Documenting Clinical Findings and Diagnosis

3 CE Credits

* CE Credits are for Doctors of Chiropractic only

** Please note this course is only approved in the state of Texas through 7/31/25.  After that there will be no CE available in TX.

Hour 1: Utilizing the history in the evaluation and management process to determine triage based upon complaints coupled with system review, past medical history, family and social history, and surgical history.

Hour 2: Correlating vitals, orthopedic testing, neuromuscular examination, and test results inclusive of basic and advanced imaging and electrodiagnostic testing as clinically indicated to determine an accurate diagnosis, prognosis, and treatment plan.

Hour 3: How to create accurate ICD-10 codes inclusive of causality and sequella codes. Ensuring that all pathologies uncovered in the evaluation and management process are included in the diagnosis and that every area treated in the body has a corresponding diagnosis. Understanding the role of re-evaluations when updating diagnosis.

Course Objective: To have documentation that meets the coding requirements and elements in an Evaluation and Management encounter (99202-99203-99204-99205).

Primary Spine Care 13

Documentation, Diagnosis and Management Online

Flyer

20 CE Credit Hours

*This course is approved for 8 credits in Oklahoma.

**This course is no longer approved in CA as of 10/31/2023.

DESCRIPTION:

This program focuses on the trends in healthcare and how clinical chiropractic, based upon the evidence in the literature, fits into the national trends. It shows the doctor of chiropractic the critical role of compliant documentation in reputation building and to prevent adverse legal issues with complaint records. The course also covers the latest MRI spine interpretation terminology and identifies biomechanical pathology using the latest mensurating tools.

Module 1

Mark Studin DC

MRI Spine Case Review

Clinical case review of MRI's including sagittal, axial, T1, T2, STIR, and proton density sequences. The vertebrate, spinal cord, discs, nerve roots, thecal sac, posterior longitudinal ligament, epidural veins, and fat saturation pulses will be identified. Pathology will include bulges, herniations, protrusions, extrusions, myelomalacia, cord edema, and Schmorl's nodes.

Module 2

Mark Studin DC

Demonstrative Documentation Reporting

Creating documentation that is demonstrable in design to show pathology visually. How to prepare demonstrable records that are legally defensible and accurate in the description of the pathology.

Module 3

Mark Studin  DC

Don Capoferri DC

Age-Dating Herniated Disc and TRauma

Age dating herniated discs and trauma is a critical skill for an expert in spine. It combines the clinical skills of interpreting X-ray, MRI, and other imaging modalities with a clinician's understanding of joint pathology. This level of expertise is critical when collaborated with other physicians or working in the medical-legal environment as an expert. Age dating pathology is also central to creating a prognosis on your patient's recovery and must be evidence-based in rationale.

Module 4Mark Studin  DC

Stroke Evaluation and Risk Factors in a Chiropractic Practice

Diagnosing, triaging, and documenting headaches, migraines, and vascular incidents (stroke) in the primary provider's office. Imaging protocols based upon history and clinical presentation will be presented, along with analyzing imaging findings in determining the etiology. There will be an extensive question and answer session following the instructional presentation.

Module 5

Mark Studin DC, FASBE(C), DAAMLP, DAAPM

Don Capoferri DC

2023 Trends in Documentation

Evidence-Based demonstrative documentation is typically the arbiter for creating successful patient-centered collaborative care. This "reputation building" focus has already helped develop relationships with MD PCPs, MD Specialists, ERs, and Urgent Care Centers.  This demonstratively removed the Non-Specific Back Pain "Dogma" that too many have held because technology and the evidence have not supported what chiropractic has known for over a century. We now have those tools and once learned, chiropractic utilization "skyrockets because of the evidence.

Module 6

Patricia Roche DO, Radiology, Neuroradiology

Mark Studin DC

MRI Spine Case Review

Clinical case review of MRI's including sagittal, axial, T1, T2, STIR, and proton density sequences. The vertebrate, spinal cord, discs, nerve roots, thecal sac, posterior longitudinal ligament, epidural veins, and fat saturation pulses will be identified. Pathology will include bulges, herniations, protrusions, extrusions, myelomalacia, cord edema, and Schmorl's nodes.

Module 7

Mark Studin DC

Dan Rosner ESQ

Demonstrative Documentation Reporting

Creating documentation that is demonstrable in design to show pathology visually. How to prepare demonstrable records that are legally defensible and accurate in the description of the pathology.

Module 8

Mark Studin  DC

Don Capoferri DC

Age-Dating Herniated Disc and Master-Class in Ligament Physiology

Age dating herniated discs and trauma is a critical skill for an expert in spine. It combines the clinical skills of interpreting X-ray, MRI, and other imaging modalities with a clinician's understanding of joint pathology. This level of expertise is critical when collaborated with other physicians or working in the medical-legal environment as an expert. Age dating pathology is also central to creating a prognosis on your patient's recovery and must be evidence-based in rationale. Master-Class in ligaments; anatomy, physiology, vascularization, neurological innervation, tissue repair and how they all relate to clinical practice.  Ligament pathology correlating to the mechanisms of patho-neuro-biomechanical lesions (vertebral subluxation complex). Also, how ligaments play a critical role in a chiropractic spinal adjustment and defining the chiropractic spinal adjustment mechanisms. 

Module 9Robert Peyster MD, Neuroradiology

After a physical examination, the doctor may also recommend that the patient schedule a diagnostic test, such as computed tomography, CT or CAT scan, or magnetic resonance imaging, or MRI. These tests will help the doctor pinpoint the location of the lesion and will also help assess the extent of damage the lesion has caused the brain. Documenting magnetic resonance imaging (MRI) results as the diagnostic test that produces three-dimensional, or 3D, images of the inside of the body using magnetic fields and computer technology. It shows brain tissue detail as well as the brain stem, and cerebellum (posterior brain) better than a CT scan. An MRI of the brain can help determine whether there are signs of prior mini-strokes. A medication (contrast) can also be injected to help high light structures.

Module 10

Mark Studin DC

Don Capoferri DC

Disproving Non-Specific Back Pain

Case Management documentation incorporating Spinal Biomechanics, MRI, and clinical findings when collaborating with medical specialists and lawyers. Using Case Management as the foundation for both consistent referrals and long-term forensic consulting relationships. Disproving based upon the evidence, the Dogma of “non-specific back pain.”

Module 11

Mark Studin DC

Don Capoferri DC

Clinical record keeping is an integral part of good professional practice and delivering quality healthcare. But as healthcare changes with new technology and reimbursement models, so should clinical documentation. It can be helpful to go back to the basics. In this step-by-step guide to taking perfect clinical notes we will cover:

• Why write clinical notes
• The importance of context
• What to include in a clinical note
• Tips for better clinical documentation
• Basic legal considerations
• Open clinical notes
• How to keep documentation efficient

TOTAL EDUCATIONAL TIME: 20 Hours

Fee: $399.00

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Primary Spine Care 13 Webinar

*This course is approved for 16/20 CE Credits in CA.

**This course is approved for 8/20 CE Credits in WI.

This program focuses on the trends in healthcare and how clinical chiropractic, based upon the evidence in the literature, fits into the national trends. It shows the doctor of chiropractic the critical role of compliant documentation in reputation building and to prevent adverse legal issues with complaint records. The course also covers the latest MRI spine interpretation terminology and identifies biomechanical pathology using the latest mensurating tools.

Coordination of Care, Documentation, Diagnosis Online

3 CE Hours

  Don Capoferri DC, FSBT

Clinically coordinating diagnosis, prognosis, and treatment plans, with collaborating with medical specialists as indicated.

Syllabus

Hour 1 

Disc pathology overview; herniation, bulge, protrusion, extrusion. Connective tissue pathology and diagnosis 

Hour 2 

Case 1 presentation with multiple herniations, documentation, triage, diagnosis 

Hour 3 

Case 2 presentation with no herniations and connective tissue pathology, documentation, triage, diagnosis 

Imaging, Case and Strain/Sprain Reporting

3 “Online” Hours

Faculty

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

Don Capoferri DC, FSBT, DAAMLP

90 Minutes:

1.  Report of Findings coding and time requirements

2.  X-ray review coding and time requirements

a.  Taken in office

b.  Taken out of office

3.  X-Ray digitizing coding and time requirements

4.  Evaluation and Management requirements that include the above elements

90 Minutes:

1.  Physiology of ligamentous connective tissue

2.  Patho-Physiology of ligamentous connective tissue

3.  Using digitizing tools to demonstratively show connective tissue pathology

4.  Diagnosing patterns of spinjhal pathology ujsing a “whole spine model”

Total Hours: 3

This is a Suny Buffalo course which includes a final exam and course eval.

This is a Suny Buffalo Course - Only final exam and course evaluation.

This course is not for online purposes it is for Suny B fellowship and only includes the course eval and final exam.

This course is for the Suny B. Fellowship only and is not to be taken as an online course.  It is a final exam and course eval only.

This is for Suny B Fellowship only.  ONly course eval and final exam are included.

This is for Suny Buffalo Fellowship - only final exam and course eval.

This course is test and course eval only for Suny B Fellowship Only

Coding and Care Plan from Acute Through Rehabilitation Free WEbinar

3 CE Hours

Instructors: Mark Studin DC, FASBE©, DAAPM

  Don Capoferri DC, FSBT

Syllabus

Hour 1 

ICD-10 and CPT coding of initial care from the E&M encounter to the treatment with cross-linking services to diagnosis.

Hour 2 

ICD-10 and CPT coding of post-acute care through rehabilitation, including home exercise programs.  This includes cross-linking services to diagnosis.

Hour 3 

Validating the necessity of care through demonstrable documentation. This encompasses x-ray digitizing, ranges of motion, muscle testing, and the comparative assessment of global dysfunction vs. motor unit dysfunction.

Testifying 4: Creating Ethical Financial Relationships

10 “Online” Hours

* CE Credits are for Doctors of Chiropractic only

** Please note this course is only approved in the state of Alabama through 7/22/25.  After that there will be no CE available in AL

** Please note this course is only approved in the state of Kentucky through 8/7/25.  After that there will be no CE available in KY

Topic: Practice Management

Pre-Test 30 Minutes

Module 1 – Introduction, Documentation Standards and Patient Documentation – 90 Minutes

This module is an introduction to ethical financial relationship with lawyers and the documentation needed from the provider to define the relationship. Assignments, release of records, right to receive information, explaining statue of limitations and document exchange are detailed.

Module 2 – Legality of Assignments– 90 Minutes

This module details the assignment of rights and benefits. What that means in a contemporary clinical practice and how to ensure you have the legal authority to bill and collect based on necessary documentation.

Module 3 – Ethical Medical-Legal Financial Relationships, Part 1 – 90 Minutes

This module discusses in detail what an ethical relationship is for the doctor and attorney. It describes the differences in ethics for a lawyer and doctor and what constitutes a licensure violation in both practices. It also details how to ensure your documentation supports ethical relationships.

Module 4 – Ethical Financial Relationships, Part 2 – 90 Minutes

This section discusses how to manage cases where lawyers are unethical and understanding the Rules of Professional Conduct mandated for lawyers nationally. It helps you creates business systems to manage these types for cases and work within the framework of the laws in each state to ensure compliance.

Module 5 – The Documentation Required to Ensure a Reasonable Conclusion to a Case with an Attorney– 90 Minutes

This module is a continuation of the “Rules of Professional Conduct” mandated by license for lawyers and further defines documentation required for a doctor to use with cases involving lawyers. It also details the necessary documentation needed for a doctor to provide in detailing injuries to patients in an evaluation and management encounter and a final narrative for the courts.

Review of PowerPoint slides for each module: 60 minutes

Post Test – 60 Minutes

Total Hours: 10

Case Management, Documentation& Diagnosis Free WEbinar

Documenting Clinical Findings and Diagnosis

Instructor: Mark Studin DC

Thursday, March 3, 2022

Syllabus

Hour 1: Utilizing the history in the evaluation and management process to determine triage based upon complaints coupled with system review, past medical history, family and social history, and surgical history.

Hour 2: Correlating vitals, orthopedic testing, neuromuscular examination, and test results inclusive of basic and advanced imaging and electrodiagnostic testing as clinically indicated to determine an accurate diagnosis, prognosis, and treatment plan.

Hour 3: How to create accurate ICD-10 codes inclusive of causality and sequella codes. Ensuring that all pathologies uncovered in the evaluation and management process are included in the diagnosis and that every area treated in the body has a corresponding diagnosis. Understanding the role of re-evaluations when updating diagnosis.

Demo Course this course doesnt render credit its just for show

DIAGNOSING

3 Credit Hours

*CE Credits are for Doctors of Chiropractic

**CME Credits are for Medical Doctors and Doctors of Chiropractic.

This course concentrates on how to diagnose a patient inclusive of external causes “causality” and starts with a clinical evaluation. The clinical Evaluation covers all the elements from a 99202 through a 99205.  Clinical diagnosis are broken into Palpatory, Neurological and Osseous derangement categories.  Primary and sequella diagnosis will be explained.  This course offers testing macros when clinically indicated as well as diagnosis for extra spinal regents treated and comorbidities.

Hour 1: Requirements for diagnosing from a clinical evaluation during an Evaluation & Management Encounter (99202-99203-99204-99205)

Hour 2: Non-musculoskeletal diagnosis, Sequella to injury diagnosis, Comorbidity diagnosis

Hour 3: Imaging diagnosis; static x-rays, biomechanical x-rays & MRI findings

Review of 87 Slides

 Fee: $99

Course Objective: For the student to be able to accurately diagnose the condition of their patient.

Instructor(s): 

Mark Studin DC, FASBE(c), DAAPM

Instructions: Once you purchase the course online, it will be immediately active in your account. If you have any issues, please contact Cara 631-804-2845 or CaraRoss220@Gmail.com

 Troubleshooting Suggestions: 

1. This course is supported by PC's and Mac devices
2. Minimum 20mbs download speed
3. Mobile device are not ideal as tracking is automated and often not mobilized

This course is Pace approved by the Federation of Chiropractic Licensing Boards.

ACCREDITATION

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University at Buffalo Jacobs School of Medicine and Biomedical Sciences and Cleveland University Kansas City, College of Chiropractic, Post-Graduate Department.

The University at Buffalo Jacobs School of Medicine and Biomedical Sciences is accredited by the ACCME to provide continuing medical education for physicians.

CERTIFICATION

The University at Buffalo Jacobs School of Medicine and Biomedical Sciences designates this live activity for a maximum of 3.0 AMA PRA Category 1 Credit(s)TM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PLANNING COMMITTEE & SPEAKER DECLARATIONS

The Accreditation Council for Continuing Medical Education (ACCME) and the University at Buffalo Jacobs School of Medicine and Biomedical Sciences Standards for Commercial Support require that presentations are free of commercial bias and that any information regarding commercial products/services be based on scientific methods generally accepted by the medical community. The following planners and presenter(s) have disclosed financial interest/arrangements or affiliations with organization(s) that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation(s). Only the current arrangements/interests are included. *Planning Committee

Activity Director and Instructor: Mark Studin DC, FASBE(C), DAAPM  – Nothing to Report

ACCME Standards of Commercial Support of CME require that presentations be free of commercial bias and that any information regarding commercial products/services be based on scientific methods generally accepted by the medical community. When discussing therapeutic options, faculty are requested to use only generic names. If they use a trade name, then those of several companies should be used. If a presentation includes discussion of any unlabeled or investigational use of a commercial product, faculty are required to disclose this to the participants.

ACCME Original Launch Date: March 22, 2022 Termination Date: March 22, 2025

Primary Spine Care 12 - CASE MANAGEMENT & DOCUMENTATION 

 20 Credit Hours 

 *CE Credits are for Doctors of Chiropractic.

**CME Credits are for Medical Doctors and Doctors of Chiropractic

***This course is approved for 8 credits in California THRU 11/31/22, approved for 19 credits until 11/30/23.  Please note this course will not be approved in the state of CA after 11/30/23.

****This course is approved for 19 credits in California from 12/1/22-11/30/23.

*****This course is approved for 8 credits in Oklahoma.

This program focuses on the trends in healthcare and how clinical chiropractic, based upon the evidence in the literature, fits into the national trends. It shows the doctor of chiropractic the critical role of compliant documentation in reputation building and to prevent adverse legal issues with complaint records. The course also covers the latest MRI spine interpretation terminology and identifies biomechanical pathology using the latest mensurating tools.

Module 1 – 2 Hours

MRI Spine Case Review

Clinical case review of MRI's including sagittal, axial, T1, T2, STIR, and proton density sequences. The vertebrate, spinal cord, discs, nerve roots, thecal sac, posterior longitudinal ligament, epidural veins, and fat saturation pulses will be identified. Pathology will include bulges, herniations, protrusions, extrusions, myelomalacia, cord edema, and Schmorl's nodes.

Module 2 – 2 Hours

Demonstrative Documentation Reporting

Creating documentation that is demonstrable in design to show pathology visually. How to prepare demonstrable records that are legally defensible and accurate in the description of the pathology.

Module 3 – 2 Hours

Age-Dating Herniated Disc and TRauma

Age dating herniated discs and trauma is a critical skill for an expert in spine. It combines the clinical skills of interpreting X-ray, MRI, and other imaging modalities with a clinician's understanding of joint pathology. This level of expertise is critical when collaborated with other physicians or working in the medical-legal environment as an expert. Age dating pathology is also central to creating a prognosis on your patient's recovery and must be evidence-based in rationale.

Module 4 – 2 Hours

Stroke Evaluation and Risk Factors in a Chiropractic Practice

Diagnosing, triaging, and documenting headaches, migraines, and vascular incidents (stroke) in the primary provider's office. Imaging protocols based upon history and clinical presentation will be presented, along with analyzing imaging findings in determining the etiology. There will be an extensive question and answer session following the instructional presentation.

Module 5 – 1 Hour

2022 Trends in Documentation

Evidence-Based demonstrative documentation is typically the arbiter for creating successful patient-centered collaborative care. This "reputation building" focus has already helped develop relationships with MD PCPs, MD Specialists, ERs, and Urgent Care Centers.  This demonstratively removed the Non-Specific Back Pain "Dogma" that too many have held because technology and the evidence have not supported what chiropractic has known for over a century. We now have those tools and once learned, chiropractic utilization "skyrockets because of the evidence.

Module 6 – 1 Hour

Documentation made easy. Effectively creating demonstrative medical-legal documentation and meeting the needs of the courts, and making your "4-Corner" (narrative) report to build your reputation as an evidence-based provider. The step-by-step minutiae of building a report, accomplishing report writing timely and effectively by understanding the regulatory and administrative rules. Learn how to educate the lawyer on bodily injury through evidence-based demonstrative reporting.

Module 7 – 1.5 Hours

MRI Nomenclature and the Evidence of the Chiropractic Lesion

The latest nomenclature in MRI spine interpretation [lots of changes], and incorporating spinal biomechanics to create an accurate diagnosis and get paid. The reason medicine gets paid more than chiropractic is they have demonstrable diagnostics. We must institute protocols that WE ALREADY HAVE to confirm patho-neuro-biomechanical lesions [Subluxations] are present.  A "MASTER CLASS" in Strain-Sprain in fully understanding the permanency of this connective tissue disorder and how to certify long-term care with a demonstrable diagnosis. 

Module 9 – 2 Hours

Imaging Joint Ligamentous Instabilities

Identifying different types of arthritis in both plain film and MRI. Inclusive of Osteo, Psoriatic, Rheumatoid, Gout, Infections, and Spondyloarthropathies. Dr. Baker is an Assistant Professor of Clinical Radiology at the State University of New York at Stony Brook, School of Medicine, and teaches the radiology and MSK radiology programs.Module 9 – 2 Hours

Module 9 – 1.5 Hours

Master-Class in Ligament Physiology and Pathology

Master-Class in ligaments; anatomy, physiology, vascularization, neurological innervation, tissue repair and how they all relate to clinical practice.  Ligament pathology correlating to the mechanisms of patho-neuro-biomechanical lesions (vertebral subluxation complex). Also, how ligaments play a critical role in a chiropractic spinal adjustment and defining the chiropractic spinal adjustment mechanisms. 

Module 10 – 1 Hour

Disproving Non-Specific Back Pain

Case Management incorporating Spinal Biomechanics, MRI, and clinical findings when collaborating with medical specialists and lawyers. Using Case Management as the foundation for both consistent referrals and long-term forensic consulting relationships. Disproving based upon the evidence, the Dogma of “non-specific back pain.”

Module 11 – 1 Hour

Spinal Disc Pathology in Clinical Practice

A roundtable discussion of diagnosing spinal pathology in clinical practice. Dr. Peyster is a Harvard-trained neuroradiologist published extensively over the last 40 years. He will be presenting typical cases managed in chiropractic offices with an in-depth discussion. He will be focusing on collaborating with a radiologist on case reviews.

Module 12 – 1.5 Hours

Neurosurgical Roundtable Discussion

A roundtable discussion of collaborative spine care. Dr. Shady has 30 years of extensive experience in both working with and supporting chiropractic care. 

Module 13 – 1.5 Hours

DC vs. MD vs. PT; The Evidence

Chiropractic vs. Physical Therapy vs. medication for mechanical spine issue; extensive research verifying chiropractic as the best first choice, resolving the non-specific back pain issue as dogma, with the evidence. The latest [overwhelming] research will institute the re-direction of MD referral patterns from PTs to DCs. The latest physiological basis for why the chiropractic adjustment works and what constitutes a patho-neuro-biomechanical lesion [Subluxations].

 Fee: $399

Course Objective:To be able to integrate causality, bodily injuries, and persistent financial losses demonstratively

Instructor(s):

Mark Studin DC, FASBE(C), DAAPM

Michael Schonfeld DC, DABCO

Don Capoferri DC

Ma

Primary Spine Care 12

Case Management and Documentation

*PLEASE NOTE THIS COURSE IS ONLY APPROVED FOR 8 CREDITS IN CALIFORNIA.

December 3 - 5, 2021

Live Webinar

Flyer

20 CE Credit Hours

DESCRIPTION:

This program focuses on the trends in healthcare and how clinical chiropractic, based upon the evidence in the literature, fits into the national trends. It shows the doctor of chiropractic the critical role of compliant documentation in reputation building and to prevent adverse legal issues with complaint records. The course also covers the latest MRI spine interpretation terminology and identifies biomechanical pathology using the latest mensurating tools.

Friday, December 3, 2021

10:00 am – 12:00 pm

Mark Studin DC

MRI Spine Case Review

Clinical case review of MRI's including sagittal, axial, T1, T2, STIR, and proton density sequences. The vertebrate, spinal cord, discs, nerve roots, thecal sac, posterior longitudinal ligament, epidural veins, and fat saturation pulses will be identified. Pathology will include bulges, herniations, protrusions, extrusions, myelomalacia, cord edema, and Schmorl's nodes.

12:00 pm – 2 pm

Mark Studin DC

Demonstrative Documentation Reporting

Creating documentation that is demonstrable in design to show pathology visually. How to prepare demonstrable records that are legally defensible and accurate in the description of the pathology.

2:30 pm – 4:30 pm

Mark Studin  DC

Don Capoferri DC

Age-Dating Herniated Disc and TRauma

Age dating herniated discs and trauma is a critical skill for an expert in spine. It combines the clinical skills of interpreting X-ray, MRI, and other imaging modalities with a clinician's understanding of joint pathology. This level of expertise is critical when collaborated with other physicians or working in the medical-legal environment as an expert. Age dating pathology is also central to creating a prognosis on your patient's recovery and must be evidence-based in rationale.

4:30 pm – 6:30 pm