by Tom Grant DC, Med-Legal Consultant, Pragma Intel Director of Education
Nov 28th, 2018
Question: Do the Croft Guidelines apply to a patient's condition immediately following the collision or are they applicable to a patient's state when they first come to see you? Whether that has been weeks or months since the collision without treatment?
Answer by Tom Grant Jr., DC
Director of Education, PragmaIntel.com
Great question, one that finds a growing number of DC's are confused and misapplying the Croft Guidelines. ICD-10 coding provides no help in identifying the type of collision and its impact forces nor do they provide an injury severity identifier. The apparent effort of the Croft Guidelines (CG's, which can be further explored at srisd.com) is to provide a set of general guidelines that prove a measure of injury severity (since ICD-10 codes don't have severity indicators) using a classification of collision type (Type I-III, Other) and a grade of severity classified by the presenting injuries of the patient (CAD Grade I-V) and the presenting stage of injury (Stage I-IV).
These provide a basis on which to warrant the appropriateness of treatment duration as published in the CG's. The CG's were arrived at using a scientific approach to injury identification. They contain data on the Type of Collision; Grade of Injury Severity; and Stage of Injury recovery (with or without treatment). The CG's also offer some additional support for the severity of injury by an accompanying Complicating Factors section in the CG's, which if present can lead to a longer recovery duration.
The CG's foundational criteria was limited in scope (Whiplash Injuries Foreman & Croft 1995, 2001) and one must use caution in applying it universally to "all" injured victims. It is, however, the only reliable source of injury severity identification we have at present and serves the DC well, IF THEY FOLLOW Art Croft's training, which sadly few DC's have ever taken his training courses.
In large measure liability insurers don't recognize the CG's as being valid, they are a "chiropractic" thing and not a "medical" thing. The CG's can gain a measure of defensive ability when a state association (or other large representative body that requires membership and abidance by that group/society/association's membership rules) have made it a published part of their tenets. Tenet adoption proves useful when a DC's treatment duration and severity statements are considered "unreasonable" or "not usual and customary" in the medical realm of things by the insurer and/or by their "Independent Medical Examiner", whose unified efforts focus on discrediting the DC's work. With the associations declaration of endorsing the CG's, the member DC can appeal to their association’s acceptance of the CG's and summarily offer justification as to why their care is reasonable and necessary, all in the hopes of gaining acceptance of their proffered treatment plan and duration of care (i.e., the DC's bills).
With that bit of background, here is my answer.
The CG's contain only 1 guide relating to TIME, that of labeling the presenting patient as being in a specific Stage of Injury recovery, namely: acute, sub-acute, remodeling or chronic injury state, and these are based on the initial date of injury.
The rest of the equally important classifications in the CG's are about the collision type, injury severity findings and companion complications.
The CG's help to identify injury severity, and more than just time alone, they combine to help convey injury severity. In documenting injuries, the presenting symptoms must be accompanied by the diagnostic validation of injury. Without a diagnostically validated injury, the DC's claim of injury severity is without medical merit and summarily dismissed by the insurer software. All the appeals in the world, CG's included, will not make a better settlement outcome (and DC's bills being paid) unless the injuries have been medically validated.
The medical validation process, as observed in the liability insurers software handling of claims, is what I teach in my online training program. My Colossus Level 1 training tools focus on using ICD-10 coding, supportive documentation and medical validation tools effectively to thwart liability insurers rejection of DC notes and the resulting loss of claims reimbursements.