JUSTIFICATION for X-RAY

In these days of managed care and retrospective review of chart notes, it is vital to document the need for every procedure utilized, carefully following the oft-repeated adage that “if it isn’t written down, it didn’t happen.” A comprehensive look at good practice for x-rays or any other diagnostic method must include several important facets:

1. Justification

The procedure must be justified by a need presented in the history and/or physical examination; that is, it must be designed to answer a diagnostic question posed by the data obtained from the history and/or physical exam that cannot be answered without the test.

2. Safety

The procedure must meet acceptable safety standards. When any small risk is present, it must be balanced by demonstrated benefit.

3. Accuracy

The procedure must provide valid, proven, reliable data.

4. Quality

The procedure must be well done, showing adherence to appropriate technical parameters.

5. Interpretation

The test must be interpreted competently and in reasonable accord with peer standards.

6. Utility of findings

Findings should be used to guide treatment in some way, or at least to rule out contraindications to treatment.

7. Cost-effectiveness

The procedure must be cost-effective; that is, it must improve patient outcomes sufficiently to justify the expenditure of having performed the test.

If you are careful to write down WHY you performed or ordered a test and HOW you used the results to guide your management of the case, you will go a long way in avoiding retrospective denial of coverage for the procedures that you need to treat your patients.

It can no longer be PRESUMED that x-rays are needed in any given case. Instead, the reason that x-rays are needed - even though it may seem obvious to the doctor - needs to be written down in the chart notes. This is especially important these days because guidelines published by the medical profession include only quite a restrictive list of reasons that x-rays may be indicated. While the items on the list may be perfectly appropriate for medical practice, it is another thing entirely to deliver an osseous thrust type of treatment, and there is a higher order of necessity for x-ray for chiropractors, especially those who utilize high-velocity types of adjustments/manipulative procedures. The trouble is that the medical guidelines are the ones most widely propagated, and the payor agencies are familiar with only those. It is up to chiropractors to list in each patient’s chart the reasons why x-rays are required.

Here are some classic reasons, typically included in medical guidelines, that x-rays are indicated:

	major trauma
	minor trauma in potentially osteoporotic patient
	age over 50 or under 20 whose history suggests question of tumor or infection
	history of cancer
	steroid intake
	immune suppression
	constitutional symptoms (fever, chills, unexplained weight loss)
	pain that worsens when supine, severe nighttime pain

Here are three additional and very common indicators that x-rays may legitimately be required in chiropractic practice:

	R/O pathology or anomaly which may contraindicate or modify adjustment/manipulative therapy. (This one could be applicable in virtually every case where x-rays were felt to be necessary at the initiation of a case.)
	Determine biomechanical factors in order to help guide the type of chiropractic treatment chosen and/or the type of exercise or postural re-training needed to help stabilize the patient’s condition. (This, too, could be applicable in virtually every case where x-rays were felt to be necessary at the initiation of a case.)
	Evaluate chronicity or delayed response to treatment (Was something missed that might explain this patient’s unexpectedly poor response to treatment?)

Going a step further, it is also important to enter a justification if more views than the limited AP and lateral are required. Did your patient have arm pain that required cervical obliques? If not, did you see degenerative changes on the AP and lateral cervical that required follow-up cervical obliques to evaluate for foraminal encroachment? Did you see a lumbar spondy or facet degeneration that required follow-up lumbar obliques for better assessment? Did the history suggest possible sprain injury, and is it necessary to evaluate intersegmental motion via bending views? If so, write it down.

Don’t worry about writing a long and flowery narrative. Just a few words will do the trick: something like the following would be fine: “Cervical spine trauma. X-rays needed to guide type of treatment. Arm pain: include obliques.”

While all of the above indicators may seem obvious, it is important to remember that - right or wrong - payors start with the presumption that the treating doctor had no reason whatsoever for taking or ordering x-rays unless that reason is written down in the chart. That’s just the way life is these days!

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