Case Management

Case management carries more weight on Part III than any domain except diagnosis, because it asks the question every patient eventually poses: what happens now? Knowing the diagnosis is only the start; the board wants to see that you can set measurable goals, choose a sensible frequency and duration of care, recognize when a patient is not responding, refer at the right speed to the right person, and leave a record that would satisfy a reviewer, an insurer or a court. This chapter turns those decisions into a repeatable process and then walks through multi visit cases that test the next best step.

Section 1Treatment plans and prognosis

What a treatment plan must contain

A treatment plan is a written contract between your findings and your actions. It flows directly from the assessment: if the diagnosis is acute mechanical low back pain without radiculopathy, the plan addresses pain control, restoring motion and returning the patient to work, and it predicts how long that should take. Reviewers judge a plan by whether a stranger reading it could tell what you intended to do, why, for how long, and how you would know whether it was working. A complete plan contains:

• Working diagnosis with the primary condition and any secondary or complicating diagnoses (for example, lumbar sprain, segmental dysfunction L4 and L5, and a history of two prior episodes).
• Baseline measures: pain intensity, a validated functional questionnaire, objective findings such as range of motion or a straight leg raise angle, and the patient's own functional limits (cannot sit more than 20 minutes, cannot lift a 15 kg box).
• Goals, both short term (two to four weeks) and long term (by discharge), written so they can be measured.
• Interventions: the techniques, regions, supportive care, exercise and education you will use, with any precautions or modifications.
• Frequency and duration: visits per week and the total trial period before formal re-examination.
• Re-examination date and the outcome measures you will repeat.
• Discharge criteria and the conditions that would prompt referral (for example, any new neurological deficit).
• Home care: activity advice, exercises, ergonomic changes and what to do if symptoms flare.

Goals that can be measured

Goals should be SMART: specific, measurable, achievable, relevant to the patient's life, and time bound. "Decrease pain" is not a goal; "reduce average pain from 7/10 to 3/10 or less and Oswestry score from 46% to below 20% within six weeks, so the patient can return to full duty as a warehouse worker" is. Functional goals are more persuasive than pain goals because pain is volatile and insurers pay for restored function. Tie each goal to an activity the patient cares about (sitting through a school day, lifting a grandchild, driving 90 minutes to work). The Patient Specific Functional Scale (PSFS) formalizes this: the patient names three to five activities they struggle with and rates each from 0 (unable) to 10 (normal).

Phases of care

Care is usually described in phases that overlap rather than switch on a fixed date. Intensity is highest early and tapers as the patient improves, while the balance shifts from passive treatment to active care and self-management.

Frequency and duration

There is no single correct schedule, but the commonly taught evidence informed pattern for an uncomplicated acute spinal episode is a trial of care of about two to four weeks (often 6 to 12 visits) followed by a formal re-examination. Consensus guidelines for chiropractic practice describe a reasonable trial as up to two weeks of care at the intensity you choose; if there is no meaningful response after two trials (roughly four weeks), the plan must change: different technique, added active care, further testing or referral. Most uncomplicated acute low back pain episodes resolve or largely resolve within 6 to 8 weeks; continuing passive care beyond about 12 weeks without documented functional gains is hard to justify. Frequency should be decided by the clinical picture, not by a fixed package sold in advance; prepaid long term plans for acute conditions are viewed critically by boards and payers.

Prognosis and the factors that change it

Prognosis is a prediction of how much recovery to expect and how fast. Start from natural history: about 60 to 70% of people with acute low back pain improve substantially within six weeks and most within 12 weeks, but recurrence within a year is common (often quoted at about half). Acute neck pain behaves similarly, though about half of whiplash patients still report some symptoms a year later. Then adjust for the factors below.

Two tools help put numbers on this. The STarT Back Screening Tool (nine items) stratifies low back pain patients into low, medium and high risk of persistent disability. Low risk patients need advice, reassurance and minimal treatment; medium risk patients benefit from physical treatment such as manipulation and exercise; high risk patients need physical treatment combined with psychologically informed care. The Örebro Musculoskeletal Pain Questionnaire does a similar job and predicts work absence. A third tool predicts who responds to a specific treatment: the lumbar manipulation clinical prediction rule identifies patients likely to improve rapidly with lumbopelvic manipulation when at least four of five criteria are present (symptoms under 16 days, no symptoms distal to the knee, Fear Avoidance Beliefs Questionnaire work subscale under 19, at least one hypomobile lumbar segment, and at least one hip with more than 35 degrees of internal rotation). The original study reported a positive likelihood ratio of about 24 when four or more were present, although later validation has been less striking.

Outcome measures and meaningful change

An outcome measure is useful only if you know how much change matters. The minimal clinically important difference (MCID) is the smallest change the patient would notice as a real improvement; a change smaller than the instrument's measurement error is noise. Commonly taught values are below.

Use at least one pain measure and one region specific functional measure at baseline and at every re-examination. Objective findings such as range of motion, straight leg raise angle, grip strength or a timed functional task supplement but do not replace the questionnaires, because reviewers and the board expect validated patient reported outcomes.

Setting expectations

Patients who understand the expected course do better and are less likely to see normal fluctuation as failure. At the report of findings explain the diagnosis in plain words, the expected time to meaningful improvement, the possibility of brief post treatment soreness, the patient's own role (exercises, activity, sleep, ergonomics), what would trigger a change of plan, and the warning signs that require immediate contact. Hurt does not equal harm is a useful message for most mechanical pain. Avoid language that creates fragility ("your spine is out", "your disc is degenerated") and avoid promising cures or fixed outcomes.

Section 2Case follow up and review

Daily reassessment versus formal re-examination

Every visit includes a brief reassessment: how the patient responded to the last treatment, any new symptoms, and a few targeted findings (pain rating, key range of motion, the tests that were positive at baseline, palpation of the treated segments). This visit to visit check guides the day's treatment and is the first place a deterioration or a new red flag is detected. A formal re-examination is more complete. It repeats the outcome questionnaires, the relevant orthopedic and neurological tests and the objective measures from the initial examination, compares them to baseline and to the written goals, and ends with a documented decision about the plan.

When to re-examine

• At the end of each trial of care, commonly every 2 to 4 weeks, or about every 12 visits or 30 days, whichever comes first.
• When the patient reports a new complaint or a new injury (a new region must have its own history, examination and diagnosis before it is treated).
• When symptoms worsen or change character, or when any new neurological symptom appears.
• Before discharge, before a change to supportive care, and before releasing a patient back to full work duty.
• When a third party requests it (insurer, attorney, employer), or after a long gap in care.

Interpreting change

Compare each repeated measure to its MCID. A patient whose ODI falls from 44% to 30% and whose NPRS falls from 7 to 4 has improved meaningfully on both; one whose ODI falls from 44% to 40% has not, even if she feels "a bit better". Look at function as well as pain: a patient whose pain is unchanged but who has returned to work and doubled her walking tolerance is improving. Patterns of change also matter. Rapid early improvement predicts a good final outcome. Improvement that lasts only a few hours after each visit and then returns to baseline suggests the passive treatment is providing temporary relief without addressing the drivers, so active care or another approach is needed.

The plateau

A plateau is the most common management problem on the exam. The patient is not worse, but has stopped improving or never improved enough. Work through the causes before changing anything:

1. Is the diagnosis right? Re-take the history and repeat the examination. Hip osteoarthritis, sacroiliac joint pain, a visceral source, early inflammatory spondyloarthritis, peripheral entrapment neuropathy or a missed red flag may be masquerading as mechanical spinal pain.
2. Is the treatment right? Consider a different technique (for example, flexion distraction for a disc patient who did not tolerate side posture), adding mobilization, soft tissue work or a directional preference exercise program, and moving from passive to active care.
3. Is the patient doing the plan? Check attendance, home exercise adherence, workstation, sleep, lifting habits and activity level.
4. Are yellow flags blocking recovery? Repeat the STarT Back or FABQ; high scores call for psychologically informed care and, often, referral.
5. Does the patient need something else? Imaging, labs, a medical evaluation, physical therapy, pain management, or a surgical opinion.

If none of these produces progress, the patient has either reached maximum medical improvement or needs care outside your office. Continuing the same treatment indefinitely without measurable benefit is the classic wrong answer.

Maximum medical improvement and supportive care

Maximum medical improvement (MMI) is the point at which further significant recovery is not expected with continued treatment, although symptoms may persist. It is the trigger for impairment rating in personal injury and workers' compensation cases, commonly using the AMA Guides to the Evaluation of Permanent Impairment. MMI does not mean the patient is pain free. Some patients at MMI repeatedly lose ground when care is withdrawn; for them, supportive care at the lowest effective frequency may be justified, provided you document the regression after withdrawal and the response to resumed care. Purely elective maintenance care aimed at prevention or wellness is legitimate but is not medically necessary treatment, and most payers, Medicare among them, do not cover it; when a Medicare patient chooses it, an Advance Beneficiary Notice is signed beforehand.

Missed visits, noncompliance and discharge

Document missed appointments and the reason, and document when you contacted the patient. If a patient stops attending without explanation, a short letter or call noting that care was discontinued, summarizing the status and advising follow up protects both parties. A provider may discharge a noncompliant or abusive patient, but must give reasonable notice, offer help finding another provider and remain available for emergencies during the transition; ending care without notice when the patient still needs treatment can constitute abandonment. Every discharge note records the final outcome measures, the goals met and not met, the home program, and the conditions under which the patient should return.

Section 3Referral and co-management

Why and when to refer

Referral is part of chiropractic care, not a failure of it. A chiropractor refers when the patient has, or may have, a condition outside the scope of chiropractic management; when a condition inside the scope is not responding; when the patient needs a service you do not provide (medication, injection, surgery, psychotherapy, supervised rehabilitation); when a second opinion would help the patient or protect the plan; and when the patient asks. The board tests two separate judgments in every referral item: to whom and how fast. Getting the speciality right but the urgency wrong (sending suspected cauda equina syndrome to a routine neurosurgery appointment) is still the wrong answer.

Matching the problem to the receiving clinician

Handling an emergency in the office

For a true emergency, call emergency medical services, stay with the patient, monitor vital signs and airway, and do not let the patient drive. Do not manipulate. Send a brief written summary with the patient or call it to the receiving department, then document the findings, the time, who was contacted and what was said. For an urgent referral, telephone the receiving clinician or department rather than relying on a letter, confirm that an appointment has been made, and follow up the same day or next morning to confirm the patient was seen.

The referral letter

A useful referral letter is short, specific and asks a question. Busy specialists read the first lines and the question; put the important things there.

1. Patient identifiers: name, date of birth, contact details, and the patient's consent to share records.
2. Reason for referral and urgency: the specific question ("Please evaluate for inflammatory sacroiliitis" or "Please assess for surgical decompression; progressive L5 weakness over 48 hours").
3. Relevant history: onset, course, red flags present or absent, past history, medications.
4. Key examination findings, positive and pertinent negative, with numbers (reflex grades, motor grades, straight leg raise angle).
5. Investigations: imaging and laboratory results with copies attached.
6. Treatment rendered and response, including outcome scores.
7. Your plan: whether you will continue to treat (co-management), modify care, or suspend care pending their opinion.
8. Your contact information and a request for a report back.

Under the federal privacy rule, health information may be shared with another provider for treatment purposes without a separate written authorization, but many offices obtain a signed release as good practice, and state law or the type of information (substance use treatment records, some mental health records) can require more. Share only what the receiving clinician needs.

Co-management

Co-management means two or more clinicians treat the same patient for the same episode with defined roles. Common arrangements: the chiropractor provides manipulation and exercise while the primary physician manages medication and comorbidities; physical therapy provides supervised strengthening while the chiropractor treats joint dysfunction; a pain specialist provides an epidural steroid injection for radicular pain and the chiropractor continues with mechanical and functional care; a psychologist addresses fear avoidance and depression while chiropractic care continues. Good co-management requires a shared diagnosis, clear roles, exchange of progress notes and an agreed point for reassessment. Questions about prescription drugs go to the prescriber: a chiropractor may discuss potential effects and interactions but should not tell a patient to stop or change a prescribed medication.

Section 4Clinical documentation and informed consent

The purpose of the record

The record serves the patient first: it lets you, a covering colleague or a later clinician see what was found, what was done and how the patient responded. It is also the evidence of medical necessity for payers, the basis for any legal defense, and the source for impairment and disability reports. The principle that governs reviewers and courts is simple: if it was not documented, it was not done. The record must also be consistent with the bill; a charge for a five region manipulation needs documented findings in five regions.

The initial examination record

The first visit record holds the full history (chief complaint, present illness, past, family and social history, review of systems), the examination (vital signs, observation, palpation, range of motion, orthopedic and neurological tests, and any other systems examined), the results of any imaging or labs, the working diagnosis and differential, the treatment plan with goals, the informed consent, and baseline outcome measures. For Medicare patients, a subluxation must be shown either by an x-ray or by the physical examination findings summarized as PART: Pain or tenderness, Asymmetry or misalignment, Range of motion abnormality, and Tissue or tone changes. Two of the four are required, and one of them must be asymmetry or range of motion abnormality. The level of subluxation must be named specifically, and Medicare covers only manual manipulation of the spine to correct it, not the examination by the chiropractor, x-rays taken in the office, or therapies.

The SOAP daily note

• Subjective: the patient's report since the last visit: pain intensity and location, functional changes, response to the last treatment, home program adherence, new symptoms. Use the patient's words for key complaints.
• Objective: what you measured today: findings at the treated segments, range of motion, repeated positive tests, neurological status when relevant, and the outcome scores at re-examinations.
• Assessment: your interpretation: diagnosis, whether the patient is improving, unchanged or worse, progress toward each goal, and any new concern.
• Plan: what you did and what comes next: technique and segments or regions treated, supportive procedures with time for timed codes, home instructions, changes to frequency, next re-examination and any referral.

Records that withstand review

Informed consent

Informed consent is a process of communication that ends with a voluntary decision by a competent patient; the signed form is evidence that the process happened, not a substitute for it. A useful memory aid is PARQ: explain the Procedure (and the diagnosis it treats), the Alternatives (including other conservative care, medical care and no treatment, with their risks), the material Risks and expected benefits, and invite Questions. Jurisdictions differ on the standard used to judge disclosure: the reasonable patient (material risk) standard asks what a reasonable patient would want to know to decide, while the professional standard asks what a reasonable practitioner would disclose. Prepare for the patient standard, which is stricter.

• Risks of manipulation to disclose: common, benign and short lived reactions such as local soreness, stiffness, fatigue or headache, occurring in roughly a third to a half of patients and usually settling within 24 to 48 hours; rare serious events such as rib or other fracture in osteoporotic bone, aggravation of a disc herniation, and very rarely cauda equina syndrome after lumbar manipulation; and cervical artery dissection with stroke, which is very rare and whose causal relationship to manipulation has not been established, but which is material because of its severity.
• Who consents: a competent adult for themselves; a parent or legal guardian for a minor (with the child's assent where possible), unless the minor is emancipated or state law allows; a legal guardian or health care agent for an adult lacking capacity.
• When to renew: when the diagnosis changes, when you add a new technique or region, when a significant new risk factor appears (anticoagulation, osteoporosis), and at the start of any new episode.
• Withdrawal: the patient may withdraw consent at any time, including during a procedure.
• Emergencies: consent is implied when a patient cannot consent and delay would cause harm.

Coding basics

Two code sets travel together on every claim. ICD-10-CM codes describe why the patient was treated (the diagnosis). CPT codes describe what was done (the procedures and evaluations). Codes must be supported by the documentation of that visit.

Section 5Worked case management scenarios

How Part III asks management questions

Management items usually describe a patient over several visits and stop at a decision point: a re-examination result, a new symptom, a test report, a patient request. The question asks for the next best step. The method is the same each time: (1) decide whether anything in the stem is a red flag that changes the urgency; (2) decide whether the patient is improving, plateaued or worse, using the numbers given; (3) ask whether the working diagnosis still fits; (4) choose the single action that addresses the most important problem first. Distractors are usually steps that are reasonable but premature (advanced imaging before a trial of care), inadequate (continuing unchanged care after a plateau), excessive (surgery referral for uncomplicated pain) or too slow (routine referral of an emergency).

Scenario 1: the disc patient who stalls, then responds

A 42 year old delivery driver has right sided low back and buttock pain for 10 days after lifting. The straight leg raise is positive at 60 degrees for back and buttock pain only, reflexes and strength are normal, and there are no red flags. Baseline ODI is 48% and NPRS 7/10. You begin side posture manipulation three times a week with advice to keep moving.

At the two week re-examination ODI is 44%; at four weeks it is 42%, still short of the 10 point MCID. Repeated movement testing now shows that sustained extension in prone centralizes his buttock pain. Two trials of care have failed, but the examination has produced new information: a directional preference. The next step is to change the plan (flexion distraction and a repeated extension home program), not to refer for surgery and not to continue unchanged side posture care. By week 8 his ODI is 18%.

Scenario 4: the imaging surprise

A 66 year old man with a five year history of mechanical low back pain has lumbar radiographs because of a recent fall. There is no fracture, but there is curvilinear calcification of the abdominal aortic wall with a diameter you estimate at 4.5 cm. He has no abdominal pain and his vital signs are normal. The aneurysm is incidental and asymptomatic, so this is a prompt, not emergency, referral: inform the patient in plain terms, send a letter and the films to his primary physician with a request for abdominal ultrasound and vascular evaluation, document the conversation, and avoid deep abdominal pressure and forceful lumbar rotation while it is evaluated. If he had back or abdominal pain, hypotension or a tender pulsatile mass, it would be an emergency.

Words worth knowing