Corporate Memberships

If a Locum Tenens (substitute) doctor of chiropractic is utilized, claims reporting services provided by the Locum Tenens provider may be submitted under the physician’s name that has contracted with the Locum Tenens provider, for all covered services provided, if all of the following requirements are met: 

• The substitute chiropractor is either in practice for himself/herself, part of another group practice or works solely as a locum tenens or “substitute” provider. In other words, the “substitute” chiropractor cannot be an employee of the regular contracting doctor of chiropractic nor have either a partnership or associate relationship with the “regular” contracting doctor. 

• The regular doctor is unavailable to provide the services on the dates that the “substitute” physician is used (i.e. out of the office). 

• The patient(s) has arranged, or seeks to receive, services from the regular physician. 

• The substitute doctor does not provide the services over a continuous period of time, i.e., longer than 60 days. 
• The healthcare record properly reflects the name of the provider that rendered each service 
• The “regular” doctor must maintain thorough and accurate records indicating the name and NPI number of the “substitute” physician, the dates the “substitute” physician provided services, and the names of all patients who received services by the “substitute” physician.  This information must be readily available to appropriate authorities and/or contracted insurers. 

Considerations 

So long as the locum tenens doctor is adequately trained, properly credentialed and carries the requisite malpractice insurance, the regular doctor should feel comfortable in employing a locum tenens.  

If the regular doctor wants to investigate the history of a locum tenens doctor, the regular doctor may access the state medical practitioner database for a listing of verified schooling, training and malpractice history at the national health-care practitioner database. 

 Tax Rules 

 Locum tenens doctors are considered to be self-employed or independent contractors. This means that no taxes will be deducted from the contracting doctor’s paycheck while working as a locum tenens doctor. A locum tenens doctor must file a tax return every year and report any earnings made while working in this capacity. 

 Medicare Rules 

Medicare has a specific set of rules regarding the billing of services provided by a locum tenens doctor. These rules require that the regular doctor must be unavailable to provide services due to illness, pregnancy or vacation; the locum tenens must be paid using a per diem method of payment; and the regular doctor or any billing provider cannot bill for the use of a locum tenens doctor for longer than 60 days. Medicare requires that all bills processed during the time a locum tenens physician is contracted clearly state that a substitute doctor provided the services listed on the bill. 

 Proper Claims Submittal: 

A substituting doctor is really just a proxy and functions as a “stand in” for the regular doctor and, as if he/she were present. For most payers, the substitute doctor does not need to be credentialed with insurers, but they must possess an unencumbered license in the same specialty. 

 Locum tenens doctors must bill for their services under the regular doctor's provider number. For this reason, the regular doctor must not be practicing chiropractic elsewhere or billing under his own provider number during this time.  

 The rules regarding the use of a locum tenens doctor state that this type of doctor must not be employed on a temporary basis during a busy season or during a catastrophic event if the regular doctor is working at the time. A locum tenens doctor is allowed to cover for only one doctor at a time and cannot provide services for multiple providers in the practice. 

 If, later, the locum tenens doctor is hired on, then Medicare (and presumably most private plans) would require the new doctor to become enrolled before submitting claims. Temporary locum tenens doctors may not be used indefinitely; CMS limits locum tenens to 60 days, and most other payers probably have similar guidelines. 

 If the locum tenens is hired from the outside, they should be paid a per diem or on a fee-for-time basis as an independent contractor and the -Q6 modifier would apply. Should the locum tenens doctor be offered a permanent position at the practice (under the same tax ID), this arrangement may constitute a reciprocal billing arrangement; thus the -Q5 modifier would apply. 

To summarize billing: 

Use modifier -Q5 or -Q6 in box 23d of the CMS 1500 form for each line item in the claim. Append the modifier for each line-item service. Enter the regular physician's national provider identifier (NPI) in box 24J of the CMS 1500 form.  

Add the NPI and name of the locum tenens doctor or reciprocal doctor (employed) in the notes line of the CMS 1500 form. This is not mandatory, but it may be helpful. 

Track the locum's NPI, their services and the calendar dates the locum provided services in case a carrier requests this information. Note that in either case, the payment goes to the regular physician.  

Note: Locum tenens is Latin for "to hold the place of" or more plainly, a "fill-in." 

 
Exerpted: 
Medicare Administration Portal 
Vanderbilt University: General Counsel Note (PDF) 
Locum Tenens: 2010 Tax Tips For 1099 Workers-Physician Resources 

Click Here for a template letter for recoupment

The Importance of SOAP Notes 

The importance of having complete documentation within your SOAP notes can’t be overstated. For instance, they: 

• Can be used to defend yourself against a malpractice suit. 

• Can help prove that the plaintiff doesn’t have a case. 
• Help keep you compliant, and in case of an audit, will prove you followed proper procedures. 
• Justify your charges in a third-party payer audit. 
• Are geared toward quality rather than quantity. 
• Enable healthcare providers to easily understand patient records. 

• Help chiropractors easily evaluate a patient’s progress over time. 
• Provide the specificity that Medicare requires. 
• Help chiropractors determine how to address a patient’s complaint by way of diagnosis and treatment. 
• Should include essential details, such as the exact type of pain and location. 

The Four Main Sections 

As previously mentioned, SOAP notes are comprised of four main sections: Subjective, Objective, Assessment and Plan. Here is the specific information you will need to include within each of these sections. 

1. Subjective
   This section should include whatever a chiropractic patient tells you about their complaint, as well as patient history and the review of intake forms. It’s subjective, because it conveys the patient’s experience of their condition, and typically includes things like neck pain, back pain, or other neuromuscular issues. Other areas to consider when describing a pain history for a new patient/complaint are:

• Mechanism of Injury. How the symptoms started. If the patient denies trauma, they should be questioned as to new activities and repetitive activities (work and home). 
• Onset. Include the actual date of injury as day/month/year, not “last Tuesday.” If the patient cannot give a specific, then “insidious onset” should be recorded with an approximate time of initiation of symptoms such as days/weeks/months/years ago. 
• Palliative/Provocative. What makes it better (palliative), and what makes it worse (provocative)? This might be things like icing, heat, bending, sleeping, moving in particular ways, etc. 
• Quality. Include patient’s description of pain. For example: achey, crampy, nagging, throbbing, etc. 
• Radiation or Referral. Radiating, or if not, “patient denies radiation or referral of symptoms,” or “symptoms remain local.” 

• Severity. Severity of sx’s “0-4” scale “0-10” scale; pain diagram; visual analogue 
• Scale Temporal Factors. Examples: 
• Is chief complaint worse in the morning or evening? 
• Is it constant or intermittent? 
• Is it worse before or after specific activities? 

• Is getting worse since onset? 
• Associated with mealtimes, worse seasonally, or associated with menstrual cycle? 
• Unrelated symptoms. Include associated symptoms, e.g. headaches or any other “unrelated” symptoms. 

The first subjective note for a patient is generally much longer, as it contains the history elements. Subsequent subjective notes on follow-up visits should include any changes in symptoms or new symptoms, the current level of pain, how the pain has changed since the last patient visit, as well as an account of how the problem affects a patient’s daily activities and any functional improvements. 

2. Objective
   The Objective part of SOAP includes the chiropractor’s measurable findings and data of the patient, including:

• Neurological tests 
• Orthopedic tests 
• Inspections of area of chief complaint, posture, gait, habitus, etc. 

• Palpation of soft tissues, subluxation/intersegmental dysfunction findings 
• Imaging studies 
• Outcomes assessments scores 

3. Assessment
   The Assessment takes into account what the doctor learns from the patient’s information and the examination performed. It includes the diagnosis and prognosis, and may also involve a differential diagnosis. When the diagnosis is unclear, the doctor should include possible diagnoses listed in order of most to least probable. This component includes a chiropractor’s assessment of the patient’s progress.

Diagnosis. This is a conclusion as to what the patient’s condition is, as gleaned from reviewing both subjective and objective data. The patient’s response to treatment (current day and overall) can be stated here as well. In regards to diagnosis, a change in severity or stage should also be noted here. For example, a change from acute sprain/strain to sub-acute sprain/strain. 

Prognosis. Note impediments to recovery, ADL limitations or changes, and short- and long-term clinical/patient goals. Important note: Medicare requires the primary diagnosis be the intersegmental dysfunction/subluxation diagnosis code (739.X) followed by a secondary code from a list of diagnoses approved by Medicare for chiropractors to treat. 

4. Plan
   The Plan should communicate what the chiropractor will do to address and treat the patient’s condition. This management plan can include things like:

• Lab work ordered 
• Therapeutic treatment and exercises 
• Expected duration and frequency of care 
• Referrals needed 

• Lifestyle modifications 
• Nutritional advice 
• Timeline for implementation 
• Modalities 
• Types of STM, CMT, modifications to ADLs 

The chiropractor should note any adjustments or other services provided during each patient visit. 

Are Your SOAP Notes Thorough? 

There’s a good way to assess whether or not your SOAP notes are thorough. Ask yourself this question: if another chiropractor had to take over and continue treatment for your patient tomorrow, would they be able to do so quickly and easily just from reading the SOAP notes? If they are concise, clear and intelligible to a third party, the answer is yes! 

*This is not legal advice, only some direction. The ISCA does not give legal advice.  Please contact your attorney and malpractice for more specifc information. *

Here is a checklist of things to consider when planning on closing your medical practice:

• Notify your staff, patients, professional associations, the Drug Enforcement Agency (DEA), Health Insurance companies, hospitals, other physicians, your suppliers and utility companies that you will be closing your practice. It is generally considered best to give 60 to 90 days notice of closing to invested parties.
• Begin referring patients to a new physician and stop accepting new patients or appointments.
• Process your Accounts Receivable to collect any monies owed to you. It may be wise to consider hiring a collection agency to reconcile these past due accounts.
• Review insurance policies and update or cancel policies where appropriate. This includes liability, health, life, disability, workers compensation, etc.
• Purchase tail coverage extended liability insurance, which will protect you from claims reported after your liability coverage expires.
• Contact the U.S. Postal Service to arrange mail forwarding after your closing date.
• Set up a phone line or answering service to direct calls, or prepare a message for office phone calls after your closing date.
• Plan to sell or dispose of your office equipment.
• If you rent your building, give your property owner the required notice that you will be vacating the premises.

If you are selling your practice:

If you’re selling your practice, including patient goodwill and records, it’s also important to review the patient records with the purchasing doctor—case by case. Before granting access to patient records, you may need a Business Associate Agreement or other document to ensure compliance with HIPAA and other privacy laws or regulations. Many patients will stay with a new doctor since he or she will already be familiar with their records. Both you and the new doctor should include a note in each patient's file to verify that the review took place. This is a beneficial step if a malpractice claim arises later.

If patients are being encouraged to stay with the purchaser, there should be an overlap in the time the selling and buying doctors are in the office, though this length of time will vary by practice. Most buyers are interested in retaining as many of the seller's patients as possible after the conveyance. For this reason, your efforts to retain patients may affect the sale price and should be spelled out in the terms of the transition.

Medpro's guide to closing can be found Here 

Sample Letter for patients can be found Here

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NCMIC has a program with information on startinga practice.  You can click here to find that information.