Using diagnostic tests and imaging can increase patient compliance and be an effective patient education tool

Which diagnostic and imaging system is right for your practice? This equipment purchase is a major investment and can be a daunting decision. Chiropractic Products asked three experts about implementing and using diagnostic testing and imaging systems in chiropractic practices.

Jim Combest is the director of marketing for Noromed Inc, Tukwila, Wash. He has more than 20 years experience in the development, marketing, and sales of diagnostic instrumentation to the health care industry.

John Falcus is a licensed physical therapist and trained electrodiagnostic technician. Currently, he is vice president of HTZ Technical Service, Boca Raton, Fla. Falcus has given numerous presentations on the subject of diagnostics. HTZ provides on-site NCV testing to chiropractors across the country.

Joyce Peterson is the director of sales and marketing for the Universal product line under Del Medical Systems, Franklin Park, Ill. Peterson has been in the private practice x-ray market for more than 30 years.

What diagnostic tests or imaging systems are the most helpful to chiropractors?

Combest: Choose diagnostic tests based on the components of the VSC. From a kinesiological standpoint, dynamic range of motion (ROM) allows DCs to measure, document, and evaluate the patient’s patterns of movement and get an objective measurement of ROM according to AMA guidelines. For the myopathic and neuropathic portions of your diagnostic testing, there is computerized manual muscle testing and surface electromyography (sEMG). Computerized muscle testing can help establish nerve root impingement/involvement and will also document muscle weakness. Static sEMG can help you locate and document areas of hypertonicity while dynamic sEMG can help you monitor muscle recruitment patterns.

Falcus: Nerve conduction velocity and evoked potential studies are proven reliable diagnostic tools that supply doctors with data to help diagnose various neurological conditions. The studies give objective data that can be used to establish diagnoses, design treatment plans, and monitor progress. The studies are backed with supportive research and are approved by the American Association of Electrodiagnostic Medicine.

Peterson: When looking at imaging equipment, a key component should be the flexibility of the x-ray equipment, which should have the capability of comfortably producing both skeletal and extremity radiographs. Look for a unit that reduces patient and equipment set-up time. There are units on the market that align the x-ray beam to the image receptor, eliminating the need to independently position the x-ray tube and the receptor (cabinet). Single positioning x-ray equipment eliminates the possibility of improper beam/patient alignment. With the trend moving toward multidisciplines in the chiropractic office, do not limit the capabilities of your x-ray equipment.

What reimbursement/insurance issues should chiropractors be aware of?

Combest: Insurance companies are accustomed to the medical model: 80% diagnostics and 20% treatment. The chiropractic model is exactly opposite: 20% diagnostics and 80% treatment. To protect you and your patients, create an evidence-based practice. Use your diagnostic tools to document what you are doing, why you are doing it, and how patients progress. Your opinion may not be believed. However, a computerized accepted diagnostic test with automatically generated reports falls within the insurance industry’s paradigm.

Most manufacturers will be able to tell you which codes to bill their tests under. Beware of outrageous claims; get a complete copy of the recommended codes. You should expect a manufacturer to be able to document information and to be conservative. Do not rely on anecdotal information.

Falcus: As with any study, testing must be medically appropriate. Patients with radicular pain, numbness, tingling, weakness, or atrophy in the extremities may be appropriate for testing. Prior to testing, benefits should be verified for appropriate insurance coverage.

Peterson: It is important to have personnel who are well versed in CPT codes. As a general rule, radiology fees are reimbursed at about 80% of the average fees charged.

Do chiropractors need to obtain preauthorization to perform certain tests?

Combest: Chiropractors are not required to obtain preauthorization for diagnostic tests in most states. However, for more specific information, check with your state chiropractic association.

Falcus: Some insurance companies will require preauthorization prior to testing. Some testing companies will provide this as an additional service.

Peterson: Routine x-rays for new patients typically do not require preauthorization. It is recommended that chiropractic coverage be verified with the insurance company before starting treatment on a new patient.

Are there any legal issues chiropractors should know about?

Combest: Before you purchase a diagnostic instrument of any type, make sure it complies with FDA requirements. Some states require state-approved training for doctors and some require training for all staff who will be performing the tests.

Falcus: If you plan to use a testing company for on-site neurodiagnostic tests, it is important to research their practices. Most testing companies lease technicians and equipment to the doctor’s office. This method is compliant with Stark and anti-kickback regulations. Certain states may have additional regulations that need to be met. Consult with your legal counsel.

Peterson: We live in a world of lawsuit-happy individuals. It is recommended that you consult your local imaging company for lead lining requirements before the build-out of a new office.

What are the leasing/financing options for DC practitioners?

Combest: Leasing is usually the easiest route and requires the least cash up-front. However, many leases do not give the option of paying off the lease for less than the sum total of the remaining payments with interest. Financing differs from leasing in that the up-front money or down payment is usually greater than with a lease. The monthly payments are usually smaller, the interest rates are lower, and typically, you have the option of paying off the balance at any time without a penalty. Most reputable manufacturers have an in-house financing option that meets all of these needs. Finally, there is the outright purchase.

Falcus: Leasing technicians and equipment is a cost-effective way to provide this service in your office. It eliminates the large capital expense of purchasing the equipment, as well as the difficulty of staffing a technician to perform the procedures. Most leases work off a monthly or day-rate amount.

Peterson: Bank loans or leasing are the two most popular means of securing money to purchase equipment. While a bank loan will offer a lower APR, banks do not offer the flexibility that can be found with leasing companies. Look for a leasing company that can tailor the lease to your particular needs. Choose the term and residual that will not put a financial burden on your monthly budget. Check with the leasing company to ensure that there is no prepayment penalty. If the practice flourishes, the lease can be satisfied earlier. Always check with your accountant to take full advantage of any tax savings that may be applicable on leasing versus a bank loan.

Are there any beneficial technological advances in diagnostics/imaging for chiropractors?

Combest: ROM diagnostic equipment has advanced beyond the static “pendulum in a box” model into motion-sensing inclinometers. sEMG equipment has expanded beyond simple static monitoring to up to eight channels of dynamic sEMG. This provides doctors with what they need to evaluate and diagnose patients. Most systems have advanced to the point where they won’t pick up stray electromagnetic signals from outside sources, such as cell phones.

Falcus: With technological advances, the equipment has become smaller and more reliable. By utilizing this noninvasive procedure, chiropractors can evaluate the full nerve pathway for injury or disease. The testing is capable of showing what portion, if any, of the nerve is affected.

Peterson: Digital imaging has been a buzz word in the radiology arena for a number of years. It is estimated that digital will be affordable for the private practitioner within the next 5 to 8 years and will be the standard for DC offices. When purchasing x-ray equipment today, invest in a high-frequency generator with a minimum output of 30 kW to allow for added digital capabilities in the future.

What should chiropractors expect from their diagnostics/ imaging company?

Combest: Expect a diagnostic company to provide a toll-free number for customer service. Also, expect a company to provide regular software updates for their products. A good equipment warranty policy is also a must.

Falcus: Chiropractors should be devoted to providing a full-service operation, including assistance with scheduling tests, verification of insurance benefits for patients prior to testing, and a customer service department to help with any other issues, including billing and collections. They should also have technicians that are certified by either the American Association of Electrodiagnostic Technologists or the American Society of Electroneurodiagnostic Technologists.

Peterson: Local imaging companies should provide chiropractors with in-service training on the use and benefits of the x-ray equipment. In addition, expect a 5-year parts warranty from the manufacturer on the equipment and a 1-year labor warranty from the local distributor. If you are opening a new practice or adding radiology to your practice, the local imaging company should assist with providing electrical and plumbing requirements to your contractor.

What are some ways that chiropractors can use these tests for patient education, referrals, and compliance?

Combest: Spend a minute with patients to review the report from the diagnostic test. Let them know what you are looking for and how you use this information to track their progress. By documenting improvement over time you give the patient the motivation to improve visitation compliance. Let them take home a copy of the report. A copy of their diagnostic report on display at home will be a constant reminder of the necessity of following your treatment plan and can be a powerful source of referrals for family and friends.

Falcus: The information helps design the most effective treatment plan for your patients, leading to faster recovery times and happier patients. By utilizing testing, you are also expanding your practice’s capabilities, making yourself more marketable to new patients.

Peterson: Having the ability to show patients the problem areas adds to their understanding of the diagnosis and increases the likeliness of the patient completing the treatment.

Any last words of advice?

Combest: Diagnostics are an investment in your practice and indicate to your patients an investment in their care. Know what your needs are and what your budget is. Also, know what you are buying. Get a copy of any product claims in writing. Do your research. Finally, get a copy of the return policy in writing.

Falcus: Using on-site diagnostic testing is a great way to expand your practice, improve patient care, offer better service to your patients, and increase practice revenue.

Peterson: When purchasing x-ray equipment, choose a brand name that has been around for years and has a reputation for providing the best value for your investment. CP

Julie Z. Lee is a contributing writer for Chiropractic Products.