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Dynamic Chiropractic – November 4, 2002, Vol. 20, Issue 23

Examinations as Criteria for Ordering Additional Tests

By K. Jeffrey Miller, DC, MBA
(Editor's note: This is part of Dr. Miller's series on examination strategies. The information is gleaned from his book, Practical Assessment of the Chiropractic Patient. This examination strategy is listed in Dr. Miller's book as "No. 19: Physical examination procedures should establish the reasoning behind ordering or not ordering additional tests, such as imaging or lab studies.")

I began my practice in Kentucky on Leap Day 1988. At that time, I did not have access to lab studies or advanced imaging procedures. State law allowed chiropractors to order these, but the local medical facilities refused to accept referrals from chiropractors. This meant relying on the patients' MDs to work with DCs to obtain lab tests or imaging studies. However, even if the general practitioner cooperated, there were additional hurdles. Hospital radiologists refused to look at film from chiropractic offices, asserting, "We don't have quality control over the film." And the local orthopedic group would not work with chiropractors, even refusing to release records of patients who wanted to seek chiropractic care.

A few years later, the local hospital began accepting chiropractic referrals for lab and imaging studies on a qualified basis. This meant that the report for every study was also sent to the patient's medical doctor, whose philosophy was, "Two heads are better than one," and "This is in the patient's best interest." Frankly, it was insurance for them, as they had never dealt with chiropractors, and did not trust our clinical skills. It was just another slap in the face. We passed our boards; we didn't need someone looking over our shoulders.

A few years later, everything became wide open: "Order anything you want: labs, imaging - even physical therapy," the MDs now said. "We want to work with you." Did they suddenly understand D.D. Palmer's principle of above-down, inside-out, or the chiropractic "safety-pin" cycle? Heck no! It was strictly a financial decision. Independent imaging and physical therapy centers were popping up, and they were certainly willing to let chiropractors help pay for multi-million-dollar machines by providing plenty of referrals. The hospitals were forced to compete, and we were suddenly everyone's new friends. Luncheons and golf outings with MDs, and receiving Christmas gifts from them, became regular occurrences. During this time, I had a friend who ordered MR scans for every personal injury or workers' compensation patient, regardless of the presentation or severity of the patients' condition. He told me that no one had ever questioned this policy.

The "boon" lasted for several years. Then, managed care or "managed cost" clamped down on these excesses. The medical doctors were less affected than chiropractors, but the MDs were on a leash for the first time, and that trend continues. The insurance companies want medical necessity to be established prior to the tests, not by their results. It is difficult to establish the need for an MR now without motor dysfunction, or abnormal reflexes present prior to the test.

There are positive aspects to the early years. Continuous, enduring prejudice makes a doctor tough. I imagine that the chiropractic pioneers who were thrown into jail for practicing chiropractic could chew glass! Another positive aspect is that our history, examination and x-ray skills were sharpened and honed, as these were the only diagnostic tools we had.

We did not completely regress under managed cost. Less expensive tests are still obtainable. A CT scan is obtained with relative ease, compared to an MR scan. Some chiropractors have purchased nerve conduction, motion x-ray, ultrasound and other diagnostic instruments. Mobile services are also available for these tests. However, just because there is easy access, it does not mean the insurance carriers will approve them for coverage. You must establish necessity, even for equipment in your own office.

How do you establish necessity? Insurance carriers want objective evidence that will assure the suspected injury or condition will be identified by the tests ordered. A negative test is only good news to the patient and doctor. To the insurance carrier, a negative test means wasted money. Obtaining the objective evidence required to establish necessity for lab and imaging studies is done through examination procedures. A hands-on approach is required, which can be to our advantage.

During the period of easy access, a medical neuroradiologist told me she had observed that the results of MR scans ordered by medical doctors found the suspected pathology in only 20 percent of cases; scans ordered by chiropractors showed a 40-percent rate.

"How do you guys do that?" the neuroradiologist asked.

"We touch our patients, we examine them and we don't order tests based solely on answers to questions asked from across the room," I explained.

We are excellent diagnosticians, but as with most endeavors, there is always room for improvement. With thorough, efficiently organized history and examination procedures, our ability to know when to order lab and imaging studies will improve. Our ability to order the appropriate tests can exceed 40 percent.

K. Jeffrey Miller,DC,DABCO
Shelbyville, Kentucky

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