We’re here today to talk about some coding issues that have come up recently that I’ve had with our network of people questioning. I know I need to do active care, but what does it mean?  What services does this mean? And what is actually the difference between exercise and therapeutic activities?

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Hi everyone. This is Sam Collins, your coding and billing expert for chiropractic the HJ Ross company, ChiroSecure as well as you. We’re here today to talk about some coding issues that have come up recently that I’ve had with our network of people questioning. I know I need to do active care, but what does it mean?

What services does this mean? And what is actually the difference between exercise and therapeutic activities? How do we differentiate? How do we document it? And that’s really conundrum because we do want to focus on active care. In fact, if you think of it, chiropractors have always done active care. In fact, if you look back in the history, do you know physical therapists really didn’t prescribe her to exercise until the middle 1980?

Chiropractic. That’s always been a part of what we do. So I think we should approach it in that way and understand we have the true ownership of it. And it’s really good manipulation with this act of care. That makes the biggest difference. So let’s take about.

To active care. What does it mean? Well, let’s take a look at a couple of insurance payers. I was like to look at the people who are going to pay us and where the guidelines are. So on the left side, you’ll notice here’s a protocol from the company Cigna, and it indicates something pretty interesting. If it says directly from their chiropractic care manual, it says this, the provider should attempt to integrate some forms of active care as early as.

Continued use of passive care modalities may lead to patient dependency and should be avoided. In reality. What they’re saying is you should do more active care and as early as possible. Now, in a funny way, if you think of it, this protocol is indicating the best care is the act of. Meaning the exercise of the rehabilitation from that standpoint and that we should minimize the passive.

And it says here, the utilization of passive modalities is not considered medically necessary. Once the acute phase is over now, let’s move all the way to the right side. Now take a look here. This is from the state insurance regulatory commission, and let’s just look at the second paragraph. There are five new studies and systemic reviews, reporting, active physical regime, including extras.

Results in an enhanced pain reduction in shortening of the post-injury disability for people with whiplash. So again, it’s high, it’s the rehab part of it. In fact, in the middle here, you’ll notice this is from Evercore and Evercore. Is it behind the scenes for United Optum blue cross blue shield? And you’ll see here on this fourth carrot, it says as treatment progress.

One should see an increase in the active regimen of care. So I want to put an emphasis here. There’s nothing wrong with passive, but where does it fit? Passive is probably a pathway to active. I mean, if passive care were the thing, why would we even worry about rehab? Just put heat on everything real. It’s relax it.

But the past that does aid in it. So passive care, even from the national institutes of health regarding just pain says. It says it’s been recommended that passive modalities not be employed except when necessary to facilitate participation in the active treatment program. So it goes on to say the conclusion about the treatment of chronic non-cancer pain is the results from traditional passive modalities or disheartening people become dependent.

It’s the act of care. If you notice, when you go to a physical therapy facility, what do you see? It’s a gym they’re doing all active care. We have to be careful are we’d married to too much passive care in the chiropractic side because of insurance reimbursement. I wonder sometimes are we treating insurance or the patient?

There’s a place for passive. Myofascial release and so forth, but without the act of, is there truly any rehabilitation? Now this doesn’t mean active treatment is better than passive or vice versa, but there’s a role of both that we have in the early stages. Of course we want passive care. They’re in a lot of pain.

There’s a lot of swelling, spasm, but it’s to progress them. So as rehab takes over, we begin to do more of that functional side of it. Get them back to functioning. That’s what insurance and what patients are looking for. Is the functional change pain relief without an increase in function, doesn’t do much good heck.

That’s what medication does. So here’s something interesting. And this is the part I want to focus on today. What is the difference? So take a look here. This person’s doing that rope exercise. That’s very popular. I’m going to ask you all for a moment. Tell me, what do you think that service is? Is it a therapeutic activity T.

Therapeutic exercise T E or could it even be normal education? I think about that. What is that person doing? The fact is it could be any one of those. It depends on the purpose. So realize all of these activities probably fall under the generic term of exercise, but it depends more about the purpose and what doing.

So what is exercise? It says this procedure includes instruction, feedback, and supervision of an exercise protocol. So we all get that that’s exercises, strength, flexibility, endurance, typical gym, weightlifting, TheraBands, and so forth to stress. To increase flexibility or to increase endurance, certainly reasonable.

In fact, I would certainly say part of every rehab program, even if it’s just home instruction. So exercises is just what we think it is. It’s one or more areas it’s just exercising and it can include things like going on a bike or a treadmill or robot gym equipment for strength, flexibility, you know, isometric isotonic, ISO, kinetic, but it can be both passive and active.

You can facilitate it with helping the patient stretches. I don’t think any more would have a problem understanding why are you doing exercise? So what do we document the exercises, the sets, the reps and the purpose, but here becomes the difference. What is a therapeutic activity? And this is often confused.

In fact, I would say, I bet more on. A doctor of chiropractics, probably doing a therapeutic activity more than doing an exercise. Now, Claire, I’ll clarify that in a moment, but I want you to think of what is the purpose? Are you only trying to strengthen a single mother? Or are you trying to enhance a function?

Well, let’s look at what our therapeutic activities defined it as. And of course it’d be looking at the definition of the CPT. It doesn’t give us a whole lot. It says there’s activities are direct one-on-one patient contact. They use of dynamic activities to improve functional performance. Well, that’s the point.

It’s more about function. This involves functional activities, bending, lifting, twisting. In fact, if you think of it, notice how most people in the gym now are no longer focusing on. I want to be a bodybuilder and lift a lot of weight, but functional strength. Like I want to be able to press myself up and rotate building the course.

So there’s an enhanced to balance coordination. All of them. So meaning in a way you’re making yourself more athletic. So if it’s more to improve a functional performance, that’s what it comes down to. So now you might look, could any of these be exercise? Well, I’ll give an example. What if I have three patients, all squeeze in a rubber ball, one patient has carpal tunnel and they just have a lot of weakness in the flexor muscles that I’m solely doing it to increase the strength of the flexors, but I have another patient.

That they have a job where they have to lift items or maybe they’re lifting their kids. And so you’re doing the grip to increase their grip, to enhance their ability, to hold things and pick them up. But the third person, maybe they’ve had a stroke and they’re squeezing the ball also. How would I cope those, the person doing it for carpal tunnel and weakness.

And that would actually be exercise the one, squeezing it to lifts. So. Would be a therapeutic activity. Cause the goal is an activity. Whereas the one with the stroke clearly would be neuromuscular education. So notice each of those kind of are the same thing, but it depends on the outcome and the program you set up.

So when choosing between exercise and therapeutic activity, it depends on the intent of the task. So here it says, for example, abdominal curls can be used for strengthening a weak abdominal muscles, and that will be exercise. You’re just doing abdominal cramps. Okay. If you were doing it though, because the patient, when they’re lying down has difficulty getting up from that line position and can’t say.

The purpose of the abdominal curls is their ability to get up from a lying down position that now makes it at therapeutic activity. So notice the intent. So if it’s solely just to strengthen, like you have an injury and you’re just doing tricep extensions to strengthen the price up muscle exercise, but if you’re strengthening the tricep muscle in order for them to be able to hit a tennis racket or a pickleball rack, and I guess now as a more.

Would that be more a therapeutic activity? Cause what’s the goal. The goal is not strengthening the tricep, but ultimately the function of being able to hit the ball. So when differentiating it always take a look and say the best practice is to determine what is the functional outcome task? Is it simply strength and flexibility or one with a functional performance.

Now why make this an issue is if it’s a functional performance, you are doing something to design. And try to correlate something specific to this patient. Again, looking at a physical therapy facility, you don’t see traditional exercise to an extent yes, but it’s almost always somewhat enhanced or changed a little bit to enhance what that person needs to be able to do.

And in that way, the exercise doesn’t have as much value because everyone does the same thing. Just do these things. But when you design a program specific to your. Our therapeutic activity has a higher value to give you the difference. The relative value of exercise is about the price of your 9 8, 9 4 oh.

The relative value of therapeutic activities is about a 9, 8, 9 41. So you’re talking about a 30% difference. If you’re designing a program specific to your patient’s needs and functional. It’s more likely a therapeutic activity. So what do I want to make sure to document the difference? Yes. There’s all types of exercises, quote unquote, but they’re designed to restore a certain function, makes it a therapeutic activity because if you think of it, aren’t we always trying to increase functional.

Or are we just going, I just need to strengthen the abdominal muscles only. I think it’s probably going to be the former, not the latter. So in differentiating, differentiating the two, I would say kind of think of it this way. Often exercise might be a pathway. Maybe initially you were only doing strengthening of the tricep muscle, but then what if that strengthening is then so they can hold a racket and begin to move.

Now that leads to it being a therapeutic area. So understanding and coding allows you to understand, to be paid. What you’re actually doing. Are you doing a simple exercise or are you doing a therapeutic activity and I’ll leave it with, how about nervous reeducation? Where does that fit in all this? Well, you have to have a deficit of balance coordination appropriateness.

If those are present and the exercises are there to change that parameter, that’s probably normal for education. However, kind of interesting therapeutic activities still has the highest value of all those. So let’s choose the code based on what we’re doing, not on what we think. Documentation would be the key at HJ Ross, where your partner take a look at our website, go to our new section.

We always update their quick note. Notice Medicare sequence duration is back. So you’re going to see a little reduction, take a look there. We’re always there to help. We do seminars. I offer a service where I become part of your office. You can join our network and be part. Let me be part of your office every day.

Next week, will be Sherry McAllister for the next program. Otherwise I’ll say to everyone next time being well and be good. Take care of everyone thing.