Psychology, Gynecology and Obstetrics, Pediatrics, Jurisprudence and Ethics

Some of the most consequential decisions in a chiropractic office have nothing to do with the spine: noticing that a patient with chronic pain is thinking about suicide, that a "low back ache" in a young woman is ectopic pregnancy, that a bruised toddler's story does not fit, or that a consent form was signed without a real conversation. This chapter covers psychology, gynecology, obstetrics, pediatrics and the legal and ethical frame of practice. Part II tests whether you can recognize these patients, adapt care, refer appropriately and act within the law.

Section 1Psychology

Theories of behavior

Explaining why patients act as they do (seek care late, skip home exercise, fear movement) draws on several schools.

Defense mechanisms appear on the board as vignettes. Denial is refusing to accept a reality ("the lump is nothing"); projection attributes one's own feelings to others; displacement redirects emotion to a safer target (angry at the boss, yells at the receptionist); regression returns to childlike behavior under stress; sublimation channels an unacceptable impulse into a socially valued activity; somatization expresses distress as bodily symptoms.

The biopsychosocial model and chronic pain

The biopsychosocial model holds that illness and pain reflect interacting biological (tissue, nervous system), psychological (beliefs, mood, coping) and social (work, family, culture, litigation) factors. It contrasts with a purely biomedical model in which pain equals tissue damage. Chronic pain, usually defined as pain lasting more than 3 months, often persists after tissues heal because of central sensitization (amplified processing in the dorsal horn and brain) and learned responses.

The fear avoidance model describes a loop: a pain episode is interpreted catastrophically, which produces pain related fear, which leads to avoidance and hypervigilance, which causes deconditioning, disability and depression, which in turn heighten pain. Patients who interpret pain as non threatening confront activity and recover. Psychosocial risk factors for chronicity are summarized as yellow flags.

Screening tools include the STarT Back tool (stratifies low back pain into low, medium and high risk of poor outcome, matching treatment intensity), the Fear Avoidance Beliefs Questionnaire, the Pain Catastrophizing Scale, and the Orebro questionnaire. Effective responses are reassurance that is accurate and specific, pain neuroscience education, graded activity or graded exposure, goal setting, and referral for cognitive behavioral therapy when yellow flags dominate. Avoid threatening language ("your disc is out").

Mental and emotional disorders seen in practice

Waddell nonorganic signs (superficial or nonanatomic tenderness, simulation tests such as axial loading and simulated rotation, distraction tests such as a seated versus supine straight leg raise discrepancy, regional nonanatomic weakness or sensory change, and overreaction) suggest a psychological contribution to low back pain when three or more of five categories are positive. They do not prove malingering; they flag patients who may need a biopsychosocial approach.

Screening for depression, anxiety and suicide risk

• PHQ 2: two questions on low mood and anhedonia over the past 2 weeks; a positive screen leads to the PHQ 9, scored 0 to 27 (5, 10, 15 and 20 mark mild, moderate, moderately severe and severe depression). Item 9 asks about thoughts of self harm and must always be followed up.
• GAD 7: seven anxiety items scored 0 to 21 (5, 10 and 15 mark mild, moderate and severe).
• CAGE for alcohol: felt the need to Cut down, Annoyed by criticism, Guilty, Eye opener; two or more yes answers is significant.

Asking directly about suicide does not increase risk. Risk factors include prior attempts (the strongest predictor), depression and other mental illness, substance misuse, chronic pain and disability, recent loss, social isolation, access to firearms, male sex (men complete suicide more often; women attempt more often), older age, and hopelessness. Screen with direct questions (for example from the Columbia scale): wishes to be dead, thoughts of killing oneself, a method, intent, a plan, and recent preparatory behavior. Passive thoughts without a plan call for same day communication with the patient's physician or a mental health professional and crisis resources (in the United States, the 988 Suicide and Crisis Lifeline). Active ideation with intent or a plan is an emergency: do not leave the patient alone, remove means if safely possible, and call emergency services.

Section 2Gynecology

Gynecological and breast examination concepts

Chiropractors take a gynecological history from every woman of reproductive age with low back, pelvic or abdominal pain: last menstrual period, cycle regularity, pain with menses or intercourse, abnormal bleeding or discharge, contraception, pregnancies, and the date and result of the last cervical screening and mammogram. Internal pelvic examination requires appropriate scope, explicit consent and a chaperone; the bimanual examination palpates uterine size, position and tenderness and the adnexa, and cervical motion tenderness ("chandelier sign") suggests pelvic inflammatory disease.

The clinical breast examination begins with inspection in several arm positions (at sides, overhead, hands pressed on hips) for asymmetry, skin dimpling or retraction, peau d'orange, nipple inversion or discharge, then supine palpation with the pads of three fingers at three pressures in a vertical strip pattern from clavicle to inframammary fold and sternum to midaxillary line, including the axillary tail and regional nodes. Most breast cancers arise in the upper outer quadrant, where most glandular tissue lies.

Menstrual disorders

The menstrual cycle averages 28 days (normal 21 to 35 in adults) with bleeding for up to 7 days. In the follicular phase, FSH stimulates follicle growth and estrogen builds the endometrium; an LH surge triggers ovulation about day 14; in the luteal phase (fixed at about 14 days) the corpus luteum secretes progesterone, which makes the endometrium secretory and raises basal body temperature. Without pregnancy the corpus luteum regresses and progesterone falls, triggering menstruation.

The female athlete triad (now framed within relative energy deficiency in sport) links low energy availability, menstrual dysfunction and low bone mineral density, and it presents to chiropractors as stress fractures of the tibia, metatarsals, femoral neck and pars interarticularis. Any postmenopausal bleeding is endometrial cancer until proven otherwise.

Endometriosis and pelvic inflammatory disease

Endometriosis is functional endometrial tissue outside the uterus, most often on the ovaries (endometriomas or "chocolate cysts"), uterosacral ligaments, pouch of Douglas and pelvic peritoneum. The leading theory is retrograde menstruation. Its classic features are cyclic pelvic pain, secondary dysmenorrhea, deep dyspareunia, dyschezia (painful defecation) and infertility. Uterosacral nodularity may be felt on exam. It commonly causes cyclic low back and sacral pain, and rare implants on the sciatic nerve cause catamenial (cyclic) sciatica. Diagnosis is definitive at laparoscopy. Adenomyosis is endometrial tissue within the myometrium, producing an enlarged, boggy, tender uterus with heavy painful periods in women in their 40s.

Pelvic inflammatory disease is ascending infection of the upper genital tract (endometritis, salpingitis, tubo ovarian abscess), most often from Chlamydia trachomatis and Neisseria gonorrhoeae. Findings are lower abdominal pain, cervical motion tenderness, uterine or adnexal tenderness, fever and cervical discharge. Complications include infertility, ectopic pregnancy from tubal scarring, chronic pelvic pain and Fitz Hugh Curtis perihepatitis.

Gynecological cancers

Breast disease

A breast lump in a young woman is most often benign; risk of cancer rises with age. Fibroadenoma is a firm, rubbery, mobile, painless, well circumscribed mass in women under 30. Fibrocystic change produces bilateral, tender, lumpy breasts that fluctuate with the cycle and are worst premenstrually. Intraductal papilloma is the most common cause of bloody nipple discharge in younger women. Mastitis is a painful, red, warm breast during lactation, usually Staphylococcus aureus; an abscess may form. Fat necrosis after trauma can mimic cancer.

Breast cancer is the most common cancer in women (excluding skin) and a leading cause of cancer death. Risk factors include female sex, age, BRCA1 and BRCA2 mutations, family history in a first degree relative, prior breast cancer or atypical hyperplasia, prolonged estrogen exposure (early menarche, late menopause, nulliparity, first birth after 30, combined hormone therapy), obesity after menopause, alcohol, chest irradiation and dense breasts. Concerning features are a hard, irregular, fixed, painless mass; skin dimpling or peau d'orange (lymphatic obstruction); new nipple retraction; bloody unilateral discharge; eczema of the nipple (Paget disease of the breast); and axillary nodes. Invasive ductal carcinoma is the most common type. Screening mammography is broadly recommended every 1 to 2 years for women from their 40s, with earlier and more intensive screening (including MRI) for high risk women.

Section 3Obstetrics

Pregnancy physiology and the spine

Pregnancy lasts about 40 weeks from the first day of the last menstrual period (Naegele rule: add 1 year, subtract 3 months, add 7 days). It is divided into trimesters of roughly 13 weeks. Human chorionic gonadotropin (hCG) from the trophoblast maintains the corpus luteum, doubles about every 48 hours early on, peaks near 10 weeks and is the basis of pregnancy tests; the placenta takes over progesterone production by about 10 to 12 weeks.

More than half of pregnant women report low back or pelvic girdle pain. Lumbar pain is felt above the sacrum and worsens with sustained postures; pelvic girdle pain is felt between the posterior iliac crest and gluteal fold or at the symphysis, often with pain on walking, turning in bed and climbing stairs. Provocation tests include the posterior pelvic pain provocation test (P4 or thigh thrust: supine, hip flexed to 90 degrees, axial pressure along the femur; positive with deep gluteal pain on the tested side), the active straight leg raise (difficulty lifting the leg, eased by pelvic compression), and palpation of the long dorsal sacroiliac ligament and symphysis. Diastasis recti is separation of the rectus abdominis along the linea alba, common late in pregnancy and postpartum.

Prenatal care

Prenatal care includes dating ultrasound, blood type and Rh status (Rh negative mothers receive anti D immune globulin at about 28 weeks and after delivery of an Rh positive infant to prevent hemolytic disease of the newborn), screening for anemia, infections (HIV, syphilis, hepatitis B, rubella immunity), aneuploidy and neural tube defects (alpha fetoprotein, raised in open neural tube defects and lowered in Down syndrome), gestational diabetes (24 to 28 weeks) and group B streptococcus (36 to 38 weeks). Folic acid 400 µg daily, started before conception, reduces neural tube defects; higher doses are used after a previous affected pregnancy. Teratogens to know include alcohol (fetal alcohol syndrome), isotretinoin and high dose vitamin A, warfarin, valproate and other anticonvulsants, ACE inhibitors, tetracyclines, lithium and smoking. Fundal height in centimeters approximates gestational weeks after 20 weeks, when the fundus reaches the umbilicus.

Labor, delivery and postpartum

The usual presentation is vertex (head first, occiput anterior). Breech presentation occurs in about 3 to 4 percent of term pregnancies; obstetric options include external cephalic version and cesarean delivery. The postpartum (puerperium) lasts about 6 weeks as the uterus involutes and lochia passes. Problems to recognize include postpartum hemorrhage, endometritis, mastitis, venous thromboembolism, and mood disorders: postpartum blues (very common, mild, resolves within 2 weeks), postpartum depression (persists beyond 2 weeks, impairs function; screen with the Edinburgh scale), and postpartum psychosis (rare, onset within days to weeks, hallucinations or delusions; a psychiatric emergency with risk to mother and infant). Ligament laxity persists for months, especially with breastfeeding, and pelvic floor dysfunction and diastasis recti respond to rehabilitation.

Obstetric complications

Chiropractic care in pregnancy

Spinal manipulation and exercise are commonly used for pregnancy related low back and pelvic girdle pain, and the available studies suggest benefit with a low rate of serious adverse events, although the trials are small and the evidence is of limited quality. Care is adapted to the changing body:

• Positioning: use a pregnancy table or pillows with an abdominal cut out for prone work, or side lying positions; avoid prolonged supine positioning after about 20 weeks (supine hypotension); a wedge under the right hip tilts the uterus to the left.
• Force and technique: lower force techniques and instrument methods are commonly preferred; avoid direct pressure on the abdomen; consider ligament laxity when choosing amplitude, especially at the sacroiliac joints and symphysis. Pelvic belts, side lying sacroiliac adjustments, drop table work and soft tissue methods are common.
• Exercise and advice: pelvic floor and transversus abdominis training, walking, swimming, sleeping on the side with a pillow between the knees, and avoiding asymmetric loading (one legged standing, stairs two at a time) for pelvic girdle pain.
• Coordination: communicate with the obstetric provider, and know that prenatal care is managed by that provider.

The Webster technique is a chiropractic analysis and adjustment of the sacrum and pelvis intended to reduce sacral subluxation and associated soft tissue tension (including the round ligament) to improve pelvic biomechanics in pregnancy. It is widely taught and generally regarded as safe, but evidence that it changes fetal position is limited, and it should not be represented as a method to turn a breech baby. Breech presentation remains an obstetric matter.

Warning signs that call for stopping care and immediate obstetric referral include vaginal bleeding, leaking amniotic fluid, regular contractions or rhythmic back pain before 37 weeks, decreased fetal movement, severe headache or visual disturbance, sudden swelling of the face and hands, severe abdominal pain, calf swelling, chest pain or dyspnea. Relative contraindications to manual therapy in pregnancy include placenta previa, placental abruption, ectopic pregnancy, preeclampsia, and threatened miscarriage.

Section 4Pediatrics

Newborn assessment

The APGAR score is recorded at 1 and 5 minutes after birth (and every 5 minutes after that if the score is low). Each of five signs scores 0, 1 or 2 for a total of 0 to 10: 7 to 10 is reassuring, 4 to 6 moderately abnormal, and 0 to 3 low. The 5 minute score better reflects response to resuscitation.

The newborn examination checks the fontanelles (the posterior closes by about 2 months, the anterior by about 18 months; a bulging fontanelle suggests raised intracranial pressure and a sunken one dehydration), the spine for dimples, hair tufts or masses that suggest spinal dysraphism, the clavicles for birth fracture (the most commonly fractured bone at birth), the hips, and the brachial plexus. Erb palsy (C5 to C6 upper trunk, "waiter's tip": arm adducted and internally rotated, elbow extended, forearm pronated) follows lateral neck traction in shoulder dystocia; Klumpke palsy (C8 to T1 lower trunk, claw hand, possible Horner syndrome) follows traction on an abducted arm. Physiologic jaundice appears after 24 hours; jaundice in the first 24 hours is pathologic.

Growth and development milestones

Birth weight doubles by about 4 to 5 months and triples by 12 months; length increases by 50 percent in the first year. Head circumference is tracked to 2 to 3 years (rapid growth suggests hydrocephalus; a small head, microcephaly). Development proceeds cephalocaudal (head control before sitting before walking) and proximal to distal. Persistence of primitive reflexes or loss of milestones (regression) is always a red flag.

Congenital disorders

• Developmental dysplasia of the hip: risk factors are female sex, breech position, family history and firstborn (and tight swaddling). The Ortolani test (abduct the flexed hip while lifting the greater trochanter) produces a clunk as a dislocated hip reduces; the Barlow test (adduct the flexed hip with posterior pressure) dislocates an unstable hip. After about 3 months these become unreliable, and signs are limited abduction, a positive Galeazzi (Allis) sign (knee height unequal with hips and knees flexed), asymmetric thigh folds and, later, a Trendelenburg or waddling gait. Ultrasound is used before about 4 to 6 months, radiographs after (Hilgenreiner and Perkin lines, Shenton line, acetabular index).
• Spina bifida: neural tube closure defect, usually lumbosacral. Occulta (bony defect only, perhaps a dimple or hair tuft) is common and usually benign; meningocele contains meninges; myelomeningocele contains neural tissue and causes paralysis, bladder dysfunction and hydrocephalus (Chiari II). Raised maternal alpha fetoprotein; prevented by folic acid.
• Congenital muscular torticollis: fibrosis of the sternocleidomastoid; head tilts toward and chin rotates away from the tight muscle; a palpable mass in the first weeks; plagiocephaly; treated with stretching and positioning.
• Clubfoot (talipes equinovarus): fixed plantarflexion, inversion and adduction; serial casting (Ponseti).
• Down syndrome (trisomy 21): hypotonia, flat facial profile, single palmar crease, cardiac defects, and atlantoaxial instability from ligament laxity, a contraindication to upper cervical thrusts without screening.
• Cerebral palsy: nonprogressive motor disorder from early brain injury; spastic type most common; hip subluxation and scoliosis are frequent.
• Duchenne muscular dystrophy: X linked dystrophin deficiency in boys; proximal weakness by age 3 to 5, Gowers sign (uses hands to climb up the legs to stand), calf pseudohypertrophy, very high CK.
• Osteogenesis imperfecta: type I collagen defect; fractures with minimal trauma, blue sclerae, hearing loss; a mimic of abuse.

Childhood infectious diseases

Musculoskeletal infections and inflammatory conditions in children include septic arthritis (the hip is a surgical emergency; the child refuses to bear weight, has fever and holds the hip flexed, abducted and externally rotated), transient synovitis (the most common cause of acute hip pain from 3 to 10 years, after a viral illness, mild or no fever), acute hematogenous osteomyelitis (metaphysis of long bones, Staphylococcus aureus), and juvenile idiopathic arthritis.

Injuries and abuse recognition

Common pediatric orthopedic conditions include Salter Harris growth plate fractures (type II, through the physis and metaphysis, is most common; types III to V carry growth disturbance risk), nursemaid's elbow (radial head subluxation after a pull on the arm in a toddler), slipped capital femoral epiphysis (obese adolescent, often a boy, with hip or knee pain and loss of internal rotation; posteromedial slip seen on the frog leg lateral view), Legg Calve Perthes disease (avascular necrosis of the femoral head, age 4 to 8, painless limp), Osgood Schlatter disease (tibial tubercle apophysitis), Sever disease (calcaneal apophysitis) and spondylolysis in young athletes who hyperextend (pars fracture at L5, "Scottie dog collar" on oblique films).

Child abuse must be recognized and reported. Suspect it when the history is vague, inconsistent, changes, or does not fit the injury or developmental stage, when care was delayed, or when injuries are at different stages of healing.

Mimics include osteogenesis imperfecta, bleeding disorders, Mongolian spots (congenital dermal melanocytosis over the sacrum and buttocks, often mistaken for bruises), cultural practices such as coining or cupping, and rickets. Chiropractors are mandated reporters in all US states: a reasonable suspicion of abuse or neglect requires a report to child protective services or law enforcement. Proof is not required, good faith reports are immune, and failing to report is an offense. Document objective findings and the caregiver's exact words.

Scoliosis

Scoliosis is a lateral curvature of the spine of 10 degrees or more measured by the Cobb method, with vertebral rotation. Idiopathic scoliosis accounts for about 80 percent and is classified by onset as infantile (under 3), juvenile (3 to 10) or adolescent (10 to skeletal maturity, the most common). Adolescent idiopathic scoliosis is typically a right thoracic curve, and large curves are far more common in girls. Other types are congenital (hemivertebra, failure of segmentation), neuromuscular (cerebral palsy, muscular dystrophy, spinal muscular atrophy) and syndromic (Marfan, neurofibromatosis). A left thoracic curve, rapid progression, pain, neurologic signs, or an early onset raises concern for an underlying cause (syrinx, tumor, tethered cord) and calls for MRI. Painful scoliosis with a stiff curve suggests osteoid osteoma on the concave side (night pain relieved by aspirin or NSAIDs).

Screening uses the Adams forward bend test: the child bends forward with knees straight and arms hanging; a rib hump on the convex side (posterior rotation of the ribs) is positive. A scoliometer reading of 7 degrees or more (some programs use 5) prompts a radiograph. Risk of progression is greatest with larger curves and greater remaining growth, judged by the Risser sign (ossification of the iliac apophysis, graded 0 to 5, progressing lateral to medial) and by menarche status. Management guidelines commonly used: observation for curves under about 20 to 25 degrees in growing children with re examination every 4 to 6 months; bracing for curves of about 25 to 40 degrees in skeletally immature patients (bracing reduces progression to surgery); and surgical fusion consideration above about 45 to 50 degrees. Scoliosis specific exercise may be used alongside. Evidence that spinal manipulation alone reduces idiopathic curves is lacking.

Learning and emotional disorders, and nutrition

Attention deficit hyperactivity disorder (inattention and/or hyperactivity and impulsivity present before age 12, in two or more settings, for at least 6 months) is treated with behavioral therapy and stimulants. Autism spectrum disorder involves deficits in social communication plus restricted, repetitive behaviors and sensory sensitivities, with signs often evident by 18 to 24 months; screening uses the M CHAT at 18 and 24 months, and early intervention improves outcomes. Specific learning disorders include dyslexia. Chiropractors should not represent spinal care as a treatment for ADHD, autism or learning disorders, because evidence does not support that claim.

Infant nutrition: exclusive breastfeeding for about 6 months, continued with complementary foods to at least 1 year, provides immune protection; breastfed infants need vitamin D supplementation (400 IU daily). Vitamin K is given at birth to prevent hemorrhagic disease of the newborn. Avoid honey before 12 months (infant botulism) and cow's milk as the main drink (iron deficiency). Childhood obesity is assessed by BMI percentile (85th to under 95th overweight, 95th or above obese) and predisposes to slipped capital femoral epiphysis, Blount disease and type 2 diabetes. Deficiencies to recognize include rickets (vitamin D: bowed legs, rachitic rosary, widened, cupped and frayed metaphyses) and iron deficiency anemia.

Section 5Jurisprudence, ethics and basic economics

Malpractice and negligence

Malpractice is professional negligence: failure to provide care that meets the standard of care, meaning what a reasonably careful chiropractor would do in similar circumstances. A plaintiff must prove four elements, often remembered as the 4 D's:

Common claims against chiropractors involve failure to diagnose (fracture, cancer, infection, vascular injury, cauda equina syndrome), failure to refer, disc injury, stroke after cervical manipulation, rib fractures, burns from modalities and inadequate consent. Related legal ideas: res ipsa loquitur ("the thing speaks for itself") lets negligence be inferred when the injury would not ordinarily occur without negligence, such as a burn from a hot pack left too long; respondeat superior makes the employer liable for employees acting within the scope of employment; contributory and comparative negligence reduce or bar recovery when the patient's own conduct contributed; the statute of limitations sets the time to file, often running from discovery of the injury. Battery is touching without consent; abandonment is ending care without reasonable notice and an opportunity to find another provider. The best defense is contemporaneous, signed, dated documentation that is never altered (add a dated late entry instead).

Consent and capacity

Informed consent is a process, not a signature. The patient must receive, in understandable language, the diagnosis, the nature and purpose of the proposed care, its material risks (including rare but serious ones, such as cervical artery dissection and stroke, and common minor ones, such as post treatment soreness), the expected benefits, reasonable alternatives (including no treatment), and the risks of declining. The patient must have capacity, act voluntarily, and be free to withdraw consent at any time. Most courts judge disclosure by the reasonable patient standard (what a reasonable person would want to know), others by the professional standard. Consent can be express (written or oral) or implied (rolling up a sleeve; emergency care of an unconscious person). Document the conversation, the patient's questions and agreement.

• Capacity is a clinical judgment, specific to the decision: the patient can understand the information, appreciate how it applies to them, reason about options and communicate a choice. Competence is a legal determination by a court.
• Minors generally need consent from a parent or legal guardian; exceptions include emergencies, emancipated minors (married, military, self supporting) and specific statutory exceptions. Seek the child's assent as well.
• For adults without capacity, consent comes from a health care power of attorney, guardian, or surrogate under state law, guided by the patient's known wishes.

Confidentiality and HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule protects individually identifiable health information (protected health information, PHI) held by covered entities (providers who bill electronically, health plans, clearinghouses) and their business associates (billing services, IT vendors, who must sign a business associate agreement). The Security Rule requires administrative, physical and technical safeguards for electronic PHI; the Breach Notification Rule requires notifying affected patients and the government after an unsecured breach.

• PHI may be used and disclosed without authorization for treatment, payment and health care operations; most other uses (marketing, disclosures to employers, testimonials) need written authorization.
• The minimum necessary standard limits most disclosures to what is needed (it does not apply to treatment).
• Patients have the right to a notice of privacy practices, to access and obtain copies of their records, to request amendments, and to an accounting of certain disclosures.
• Permitted disclosures without authorization include those required by law: reporting child abuse, certain communicable diseases, threats of serious harm, court orders, and workers' compensation as allowed by state law.

The duty to warn (from the Tarasoff case) permits or requires breaching confidentiality to protect an identifiable person from a serious threat of violence by a patient, as defined by state law.

Boundaries and reporting duties

The doctor patient relationship carries a power imbalance and physical intimacy, so the clinician alone is responsible for maintaining professional boundaries. Sexual contact or a romantic relationship with a current patient is always unethical and is grounds for license discipline and often criminal charges, regardless of apparent consent. Boards typically require termination of the professional relationship (often with a waiting period) before any personal relationship. Boundary crossings (accepting a small gift, treating a friend) are not always harmful but can slide toward boundary violations (exploitation). Good practice includes explaining every examination and procedure before touching, respectful draping, gowns, asking permission, offering a chaperone for sensitive examinations, avoiding sexual humor, and documenting.

The four principles of biomedical ethics frame these decisions: autonomy (respect for the patient's informed choices), beneficence (act for the patient's benefit), nonmaleficence ("first, do no harm") and justice (fair distribution of care and resources). Professional codes add honesty, competence within scope, and avoidance of conflicts of interest.

Billing ethics and practice economics

Accurate coding links a diagnosis (ICD 10 CM codes) to the services performed (CPT codes, such as the chiropractic manipulative treatment codes 98940 for one to two spinal regions, 98941 for three to four, 98942 for five, and 98943 for extraspinal regions), supported by documentation of medical necessity. Fraud and abuse to avoid:

Under Medicare, chiropractic coverage is limited to manual manipulation of the spine to correct a subluxation for active (corrective) treatment, which must be documented (the PART criteria: pain, asymmetry or misalignment, range of motion abnormality, tissue tone changes); maintenance care is not covered, and an Advance Beneficiary Notice informs the patient beforehand that they may be responsible for payment. The False Claims Act imposes penalties for knowingly submitting false claims.

Basic practice economics: gross revenue (charges) differs from collections (money actually received); the collection ratio is collections divided by net charges. Overhead (fixed costs such as rent, salaries and insurance, plus variable costs such as supplies) is commonly 50 to 60 percent of collections in chiropractic practices. Accounts receivable older than 90 days are hard to collect. Patients with insurance have deductibles (paid before coverage begins), copayments (fixed amounts per visit) and coinsurance (a percentage). Professional liability insurance is essential.

Words worth knowing