how the Medicare carrier will review claims to ensure that the services provided meet Medicare coverage requirements. LCDs typically include a description of each covered service represented by a CPT or HCPCS code, documentation requirements and information regarding the ICD-9 codes that do or do not support the necessity of the services provided. For chiropractors, LCDs are critical not only for understanding the requirements for Medicare patients, but they also provide key information for all services within your scope of practice. For example, most chiropractors provide timed based modalities and therapeutic procedures (e.g. ultrasound, therapeutic exercise, etc.). Even though DC s don t bill Medicare for these services, Medicare s requirements for reporting timed services has been adopted/ accepted by almost every carrier and the American Medical Association. Therefore understanding Medicare s 8 minute minimum rule and using that as the reporting standard will help keep providers in compliance almost universally. Some of the important factors addressed in an LCD are: Relationships between codes and information needed to bill for specific services. Specific documentation requirements that must be included in patient records to justify coverage for services. 279 Third avenue, suite 601 long Branch, nj Tel: fax: Parameters for typical or expected utilization of specific services. Diagnosis codes that support medical necessity for a particular service. Basing your coding and documentation protocols using LCDs as a guide will provide your practice a rock solid foundation based on federal guidelines. Step 3 The third, and often overlooked step, is for providers to understand what is contained in their provider agreements. When a doctor becomes a participating provider for a carrier, they sign a contract. Among other things, this contract details coding, documentation, and utilization guidelines for that carrier. When you participate with that carrier you have agreed, in writing, to abide by their rules this is called contract law. Unfortunately, most providers don t even know where their provider agreements are, let alone what they say, and this often results in recoupment. For example, many providers have intersegmental traction tables and they bill them as traction, CPT Even though the AMA has said that traction can use the body s own weight to create the degree of force, certain carriers deem intersegmental traction tables as experimental/ investigational and do not reimburse for that particular type of traction. If you participate with one of those carriers, and are billing intersegmental traction as and are getting paid, you run a high risk of having to pay that money back if the carrier finds out. Based on this, understanding what your provider agreements say is absolutely necessary to running a compliant practice. As a certified professional coder and healthcare compliance expert, I use many other resources when advising a client, AMA CPT Assistant, NCCI Edits, Office of Inspector General (OIG) Advisories, and many more. However, for a provider, understanding the key resources will make a huge difference in a practice s ability to stay compliant and maximize their reimbursement, while still allowing them to focus on what they were trained to do, which is of course caring for their patients NEW PRODUCTS Dim Renew Glycan Renew Greens Renew Chewable LV Renew Methyl B-12 Lozenges Methyl Renew Phyto Renew Chewable Phyto Renew Powder SAMe 200 SLP Renew Serene Renew LEGAL EASE Q: What are the basic requirements for a New Jersey licensed chiropractor to provide nutritional advice and supplements? The New Jersey Chiropractic Scope of Practice Statute, enacted in January 2010, provides that: A licensee may provide dietary or nutritional counseling, such as the direction, administration, dispensing and sale of nutritional supplements provided the chiropractor has successfully completed a course of study concerning human nutrition, consisting of not less than 45 hours from a college or university accredited by a regional or national accrediting agency recognized by the United States Department of Education and approved by the board. Once a chiropractor meets these criteria, they may provide nutritional advice and counselling and can sell and dispense nutritional supplements in their office provided they comply with the applicable regulations and laws concerning same. For example, the chiropractor may not charge an unreasonable mark up, must maintain a patient chart, and must comply with the chiropractic advertising regulations. A discussion of the proper entity structure for selling supplements is beyond the scope of this Q&A. Q: I have an inactive license to practice chiropractic in New Jersey. Do I have to complete 30 Continuing Education (CE) Credits every two years and maintain malpractice insurance? If your license is inactive, which also provides the presumption that you are not treating any patients, you are not required to take the mandatory 30 CE credits every two year licensing cycle nor maintain malpractice coverage as the scope Q: I just updated my new billing software to go along with the new 1500 forms and diagnosis codes. What is required now with diagnosis codes for Medicare? Do all codes have to have five digits and are the changes for all insurance types or just Medicare? A: The only thing that has changed in regards to diagnosis coding is the number of codes you can put on the new CMS 1500 form. There is no requirement to have five digits on a code but rather the number of digits depends on the diagnosis chosen. In other words, do everything the same way you have been doing and recognize you can add more than four on a claim form. I would also add that on October 1, 2015 all this will change with ICD-10, then there will be a whole new set of codes to learn. We will be having seminars on this subject in Q: How many times may CPT By Jeffrey Randolph, Esq. - ANJC Legal Counsel of practice statute specifies these requirements apply to active licensees only. However, it is prudent to maintain malpractice tail coverage for a period of years following your active practice as claims could be filed against you for prior alleged acts of malpractice even though you are not actively practicing. New Jersey follows the Discovery Rule for malpractice cases, which allows a claimant to file a malpractice action against a healthcare provider two years from the date of incident or two years from when the patient knew or should have known that malpractice occurred. This could extend the malpractice statute of limitations for many years following the cessation of active practice. In addition, if you attempt to reinstate your license, the Board of Chiropractic Examiners may require you to complete CE credits as a condition of reinstatement. Q: Can a New Jersey licensed chiropractor issue a disability note or determination under their scope of practice? Yes. Since as far back as 1951 this has been permitted by New Jersey case law. In the case of Thomas v. Carlton Hosiery Mills, 14 N.J. Super. 44 (App. Div. 1951), the Appellate Division held that a patient under the care of a chiropractic physician complied with the statutory mandate of the Temporary Disability Law to be under the care of a legally licensed physician. Further, the New Jersey Chiropractic Scope of Practice Statute, effective January, 2010, expressly provides: A chiropractor may... Sign or certify temporary or permanent impairment and other certifications consistent with chiropractic practice... See N.J.S.A. 45: et. seq. Insurance By David Klein, CPC, CHC ANJC Insurance Consultant code 97035, Application of a modality to one or more areas; ultrasound, each 15 minutes, be reported if treating three body areas, such as the neck, wrist, and knee, on the same date of service? A: Both the supervised modality codes and the constant attendance modality codes include language in their code descriptors that indicate application of a modality to one or more areas. The constant attendance codes also have time indicated in their code descriptors (each 15 minutes). Therefore although the number of areas of application is not a consideration in the reporting of these constant attendance codes, the amount of time the provider spent in constant attendance with the patient providing the ultrasound would need to be indicated in order to support the number of units billed. AMA CPT Assistant, November 2010 The Council on Technique and Clinical Excellence: Great Plans for 2015! After a good start in 2014, the ANJC Council on Technique and Clinical Excellence will be putting on exciting programs for 2015! Created to improve the tools we chiropractors have in caring for our patients, a full program of seminars and webinars is in the works. All emphasize the specific tools that differentiate chiropractors from every other type of practitioner. Planned for the first half of 2015 are courses on lower extremity adjusting to be given on Thursday afternoons in both north and south Jersey. This year s Spring Summit on April in New Brunswick, NJ, will feature a program on pediatric adjusting. These courses will be live and hands-on. In addition, webinars on pediatrics, cervical spine adjusting, and motion palpation are scheduled. These are all CEU approved and free as part on your ANJC membership! SEE AD ON PAGE 19 By Glenn Gabai, DC One of the best side-effects of the Technique Council meetings has been the sharing going on between the participants in the program. It has been remarkable to get a group of chiropractors together that want to share what they are doing successfully in a mutual learning experience. Doctors of chiropractic experience hands-on training and have conversations with each other about the thing that makes chiropractic unique. Many doctors comment that this kind of learning environment has not been experienced since their chiropractic college days. We look forward to having all ANJC doctors participate with the Technique Council programs. Together we will learn, grow, and most of all enjoy what we share. Glenn Gabai, DC is the co-chairperson of the ANJC Council on Technique and Clinical Excellence. He practices in Pennington, NJ with his son, Aryn Gabai, DC. Help your patients get healthy and LIVE healthy. Superior Supplements for Healthy Aging The Sirtuin line from Biotics Research provides the highest quality of nutritional supplements on the market with the best scientific research. The complete array of nutrients in the Sirtuin products are designed to support the cardiovascular system, blood pressure, vascular aging and aging in general, cholesterol and serum lipids and much more to improve health and longevity. 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10 18 Winter LEGAL EASE NJ PIP Regulation Amendments Coming By Jeffrey Randolph, Esq. - ANJC Legal Counsel Winter INSURANCE UPDATE By Matt Minnella ANJC Director of Insurance A s you are aware from prior updates, the Department of Banking and Insurance (DOBI) enacted new regulations relating to the personal injury protection (PIP) benefits available under the New Jersey No-Fault Act to persons injured in automobile accidents on January 4, Two outstanding items remain from the promulgation of these regulations back in 2013: i) a lawsuit was filed by healthcare provider coalitions attacking the validity of the regulations, and; ii) a new, uniform appeal procedure that was promulgated was stayed by DOBI for further review. With regard to the litigation, two healthcare coalitions consisting of healthcare providers of various specialties filed suit raising a number of grounds that called into question the validity of the regulations. The ANJC officially signed on as a member of one of those coalitions the New Jersey Coalition for Quality Healthcare. The Appellate Division recently heard oral argument on the matter on October 28, 2014 and a decision should be forthcoming in the next few months so stay tuned. With regard to the stayed uniform appeal process, DOBI has now indicated that it is re-addressing the prior proposal and is inclined to promulgate new, amended regulations in this regard. The preliminary proposal (which is merely preliminary and may change significantly prior to being promulgated) provide for: A uniform appeal form similar to the ATPT Precertification Form must be used for all appeals. The timeframe for medical necessity appeals (i.e., precert denial) would be increased from 5 days to 30 days. The timeframe for non-medical necessity appeals (i.e., coding is- sues) would be reduced from 180 days to 60 days. Allowing electronic methods of submitting appeals in carrier s Decision Point Review Plans. Allowing a single resubmission of a precert request if a provider misses the appeal deadline. Limiting the records and issues addressed in the internal appeal and submitted by the provider as the only issues and records that can be addressed in any subsequent PIP arbitration. Requiring that an insurer s decision on an appeal shall be sent to the provider, rather than received by the provider, no later than 10 days from the date of the submission of the appeal, rather than the date the provider receives the acknowledgment of the appeal. Any service or good rendered after the provider is notified of a denial and before the insurer issues a decision on the appeal shall be subject to a 50 percent copayment penalty. Failure to exhaust the internal appeal process precludes PIP arbitration. Clarifies what information must be included on an EOB form by an insurer. Please understand that these edits have not yet been published in the New Jersey Register and at present DOBI is merely meeting with stakeholders to discuss these amendments. Rest assured the ANJC is participating in these discussions to protect the interests of its members. Once a final version of the proposed amendments are issued by DOBI, we will inform membership and advise as to any action necessary at that time. Big Brother and His Siblings: Social Media Creates a Society of Watchers By Dr. Ray Foxworth I ncreasingly, the doctors I talk to have some kind of social media in play. If they don t, they have the perhaps justifiable feeling that they probably should. It s actually a great idea as long as you keep your eyes focused on the goal: to engage your patients and potential patients, to educate them about what you do and how it impacts their wellness, and to boost your presence in your community. Everybody s listening. As in most cases when you are talking about your business aloud, social media posting is not without risk. Keep in mind that Facebook, Twitter, Google+, LinkedIn, or even a social media outlet you may not have considered, such as Instagram or Pinterest, are public forums. If you wouldn t say it in a waiting room full of patients, don t even consider saying it online. Maintain a professional presence online. If and when you decide to put yourself out there in cyberspace, do so as your practice not as yourself. When a doctor puts up a personal online presence, invitations to like others pages are land mines of favoritism, blurred boundaries, and hurt feelings. Conscious, intentional engagement. Elevate your Practice to The Cloud Our all-in-one chiropractic software is EHR-certified and web-based, providing: s Secure access anywhere s Automatic, continuous updates s Four integrated, easy-to-use modules s Affordable fees s And, no need to install software, purchase hardware, or pay maintenance fees ever again Register for a Free Demo at or call NJChiroSpring_Feb14_v1.indd 1 3/25/14 12:00 PM If you want to put social media to work for your practice, it s important to go beyond simply putting a follow us style widget on your website. You ll want to regularly post engaging, informative content with the specific intent of educating and creating deeper relationships with your existing patients and attracting new ones. In order to do that, you ll need to create conversation, dialogue, and interest in other words, a reason for people to come back, read, and interact. Establish an office social media policy. Don t even consider social media before instituting an office-wide social media policy. Are your staff members allowed to post on your social media? If you don t have an established and written policy for social media guidelines, you re running a real risk of something getting put out there by even a wellintentioned employee that could blow up in your face. Remember, your staff will be posting on their own social media outlets, too. Can you imagine the potential ramifications of your CA posting on Facebook about what a horrible day he or she had, or how awful one of your patients is, or that the staff went out and got drunk after work? Keep patients happy and positive. Guess who else is going to be posting? That s right your patients. And you have absolutely no control over what they might say. Certainly you can moderate your own forums with an iron fist, but when it comes to what patients post on their own Facebook, Twitter, or Google+ feeds, it s out of your hands. The best advice here is preventive: don t give patients anything negative to write about, and make sure unhappy patients have a chance to air and work through their grievances in your office, not on their computer. Be careful about running promotions. Finally, many businesses run contests or giveaways to boost page likes or number of followers. Take extraordinary care here, because this is where you can tip over the line between legal promotion and illegal inducements. Stay safe, legal, and compliant. Here at ChiroHealthUSA, a DMPO (Discount Medical Provider Organization) that gives our participating DCs the ability to offer patients safe and legally discounted fees to their patients, we know how to keep chiropractors on the right side of the OIG when it comes to dual fee schedules, inducements, and improper coding and billing that could result in an expensive, nerve-wracking, and time-consuming audit. When you put your practice up on social media, you open its books, metaphorically speaking, to everyone. All it takes is a single misguided online promotion or one patient who misunderstands their bill and posts about it to put you under scrutiny. Remember, big brother is watching you, as are his siblings Mark Zuckerberg, Google, the OIG, and the guy next door. Make sure your social media presence is a friendly wave of your hand not the wave of a red flag. Dr. Ray Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing chiropractor, he remains in the trenches facing challenges with billing, coding, documentation, and compliance. You can contact Dr. Foxworth at , or visit the ChiroHealthUSA website at H orizon/ : It has come to our attention that Horizon has begun denying the code when it is billed with the -51 modifier. This is not an inappropriate policy by Horizon. The AMA has clarified as of December 2013 that the -51 modifier is not appropriate on the code when billed with other CMT codes ( ). The problem is that there was no communication of this policy, which left many providers with erroneously denied bills. At the time of printing we are still awaiting a definitive explanation from Horizon on why no communication went out and if they will automatically reprocess these claims for the affected providers, and if not, what the preferred method of reprocessing would be. Anecdotally from the field, we have heard several providers simply rebilling just the code alone without the -51 modifier has led to corrected payments being issued. We would like to take this opportunity to remind the membership of the AMA s clarification on the -51 modifier and the Under CPT guidelines it has been declared this modifier is not appropriate to be billed with this code, You should cease using the -51 modifier when billing to any payor. NJ Assembly Testimony: In late November, ANJC s Director of Insurance gave testimony to the NJ Assembly Financial Institutions and Insurance Committee. The hearings were intended to gather information and hear from stakeholders regarding the ever growing cost of out-of-network medical care to the consumers of the state. Many provider groups spoke on all manner of issues regarding out-of-network reimbursement and administrative problems. The ANJC took this opportunity to highlight the new and rapidly growing problem of insurance carriers developing products that have both a very restrictive narrow network of providers and very often no out-of-network benefits at all. Having such a limited network of medical professionals in a plan with no out-of-network benefits not only hinders the income of the doctors but more importantly it severely restricts the access to care of the consumers who purchase those plans. The carriers are able to develop such narrow networks in NJ at this time because the regulatory policy mandates that a carrier only needs to have two doctors of any particular specialty per county in order to claim they have a network of that type of doctor. The committee was searching for solutions to out-of-network costs to consumers. We suggested strengthening the requirements put on carriers to claim they have a network of a particular specialty. If the networks attached to plans are more adequate to reasonably serve the population of the plan, this would reduce the number of patients going out-of-network and in many cases paying the full cost of the medical care themselves despite having insurance. This kind of regulatory reform would also help stem the tide of carriers creating new plans with networks much smaller than their current products, excluding many providers who The ANJC took this opportunity to highlight the new and rapidly growing problem of insurance carriers developing products that have both a very restrictive narrow network of providers and very often no out-ofnetwork benefits at all. had been long standing in-network providers. Medicaid: We have discussed Medicaid in previous issues this year. Medicaid has become a topic of more interest recently for several reasons. Approximately 15% of the entire state of NJ receive some form of Medicaid benefits. Due to new eligibility guidelines under Obamacare there were 300,000 more enrollees in NJ this year over last year. Managed care companies now run all the Medicaid policies and the reimbursements (while still lacking) are higher than the standard state fee schedule. Also, there is a Medicaid ACO Demonstration project launching this coming year that could be a tremendous opportunity to show the cost effectiveness of chiropractic care within this system. Representatives from the ANJC met with the NJ Division of Medical Assistance and Health Services, which runs Medicaid in December. Many issues were discussed and the association was well received. Perhaps the most critical issue for the expansion of chiropractic s role within the Medicaid system was that of the moratorium on allowing chiropractors into the Medicaid panel. We have discovered that as of 2006 there has been a state moratorium disallowing any new chiropractors from enrolling as Medicaid providers. From our discussions, the department is not opposed to removing the moratorium. However, the final decision must be made by the state legislature as the action is part of the annual budget bill. We are working to ensure this is removed upon the next budget renewal. Obamacare: A series of lawsuits challenging some of the key elements of Obamacare that were considered frivolous and lacking merit at the end of last year have boiled down to at least one case that will be heard by the Supreme Court next year. King vs. Burwell is a case in which the plaintiffs are claiming that the federal government cannot give out tax subsidies to consumers who purchase plans through health exchanges that were established by the federal government. The premise of their case is that the actual language of the law referred to as Obamacare states that individuals can receive subsidies through an Exchange established by the state. The case is that the subsidies should only be given to consumers who purchase insurance through an exchange that was set up by their state government, not the federal government. Currently, 36 state exchanges are operated by the federal government while only 14 state exchanges and the District of Columbia run their own. If the plaintiffs win this case it would mean that no one in those 36 states where the federal government runs the exchange would be able to received tax credits towards their premiums in order to afford coverage. This would essentially remove health insurance coverage for millions. Further, the way the law is written, the only trigger for the employer penalties for not offering coverage to their workers per the law s mandate is if an employee of such a company receives a subsidy on the exchange. So, if this case is won by the plaintiffs not only would subsidies be lost, but the employer mandate would be completely nullified in those 36 states. The Supreme Court is expected to hear oral arguments on the case in March 2015 and render a decision by June SEE AD ON PAGE 14

11 20 Winter Winter If It Doesn t Hurt, Nothing Is Wrong By Dr. Mark N. Charrette We ve all heard this statement many times and I think most would agree that it is not accurate. We know that, in order to feel the conscious sensation of pain, an action potential must be achieved in the sensory cortex that reaches threshold for that patient. Thresholds are individual so what I feel as pain you may or may not feel as pain. Furman and Gallo write, While the brain can process several trillion bits of information per second, it appears that we are perhaps only consciously aware of 50 bits of information per second at any given time. Since pain is a conscious sensation, it is understandable why a prominent chiropractor, Dr. James Chestnut writes, A clear indication that using the conscious perception of pain to determine the need for care is hugely inadequate and inaccurate. How can any scientist knowingly rely on less than 50/3 trillionths of the information and claim it to be a valid analysis? When research is examined we find that adjusting minimally or nonpainful areas can have very beneficial global effects on the body. Neurological research has presented us with a model that gives an explanation to reasons why chiropractors achieve For all chiropractic providers that use the paper 1500 form for submission of claims to Medicare, rather than electronic submission, you may be interested in this recently published paper by CMS. Listed below are instructions on the preferred method of submitting the CMS 1500 Claim forms (version 02/12). We encourage providers to also follow the Part B Reference Manual, Chapter 9 for the instructions on how to complete information submitted in Blocks Failure to adhere to these guidelines will be considered a billing error on the Laser Therapy Shockwave Therapy ThermoStim Ultrasound Cardio Equipment Electric Stimulation Strength Equipment TENS Tables Traction Rehabilitation Equipment Supplies Electrodes Pillows Lumbosacral Supports Low Back Cushions Cervical Collars Paper Products Lotions Gels Kinesio Tape Theraband Hot Packs Cold Packs...and Much More! All the products you need... and the personal service you deserve. PO Box 8421 Pelham, NY positive clinical results when patients asymptomatic articulations are examined and appropriately adjusted. The model known as dysafferentation gives an explanation why a variety of symptom complexes not usually associated with altered joint function are reduced or eliminated. This model deals with the two main types of sensory receptors, nociceptors and mechanoreceptors, that innervate the joint structures. The depolarization of nociceptors occurs via mechanical stimuli and the chemical mediators released in response to injured tissue. The depolarization of mechanoreceptors (Pacinian corpuscles, Meissner s corpuscles, Ruffini corpuscles, Merkel s receptors, muscle spindles, and golgi tendon organs) occurs only via mechanical stimuli such as those associated with touch and normal body movements. It appears that with joint subluxation/misalignment/hypomobility, nociceptors will excessively fire while the mechanoreceptors will decrease their firing rate. Research of Hooshmand, back in 1993, demonstrates how restricted joint motion causes an increase in firing of nociceptive axons (the A-delta and C fibers) and a decreased firing of large diameter mechanoreceptor axons (the A-beta fibers). Submitting Medicare Claims by Paper: Tips to Follow By Dr. Richard C. Healy - ANJC Medicare Consultant provider s part and could result in denials and/or claims returned as unprocessable. 1. The recommended font size is 10 point font set to either Courier New or Times New Roman. Maintain the same font size and type on the entire form. 2. Use computer-printed forms and only type the data within the boundaries of the fields provided. Information reported on the claim form that is not completely within the block on the form, will be considered a billing error. 3. Only submit red drop out ap- Ask for details about our 6 month No Payment Financing (800) Dynatronics Chattanooga Multi Radiance Medical Zimmer Hill Tables Lloyd Tables Landice Scifit Quantum Hausmann And Many More An important function of mechanoreceptor input is to inhibit nociception at the level of the spinal cord. It would be reasonable to think that reduced mechanoreception (decreased firing rate due to subluxation) may magnify the symptoms generated by excessive nociceptor input. Dysafferent input can and does produce a variety of symptoms that one would not usually associate with dysfunctional/subluxated joints. Research written by Nansel and Szlazak explains that nociceptive input from dysfuntioning/subluxated joints can cause symptoms such as sweating, palor, nausea, vomiting, abdominal pain, sinus congestion, dyspnea, cardiac palpitations, and chest pain that mimics heart disease. Cabell authored research that states, nociceptor activity reflexively activates the sympathetic nervous system... In addition to relieving symptoms classically associated with joint subluxation/misalignment, most chiropractors experience their patients leaving their offices with a much more relaxed and lighter feeling. In a paper written by Patterson, it states, Adjustments to decrease nociceptor input to the spinal cord seem to be an effective way to decrease the hyperexcitable central state. Therefore, based on the information presented, I would like to stress the proved CMS-1500 (02-12) claim form using black ink for ultimate quality of scanning. Copies of claims will not be accepted. 4. Avoid totally or partially hand written forms as this can cause delays and errors in processing and slow down the turnaround time for reimbursement. 5. Preference for submission of OCR claims should either be typed or computer printed forms. 6. Ensure all required fields of the CMS-1500 (02-12) have valid information reported. Refer to the Part B Reference Manual, Chapter 9 for detailed information regarding Blocks Do not submit continued or multiple claims to one CMS-1500 (02-12) form. 8. Periodically review the fields spacing and placement of information contained within Blocks 1-33 when using computer printed or typed CMS 1500 (02-12) claim forms. Information should only be located within the specified block placement on the form. 9. Do not use a rubber stamp for any fields on the CMS-1500 (02- importance of including extremity and extravertebral adjusting procedures in the chiropractic care of patients. Like D.D. Palmer said in 1910, When we as chiropractors, have adjusted all displaced bones of the skeletal frame... what more can we do? References 1. Guyton A. Basic Neuroscience. 2nd ed. Philadelphia: W.B. Saunders, Hooshmand H. Chronic pain: reflex sympathy dystrophy, prevention and 3. management. Boca Raton,FL: CRS Press:1993. p Nansel D, Szlazak M. Somatic dysfunction and the phenomena of visceral disease simulation: a probale explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from visceral disease. J Manipulative Physiol Ther 1995:18: Cabell J. Sympathetically maintained pain. In: Willis W. ed. Hyperalgesia and allodynia. Raven Press. NY: Patterson M. The spinal cord: participant in disorder. J Manipulative Physiol Ther: 1993:9(3) Furman and Gallo, 2000, The Neurophysics of Human Behavior 8. Palmer DD: The Chiropractor s Adjustor, The Science, Art, and Philosophy of Chiropractic. 1910, Portland Printing House, Portland, Oregon. Ensure all required fields of the CMS-1500 (02-12) have valid information reported. Refer to the Part B Reference Manual, Chapter 9 for detailed information regarding Blocks ) claim form. The OCR scanner cannot properly read the data. Regularly change your print ribbon to ensure the print is legible. Light red or smudged print cannot be read by the OCR scanner and must be manually keyed. 10. Avoid overlapping print, extra labeling in fields, and the use of correction fluid or tape. 11. Avoid the use of special characters such as dollar signs, hyphens, slashes, or periods. 12. Use black ink only. Do not use red or blue ink as the scanner is unable to read the data and can cause your claims to be returned as invalid or unprocessable. 13. Report all information regarding a service on one line. If the service dates, diagnosis codes, charges, etc., are reported on separate lines, the OCR scanner creates an extra line. This causes the claim to suspend, increasing processing time. 14. Do not highlight the claim form or attachments. Highlighted information can become blacked-out when scanned and is not readable by the OCR scanner. Rehab Made Easy Postural Correction of the Cervico-Thoracic Spine By Donald C. DeFabio, DC, DABSCP, FACO Pain and loss of function drive most patients to our offices. Every day we treat patients suffering with headaches, neck and back pain, shoulder pain, vertigo, upper extremity radicular pain, and whiplash. They all have a common denominator: poor posture in the cervico thoracic spine. As chiropractic doctors we are focused on finding and treating the cause of a problem, whereas a patient in pain is looking for relief. Therefore, embracing the treatment of the underlying cause of their pain and giving them long term correction strategies may not be on their radar. However, postural correction transcends that gap because it can be seen and quantified by the patient. Our lifestyles today are creating a population that has significant postural imbalances. Rounded shoulders and an anterior head carriage are the hallmarks of laptops, long hours of desk work, iphones, and electronic games. Vladimir Janda, MD, originally described this postural distortion as an upper crossed posture and it fits this patient population perfectly. Even better, is that Janda also developed a series of exercises to correct this imbalance. Coupled with chiropractic adjustments the results are phenomenal. Briefly, the upper crossed posture exhibits tightness in the chest muscles (pectoralis major and minor), upper trapezius, levator scapulae and sub-occipital group. The combined effect is an increase in the thoracic kyphosis, anterior head carriage and suboccipital extension. Janda further established that due to reciprocal inhibition weakness will be found in the deep cervical flexors as well as the scapular retractors and depressors (mid and lower trapezius, rhomboids, serratus anterior). The answer now becomes easy: stretch and lengthen the tight muscles and strengthen the weak ones. Before we move onto the exercise protocols, there is one essential link to include before starting your patients on an upper crossed postural correction program. Restore normal motion and mechanics to the cervical and thoracic spine. This must be done prior to a successful posture correction plan to ensure long term correction. Exercises alone will work but it will take time and if the patient stops exercising then the poor posture and pain that drove them to the office will return. First, fix the underlying spinal pathomechanics, then reinforce the adjustments with corrective postural exercises. Creating an exercise program is easy once you know the goal. In this instance we need to STRETCH and LENGTHEN the chest, upper trapezius, levator scapulae, and suboccipital groups and STRENGTHEN the deep cervical flexors, scapular retractors, and depressors. My favorite exercises are listed below and if anyone would like an electronic copy me 1. Seated Chest Stretch can also be done standing: 30 second, hold three times. 2. Cervical Retraction build to three sets of 15 w/o resistance band then add resistance band 3. Seated Rows being sure the upper trapezius remain relaxed: three sets of Bruegger s Scapular Retraction Protocol three sets of Y-T-A s: three sets of 20 w/o weight then progress to 3X20 with three pound dumbbells As for stretching and lengthening, passive and active assisted stretches can be done with the patient in the office or prescribed for home. Personally, I prefer to do post isometric relaxation, neuromuscular stretching, and myofascial release in the office both manual and instrument assisted and let the patient do passive stretches at home. Here are the steps to begin using these protocols today: Mention postural defects found on the initial examination and relate it to your patient s pain. Reinforce that to prevent recurrence it will require postural correction on subsequent visits. Begin the lengthening and stretching exercises once the pain is reduced. Progress to the strengthening exercises. Remind patients that postural correction is beyond pain control. Adjustments are essential: the cervical and thoracic spine must be freely moveable for the best response. These protocols can be used on every one of your patients and can be done right in your current treatment room. Postural defects are increasing at an alarming rate and as chiropractic doctors we are in the best position to treat postural imbalances to enable our patients to look better and to live better. Dr. Donald DeFabio is in private practice in Berkeley Heights, NJ and is the team chiropractic doctor for a local university as well as the strength and conditioning coach for two local high school track programs. He conducts Rehab Made Easy seminars, small group tutorials on low tech rehab for everyday practice, functional assessment, and Running Boot Camp seminars. He can be reached at for questions, to register for his workshops and copies of his patient handouts. Upper Crossed Rehab Made Easy: Phase of Care First Phase Second Phase Third Phase EVERY PHASE Goal/Objective Lengthen chest, levator scapulae and upper trapezius Teach isolation of mid and lower trapezius and cervical retractors Continue lengthening Continue lengthening Increase strengthening Restore spinal mechanics Examples Passive stretches Assisted stretches, pain free Bruegger s Positioning Manual or instrument assisted Soft Tissue Manipulation Manual or instrument assisted Soft tissue manipulation Seated rows Y-T-A s Cervical retraction Adjust the cervical and thoracic spine as needed

12 22 Winter Winter Protect Your Business from Snow and Ice By Garry R. Salomon, Esq. Cash Practice Alternatives: Considerations for Chiropractors By Mark Sanna, DC, ACRB Level II, FICC For the past few years, winters in the Northeast have been nothing short of treacherous. As the days get colder, most people fear a repeat of last year s artic winter weather. The menacing snow and ice caused serious injuries to many people, including spinal injuries. Chiropractors may see an increase in patients this time of year but as property or business owners, they need to remember their responsibility to guard against slip-and-fall risks on their own property. Under certain circumstances, a person who slips or falls and suffers an injury due to ice and snow may sue both tenant and the property owner and hold them liable for medical expenses, lost wages, and pain and suffering. Sometimes, a contractor responsible for clearing snow and ice may also be held legally liable. Generally, a claim may proceed if the injured person had a right to be on the property, was reasonably careful, and the property owner was negligent in responding to the buildup of snow and ice. Typically, under premises liability law, property owners (800) have a duty to ensure their properties are safe for those who visit. Property owners must eliminate or mitigate any snow and ice dangers, by shoveling or spreading salt or sand, in reasonable time to prevent slip-and-fall accidents. This includes snow and ice on sidewalks, steps, parking lots, and other walkways. The burden of providing safe premises falls more heavily on business owners than on residential property owners. This is because businesses invite people to enter their properties. New Jersey courts have indicated that businesses have an absolute duty to the safety of customers or potential customers. Similarly, operators of places that are open to the public such as parks, shopping centers, hospitals, and apartment complexes with common areas also have a duty of safety toward visitors that is typically higher than that of a homeowner. All commercial establishments have a duty to maintain their sidewalks reasonably free of slipping hazards such as ice and snow. Besides the property owner s responsibilities, the injured person has All the products you need...and the personal service you deserve. a responsibility for their own safety. Visitors to a business or to another person s property must exercise reasonable care to avoid reasonably foreseeable risks. Snow and ice are understood to present a slip-andfall hazard, particularly after winter weather events. However, as an example, someone running when they fell may have a difficult time proving their case because of comparative negligence on their part. I recommend you first establish under the terms of your lease whether you or your landlord have a duty to clear parking lots, sidewalks, and entryways. You may be surprised to learn that your lease is vague, silent, or ambiguous as to your responsibilities and more importantly, your legal obligation and exposure. Your lease or letter agreements should specify each area to avoid ambiguity, lack of coverage, and unnecessary legal bills. However, if you are responsible, stock up on salt and de-icing agents and place them prominently near your entry way. It s good business to show your patients that you are a responsible proprietor concerned about their safety. It s also recommended that business owners periodically replace their interior weather mats. For peace of mind, confirm with your insurance broker that you have coverage, or that you also have secondary coverage should your landlord default in their obligations. Your obligation to keep the premises safe continues whether you are in the office or away. We recommend you create a snow and ice safety policy and protocol and explain it to your staff so that they help keep your patients safe when you are busy or away Garry R. Salomon is a personal injury trial attorney certified by the Supreme Court of New Jersey as a Civil Trial Attorney. He is a founding member and serves as the managing partner of Davis, Saperstein & Salomon, P.C. His main areas of concentration include all areas of personal injury law. During his 35 years of practicing law he has successfully represented thousands of clients. Starting with Your Next New Patient By William D. Esteb Itracked down an appreciative patient of yours that you helped almost a year ago. After some small talk, I asked a few questions about her experience. Why did you originally consult a chiropractor? I asked. I kept getting headaches and my friend suggested that I see her chiropractor. Finally, months later, I made an appointment. Why did you wait so long to make an appointment? Fear, mostly. Not just because of the neck adjustment, but I didn t want to get myself into something I couldn t get out of. I don t understand. I heard that once you go to a chiropractor, you have to go for the rest of your life. I didn t want to become dependent on a chiropractor any SEE AD ON PAGE 3 more than being dependent on pain relievers. I d heard this before. But what I really wanted to know was what she had learned from your patient education process. I wonder how many chiropractors have taken the time to list the key concepts or principles that they d want every patient to know? Without a specific plan, I m guessing many take the path of least resistance; keeping chiropractic safely tethered to a form of physical medicine. The predictable result is that patients leave once they feel better, producing a never-ending appetite for more new patients. You could change that, starting with your next new patient. Based on my beliefs about chiropractic, subluxation and adjustments, here are the The nervous system is the master system. Most patients figure blood chemistry is the biggest factor affecting their health. seven things I d want every patient to know. Your list may be different: 1. Chiropractic care is different from medicine. Although medical bashing is a popular pastime among some chiropractors, that s not what this is about. Instead, realizing that we only learn something new in relation to something we already know. Since most patients have experienced medicine, you d want to use medicine to frame your explanations. Medicine and chiropractic are separate and distinct professions and each has its place. The heroic measures of medicine can save your life, but rarely advance health. While medicine is interested in the problem in the person, chiropractic is interested in the person with the problem. Don t be afraid to point out the differences. Frankly, the fact that chiropractic isn t medicine is what makes chiropractic attractive. 2. Chiropractic care doesn t treat anything. This concept may be too scary for some chiropractors but critically essential. While it s almost always an ache or pain that prompts patients to begin care, it s important that every patient understand that chiropractic doesn t treat headaches, back pain, strains, sprains, or any other named or unnamed disease or condition. Including vertebral subluxation! That would be the practice of medicine. Instead, chiropractic care is designed to arouse the ability of the patient to self heal. Big difference. Huge actually. Neglect this distinction and patients think your cervical adjustments treat headaches and lumbar adjustments treat sciatica. 3. The nervous system is the master system. Most patients figure blood chemistry is the biggest factor affecting their health. The more astute might believe that their DNA is their destiny. So, for most patients, learning that the nervous system controls and regulates every cell, tissue, organ, and system of the body is a new idea. This nervous system focus of chiropractic is lost on many who think it s about bones, posture, curves, disc spacing, or tight muscles. Which is why you might want to point out that bones are static structures that only move when muscles contract. And that muscles contract only when commanded by the nervous system. Thus, chiropractic is ultimately concerned with the integrity and tone of the nervous system. 4. Vertebral subluxation is the result of stress. While some see vertebral subluxation as the body s mistake or an example of the body becoming suddenly dumb, my belief is that subluxation is one of the body s gorgeous, creative strategies to accommodate physical, chemical, Continued on Page 24 The entire American healthcare delivery system stands at the threshold of significant changes in healthcare reimbursement brought about by the Patient Protection and Affordable Care Act, popularly known as Obamacare. Unsure of how they will navigate the maze of new health insurer contracts, many chiropractors are questioning how the new law will impact their practice. Confronted with declining reimbursement rates from traditional insurance payors and seeking ways to simplify their practices and reduce administrative overhead, many chiropractors are electing to opt out of the third party payor system and to convert part or all of their practice to a cash practice reimbursement model. While the decision to disengage from the third party payor system brings with it certain freedoms, there remain several significant legal pitfalls that can sink even the most well intended practitioner. What Is a Dual Fee Schedule? A dual fee schedule means having different fees for different types of patients. In order to capture the most of a diminishing percentage of their fees covered by insurance, doctors are required to regularly increase their fees to keep up with the usual, customary and reasonable (UCR) fee schedules established by third party payors. This can result in a level of cost that is unbearable by many under- and un-insured patients. This dichotomy sets in motion the dual fee schedule and, in some practices, the corresponding illegal discounting of fees for cash paying patients. When dealing with cash and underinsured patients, chiropractors must keep in mind that all patients are financially responsible for their care. This means that many patients may have two problems: a health problem and a financial problem. Let patients know when you can help them with their health problem and inform them that together you can work on their financial challenge. There are several legal options that allow chiropractors to discount their fees to ensure that their patients budgetary limitations do not get in the way of them receiving the care that they need. What Is an Inducement? Under section 1128A(a)(5) of the Social Security Act, an inducement is any offer of valuable goods and services as part of a marketing or promotional activity, regardless of active or passive. Indirect marketing, like word of mouth, counts as marketing too. Discounting your fees is considered an inducement and is against the law. It also creates an unfair business advantage between your practice and the other healthcare practices in your community. In cases involving federal health programs, such as Medicare, Medicaid and other federal plans such as U.S. Postal Service and railroad employees, offering an inducement can result in both financial penalties and criminal prosecution. What Is a Time of Service or Prompt Pay Discount? In many states, chiropractors can discount their fees by a percentage if payment is made at the time of service or within a designated time frame. This is called a time of service or prompt pay discount. The allowances vary from state to state, however state laws may not supersede federal laws that link the percentage of discount to fair market value. The Office of the Inspector General (OIG) has issued an opinion indicating that between 5% and 15% could be considered a reasonable prompt pay discount. For example, 10-15% discount on the balance if paid at the time of service and 5-10% on the balance if paid within 30 days. The OIG placed additional restrictions on prompt pay discounts. You must bear all costs of the discount and may not claim the discount as bad debt. You must offer the same discount to all patients on all services regardless of the reason for their care or length of treatment (this includes personal injury patients). You may not advertise that you offer a discount for prompt payment. You must notify any third party payors that you are under contract with to address any issues that may come about due to restrictions within your contract. Finally, the amount of the discount must bear a reasonable relationship with the fair market value of avoided collection costs. In other words, the equivalent of what it would cost your practice to pursue collection had payment not been made promptly. What Is a Hardship Discount? The Health Insurance Portability and Accountability Act (HIPAA) dictates that offering a discount on the patient-due portion (co-payment and deductible) could be considered a financial kickback when it is used to induce a patient to receive a course of care that their insurance carrier will pay for. The routine write-off or discounting of the patient-due portion is illegal. You may however offer a hardship discount to patients based on their documented financial need. This can be a discounted or sliding discount based on level of need, for example in accordance with the published poverty guidelines, but must always be based on a percentage of your full fee. Your hardship policy must be in writing and non-discriminatory. You must customize your hardship policy to your local region. Routinely offering patients hardship discounts can open your practice to scrutiny, so you must be exact in how you implement this procedure. And remember to document, document, and document every step of the process! There are also rules that govern how to determine which patients are eligible to receive a hardship discount. Offering a legal hardship discount requires some sort of verification of need. It is acceptable to accept a patient s word on a one time (one visit) request, however in cases of an ongoing hardship discount, tax returns or pay stubs are required to sufficiently document need. You may also base your decision on participation in public assistance programs such as Sup- plemental Security Income (SSI), the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), or the National School Lunch Program (NSLP). What Other Legal Discounts Are There? In the absence of a prompt pay discount or documented financial hardship, you must have all of your under- and un-insured patients pay your full fee schedule. You also must avoid inducements with federal plans including Medicare. In most states, there is a third alternative that allows chiropractors to legally offer patients a discount through something called a Discount Medical Plan Organization (DMPO). A DMPO is a network that creates a triangulated relationship between patients and providers that allows you to offer patients contractual discounts based on their provider-member relationship. Patients pay a fee to become members of the DMPO and providers agree to offer a published discounted fee schedule to members of the plan. It is the same principle by which insurers may set a fee schedule below UCR for their policyholders and providers based on their contractual agreements. Like insurance companies, DMPOs are regulated and must be properly registered within the state they operate. Which Model Will Work for My Practice? No single reimbursement model works for every chiropractic practice. Depending on the nature of your practice, the characteristics of your patient mix, your environment and community, whether you have partners or associates, your lifestyle desires, and even your personality, some combination of these cash practice components may or may not be right for your practice. Regardless of which model you pursue, your personal satisfaction and financial success will depend on your ability to deliver quality chiropractic care and to honor the commitments you ve made to your patients. Dr. Mark Sanna is a member of the Chiropractic Summit, the ACA Governor s Advisory Board, and a board member of the Foundation for Chiropractic Progress. He is the president and CEO of Breakthrough Coaching ( ). Get Nutrition Education & Resources! Just for the health of it... NECTM Nutrition Education Council

13 24 Winter Immune Activation During the Winter Months By Dr. David Seaman T he most common view of immune function during winter months is that it weakens and needs strengthening. We have been conditioned to think that the cold and flu season is due to immune weakness, which makes us more susceptible to viruses that love to hang out in sub-zero environments. This view is promoted on the television, radio, and in doctor s offices. Unfortunately, this is actually a simplistic and mostly inaccurate view. Rather than weakening during the cold and flu season, our immune systems actually become activated, which leads to sickness symptoms. Consider for example that many people gain 5-10 pounds of fat during the winter months. This is due largely to overeating the calorie-rich holiday foods made from sugar, flour, and fat. extent of postprandial inflammation has been correlated to the extent of postprandial hyperglycemia. The intake of sugar-flour-fat calories also causes gram-negative bacteria in the small intestine to release lipopolysaccharide (LPS), which is then absorbed into body circulation. LPS is also known as bacterial endotoxin, which means that sugarflour-fat calories leads to systemic low-grade endotoxemia. Immune cells respond to endotoxin in the same fashion as hyperglycemia; NF-kB is activated and pro-inflammatory chemicals are released. This acute immune activation may lead to no appreciable symptoms or may promote sickness symptoms, such as malaise. Stress and a lack of sleep have the exact same immune activating effect. Acute dietary inflammation The mere act of eating these calorie-rich foods leads to postprandial hyperglycemia and lipemia, which stimulates the immune system. In particular, the hyperglycemia leads to an influx of glucose into immune cells, which leads to an excess of free radicals produced by mitochondria. This stimulates a cell-signaling molecule called nuclear factor-kappa B (NF-kB), which enters the nucleus to stimulate the production of proinflammatory chemicals that are then released by the immune cell. The Chronic dietary inflammation As we overeat during the holidayrich winter months, we often pack on extra pounds. When adipocytes swell in size, they begin to attract proinflammatory immune cells. In other words, swelling adipocytes are perceived by the body in a fashion that is similar to an antigen that requires an immune response. As one becomes obese the immune cell population living in concert with adipocytes goes through a transformation. Lean adipose tissue contains adipocytes and anti-inflam- matory immune cells, however, obese adipose tissue typically has multiple pro-inflammatory immune cells including cytotoxic T-cells, pro-inflammatory T-helper cells, mast cells and neutrophils, which continuously release pro-inflammatory chemicals into body circulation. The term adiposopathy has been put forth as a way to distinguish sick adipose tissue or sick fat syndrome from normal healthy adipose tissue. Someone with adiposopathy is chronically inflamed whether they are eating, not eating, or sleeping. When these people consume sugar-flour-fat calories, they have a more robust immune activating response. Avoiding acute and chronic dietary inflammation People often overreact when it comes to the idea that one must give up the calorie sources that taste so good us. Such an overreaction ultimately prevents the development of proper dietary habits. The goal should be to minimize the consumption of foods made of flour, sugar, and fat that is, eat them in moderation. Replace these calories with healthy animal products and vegetation. It is that simple. Consider also taking supplements that offer anti-inflammatory benefits, such as magnesium, fish oil, vitamin D, probiotics, and anti-inflammatory botanicals such as ginger and turmeric. By taking this approach, we Get expert support and access to the best speakers and trainers in the industry TM Promoting Your Chiropractic Practice on Facebook in the New Year? Read This. S can calm down the immune system and feel better throughout the year, but especially during the dreaded cold and flu season. The information presented in this article is a synopsis of an article I wrote for Practical Pain Management in 2012 (1). Reference 1. Seaman DR. Anti-inflammatory diet for pain patients. Pract Pain Management. 2012;12(10) com/treatments/complementary/ anti-inflammatory-diet-pain-patients Dr. Seaman is a Professor of Clinical Sciences at the NUHS Florida site in Pinellas Park, where he teaches nutrition and evaluation and management courses for the musculoskeletal and cardiorespiratory systems. Dr. Seaman has authored a book on clinical nutrition for pain and inflammation, and has written several chapters and articles on this topic. His website is a source of this information for the general public. Continued from page 22 Looking to Improve Your Clinical Skills through Hands on Training? 25 By Dr. Matthew Loop Starting with Your Next New Patient or emotional stress. And while this survival strategy can start a chain reaction of other health issues, the underlying cause of the cause is stress. Stress is so common for most people they rarely see it as the influence it actually is. Practitioners who successfully make this distinction rarely experience the December, end-of-the-year slow downs, the most stressful month of the year. And let s not forget the relentless effects of gravity that should prompt everybody to embrace some type of ongoing chiropractic care. 5. A series of consistent visits will be necessary. Granted, there are those occasional one-visit miracles, however, if you re working with an adult who has had their problem for months or years, then the six or 12 visits doled out by an insurance carrier will offer little than the most basic palliative care. The consistency aspect is especially important. Missing visits compromises the momentum necessary to make spinal changes. (Be sure to ask patients what they think would happen if their visits were spaced too far apart.) 6. Patients control the speed of their recovery. Many patients equate their three-adjustments-a-week with the doses of medication they ve received. And since you created the prescription you re often blamed if your care plan doesn t resolve their problem in a reasonable (as defined by the patient) timeframe. Conversely, you re often given credit when your care plan results in the hopedfor symptomatic improvement. Yet, what patients do between visits can Winter profoundly effect whether the symptom resolution the patient wants will manifest. There are things you need to do and there are things they need to do to enhance the healing process. Unlike medical treatment, make sure every patient understands that this is a partnership. 7. How long you benefit is entirely up to you. Many chiropractors project the value that they place on their health onto patients, making patients feel ashamed if they don t seek out grass-fed, antibiotic-free beef or feel guilty for consuming a Diet Coke. And while shame and guilt can be powerful ways to get patients to do the right thing justified as being in the patient s best interests this is classic manipulation. True, you may extract an additional visit or two more, but the wake of resentment you create will reduce referrals and virtually eliminate subsequent reactivations. Remember, your job is to provide the very best chiropractic care possible, and it s the patient s job to decide how much of it they want. It s their health, not yours. What do you want every patient to know? Make a list. And then relentlessly present it. Boldly. Confidently. And consistently. William Esteb is the creative director for Patient Media, Inc., a patient education resource company for chiropractors. Subscribe to his weekly , Monday Morning Motivation, read his blog, and add his disruptive patient education tools to your procedures at ince Facebook has over 1.1 billion members right now, it s critical we discuss some of the newest trends regarding promoting your chiropractic practice on this powerful platform. Times are changing and so is the world s biggest social network. The very last thing you want to do is to appear outdated and out-of-touch with prospective and current patients. This post will help you get up to speed in the new year. If you don t have an overwhelming presence on Facebook, studies show that consumers don t trust you as much. It s kind of like twenty years ago when everyone was in the yellow pages. If you weren t in that directory, you looked suspect and people were more skeptical about your brand. Why? It s because every reputable business was in there. The public s mindset has shifted but the same principle applies to Facebook. There s no use in battling the trend or holding out any longer. You ve got to start marketing your practice like it s the actual year we live in and have a large presence on the social network! With that said, here s what you need to know this year so you can be more effective. Facebook has hijacked your fans and friends: Did you know that on any given status update, only 7-10% of your fans and friends see it? Yes, you read that correctly. All of those people that came to your Facebook business page over the years, clicked the like button, became fans expecting to see your content regularly are more than likely not getting your updates now. That will come as a shock to many unsuspecting chiropractors. Facebook is a business and now wants you to pay for newsfeed visibility. Yeah, it s kind of a bummer. However, there s no sense in getting worked up about this bait and switch. We as chiropractors must adapt or perish. The gatekeepers have reared their ugly head again. If you want the large reach, you re going to have to pay. Facebook is not your home online: One of the biggest mistakes so many doctors have made over the years is that they ve used the social network as their central hub of communication online. They ve driven much of their traffic in their videos, blogs, press releases, and articles to the social network to get more fans. The problem with this has always been that you and I don t control what Facebook does tomorrow. Facebook could update their algorithm (like they did) and crush your visibility overnight and your ability to get your message to your audience. Less visibility = diminished exposure = decreased website traffic = fewer people walking through your door. Ideally, you should be building an list of prospective patients. You do this by offering something of value on your website in exchange for a name and . For instance, you might offer a free report titled, Three Questions You Must Ask Before Choosing a Chiropractor, or Five Mistakes Most Make when Choosing a Chiropractor. Make the report consumer friendly and address the commonly asked questions as well as the myths that surround chiropractic. This is so we can overcome objections before they consciously arise in the prospective patients mind. We need to build an list because most people aren t ready to come and see you on the first online interaction. They hardly know you. When they re on your list, you can deliver great informative content, patient case studies, and then make an exceptional offer. We have to get people to know, like, and trust us first. The goal is to build a relationship and a strong bond with subscribers. How to beat Facebook s newsfeed filter: If you re looking to maximize your reach and post distribution on the social network, pay close attention. Of all the engagement factors, comments are the most important. The more comments you get to each status update, the more exposure you get in the newsfeed. Simple. Likes and shares are great but in my experience comments can give your posts the most legs and viral exposure. So, how do you create this type of engagement? Ask open-ended questions. Have image caption contests. Incorporate fill in the blank or multiple choice status updates to spark conversation. Not only that, make sure you are commenting on your own threads. As Facebook sees this windfall of engagement, they end up showing the content to more of your friends and fans. Facebook advertising: The holy grail of promotion: After spending over a half million dollars personally on Facebook advertising and managing close to a million dollars in ads for other companies, I will encourage you to get while the gettin s good. The social network s ads platform is the fastest way to reach critical mass in your market and mold public perception. Funny we, as chiropractors always talk about hitting the mainstream but so few doctors seem to be doing what it takes to get there. Social media and strategic Facebook advertising is one of those things that can influence hundreds of millions if done right. You can run ads all day long and shape what you want the public to think about chiropractic, much like what drug companies have done using expensive television advertising. Our best ads are getting.08 cents per website click (CPC) with over 6% click through rate (CTR)! You should strive for below.33 cents per click, though. Anything higher than that means you re doing something wrong. The landing pages you re driving the traffic to should get at least 10 people out of 100 to give you their name and in exchange for something of value (free report, video trainings, etc.). In my flagship training, Social Media Elite, I walk you through all the ins and outs of Facebook advertising so you can look over my shoulder and get it right the first time without wasting money. This is also another way to beat the algorithm filter if you have the budget. You can boost a status update. Once you post something, look on the right below the update and you ll see a little blue button that says boost post. With that option you can target your business page fans, friends of fans, or a custom local audience. I would get in the habit of boosting your best content. The social landscape is consistently changing. We, as chiropractors, need to stay abreast of these updates so we don t get left behind. Facebook is not a fad and there s a huge opportunity for those who are open-minded, willing to put the time in, along with creating systems that feed the office for years to come. Not only can you get more exposure, website traffic, and new patients through your doors, but you can also help slingshot the profession in a positive light to the masses. Check out my blog for more powerful trainings that grow your practice quickly using sites like Facebook, YouTube, Google, Instagram, Twitter, Pinterest, etc. Dr. Matthew Loop is an author, chiropractor, speaker, philanthropist, and the highest paid social media revenue strategist in North America. He s the president of DCincome, which is the world s largest social media training company for chiropractors. Since social media s infancy in 2005, he s been successfully teaching doctors and entrepreneurs how to reach, impact, and earn more. Nutri-west mid Atlantic Toll Free: Wilmington Delaware 2015 Seminar Schedule Save The Dates IMMU-NITION March 21, 2015 Intro to Functional Medicine April 25, 2015 Presented by: Dr. Don Bellgrau, PhD & Dr. Lynn Toohey, PhD Mt. Laurel, NJ 8 CE Credits Presented by: Dr. Brandon Lundell, DC Southern NJ/ Philly area 8 CE Credits For detailed info contact us! Are You Meeting Current Demands for Physical Rehab & Performance Enhancement? You re in good hands with ANJC TM Council on Physical Rehab & Performance

14 26 Winter Winter Research Updates Continued from page 9 Not Just for CE Alone Continued from page 1 Not Just for CE Continued from previous page Hypothyroid, PMS, Adrenal Fatigue Does Everyone Have This? interventions still is limited, requiring further research. 1 Tsertsvadze A, Clar C, Court R, Clarke A, Mistry H, Sutcliffe P. Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomized controlled trials. Journal of Manipulative and Physiological Therapeutics 2014; 37(6): Welcome New Members! Dr. Ophelia Adams Dr. Diana Arteta Dr. Anish Bajaj Dr. James Ballantine Dr. Andrew Beko Dr. David Blumenthal Dr. Mark Brandwein Dr. Susan Clothier Dr. Joannie D. Connor-Charles Dr. Daniella D Alessio Dr. David T. Decker Dr. Nicole C. Eckert Dr. Daniel Eleuteri Dr. Steve Gallina Dr. John S. Garner Dr. Anita Gerath The New Jersey Chiropractor is a bimonthly publication of the Association of New Jersey Chiropractors. To assist with the many challenges of everyday practice, it is filled with updates and extraordinary ideas from our profession s best and brightest minds and serves as a leading information resource for the more than 3000 chiropractors located throughout the Garden State. We hope you enjoy ANJC s latest effort to keep you updated and informed. The Association of New Jersey Chiropractors - The kind of association you ve been aching for! ANJC ELECTED OFFICIALS Dr. Mike Kirk President Dr. Don DeFabio Vice President Dr. Jeannine Baer 2nd Vice President Dr. Dan Fuzer ANJC Secretary EXECUTIVE DIRECTOR Dr. Sigmund Miller Anthony Rosner is a champion of interdisciplinary research in the health sciences, having served as Research Director of the International College of Applied Kinesiology, previously having been Director of Research and Education at the Foundation for Chiropractic Education and Research, Director of Research Initiatives at Parker College, Department Administrator in ASST. EXECUTIVE DIRECTOR Diane Philipbar-Fetzer ANJC APPOINTED OFFICIALS Dr. Richard Healy Treasurer IMMEDIATE PAST PRESIDENT Dr. Joe D Angiolillo ANJC STAFF Matt Minnella Director of Insurance Susan Cully Events and Member Services Jennifer Mukuna Administrative Assistant and Operations Clara Campbell Financial Operations Associate ANJC LEADERSHIP ANJC STATE BOARD MEMBERS Central Dr. Robert Blozen Dr. Joseph D Angiolillo Dr. Kostantinos Linardakis Dr. Alfonso Manforti (Alt.) Northwest Dr. Don DeFabio Dr. Dave Graber Dr. Jeannine Baer South Dr. Rick Brown Dr. Dan Fuzer Dr. Michael Kirk Northeast Dr. Steven Clarke Dr. Ed Cohen Dr. Tom D Elia Dr. Bob Haley (Alt.) Council Dr. Alan Vargas Dr. Lenny Siskin (Alt.) Dr. Joe D Angiolillo Legal Advisory Dr. Jeannine Baer COCSA Rep Dr. Richard Healy Medicare Consultant Dr. Steven Clarke Legislative Dr. John Cerf Hospital Protocol Dr. Mark Spratford Communications Dr. Tom D Elia Insurance Dr. Barry Coniglio Rules and Regulations Dr. Joseph Garolis NJ Board of Examiners Dr. Christopher Bump Nutrition Education Council Dr. Frank Zaccaria College Liason Dr. Mark Magos Senior Advisory Dr. Richard Healy Finance Dr. Joseph D Angiolillo Executive Committee ANJC VISION & MISSION Chemistry at Brandeis University, and Technical Director of multiple laboratories at Beth Israel Hospital (a teaching hospital of Harvard University) and an affiliate of the Mayo Clinic. He currently is a Research Director for Apex Energetics, Inc, a nutritional supplement company based in California. He was designated as Humanitarian of the Year in 2000 by the American Chiropractic Association and holds an honorary degree from the National University of Health Sciences. He obtained his Ph.D. from Harvard in Medical Sciences/Biochemistry in His bibliography lists over 85 peer-reviewed publications Beacon Street, Suite #315 Brookline, MA [office] [cell] FAX Dr. Robyn Gotthoffer Dr. Faisal Hussain Dr. Jeng Kuan Dr. Larry Lemieux Dr. John Marks Dr. Jeffrey T. Massarone Dr. Emmanuel M. Messili Dr. Angela Minhas Dr. Robert T. Robbins Dr. Gregg Salzman Dr. Joseph M. Schafer Dr. Leo A. Staten Dr. Stacey Stefanski Dr. Randy R. Stephan Dr. Tracy A. Tomaino COMMITTEE CHAIRS ADVISORS CONSULTANTS Dr. Kostantinos Linardakis HQ Committee Dr. Mike Kirk PR Committee Dr. Richard Fellows PAC Committee Jon Bombardieri Lobbyist Lynette Contreni Insurance Consultant Dave Klein, CPC, CHC Insurance Consultant Dr. Mike Goione Insurance Consultant Anthony Rosner, PhD Research Consultant Jeffrey Randolph, Esq Legal Counsel Dr. David Graber Council on Technique & Clinical Excellence Dr. David Graber ED Committee Dr. Don DeFabio Council on Physical Rehab & Performance Katherine Lusk Editorial Assistant Vision: To position Doctors of Chiropractic as providers of first choice for New Jersey families to obtain optimal health and wellness, while improving the quality of their lives. Mission: To improve the health of patients, families and communities by promoting high standards of professionalism and patient care through chiropractic methods, education, advocacy and accountability. ASSOCIATION OF NEW JERSEY CHIROPRACTORS 3121 Route 22 East, Suite 302 Branchburg, New Jersey fax numbness of the four fingers of the left hand. History shows that four years previously she was taken to the hospital ER with a similar pain, given morphine and x-rays were taken and she was sent home. Other pertinent history was a pilonidal cyst removed, hysterectomy for fibroid tumor, and a rotator cuff tear repair of the right shoulder. She is also presently on methotrexate for psoriasis yes, this is correct, it is not for rheumatoid arthritis and muscle relaxants for her neck pain. She smokes a pack of cigarettes a day and is a caregiver for her husband. Exam: Vital signs are BP 140/90, normal heart and lung sounds, oriented times 3, very cooperative, pleasant, and ambulates well. Range of motion of the cervical spine was impossible to ascertain on first visit due to pain. The left C2 and C5-7 levels were very painful to palpation with pain extending into the left rotator cuff muscles and down the left arm. The deep tendon reflexes of the upper extremities were plus 2 bilaterally and sensory examination was normal. Due to pain, muscle strength examination of the upper extremities was not possible. Compression did exacerbate cervical spine pain at C2 through C7 on the left side. Figure 1 Figure 2 Imaging: Figure 1 is a left anterior oblique view showing foraminal narrowing due to posterior endplate hypertrophy at the C6-7 level. Figure 2 is a lateral view of the cervical spine showing anterior head carriage, flexion subluxation and anterolisthesis of C5 with degenerative disc disease of C5-6 and extensive C6-7 disc space narrowing with endplate hypertrophy responsible for the foraminal stenotic changes seen in Figure 1. Treatment: The orthopedic surgeon was apprised of our findings, and a treatment regime and goals were established as follows. Proprioceptive neurofacilitation of the cervical spine muscles was given followed by decompression of long y axis and adjusting of the cervical spine with protocol I. Ultrasound followed the adjustment to the cervical spine. The treatments are given three times weekly until 50% subjective relief is attained, and then the frequency of adjustments is reduced by 50%. She did home therapy of alternating hot/ cold/hot to the cervical spine and left shoulder girdle. She attended back wellness school to study ergonomics of spine function. She took calcium citrate for osteoporosis of bone. She understood that failure of 50% relief of the pain in 4-6 weeks of care would precipitate re-examination and re-evaluation. Clinical Outcome: In 10 days / 4 visits, the arm pain was absent, return of range of motion of the cervical spine to 70% of normal, and negative compression test. Comment: Yes, this is a common case but that makes it very important. We see these cases routinely and sometimes forget how beneficial our form of care is to these type of patients. Perhaps you may consider the use of decompression adjusting in your practice, especially since this is a case of a woman who could not tolerate high velocity adjustment. She is frail, concerned about being hurt by a chiropractor. (Do you get these patients as I do?) She is very happy with our care. Since this episode, I have also treated, successfully, left hip and lower extremity pain from spinal stenosis and am presently treating the failed surgery for a right supraspinatous tendon partial tear of the rotator cuff. In 10 visits, it is also 80-90% relieved of pain with return of range of motion. Good treatment begets happy patients who respect and use our talents. Lumbar Spine - L4-5 Disc Herniation with Motor Weakness: A Journey to Low Back Pain and Left Leg Pain Relief via Surgeon Consults, Steroid Injections and Finally Successfully with Cox Technic Introduction / History / Examination: This 42-year-old white female is seen for low back and left leg pain with Grade 3 of 5 left dorsi-flexion of the foot at the ankle and Grade 1 of 5 extension of the extensor hallucis longus tendon of the great toe. She has been seen by two orthopedic surgeons who have scheduled her for a selective foraminal steroid injection. Imaging: An MRI, shown in Figures 3 and 4 below, was ordered on her first visit due to the motor weakness. The MRI shows on sagittal image loss of signal intensity at the L4-L5 disc with a large left paracentral disc prolapse that contacts the cauda equina and the left L5 nerve root. Figure 3 Figure 4 Continued on Next Page Treatment Plan and Goal: Long y axis decompression with flexion distraction of the L4-L5 disc space is instituted with Protocol 1. This is followed by positive galvanism for 12 minutes and tetanizing bilateral electrical stimulation at the L4-L5 level, the left posterior retrotrochanteric space, and the anterior tibialis muscle. Home care consists of ice to the low back for 30 minutes twice a day. Outcome: On day two after the first treatment, the dorsiflexion strength at the left ankle for 4/5 and of the great toe 2/5. This case was very closely monitored for any progressive neurological deficit that would necessitate surgical discectomy. After treatment from October 20, 2011 through December 23, 2011 (12 visits), there was gradual relief of the left lower extremity pain with return of motor power of the left great toe dorsiflexion and dorsiflexion of the foot until her pain was VAS zero and motor power 5/5 at the ankle and 4/5 at the great toe. As of December 23, 2011, this patient has not been seen because the number of visits allowed by her insurance company expired, and she would not fund her own care. Luckily, her insurance coverage equaled her required treatment. So in the end, the state association conference attendee gets to choose whether the experience is just for CE credit or for more. Dr. Cox certainly trusts the experience culminated in implementation and was not just for CE alone. It wasn t for him. Thank you. Julie Cox-Cid is the coordinator for Cox Technic: seminars, researchers, online communications, webinars, physicians, patients, website (where more patient cases like these may be found), and much more. She is privileged to be able to work alongside her father for these past 22 years, building on her earlier family life experience of Dr. Cox s devotedly nurturing Cox Technic flexion distraction with a drive to make chiropractic scientific and evidence-based for the pain relief, ultimately, of patients. com (800) Senate Commerce Committee Approves Chiropractic Assistants Legislation Continued from page 1 Chairwoman Senator Nia Gill posted the legislation to be heard. The prime sponsor of the legislation was Senate President Steve Sweeney. The legislation has already passed favorably from the Assembly Regulated Professions as well as the entire 80 member Assembly. The ANJC has been working with the Legislature throughout the entire process and will continue to provide information and testimony to assist the Legislature in moving this bill toward the Governor s desk for consideration. As always, ANJC will keep members abreast of developments, but once again this is another positive step forward for the legislation. By Dr. Nicole Rivera How many times have you heard or said yourself, I m so tired, Ugh, my cramps are horrible, I have a migraine, I must be getting my period, or I am so moody, I can t stop crying at every Snuggles fabric softener commercial. As women, we can all admit that we have been there at some point. But why? Is this what we must endure as women? Must we accept that there is no end for these debilitating hormonal symptoms? Or is there a solution? Before answering these pressing questions, let s elaborate on what PMS, hypothyroid, and adrenal fatigue look like, and why they are all tied together. The endocrine system is comprised of various organs including: the hypothalamus, the anterior pituitary gland, the thyroid gland, and the adrenal gland. PMS is correlated with an imbalance of sex hormones typically too much estrogen and not enough progesterone. The adrenal glands are complex organs that produce your sex hormones as well as your stress hormones. The liver also plays a large role in the production of your sex hormones. Before I lose you, let s simplify: Your liver and adrenals produce your sex hormones, your thyroid communicates with your liver and adrenals and, therefore, thyroid function will be negatively affected by hormone imbalances (see the infographic below). We must also consider that the liver is our primary detox organ and assists in the elimination and removal of excess estrogen. The liver often becomes taxed from a lifestyle containing prescription medications, alcohol, and other toxins from our food and water. The decreased functionality will not allow the body to rid excess estrogen. There are many things in the typical American diet/ lifestyle that can contribute to an overabundance of estrogen in the body, including: Birth control pills, shots, or patches Non-organic meats Non-organic produce Soy consumption Overconsumption of flax Overuse of plastics, and heating of plastics High body fat So what s the big deal with having too much estrogen? Too much estrogen and not enough progesterone will increase the release of cortisol binding globulin and thyroid binding globulin. The thyroid binding globulin binds to the thyroid hormones in the blood so that they cannot enter the cells and produce energy. This will create a hypothyroid. Thyroid hormones help to fuel the thyroid and keep you energetic and healthy. Cortisol is a stress hormone that helps regulate immune function, regulates blood pressure and blood sugar, as well as regulating your body s inflammatory response. Too much estrogen will cause cortisol binding globulin to bind cortisol in the blood, preventing it from entering the cell and from activating cells to produce energy. Progesterone is a precursor to cortisol, and low levels of progesterone can result in adrenal fatigue. For those women who have gone through, or are going through, meno- PMS symptoms Cramping Irritability Increased Appetite Breast Tenderness Heavy Bleeding Depression Fatigue Migraines pause there is still a chance that imbalances of estrogen and progesterone exist. Because of the large amount of soy in our food supply, we are exposed to estrogen even if we re not consuming soy products (i.e. soy meats, edamame, and tofu). Soy is mixed into the feed of many animals we consume and is also the primary oil used in prepackaged foods and fried foods. Aside from soy-based feed, many animals are pumped full of estrogen-based growth hormones. Plastics also contain BPA that will mimic estrogen in the human body. Hormonal Conditions Endometriosis Hair Loss Dry Skin Fibroids/Cysts Irregular Periods Amenorrhea Adrenal Fatigue Hypothyroid Cortisol Imbalances So what can be done? First, determine if any of your symptoms fall under the following categories in the table above. The next thing that must be done is an evaluation of the liver because the liver plays a crucial role in the endocrine system. If you are suffering from high cholesterol, chances are that your liver is not in ideal health. A liver cleanse may be helpful in healing the liver, removing excess estrogen, and balancing the endocrine system. There are various supplements and herbs that can support the natural production of progesterone by stimulating the ovaries and adrenal glands. Ashwaganda is an adaptogenic herb for the endocrine system that will adapt to your condition whether you are hyper or hypothyroid. Glandulars are a category of supplements that can be used to support certain glands in the human body, but should not be used without the supervision of a functional medicine nutritionist or a specialized practitioner. Reduce the use or intake of products that can produce estrogen in the body. If you re currently taking birth control, consider an IUD with no hormones (like the Copper IUD). Focus on organic, non-gmo foods that are grown without the use of Hypothyroid/ Adrenal Fatigue Decreased Energy Thinning Hair/Hair Loss Salt Cravings Dizziness/Lightheadedness Inability to Lose Weight Cold Extremities fertilizers and without the use of antibiotics. Remove soy products from the diet such as soy milk, soy cheese, soy meats, soy sauce, foods cooked in soy oil, and processed foods containing soy. Limit flax in the diet because it is a phytoestrogen, which mimics estrogen in the body. Also limit the use of plastic bottles or containers that might contain BPA. Lastly, decreasing body fat will help to decrease the amount of estrogen in the body. Contrary to popular belief, weight loss is possible even with a compromised endocrine system. Focus on a high fat, low sugar diet of whole foods. Choose high quality products by shopping at natural food stores, farms, farmer s markets, and butchers. Remember that just because it is found in a health food store doesn t mean it s healthy. Reading labels and asking questions is a key part of consuming a healthy diet. Nicole Rivera, D.C. is a chiropractor, functional medicine nutritionist, and co-owner of Integrative Wellness Group in Belmar, NJ. Dr. Nicole specializes in blood and hair analysis, as well as endocrine and neurotransmitter testing as part of her functional medicine nutrition program. Learn more at DISCLAIMER - The author of this article is an independent person of the ANJC and his views are not authorized, sponsored, or otherwise approved by the A.N.J.C. The information provided is for general guidance on matters of interest only and may not take into account particular facts relevant to your individual situation. The application and impact of laws and health care can vary widely based on the specific facts involved. Given the changing nature of laws, rules and regulations, there may be omissions or inaccuracies in information contained in these materials. Accordingly, the information you receive is provided with the understanding that the author and the A.N.J.C. are not herein engaged in rendering legal, accounting, tax, health care or other professional advice and services nor are they providing specific advice with regard to your practice, the treatment of any specific illness, disease, deformity or condition, or any other matter that affects trade, commerce, or legal rights of others. As such, this article should not be used as a substitute for consultation with professional accounting, tax, legal, health care, or other competent advisers. Before making any decision or taking any action, you should consult an appropriately trained professional.



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