Three diganostic experts explain what chiropractors should look for in a neurodiagnostic testing company

What are the decisive factors in choosing a neurodiagnostics testing company? Chiropractic Products sits down with three industry experts for advice to help you make this important decision. The advantages of neurodiagnostic testing will be clarified by three diagnostic authorities: Ron Kimmel, DC, owner and president of Integrated Medical Diagnostics; Brian Koslow, managing director of Atlas Diagnostics LLC; and William P. Stearns, DC, owner of Comprehensive Medical Diagnostics LLC.

CP: Why is neurodiagnostic testing becoming so popular among chiropractors today?

Kimmel: Neurodiagnostic testing allows doctors to make a comprehensive diagnosis of a patient’s complaint in the comfort of familiar surroundings—the doctor’s office—which is also convenient to the patient. Diversification of [chiropractic treatment] combined with a new profit center adds to the popularity of on-site diagnostic testing.

Koslow: The increased need to objectively substantiate claims and validate patient treatment and progress has led to a rise in the demand for objective computerized diagnostic studies.

Stearns: Neurodiagnostic testing has become popular today among chiropractors because of two things: first, as a differential diagnosis, chiropractors can utilize neurodiagnostic testing to pinpoint where the patient has nerve interference or nerve damage in the large fiber tracts of the upper and lower extremities. Nerve conduction studies simply measure electrical impulses from point A to point B along the nerve tracts. This provides measurable objective findings that aid chiropractors in forming the best possible treatment plan.

Second, chiropractors—by becoming gatekeepers—can provide the testing on-site, thereby significantly increasing revenues.

CP: When should chiropractors order testing for patients?

Kimmel: Testing should be ordered to determine the degree of nerve injury and/or compression and to localize the injury along the course of the nerve. It should be used if the patient does not respond to care as anticipated, with negative X-rays, CT scans, or MRIs, and the patient continues to have complaints. Neurodiagnostic testing will justify continued care and substantiate the effectiveness of treatment.

Koslow: There are different types of diagnostic tests—each having respective protocols for ordering on behalf of patients. Some of the reasons that chiropractors may order diagnostic testing are: to document objective findings for an injury; to verify soft tissue irritation or damage; [when] a patient is not responding to care; to document old vs new injuries; [when] subjective complaints are evident but [do not support] objective findings; to rule out the possibility of muscle or nerve damage; if the patient is experiencing muscle weakness, numbness, nerve injury, radiating pain, diminished sensation, mechanical nerve pressure, nerve disorders, or abnormality due to an auto accident or diseases; if other diagnostic tests such as X-rays, CTs, MRI, or EMGs are negative, yet patient symptoms persist; and to substantiate claims.

Stearns: Indications chiropractors would order diagnostics testing for patients include: post injury; differential diagnosis: nerve vs muscle vs ligament, or specifically at the site along the nerve tract [with] abnormal nerve flow—nerve root vs carpal tunnel; non-resolving radicular signs and symptoms; patient is not responding to care; determination of nerve damage or irritation; CNS injury with peripheral signs and symptoms; and effectiveness of treatment.

CP: What should a doctor look for in a neurodiagnostic testing company?

Kimmel: Chiropractors should look for companies that utilize doctors or registered technicians so results are reproducible and accurate. They should also expect a turnaround time of 3 to 5 days and a neurologist for consults. Depending on what is needed, DCs should have a company that can perform extra testing such as brainstem auditory evoked response (BAER)—hearing and balance problems, visual evoked potential (VEP)—vision problems, P300—memory and closed head injuries, thoracic outlet study (TOS)—thoracic outlet, and BLINK—facial nerves. Musculoskeletal ultrasound will provide soft tissue imaging that identifies inflammation of facets, nerve roots, tendons, ligaments, and muscles.

Koslow: The company should be run or consulted by physicians with experience in neurodiagnostics. Physicians who are providing interpretation of diagnostic testing should be board certified in their specialty. Moreover, the diagnostic company should have a [thorough] understanding of the chiropractic profession.

Stearns: Chiropractors should look for a company that utilizes professional/technical billing only.

CP: What should a doctor look out for?

Kimmel: A diagnostic company should be consistent with current medical legal guidelines and compliant with all state and federal laws, including self-referral—Stark laws, Senate bill 2264 legislation, Medicare kickbacks, and fee-splitting laws. A diagnostic company should not guarantee returns or "rent" space from the doctor.

Koslow: The most important thing is that there is a necessity for the diagnostic testing being ordered and that chiropractors’ notes [justify] the test(s).

Stearns: A doctor should look out for neurodiagnostic companies that are not compliant with all state and federal laws including Stark—self-referral, Senate bill 2264 legislation, Medicare’s anti-kickback act, and fee splitting laws. Companies that promote diagnostic testing while promising guaranteed returns regardless of the tests performed should be viewed with extreme caution as they may be in violation of one or more of the above laws.

CP: What new tests are available to chiropractors?

Kimmel: Diagnostic companies are offering a wide range of new testing including: VEPS, BAER, which tests the eighth cranial nerve and brainstem pathway, TOS assesses pathways commonly compressed by the first rib, P300, which assesses changes in memory functions, and blink reflex, which assesses the function of the facial nerve.

Musculoskeletal ultrasound is used to image soft tissue and structures and identify signs of inflammation in the facets, nerve roots, tendons, ligaments, and muscles. Some diagnostic companies also offer sleep studies.

Koslow: Diagnostic testing is not new. In fact, chiropractors have been performing diagnostic tests since the invention of the neurocalometer. X-rays, MRIs, CT and MRI scans, diagnostic spinal ultrasound imaging, and nerve conduction studies have been around for many years. However, the increasing need for objective computerized documentation, outcome measurement, and substantiation of care have accelerated the need for diagnostic testing.

Stearns: New tests include: BAER, which evaluates the auditory pathways from the ear to the brain—headaches, head trauma, vertigo, and balance problems; and VEP, which evaluates the visual pathways from the eyes to the brain—headaches, blurred vision, vertigo, and optic neuritis.

CP: Will diagnostic testing have a negative effect on my treatment allowance with insurance companies?

Koslow: Most insurance companies recognize the need for diagnostic testing and objective documentation of conditions. As a result, most pay for diagnostic tests without any offset to predetermined medical or chiropractic treatment allowances. However, coverage offered by any individual health insurance plan can vary, and as a result, coverage should be verified.

Stearns: Usually not. Insurance companies list diagnostics under a separate allowance format, which does not interfere with treatment coverage.

CP: How are chiropractors legally entitled to be paid for the technical component of the test?

Kimmel: [They] are able to receive payments from insurance companies because they are leasing the machine and the technician for each test—therefore, the machine is theirs for that [period]. The tests are performed on a machine they have leased by a technician whom they have [also] leased.

Koslow: If leasing the equipment and technician, a chiropractor is entitled to bill for the "technical component." However, in addition to the terms and conditions of the lease agreement, a DC is also bound by federal and state laws and regulations.

CP: Does reimbursement vary for different health care professionals?

Kimmel: Usually not. There is a preset reimbursement allowance for diagnostic examinations and is usually consistent for all ordering physicians—MDs, DCs, DOs, and DPMs.

Koslow: Reimbursement for diagnostic testing varies [as does] reimbursement for any treatment procedure. Some reasons could be the underlying insurance contract, mandated fees, geographic location or region, physician’s level of education, licensing/board certification, experience, and overhead.

CP: Do DCs need preauthorization to perform the tests?

Kimmel: In states where preauthorization is required, some neurodiagnostic testing companies will obtain all necessary authorizations. Be sure to check with the company.

Koslow: Some insurance plans, including worker’s compensation, require preauthorization. Look for a company that obtains all insurance verifications and preauthorizations so your CAs do not have to do extra work.

Stearns: Some companies will obtain the necessary authorizations if required by the patient’s insurance plan.

About the Author
Christina Chang is a contributing writer for Chiropractic Products.