Products – Asian Therapies

SOAP Note Best Practices: Case Study 3 – ReEvaluation Acupuncture

Galina Roofener — Wed, 30 Nov 2022 19:45:08 +0000

As healthcare providers, Licensed Acupuncturists are subject to mandatory documentation and practice guidelines. In each class of this monthly series of interactive SOAP NOTE BEST PRACTICES: Case Study webinars, we will document an actual patient encounter together. This class will navigate Reevaluation Acupuncture SOAP. Suggested prerequisites SOAP Note Best Practices Introduction: Evaluation & Management Guidelines, Case Study 1 – Initial Acupuncture & Case Study 2 – Initial Herbal Webinars.

This class focus:

Brief review of necessary health data to satisfy mandatory CMS healthcare documentation guidelines
Discuss Outcome Assessment Tools used in the acupuncture practice
Discuss how to write an assessment with a focus on Functional improvement
Review strategies to mitigate potential Adverse Effects
Re-establish treatment goals if the treatment course is continued
Discuss referral guidelines if set goals are not achieved, or the patient’s condition worsened
Discuss plan changes if the patient presents with a new complaint
Select and appropriately record standardized ICD-11 Ch. 26 Traditional Medicine pattern associated with billable current ICD-10 diagnosis
Review proper Coding for E/M and acupuncture procedure
Navigate how to write a discharge SOAP note for the completed course of the treatment

Included in this class: Access to standardized Outcome Assessment Tools and SOAP note Templates.

Through this series of monthly interactive webinars, also we will discuss how to:

Identify and Formulate Chief Complaint(s)
Determine the accurate amount of information you must collect to support the level of Medical Decision Making
Assess Complaint Improvement
Support Medical Necessity
Record Patient’s Non-compliance
Justify the Lack of Improvement
Select & Record Treatment Strategy
Justify ICD-10 Western Diagnosis
Select & Record the Appropriate TM Patterns
Identify Appropriate Treatment Method
Formulate Treatment Principles based on the different Styles of Acupuncture
Formulate and Record an Appropriate Treatment Plan
Establish a Short and Long Term Goal
Identify Potential Red Flags and Appropriate Referrals
Establish Necessary Labs/Imaging to be Ordered
Record & Select Appropriate Acupuncture Procedure Codes and the desired Number of Units
Select & Record Adjunct Treatment Techniques and Procedures
Select & Record Supplements Prescribed Accordingly to the TCM Pattern
Select & Record Patent TCHM
Record Custom Compounded Formula from 5:1 TCHM granules
Legally Reopen & Amend Closed and Signed SOAP Notes

Documentation guidelines, known as Evaluation/ Management guide (EM), are routinely reviewed and amended by the Centers for Medicare & Medicare Services. The most recent revision of the EM guide was implemented on January 01, 2021. The 2021 EM guide contains significant changes which are beneficial to LAc. New guidelines were added, allowing healthcare providers to collect the clinically necessary amount of subjective data and physical examination.

With the release of the ICD-11 Chapter 26 Traditional Medicine Diagnostic codes in standardized terminology. Licensed Acupuncturists, as a profession, are making the first grand step towards worldwide acceptance as a healthcare profession, not only as an acupuncture procedure service. The ability to make an independent diagnosis moves us from a technician performing the acupuncture procedure to a diagnosing clinician category, subject to physician-level regulations and reimbursement. (Do Not Mistake this with the legal scope of practice of your State)

You are welcome to present your case for discussion in the subsequent webinar.

SOAP Note Best Practices: Case Study 2 – Initial Herbal

Galina Roofener — Sun, 23 Oct 2022 15:20:03 +0000

As healthcare providers, Licensed Acupuncturists are subject to mandatory documentation and practice guidelines. In each class of this monthly series of interactive SOAP NOTE BEST PRACTICES: Case Study webinars, we will together document an actual patient encounter. This class will navigate Initial Traditional Chinese Herbal Medicine (TCHM) SOAP. Suggested prerequisites SOAP Note Best Practices Introduction: Evaluation & Management Guidelines Webinar & Case Study 1 – Initial Acupuncture Webinars.

This class focus:

Brief review of necessary health data to satisfy mandatory CMS healthcare documentation guidelines
Discuss how to formulate a diagnosis compliant with the FDA language pertaining to TCHM Rx.
Select and appropriately record standardized ICD-11 Ch. 26 Traditional Medicine pattern associated with billable current ICD-10 diagnosis
Discuss and order Lab Work necessary for risk assessment
Review drug-herb interactions & identify potential Adverse Effects
Formulate appropriate Taiwanese-style 5:1 granule formula, including patient-specific dose calculation
Place a custom formula order into 3rd party compounding pharmacy and outline the FDA requirements for TCHM formula recording in the SOAP
Issue to the patient EHR portal homegoing instructions, including legal language pertaining to TCHM

Included in this class: Access to standardized Intake and SOAP note Templates.

Through this series of monthly interactive webinars, also we will discuss how to:

Identify and Formulate Chief Complaint(s)
Determine the accurate amount of information you must collect to support the level of Medical Decision Making
Assess Complaint Improvement
Support Medical Necessity
Record Patient’s Non-compliance
Justify the Lack of Improvement
Select & Record Treatment Strategy
Justify ICD-10 Western Diagnosis
Select & Record the Appropriate TM Patterns
Identify Appropriate Treatment Method
Formulate Treatment Principles based on the different Styles of Acupuncture
Formulate and Record an Appropriate Treatment Plan
Establish a Short and Long Term Goal
Identify Potential Red Flags and Appropriate Referrals
Establish Necessary Labs/Imaging to be Ordered
Record & Select Appropriate Acupuncture Procedure Codes and the desired Number of Units
Select & Record Adjunct Treatment Techniques and Procedures
Select & Record Supplements Prescribed Accordingly to the TCM Pattern
Select & Record Patent TCHM
Record Custom Compounded Formula from 5:1 TCHM granules
Legally Reopen & Amend Closed and Signed SOAP Notes

You are welcome to present your case for discussion in the subsequent webinar.

SOAP Note Best Practices Introduction: Evaluation & Management Guidelines

Galina Roofener — Mon, 10 Oct 2022 18:23:08 +0000

This class will introduce new guidelines for Evaluation & Management (E/M) visits effective 01/2021. We will navigate how Medical Decision-Making affects practice of ancient medicine in the modern world. This class presents the TCM practitioner viewpoint for note-taking, enhances the efficiency of TCM clinical practice, and facilitates the accuracy of TCM pattern differentiation diagnosis.

COURSE LEARNING OUTCOMES: Through the successful completion of this course, each student will be able to:

Understand the importance of Medical Decision Making (MDM).
Understand and apply MDM Elements for most effective time management.
Select appropriate Evaluation and Management (E/M) visit CPT Code, specific to acupuncture or herbal service.
Determine level of subjective and objective data necessary to support the diagnosis.
Identify elements of Assessment that justify medical necessity.
Learn how to think on paper.
Parallel current ICD-10 and/or future ICD-11 billable diagnosis to NON-billable Traditional Medicine (TM1) pattern diagnosis.
Understand and apply legal language in SOAP.
Formulate and reassess treatment goals.
Learn proper recording of administered treatment,
Learn proper recording of home going instructions, recommendations, ordered labs, and referrals.
Explore in details real SOAP notes.

SOAP Note Best Practices: Case Study 1 – Initial Acupuncture

Galina Roofener — Wed, 17 Aug 2022 18:56:46 +0000

As healthcare providers, Licensed Acupuncturists are subject to mandatory documentation and practice guidelines. In each class of this monthly series of interactive SOAP NOTE BEST PRACTICES: Case Study webinars, we will document an actual patient encounter together. This class will navigate Initial Acupuncture SOAP. Suggested prerequisite SOAP Note Best Practices Introduction: Evaluation & Management Guidelines Webinar.

This class focus:

Brief review of necessary health data to satisfy mandatory CMS healthcare documentation guidelines
Discuss Red Flags Detection
Review how to record and apply Imaging tests in the Traditional Medicine
Discuss how to write an assessment with a focus on Risk Assessment
Select and appropriately record standardized ICD-11 Ch. 26 Traditional Medicine pattern associated with billable current ICD-10 diagnosis
Review proper Coding for E/M and acupuncture procedure
Review strategies to mitigate potential Adverse Effects
Discuss the patient’s EHR portal homegoing instructions specific to acupuncture

Included in this class: Access to standardized Intake and SOAP note Templates.

Through this series of monthly interactive webinars, also we will discuss how to:

Identify and Formulate Chief Complaint(s)
Determine the accurate amount of information you must collect to support the level of Medical Decision Making
Assess Complaint Improvement
Support Medical Necessity
Record Patient’s Non-compliance
Justify the Lack of Improvement
Select & Record Treatment Strategy
Justify ICD-10 Western Diagnosis
Select & Record the Appropriate TM Patterns
Identify Appropriate Treatment Method
Formulate Treatment Principles based on the different Styles of Acupuncture
Formulate and Record an Appropriate Treatment Plan
Establish a Short and Long Term Goal
Identify Potential Red Flags and Appropriate Referrals
Establish Necessary Labs/Imaging to be Ordered
Record & Select Appropriate Acupuncture Procedure Codes and the desired Number of Units
Select & Record Adjunct Treatment Techniques and Procedures
Select & Record Supplements Prescribed Accordingly to the TCM Pattern
Select & Record Patent TCHM
Record Custom Compounded Formula from 5:1 TCHM granules
Legally Reopen & Amend Closed and Signed SOAP Notes

You are welcome to present your case for discussion in the subsequent webinar.

Is Your Herbal Practice Safe? Know the Clinical & Legal Standards.

Supprt Staff — Wed, 29 Jun 2022 19:46:41 +0000

This web series of Building Better Business webinars will introduce you to how to:

select quality herbs,
questions to ask when selecting your vendor,
discuss different forms of TCHM (raw, granules, patent)
calculate dose for a specific patient using different forms from different manufacturers
record herbs in the SOAP to protect yourself legally
collect and report adverse events

Head & Neck Imaging in the TCM Practice

Galina Roofener — Mon, 27 Jun 2022 17:54:27 +0000

This class is designed to provide necessary integrative tools in the modern acupuncture practice

COURSE LEARNING OUTCOMES Through the successful completion of this course, each student will be able to:

Navigate Imaging ordering logistics,
Apply legal aspects of imaging ordering,
Understand the difference between X-Ray, MRI, MRA, PET, CT, Ultrasound, Thermography,
Understand the application of imaging in diagnostics of head and neck disorders,
Identify TCM patterns manifestation in the imaging tests,
Review acupuncture action confirmed by Imaging research,
How to translate Imaging findings into TCM Theory.
Investigate most common disorders in acupuncturist practice imaging tests case studies,
Review red flag referrals,
Clarify imaging test ordering,
Understand imaging tests interpretation,
Reinforce imaging tests records in the SOAP note,
Introduction into imaging effects on medical decision making/billing codes,

Principles of Combining TCHM with Pharmaceuticals & Nutraceuticals

Supprt Staff — Mon, 13 Dec 2021 21:54:45 +0000

The practice of Traditional Chinese Herbal Medicine (TCHM) may appear archaic to those that misunderstand the theories and principals that guide it. In fact TCHM continues to evolve and new systems are consistently being discovered and applied within the tradition. Never the less the biggest challenge of great unknown of herb-drug interaction faced by TCM practitioner in the world today remains.

Though modern scientific analyses have been utilized to look at herbs from a chemical perspective, it is unrealistic to perform double-blind study of every drug-herb/formula combination. This class will introduce principles of drug-herb combination according to TCM philosophy.

Select western pharmaceuticals and nutraceuticals are described in the tradition of TCM Materia Medica, including flavors, temperature, meridians entered, actions, indications and modifications. Interactions with Chinese herbs are discussed. Principles of Drug-Herb combination and possible interactions are demystified and discussed in details.

Drug induced mortality became a serious thread in modern times, accordingly ability to anticipate and avoid drug-herb interaction is a matter of a paramount importance. This class provides an advance understanding of safe drug-herb compatibility.

Click here to see example of a drug description.

Modern Pulse Diagnosis: Mobile ECG Based

Supprt Staff — Mon, 13 Dec 2021 21:51:44 +0000

This class is intended for individuals familiar with the theory and clinical practice of East Asian medicine and illustrates a modern perspective on describing the TCM pulse through the interpretation of mobile ECG data.

Palpation of the pulse is one of the important diagnostic signs used by East Asian medicine practitioners to determine the state of Qi in the body. Reading a pulse traditionally relies upon developing refined palpation skills through extensive practice guided by a skilled teacher, which can be challenging to attain and master, and impossible to collect virtually. During this class you will learn how to obtain the pulse remotely in the telemedicine era.

Recent developments in mobile electrocardiogram (ECG) devices provide an excellent resource for practitioners to have a convenient and affordable tool for an objective pulse measure. Qi is an electric impulse that commands the heart chambers to contract that subsequently generates the pulse.

An ECG is an accepted scientific test to detect the electrical activity of the heart. It can also be used to measure and interpret the state of Qi in the human body. We can determine the strength of Qi by measuring the strength of the electric impulse that is clearly visible as the height of the R wave spike on an ECG. We can also determine TCM heat or cold conditions by the pulse rate, which is automatically registered on an ECG. The ECG can be read through a TCM perspective to determine a pulse diagnosis.

Traditional Medicine Standard Terminology: Bridge to the ICD-11 Billing Practice

Supprt Staff — Mon, 13 Dec 2021 21:49:05 +0000

The purpose of this course is to provide practitioners with the knowledge and skills to perform in the approaching era of ICD-11 Chapter 26 (TM1) Traditional Medicine Billing Codes. Students will be able to navigate a Medical-decision making and implement it in the Traditional Medicine SOAP notes in compliance with the Medicaid/Medicare reimbursement requirement standards.

What to expect: 7 hours classroom (add 1-hour lunch) + 14 hours home study

COURSE LEARNING OUTCOMES

Through the successful completion of this course, each student will be able to:

1. Understand the importance of standard terminology.  

2. Identify resources for standard terminology reference.  

3. Understand the purpose of ICD-11 Chapter 26 (TM1).

4. Diversify the WHO International Standard Terminology pertaining to a specific style of Traditional Medicine, including but not limited to Japanese, Korean, Five Element, Famous Masters, Scalp, etc.  

5. Parallel current ICD-10 and future ICD-11 billable diagnosis to NON-billable Traditional Medicine (TM1) pattern diagnosis.

6. Formulate treatment principles adapted to a specific style of Traditional Medicine using WHO International  Standard Terminology.

7. Write a SOAP note adapted to a specific style of Traditional Medicine using WHO International Standard Terminology in the standardized format to fulfill billing requirements.

8. Implement general principles & rules reflecting a coding level of Traditional Medicine decision-making in compliance with USA insurance billing requirements revised for 2021.

Safety & Regulations of TCM Herbal Telemedicine

Supprt Staff — Mon, 13 Dec 2021 21:41:18 +0000

Telemedicine offers a lot of promise for both physicians and patients. This class explores how Traditional Chinese Herbal Medicine can be safely and legally practiced in the realms of modern telemedicine. Most states now have laws regulating the practice of telemedicine. Safety is of primary concern. The laws only get more complicated and more uncertain when telemedicine is practiced across state lines. This class is based on Cleveland Clinic TCHM virtual visits experience and will explore safety concerns, legalities of informed consent, initial and follow up visit, gathering of objective signs, herbal prescribing, billing requirements and required EMR records keeping.

Through the successful completion of this course, each student will be able to:

The student will learn law governing telemedicine by state
Gain an understanding of potential medical errors in Telemedicine
Understand technology compliance with HIPPA for Telemedicine
Develop a deep understanding of the ethics involved in Telemedicine
Learn techniques to collect objective signs including pulse & tongue remotely
Have a working knowledge of Telemedicine record keeping and billing