March 22, 2004

To the Editor,

    The article on the Outpatient Musculoskelatal Exam Form by Sleszynski et.al. in JAOA V104, #2, February 2004 is the latest update on an admirable, ongoing project designed to serve three purposes simultaneously:

  1. Address the elements necessary to justify a billed level of service to a third party payer.
  2. Provide a useful format for understanding a patient’s compensatory pattern of somatic dysfunction and how it evolves with treatment.
  3. Generate a form that will facilitate the gathering of data for research and defense of osteopathic practice patterns and billing codes. Along the way, the format must be “sold” to physicians who must “prefer” to use it.

    In the hope of continuing interest and discussion of this project, I would ask your indulgence to play devil’s advocate for a few questions, acknowledging from the start that this original contribution is about training and certification for the form, and needs no defense. Nevertheless, the “selling” of the form may best be accomplished by the asking and answering of reasonable questions about the contents.

I. Under *Cardiovascular, “observation” and “palpation” don’t really register with me. Why not “auscultation” and “Peripheral findings”?

II. Within the osteopathic and allopathic literature, there is considerable agreement that physical exam is fairly inaccurate when it comes to short leg evaluation except in the most extreme cases. The physical finding of apparent short leg does belong on the exam form, as does some means for capturing the effect of the lower extremities upon the torso via the psoas, quadratus femoris and piriformis muscles. Ranges of motion come in handy too, for disability evaluations and to show “progress” during a series of treatments. Why not use a chart like this?

 

 
Cervical
   
Norms***		 Lumbar &
Thoracic		    
Norms***		  
Wrist		  
L		  
R		  
Norms***
F ___   80º F ___   45+60º F ___ ___ 80º
E ___   80º E ___   45+60º E ___ ___ 80º
SB L ___ R ___ 45º SB L ___ R ___ 40+30º RD ___ ___ 20º
Rot L ___ R ___ 85º Rot L ___ R ___ 50+15º UD ___ ___ 30º
Spurling ___     SLR L ___ R ___          
Push Button L ___ R ___ Tripod L ___ R ___        
Jaw Opening ___ >4.0cm              

 

SH L R         Hips L R         Ankle L R  
F ___ ___ 180º       F ___ ___ 135º       PF ___ ___ 50º
E ___ ___ 60º       E ___ ___ 30º       DF ___ ___ 20º
Abd ___ ___ 180º       AB ___ ___ 45º       Inver ___ ___ 30º
IR ___ ___ 70º       AD ___ ___ 30º       Ever ___ ___ 20º
ER ___ ___ 90º       IR ___ ___ 35º              
              ER ___ ___ 45º            
              Fabere ___ ___              

 

Elbow L R          Knee L R            L R  
F ___ ___ 150º   F ___ ___ 135º   Seated Flxn ___ ___  
E ___ ___ 0-5º   E ___ ___ 0º   Ap't Shrt Leg ___ ___  
Pron ___ ___ 90º             Tight Psoas ___ ___  
Supp ___ ___ 90º             Quad Femoris  ___ ___  
                    Piriformis ___ ___  

 

III. If I remember correctly, the 1997 revised guidelines for the single system comprehensive evaluation and management of the musculoskeletal system(99205) require significantly more than the 12 elements required for a 99214 visit. Wouldn’t it be nice to have to have a five by six chart in which you could quickly jot down all the musculoskeletal normals for their six anatomic areas? Rows three thru seven in the following chart allow just that to happen. Rows one and two allow for quick duplication of documentation for somatic dysfunction,** complete with a very fine print definition somewhere else in the form.

  Head &
Neck		 Trunk LUE RUE LLE RLE
Somatic Dysfunction**            
Active Trigger Points*            
Joints with full ROM,
no pain, crepitus or
contracture on palpation		            
No visible asymmetry,
defects or deformities		            
Joints intact, without
dislocation, or laxity		            
No muscle atrophy or
weakness		            
SKIN: No scars, rashes,
lesion or ulcers		            


IV. My fourth and final question involves the use of TART subcomponents of a palpatory exam. TART is a didactic system for expanding and integrating the palpatory skills of students. In breaking the palpatory experience into four verbal constructs, are we not begging for insurance persons to disallow a given somatic dysfunction because it was only documented by two of the four TARTs? In the absence of a coherent medical system and what seems to be a deep desire amongst the American people to retain the 3 or 4 tiered current system of access to quality medical care, it will be necessary to continue to play the game of pin the tail on the donkey with the moving target that is third party reimbursement. By presenting an official form that emphasizes those attributes, might we not be hoisting ourselves on our own petard?

Respectfully yours,

John H. Juhl, D.O.
drjuhl@drjuhl.com

Business Address:

John H Juhl, D.O.
625 Madison Ave., Suite 10A
New York, N.Y.. 10022
(212) 838-8265

 

I have no financial associations with this topic, and other than an abiding interest in the osteopathic understanding of common compensatory mechanisms, no conflicts of interest.

* Trigger Points are specific areas in muscle tissue which display any or all of the following symptoms: reproduction of referred pain on sustained stimulation, restricted muscle motion, mild muscle weakness, focal tenderness with palpable taut band or jump sign.

** Somatic Dysfunction may include any or all of the following symptoms: altered and impaired joint motion, periarticular tenderness and/or soft tissue swelling, myofascial strain, muscle hypertonicity, increased pseudomotor activity, venous/lymphatic congestion, and somatic and/or visceral reflexes.

*** AAOS, Chicago, 1965;  Hoppenfield, Physical Exam of the Spine and Extremities, New York, 1976.