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According to the Centers for Medicare and Medicaid Services (CMS) guidelines, chiropractors are deemed physicians in the Medicare system and for consistency throughout the term chiropractic physician will encompass chiropractor, chiropractic doctor, doctor of chiropractic and chiropractic physician. Chiropractic physicians must document subluxation of the spine through x-ray or physical examination. The documentation of subluxation of the spine through physical examination includes the identification of two out of four criteria including: Pain/tenderness, Asymmetry/misalignment, Range of motion abnormality, Tissue tone, texture, and temperature abnormality (P.A.R.T.) with at least one of the two criteria being either A or R. Since special needs children often have difficulty expressing pain, and/or experiencing pain the way a typical child can, it is necessary to understand approaches to the special needs child that allow the doctor to evaluate and treat the child, as well as comply with insurance mandates to establish medical necessity. The paper reported here is to help the doctor understand approaches to document the diagnosis/diagnoses and procedures utilized for the medically necessary care of special needs children to while remaining in compliance with the billing to 3rd party payers. Chiropractic philosophy and practice teach us that all dysfunction has a neurologic component. By far, the greatest growth of neurologic dysfunction in children is the increasing presence of autism spectrum disorders (ASD). ASD includes autism, ADD/ADHD, Rett’s Syndrome, Asperger’s Syndrome, Pervasive Developmental Delay and Childhood Disintegrative Disorder, among others. Commonly, these children lack communication skills, perceive pain differently than non-spectrum children, and present with uncommon signs and symptoms not frequently seen in a chiropractic office. As chiropractic physicians, we are comfortable with back pain, neck pain and headaches, but when a patient presents with self-stimulatory behaviors, self-injurious behaviors, digestive challenges and abnormal preferred postures, the chiropractic physician may become intimidated. The quality of life of children challenged with these issues may be enhanced by chiropractic care. Chiropractic physicians, as they often provide family care, are encouraged to expand their knowledge and practice to include these children. By providing competent chiropractic care, we demonstrate to our patients and their families and other providers that chiropractic is not limited to pain management. At Kentuckiana Children’s Center, we observe physiologic, behavioral and social improvements with the addition of chiropractic and complementary care. Medicare guidelines require the presence of two of the four P.A.R.T. features to be present to demonstrate medical necessity. At least one of the features must be A and/or R. This makes the job of the chiropractic physician easier since spectrum children cannot communicate pain in the way a non-spectrum individual can. At Kentuckiana Children’s Center, the majority of our patients are ASD children. We also have a wide variety of children with genetic syndromes, like Down Syndrome, and other complex diagnoses that present with varying levels of function. Optimally, after an examination and differential diagnosis and treatment plan are in place, a patient is adjusted. This could happen on the first visit in an acute case or second office visit after a report of findings. We have observed when working with spectrum children, it may take several visits to establish trust so that hands-on work can be accomplished. The treatment environment must be soothing, as non-clinical as possible and quiet. Loud, bright environments are more likely to stimulate unwanted behaviors and make the treatment of the child impossible. It is also important to note that most spectrum children are unable to tolerate light touch. Activator checks, Total Body Modification (TBM) analysis and other techniques that involve analysis via brushing or lightly touching a body part could provoke an unwanted, and possibly violent, reaction. As much as possible, firm, intentional touch is preferred and can have a calming effect. Once tolerance of the environment and hands-on contact is established, it is not difficult for a competent chiropractic physician to identify Asymmetry/misalignment, Range of motion abnormalities and Tissue tone, texture, and temperature abnormality. We commonly find a short leg (asymmetry), retracted scapula (asymmetry, tone), forward head carriage (asymmetry, tone), heel-to-buttock restrictions (asymmetry, tone) and limited spinal ranges-of-motion. Adjusting the ASD child, then, may be accomplished by any number of methods. We often find that children who are high functioning will tolerate Activator Method, but low functioning children will not allow this technique. Drop table adjustment mechanisms are effective, but can be very alarming. The most frequently used techniques include Diversified, Gonstead and sustained deep pressure. Modifications of range-of-motion and tension/tone analysis refer to meeting the special needs child where they are at time of presentation. Behavior often dictates how much touch a child will allow. Usually, over time, even the most reluctant special needs child will allow touch. Source: https://chiro.org/wordpress/2019/12/why-arent-chiropractic-physicians-treating-more-children-with-complex-diagnoses/
Pain/tenderness, Asymmetry/misalignment, Range of motion abnormality, Tissue tone, texture, and temperature abnormality (P.A.R.T.) with at least one of the two criteria being either A or R.