Delegating Services to Ancillary Personnel

Who Can I Delegate Services to?

Delegating services to unlicensed individuals within a practice can be a very gray area and is often misunderstood by health professionals nationwide. The requirements set by the state where you practice determine who is allowed to provide services under the direction of the licensed DC. There are also circumstances that dictate what can and cannot be delegated, such as individual provider agreements. Usually, your state law is the final authority for decisions about delegation, but you should be aware that provider contracts can be more stringent than a state rule. For example, in some states, it is acceptable for Chiropractic Assistants to help supervise exercises in the rehab area but your contract with XYZ Insurance may indicate that if Therapeutic Exercises are to be considered medically necessary, they must be provided and supervised by the DC. It’s imperative that you not only check with your State Board regarding supervision but that you review all third-party agreements to clarify those rules.

Here is an example of what was decided in an Illinois case:

In 2011, the Illinois legislature added Section 54.2 to the Medical Practice Act regarding physician delegation of authority to licensed and unlicensed personnel in the office. In response to questions submitted by a Blue Cross Blue Shield of Illinois medical director, the Illinois Department of Financial & Professional Regulation (IDFPR) Medical Board counsel recently issued information about the Department’s interpretation of the law: The applicable part of the law states: “(a) [Physicians may delegate] patient care tasks or duties by a physician, to a licensed practical nurse, a registered professional nurse, or other licensed person practicing within the scope of his or her individual licensing Act…No physician may delegate any patient care task or duty that is statutorily or by rule mandated to be performed by a physician. (b) In an office or practice setting and within a physician-patient relationship, a physician may delegate patient care tasks or duties to an unlicensed person who possesses appropriate training and experience provided a health care professional, who is practicing within the scope of such licensed professional’s individual licensing Act, is on site to assist….”[Emphasis added].

This law addresses delegation of duties to licensed persons in paragraph (a) above, as well as to unlicensed persons in paragraph (b).

Based on the language of subsection (a) cited above, the IDFPR has stated the following regarding delegation to a Licensed Massage Therapist (LMT) in the office:

Where the LMT is held out to the public as an LMT (i.e., by name badge, office promotional and advertising materials, website, signage, business cards, and the like), the physician may delegate tasks to the LMT that are within the LMT’s scope of practice. These tasks could include myofascial release, trigger point therapy, or therapeutic massage. In this situation, the delegated tasks must be limited to those within the scope of the LMT’s license.

Based on the language of subsection (b), however, the IDFPR has stated that a physician may delegate “patient care tasks or duties” to an unlicensed person who is appropriately qualified, provided a licensed health care professional (such as the physician) is on site to assist. This type of delegation could include a broader range of tasks than those that may be delegated to a licensed person if the other requirements of the law are met. If the employee is not licensed, there is no qualification in subsection (b) limiting the range of delegated tasks to a particular license scope, other than the scope of the delegating physician.

This language may leave some chiropractic physicians with an ironic result: they may be more limited in the tasks they may delegate to an identified LMT employee than to an unlicensed (albeit qualified) assistant. To address this issue in instances where an LMT is employed, the IDFPR has said that the D.C. may delegate patient care tasks and duties to persons holding a massage therapy license as if they were unlicensed, including tasks beyond the scope of the LMT license, if the LMTs are not in any way held out to the public as being LMTs. In this situation, the LMT would be acting in the capacity of an unlicensed, qualified assistant and would not have to limit his or her tasks and duties to the scope of the LMT license. For example, in addition to massage, you may wish to delegate ultrasound therapy to your LMT employee, a procedure not considered in the scope of LMT practice. You may do so only if he or she is not in any way represented as an LMT, including by verbal communication with the patient, wearing a badge indicating LMT status, or advertised as an LMT on any of the practice’s promotional materials, including its website.

Therefore, the IDFPR’s interpretation means if you employ LMTs in your office, it is important that you consider what tasks you need them to perform. If they are limited to activities that are within the scope of an LMT, you may promote them as such, and they may use their LMT designation on their name badges. However, if you need your LMT to be able to perform duties that go beyond the scope of the LMT license, you may still be able to delegate those duties IF you remove all advertising and indicators of the LMT status, and represent them as if they are unlicensed assistants.

As clarified in Illinois, there could be very specific rules that apply to ancillary personnel providing services to patients. Don’t assume that you know the rules—not those of your state or those of the carriers you are billing on behalf of your patients. If you delegate to ancillary personnel, be sure you know the parameters; write policy for your compliance program about how to abide within those parameters. Only then can you feel safe and secure in the knowledge that you are working within the rules.


Therapy-Modality Cheat Sheet

Download Support Tool

Supportive Therapies are a great addition to the primary Chiropractic Adjustment. Sometimes, these therapies are the primary or only therapeutic procedure delivered to the patient during a routine visit. Documentation requirements by various regulating bodies or payors detail the specific information needed for these therapies. This page is a printable tool illustrating the details for these therapies, grouped by CPT code use or category, and show what to record in the plan for each of them.

Therapy-Modality Cheat Sheet

We revisit this Help Desk video seen in module 2.6 because we now recognize potential reasons to integrate a new treatment plan for a new problem, or an exacerbation of a previous problem, into a current active treatment plan for a different problem and diagnosis. Alternatively, if something has changed, we may need to change an existing plan.  There are many types of scenarios that challenge the “Plan” documentation. For example, patients can present with a new cervical radiculopathy episode during visit #5 of a 12-visit active low back treatment plan. We would maintain 1 SOAP note and incorporate the new information and cervical radiculitis plan into it. The video details the steps needed


Documenting Ancillary Services in Routine Office Visit Notes

Necessary Documentation in Routine Daily Visit Note

Daily visit notes reflect the services ordered in the treatment plan based on the initial visit findings. It includes recommendations for both the primary service, Chiropractic Manipulative Treatment (CMT), and all ancillary services like therapies and active treatments. Every service you render during a routine office visit must be properly documented. Now, more than ever, third-party payers are disallowing ancillary services on an audit when complete information is not included in the note. This section addresses various non-CMT services and the standards for appropriate documentation in the routine office visit note plan section. For additional information on how each of these services must be documented in the treatment plan, refer to this module. The most significant and common codes are listed here. *

Code/Service Service Description Necessary Documentation in Routine Daily Visit Note
All Codes All Services Minimum Documentation: area(s) treated today, time and/or units performed; who performed the service
97010 Hot/Cold Packs Define whether hot, cold, or both; minimum documentation noted above
97012 Mechanical Traction Type of traction (intermittent, continuous, over the door, linear, auto-traction); pounds/kilograms; minimum documentation noted above
97014/G0283 Electric Muscle Stimulation (unattended) Type of stimulation (Interferential Current [IFC], Transcutaneous Electrical Nerve Stimulation [TENS], cyclical muscle stimulation [Russian stimulation], sine wave, galvanic; frequency (MHz); minimum documentation noted above
97032 Electric Stimulation (manual) Type of attended stimulation (direct motor point stimulation delivered via probe, Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES); frequency (MHz); minimum documentation noted above
97035 Ultrasound Type of ultrasound (pulsed or continuous); contact medium; frequency and intensity; minimum documentation noted above
97110 Therapeutic Exercise Specific exercises performed (active, active-assisted, passive participation by patient); number of reps/sets; settings; minimum documentation noted above
97112 Neuromuscular

Re-education (NMR)

Type of NMR (proprioceptive neuromuscular facilitation [PNF], BAP’s boards, vestibular rehabilitation, desensitization techniques, balance and posture training); number of reps/sets; settings, if applicable; minimum documentation noted above
97124 Massage Type of massage technique (effleurage, petrissage, tapotement, stroking, compression, percussion, mechanical); muscle group treated rather than simply area; minimum documentation noted above
97140 Manual Therapy (MT) Type of MT technique(s) manual traction, joint manipulation, myofascial release, trigger-point therapy [TPT], soft-tissue mobilization, manual lymphatic drainage); muscle group treated rather than simply area; minimum documentation noted above
S8948  LASER Class of LASER; light wave frequency; intensity; minimum documentation noted above

*KMC University has additional training resources on the use of many of these specific codes for further clarification.


Documentation Samples

Download Support Tools

Third-party payers cover medically necessary care within their definition.  At times, even with our patients’ best efforts, their healing does not progress as outlined in the plan(s). They may require a change in home care, DME, therapy type, CMT technique, or other.  What detail is necessary when the patient suffers an exacerbation within an existing plan?  We break down the Plan, part by part, to show how to fit the additional information into the current Assessment and Plan, including functional goals.

We encourage you to print these examples and place them in a plastic sheet for your quick, easy, and continued reference on documenting a change in plan. These are not cut and paste into your notes tools, but rather excellent examples for what type of information should be in the P of SOAP in a patient’s record.

The Anatomy of a Routine Office Visit Plan

The Anatomy of Subsequent ROV Note- Additional Exercises


Appropriate Contents of Routine Office Visit (ROV) Plan Section, Part 2

Parts of the Plan Continued

The Plan section of an ROV note is usually the quickest and easiest to complete; it’s also the most important element for compliance because it determines the coding needed to ensure proper billing. Use this guide to make sure all required elements are included. The following ROV PLAN overview is a table with the remainder of the 7 different Plan elements and their rationale. This is not an exhaustive list, but a guide to help you identify any holes in your documentation that may need to be filled or resolved.

Coordination of Care

Includes Rationale
Referrals to other providers for co-management, second opinion, evaluation, and treatment
  • Referral to a Chiropractic specialist [Chiropractic Internist (DABCI), Chiropractic Neurologist (DACNB), Chiropractic Nutritionist (DCBCN), Chiropractic Pediatrics (DABCP), Chiropractic Rehab Specialist (DACRB) or others]. For a full list, click on American Board of Chiropractic Specialties (acatoday.org)
  • Referral to Allopathic provider or specialist (Orthopedist, Neurologist, Rheumatologist, Surgeon, Endocrinologist, PCP, Psychiatrist, or others).

Changes to Plan

Includes Rationale
Therapy performed, frequency, duration, etc. Document the execution of the service(s). Examples include:

  • Change in Primary treatment (Chiropractic Technique addition, subtraction, frequency)
  • Supportive therapy stopped, added, or parameters modified
  • Use your discretion to determine whether a whole new treatment plan is needed (this depends on the amount of change needed or implemented).

Changes to Home Care

Includes Rationale
Ergonomics, exercises, or home therapy the patient is performing Examples:

  • Stop home cryotherapy.
  • Heat therapy 10 minutes BID to the neck for 5 days.
  • Supine sleeping, pillow under knees, patient in semi-fowler’s position (semi-elevated).
  • Home EMS unit frequency use to decrease to supportive use: ongoing 1 time per week, 15 minutes to neck and low back.

Response to Care

Includes Rationale
Did the patient encounter an increase in pain or did the care cause anything new?  If so, what you or the patient will do as a result. Patients generally respond well to chiropractic care. They may stand up after a treatment and say, “That feels great! The pressure in my neck and head has decreased!” However, occasionally, they may respond poorly and deteriorate through the plan. Other times, patients may experience soreness following treatment, but it can be addressed immediately. Communicate this in the plan notes. It might look like,

  • “Patient tolerated treatment well, no untoward effects noted”
  • “Treatment rendered without incident and patient is responding as expected”.
  • Some providers document the “plan” for the next visit, e.g.
    • “Continue with treatment plan as scheduled”

Appropriate Contents of Routine Office Visit (ROV) Plan Section, Part 1

ROV Plan Overview

Routine office visit documentation can be more succinct and direct than that of an initial visit for an episode of care. Examples of this are found in the plan section and the full treatment plan in the corresponding section of an initial visit. At the beginning of an episode of care, the provider lays out the plan for the full episode while the plan section of a routine office visit simply outlines what was completed that day and the services rendered to select the appropriate codes.

Parts of the Plan

The Plan section of an ROV note is usually the quickest and easiest to complete; it’s also the most important element for compliance because it determines the coding needed to ensure proper billing. Use this guide to ensure all required elements are included. The following ROV PLAN overview is a table with the 7 different Plan elements and their rationale. We have broken the list up into 2 pages, for ease of its’ digestion. This is not an exhaustive list, but a guide to help you identify any holes in your documentation that may need to be filled or resolved.

ROV PLAN Overview

Treatment
Includes Rationale
Primary: CMT/Technique

    • 1o Subluxations
    • 2o Incidental Subluxations
Primary Treatment:  Usually Chiropractic Manipulative Treatment (CMT) (98940-98943). The spinal regions that have been prescribed treatment are noted here. Indicate the specific segments adjusted. Best practice is to identify the medically necessary spinal segments separately from the compensatory, clinically appropriate spinal segments that were adjusted. This makes it easier to count spinal regions and apply correct CMT billing codes.
Secondary or Supportive Therapy:

    • Passive (attended/unattended)
    • Active therapies
    • Total therapy time
Supportive Therapies and Procedures: If ancillary services are rendered (e.g., modalities and procedures), record each according to best practices; documentation should include time spent, location, and intensity. If multiple timed codes are performed, include total time in the documentation. For therapeutic procedures, documentation may need to include the number of reps for exercises, or the muscle groups involved if providing muscular therapy. Always include who performed the service if other than the doctor. The services should follow the detail outlined in the treatment plan, simply list the service and details. Coding comes from the documentation so the appropriate code should be clear and based on the daily plan documentation.
DME Rx
Includes Rationale
Orthotics, heel lifts,
EMS units, etc.
Durable Good Dispensed: If any supplies or durable goods are dispensed (e.g., a pillow, a belt, prescribed orthotics, etc.) add the details to the plan section. List the item dispensed; include all orthotics (e.g., ankle braces, pedal arch supports, heel lifts, low back belt supports, shoulder braces, wrist braces, TMJ Splints, etc.), EMS or TENS units, Vaso pneumatic cryotherapy packs, etc.
Counseling
Includes Rationale
Diagnostic test results; prognosis, risk & benefits; instructions; compliance; risk factor reduction; patient and family education “Counseling” occurs when you discuss the following with a patient or their family member:

  • Diagnostic results (Radiology: Xray/MRI/CT/ Dexa Scan/US, blood labs, NCV, Needle EMG
  • Prognosis
  • Risks and benefits of the treatment options (conservative care options, more invasive options such as injections, surgical consults, or surgery). Be sure to know and communicate to the patient the threshold they need to reach to get to a referral for the more invasive options).
  • Instructions for treatment and/or follow up
  • Importance of compliance with chosen management option
  • Risk factor reduction (examples include):
    • Problems related to obesity, HBP, elevated cholesterol and/or Cardiac CRP; tobacco use and abuse, alcohol abuse, illicit drug use and abuse, other behaviors related to addiction.
    • Prescribed dietary changes, injury prevention practices.

Patient and family education (we may need to teach a spouse how to help or care for the patient, to help get them up and down from a chair or the bathroom, for example).