JANUARY CASES
January 7, 2019

Gender: Male Age of Patient: 70

Special Considerations: Spinal stenosis of thoracic and lumbar spine

 Your Case or Question: I have a Medicare patient who has spinal stenosis in the thoracic and lumbar spine, I have worked with him for years he has a stimulator implanted in the lower back and into the thoracic spine. It helps some but he also has severe balance problems and still has a huge amount of pain in the thoracic and lumbar spine. He comes in weekly, I try to get him to go longer between visits but when he does his symptoms increase and he will become immobile without coming in every week to 9 days. I am a walk-in clinic and file this with Medicare but am afraid of having issues with Medicare if the visits remain too frequent. I believe this is not maintenance care, he cannot function he says without CMT, he gets injections in the low back through pain management on a regular basis.

Answers:

This type of problem is much more frequent in doctor’s offices then you might think.
The stenosis means that treating this patient is like treating a diabetic. You will never “cure’ him of this, but it needs to be managed on a regular basis to keep him as functional as possible.

He should consider spinal decompression for his lumbar spine and then realize that he is treating the patient for “chronic management” of his condition, even though he is still symptomatic and reduce his billing code to a 98940. Have the patient sign an ABN form telling him that he doesn’t expect Medicare to pay for his services and collect from the patient with cash for the reduced Medicare rate for the services he is providing.

There is no happy ending for patients with issues like this where Medicare only wants to pay for acute care and not for any type of maintenance of any long term problem like stenosis. It’s not fair, it’s just how the system works for these people.

He should get some benefit from spinal decompression that can reduce his need and frequency of care, but Medicare won’t pay for decompression either, so he will have to pay for that with cash too.

This is so great we should get Medicare for everyone as a political stunt, while actually not giving them much of any benefit at all!! :-( Sorry.
Dr. Rob Jackson
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The bad news is, this is Maintenance care based on the Medicare Definition. According to Medicare, Maintenance Care is defined as: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A)

Unfortunately, this becomes the responsibility of the patient. If there is a true exacerbation, then it is the responsibility of Medicare. Chiropractors have been hammered over this by the OIG, and because of that the carriers. At this point, there is nothing that can be done about it. Most people would consider the care necessary, and chiropractors by there nature want to help these patients, but, based on the law, it is not covered.
Brad Hayes D.C..
Former member of the Medicare Advisory Committee for Trailblazer Health and Novitas.
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Since the doctor mentioned that CMT provides good results, it seems to me the concern is more about whether insurance will pay - for maintenance care versus no maintenance care. I would ignore the concern about insurance and provide the patient what the doctor thinks he needs rather than what the insurance thinks he needs. This may mean that the patient will have to pay out of his own pocket. If the patient is unable to pay out of pocket, then the doctor may have to treat the patient at a reduced fee.

John Hart, DC, MHSc
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This is in response and regarding the case in which a 70 year old male patient is suffering from spinal stenosis in the thoracic and lumbar spine. Since he has responded favorably to the doctors chiropractic treatments the challenge is to find a way to enhance the affects of the adjustments and hopefully help to increase the structural integrity and stability and perhaps increase the lasting affects of each individual adjustment.

The first thing that comes to mind would be to try taping the involved areas with kinesio tape. Applications of kinesio tape can aid in capillary circulation and lymphatic drainage. Taping can also aid proprioception and enhance the biomechanics of the involved area. Also importantly, there is almost no contra-indications to applications of kinesio tape. The tape may well help the patient’s condition, with little to no risk of complications.

I would suggest a gentle application of kinesio tape to both the thoracic and lumbar paravertebral musculature. I’ve attached a few pictures of taping methods I might suggest. There is a certain art and method to properly applying the kinesio tape. The patients skin must be clean and free of any sweat, gels, lotions or oils. Any body hair in the area to be taped must be removed. I use an inexpensive beard trimmer for this purpose. T apply - the tape backing should first be torn and and a portion peeled back. You must avoid touching the adhesive portion of the tape - hold it by the backing paper as you apply the tape. Place the uncovered portion of the tape on the target area, then peel back the tape backing as you apply the tape to the involved area. In this case, I would suggest little to no stretch to the tape as it’s being applied, with no stretch (ever) at the ends of the tape. Note that the ends of the tape should be rounded (with scissors) to prevent peeling and compromise of adhesion of the tape.

Although rare, there are certain contraindications. Open sores should be avoided. Although the tape is hypo-allergenic, some people can develop mild skin conditions, such as redness, rash or itching. In those cases, remove the tape. The KT brand of Kinesio tape (my personal favorite), has several different levels of tape available. I would suggest either the basic cotton or the Pro Synthetic tape. The tape can remain in place for several days.
Dale Morgan, DC, CCSP
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It sounds like the MC patient does well with passive therapies, but does not perform any active therapies at home to help out from the limited information supplied above. I use analogies with patients to describe how and why you should be performing this “self help” therapy at home to help them understand why they’re doing it. Self help could include anything from a daily/twice-daily exercise program to promote mobility of the joints and flexibility of the muscles. Some great exercises my patients love include cat/cow yoga pose where you’re gently flexing and extending through the spine or other gentle ROM exercises. If the patient is comfortable using mobility products like a foam roller, I think he would see some great improvement. With this, I am primarily talking about the thoracic spine as you don’t want the patient to put pressure on the spinal stimulator. This can be too aggressive for some MC patients so that’s why I focus more with exercises. The more proactive they can be with their health, the more relief they will have between visits.
Explain to the patient that the more they are proactive/active, the easier it will become to stay active. One simple thing that a toddler can see between someone that is alive vs. someone is dead is the lack of movement. We see those adults that come into retirement age very quickly. I believe a lot of this is because of adapting to a sedentary lifestyle. Promoting self sufficiency will be the best way to prevent the patient from using you as a crutch.
Brandon Aucker, DC