Consensus Terminology for Stages of Care

By Mark D. Dehen, DC

Over the past several years, the chiropractic media has published numerous articles discussing Medicare reviews of the care delivered in chiropractic offices. Care that is delivered for maintenance or wellness purposes is, by definition, not reimbursable under most third-party-payer contracts. However, most chiropractic practices are riddled with senior patients who opine that they continue to live and function independently, partly due to the care they receive at the hands of their chiropractor. Therefore, should not such maintenance care be covered?

While ongoing medical care, ranging from prescription hypertension medications for heart conditions to dialysis for renal failure to various medications for the treatment of ongoing musculoskeletal pain, is routinely reimbursed by third-party payers for incurable conditions, ongoing chiropractic care for degenerative disc disease and osteoarthritis in chronic low back pain is routinely denied. This despite the direct costs of LBP having been estimated at $12.2 billion to $90.6 billion annually in the U.S., or $45 to $335 per person each year.1 It's not fair!

Over the past 100-plus years the chiropractic profession has generally matured outside the health care area, tending to isolate itself from the other health care professions. While this isolationism has helped chiropractic survive, it has also allowed chiropractic to develop its own lexicon of terminology outside of mainstream health care. However, as we now enter the modern era of electronic health records and their meaningful use mandate that requires sharing with other health care disciplines, it will become increasingly important that all providers speak a common language.

The ACA's Insurance and Managed Care (IMC) committee was among the first to recognize the need to update the policy language utilized by chiropractors in order to address the evolution occurring within the profession. The original language, e.g., "supportive care" and "maintenance care," developed as part of the Mercy Guidelines project in the early 1990s had become marginalized by the third-party payer system over the interim.

Therefore, in light of national health care reform and its focus on evidence-based care, the ACA IMC turned to the Council on Chiropractic Guidelines and Practice Parameters for assistance in addressing this language issue. The CCGPP has been accumulating and collating evidence across the spectrum of chiropractic care over the past five years in an effort to better position the chiropractic profession within the health care arena. Seed statements were developed regarding the typical phases of patient care and a multidisciplinary panel was convened to define the scope of chiropractic care.

The resulting paper, published in the July/August 2010 issue of JMPT, is titled "Consensus Terminology for Stages of Care: Acute, Chronic, Recurrent, and Wellness."2 This paper defines and describes appropriate care throughout the spectrum of typical chiropractic patient encounters, providing perspective relative to other health care conditions and treatment modalities. Those stages of case management are defined as follows:

Care of Acute Conditions

  • Medically necessary care of acute conditions is care that is reasonable and necessary for the diagnosis and treatment of a patient with a health concern and for which there is a therapeutic care plan and a goal of functional improvement and/or pain relief.
  • The result of the care is expected to be an improvement, arrest or retardation of the patient's condition.
  • Initially, the care may be more frequent, but as levels of improvement are reached, a decrease in the frequency of care is to be expected.
  • A patient may experience exacerbations of an acute injury/illness being treated that may clinically require an increased frequency of care for short periods of time.
  • A patient may also experience a recurrence of the injury/illness after a quiescence of 30 days that may require a re-institution of care.

Care of Chronic/Recurrent Conditions

  • Medically necessary care of recurrent/chronic conditions is care that is provided when the injury/illness is not expected to completely resolve following a treatment regimen, but where continued care can reasonably be expected to result in documentable improvement for the patient.
  • When functional status has remained stable under care and further improvement is not expected or withdrawal of care results in documentable deterioration, additional care may be necessary for the goals of: supporting the patient's highest achievable level of function, minimizing or controlling pain, stabilizing injured or weakened areas, improving activities of daily living (ADLs), reducing reliance on medications, minimizing exacerbation frequency or duration, minimizing further disability or keeping the patient employed and/or active.
  • Chronic/recurrent care may be inappropriate when it interferes with other appropriate primary care or when its benefits are outweighed by its risks, e.g., psychological dependence on the physician or treatment, illness behavior or secondary gain.

Care for Wellness

  • Achieving wellness requires active patient participation.
  • Wellness is a process of achieving the best health possible, given one's genetic makeup, by pursuing an optimal level of function.
  • "Optimizing levels of function" may include a combination of health care strategies such as chiropractic adjustments, manipulative therapy, manual therapies, exercise, diet/nutrition counseling and lifestyle coaching.

With proper definition of the patient's stage of care based on the above and documentation, there is now good scientific evidence substantiating appropriate chiropractic care for your patients. The CCGPP has also developed "Management of Chronic Spine-Related Conditions: Consensus Recommendations of a Multidisciplinary Panel,"3 a guideline to assist doctors in the management of chronic/recurrent patients. (The application of this new chronic/recurrent care guideline will be the subject of a future article.)

It is imperative that the chiropractic profession adoapt and employ these definitions in daily use as they document their patient encounters. In so doing, individual doctors of chiropractic will leverage the work of the CCGPP and the ACA in integrating chiropractic care into the evolving and emerging national health care reform.

As Hubert Humphrey stated, "In real life, unlike in Shakespeare, the sweetness of the rose depends upon name it bears. Things are not only what they are. They are, in very important respects, what they seem to be." Doctors of chiropractic, the nation's spinal health care experts!


  1. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal, 2008(8):1-7.
  2. Dehen MD, Whalen WM, Farabaugh RJ, Hawk C. Consensus terminology for stages of care: acute, chronic, recurrent and wellness. J Manipulative Physiol Ther, 2010 July-August;33(6):458-463.
  3. Farabaugh RJ, Dehen MD, Hawk C. Management of chronic spine-related conditions. Consensus  recommendations of a multidisciplinary panel. J Manipulative Physiol Ther, 2010 September;33(7):484-492.

Dr. Mark D. Dehen is a second-generation doctor of chiropractic practicing in North Mankato, Minn., where he does ergonomic consulting and injury prevention for local industries. Dr. Dehen is a past president of the Minnesota Chiropractic Association and the immediate past chair of the CCGPP.

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