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Moshe Heller & Stephen Cowan

Phlegm – Etiology pathology and treatment Moshe Heller

Hi, my name is Moshe Heller. First I’d like to thank the American Acupuncture Council for hosting this show, and providing this really wonderful platform for writing information.

I’d like to start talking today, and today’s lecture would be, I will talk a little bit about pediatric phlegm, or phlegm in general. I want to just have a short discussion about etiological factors, pathology, and also the treatment. Since phlegm is actually a very, very common thing nowadays because of, as we know, a lot of … The flu is very common and upon us. As disease progresses, I see many children presenting with phlegm presentations in the past few weeks.

Let’s start. I think the slides are on, and you’re seeing it. The first thing I’d like to just talk about is that … Why do children actually have phlegm, or tend to have phlegm? There’s a famous saying that children produce phlegm very easily, and there’s a few reasons for that.

It all starts with the fact that, actually, children are born with very weak spleens. We assume that, at the beginning of their life, they will always have spleen vacuity. That presents with their tendency to have difficulty digesting, also having very soft stools. That’s a normal thing for them, and that’s a very clear sign their spleen is deficient. Therefore, when you have a spleen deficiency, dampness can easily accumulate and therefore transform into phlegm.

Also there’s another saying that the exterior of children is not secure, and they contract pathogens very easily. WHen the child contracts a pathogen, it influences the way that the lung functions, and the spleen. Therefore, also, the end result could be an accumulation of phlegm, or dampness and then phlegm.

There are a few other supportive factors to the production of phlegm, and one of them has to do with … What I see very commonly now is that the feeding schedule is not as … Parents tend to feed babies on what we call “on demand”. Therefore their scheduling of feedings are random, and sometimes cause this eating on various times, and end up a lot of times overeating. That in itself can also cause an issue with or become a burden on the spleen, and therefore produce more phlegm.

Also, as the children grow, and we start to introduce new foods, a lot of times wrong foods can be presented to them. Meaning either they’re too cold or difficult on the digestive system, and that could be because one of the most common thing is introducing fruits earlier on, or too early. As we believe in Chinese medicine, that fruits are cold and therefore can really burden the spleen, also.

There’s also the issue of formula. I think that sometimes the formula is very heavy and is actually over rich, and therefore not so easy to digest. A lot of children, once they’re put on formulas, actually start developing phlegm. It’s a very interesting thing to watch, because we have then the issue of, what to we do if there’s no other sources of food, and we have to look at different formulas as solutions?

I also want to mention one other thing that’s really commonly seen in my office is that a lot of times antibiotics are given inappropriately, meaning that … Antibiotics definitely have a place and a time to be used, and they are very important. Nonetheless, if they’re used inappropriately, they can produce a dampness very easily because of their nature. As we know, from a Chinese medical perspective, antibiotics are cold and bitter, and therefore they are hard on the spleen. If we have a cold condition, and it’s a cold exterior condition, and we give out antibiotics, the end result will be that there will be some phlegm developing, or damp and then phlegm.

How do we diagnose? How do we know that there is phlegm in the body? Sometimes in children the easiest way is that we see it. As we saw in the first picture of the slides, sometimes it’s very visible, but sometimes it isn’t. If there’s no discharge, there are other telling signs that are important to realize.

One thing ends up as a result of this, especially if the phlegm is stuck in the sinuses, the child becomes a mouth breather. A lot of times we’ll see that their lower lip is a little saggy. Especially if they’re trying to concentrate, you’ll see that their lower lip opens and falls down, and it doesn’t shut down. A lot of times it will also result with some more drooling, or a tendency to drool, heavier if they’re at the teething age.

We have this drooped lower lip, and then mouth breathing. Then we can hear them breathing a lot of times. Another telling sign is snoring at night. Snoring at night usually indicates there’s something that’s blocking, and that phlegm is one of the causes of snoring in kids. Mouth breathing, heavy breathing, or snoring at night, those are all really strong signs.

Of course, palpating the lymph glands is a very important diagnostic procedure in children, because if the lymph glands are swollen, that’s a really strong sign that there is some phlegm accumulating, and a very particular type of phlegm, which we’ll talk in a second. Then, also, the actual history itself of the disease. If there’s chronic sinusitis, or chronic ear infection, or tonsillitis, all these are signs that maybe there’s this phlegm that’s lingering, and is a part of the pathology of the disease.

Another thing that’s really important to use as a tool is listening to the lung sounds. That’s something that, if you’re seeing children, you should probably have a stethoscope with you, because listening to the lung sounds can help in your diagnosis, another sign that can help you in the diagnosis of the patient.

For example, if you hear wheezing when you listen to the lung, you know that that is a constriction of the bronchials. That means that there’s Chi stagnation. But, if you hear crackles, crackles are the sounds like little balloons popping, that is a sound that there is phlegm in the lung. I use it as a diagnostic technique. I listen to the lung. If I hear those crackles, I know that I’m going to need to clear phlegm from the lung.

I want to go over two patterns, this is diagnostic patterns, that are very common in children. The first one I want to discuss is accumulation disorders. We discussed this many times before, but I’m just want to remind you that a lot of times accumulation disorders are the reason that children are presenting with phlegm.

What it is is that … It’s like food stagnation in adults, but its difference is that this could be just from either overeating or eating things that are very difficult for them to digest, and then that accumulates in the stomach and creates this heat and phlegm. The heat symptoms manifest with these red cheeks that are there all the time. This is heat rising from the stomach, and you’ll see these little, almost like stop lights, with the two red cheeks. They’re very distinct. It’s a sign that the digestion is a little overheating and stagnant.

Of course, that will also affect their … They’ll be a little more cranky and irritable, and maybe have difficulty falling, or staying, or waking up frequently. These children don’t sleep as well because something’s not digesting well.

Of course, once these fluids go up and stagnate, they can cause phlegm to accumulate. Then you’ll see this green nasal discharge, exactly like you saw in the first picture. Then you’ll probably see cough involved with it that is very rattly, and maybe some slippery coughs. These are all phlegm signs that come from the accumulation disorder.

When we recognize or diagnose accumulation disorder as the source, we always need to think of Si Feng as the treatment points. Of course, Stomach 36, Stomach 25, and CV-12 are also really important to help, and San Jiao 6, which really helps to move the Chi and resolve the blockage in the digestive system. These are all really important points, but the main treatment point will be Si Feng.

Then the formula that you might be considering has to do with helping the digestion. I have a great formula that’s based on Bao He Wan in my new motion line. I have a website that will be at the end of the slideshow. You can log on and look at digest. It’s a really fantastic formula for supporting the digestive system in situations just like that.

The other aspect is lingering pathogenic factors. Lingering pathogenic factor, a lot of times either cause phlegm or are the phlegm itself. When we diagnose lingering pathogenic factors, we usually have three types or three syndromes under that. One is more of a deficient kind that’s a little more rare, and it involves spleen Chi deficiency. The other one is called retention of phlegm, and retention of very thick phlegm.

We’ll go over the last two just to remind you how we diagnose them. When we only have retention of phlegm, usually you’ll see that there’s this recurring infection, and it can be anywhere from the sinuses, to the throat, to the chest, to the ears. There’ll be a lot of phlegm or discharge from the nose, or cough with a gurgling or rattling sound. There’ll be mouth breathing, like we discussed earlier. There’s emotional state where they want things, but they don’t really want them. They’ll say, “I want this,” but when you give it to them, they’ll throw it away. That’s a very typical sign of that. Then, also very choosy, and wanting only sweet or white foods.

Sometimes you’ll see a manifestation of that phlegm on the stool itself. That’s question we have to ask parents. How does the stool look? Does it change color? Have you noticed any changes in … If there’s this glistening, or it’s a little bit shiny, that’s a sign that there’s phlegm in the stool. Then, of course, enlarged lymph glands, which is really a very important sign for the lingering pathogenic factor.

When it becomes thick phlegm, there’s a lot of the same symptoms. A lot of times the thing that triggers me is that, when I ask, when we discuss the illness history with the parents, they’ll always say a sentence like, “Since their illness, they haven’t been really the same.” The underlying mechanism is that the child’s character is altered or really changed. There’s something either subtly or really more significant change in their character.

Then, that’s very typical of that, when we think that phlegm is becoming so distinct that it actually changes the spirit, or changes … With an adult, we’ll say that there’s phlegm blocking the heart orifices, and then the Shen is not as clear. That’s when we start seeing that in children.

A lot of times there’ll be two other signs that I want to say. They’ll have these energy crashes. They’ll suddenly have periods where they just are really cranky, and they only want to really rest. Also it is sometimes associated with intermittent abdominal pain. These are all signs of the lingering pathogenic factor with very thick phlegm.

The treatment, when you recognize that, is combination of four points, Bai Lao, which is an extra point in the back, UB13, 18, and 20. This is the basic protocol. Sometimes I combine it with the Shao Yang combination of Gallbladder 41 and Triple Warmer 5. Also I will palpate UB43. If it feels very full and excess, I might needle that also.

The main form that I use for that is a combination of Xiao Chai Hu Tang. We’ll talk a little bit about Xiao Chai Hu Tang, because it’s not the first formula that you would think for phlegm, but I found it really helpful with many children, especially with children, to resolve phlegm. I guess because [Ban Xia 00:21:00] is in that formula, but it really is a mild way to resolve phlegm. Helps the children resolve it. I’ve used it many times. You can see that, once Xiao Chai Hu Tang is used in its correct formula, you will see a slow drying of that phlegm, and the symptoms are reduced. I really want you to remember Xiao Chai Hu Tang, especially with kids when they have phlegm.

I want to give a case example that I was treating, actually, a few days ago, last week. There’s this two-year-old boy that came to my office that the parents were saying that was experiencing back-to-back ear infections. Again and again, the ear infections would repeat. Also it always comes with fever and pain. The child really is two years, but still is talking already, and expressing pain in the ear. He mostly tugs and pulls on the left ear, but both ears is something that he’s experienced.

His mother says that everything was normal during pregnancy. The delivery was fine. At the end he needed to be vacuumed, but he was healthy otherwise. Around nine months of age, something around then, she had to stop breastfeeding, go back to work. Although she was giving him formula beforehand as a supplement, at around nine months, around that time, formula was a the only thing she was giving, of course and the introduction of solids.

At that time, there was a lot of dairy products that were introduced. That created a lot of wheezing, or he started to have these episodes of wheezing, almost like asthma. Went to the doctor, the doctor gave steroids in a nebulizer, an inhaler. That really calmed the wheezing, as the mother was reporting.

Then, a few months later, he got another really bad cold. Then that developed into an ear infection, and he was given antibiotics. Since then, it’s been repeated ear infections and rounds of antibiotics. Last round of antibiotics was about three weeks ago. He was given Amaxicillin, and he is currently still complaining of ear infection, although there’s no fevers, which the mother was relieved. She took her to the pediatrician a few days before the appointment, and there was still accumulation of fluids behind the ear drum. The doctor was saying that they may need to consider doing ear plug operation. That’s why they were looking for an alternative way to treat him.

The mother was saying that the baby is a very picky eater, and in the last month they were trying to get him off of dairy, because they thought that that could be a problem, and that’s why he’s having the ear infections, which I agreed. We also agreed that, from now on, they should probably stop wheat.

Bowel movements are two to three times a day. The mother thinks it’s pretty normal, and they don’t seem to be too soft or hard. He doesn’t complain of stomach aches. But, his sleep is not good. He wakes very frequently. He drinks a lot of water throughout the night, and also the mother reports that he’s addicted to the pacifier throughout the day. She’s wanting him to stop, or trying to wean him off of that.

On examination, I found submandibular lymph nodes that were positive or enlarged. His finger vein, which is something that I observed, was very dark, which means heat, and wide. That means that the pathogen is strong, and it’s reached the wind gate. It hasn’t really penetrated extremely deep. Therefore we could address it by resolving it on the [Yan 00:26:43] layers. I’ll explain in a second. Also, when I was examining him, it was clearly that his breathing was heavy and he sounded very congested.

Out of that, I was very clear that his diagnosis was that he had what we call thick phlegm LPF. I believe that it had developed from what we might call a food accumulation, or an accumulation disorder prior to that. I needled the points San Jiao 5 and Gallbladder 41. That is a combination I use for ear infections, because when we address the Shao Yang, it opens up the flow of Chi around the ear. That could be, in itself, the treatment for the ear part of the disorder.

I also added Bai Lao UB13, 18, and 20, as we know, because of the lingering pathogenic factor. I also prescribed Xiao Chai Hu Tang. The first days after the treatment, I got a report that the child was sleeping much better, which was I think a very important sign to see.

I’m running out of time, but I wanted to just mention a few formulas that we usually use for phlegm. Including Er Chen Tang, is an important basic formula for phlegm that we know. Sometimes you can combine that with Xiao Chai Hu Tang. I usually think of Er Chen Tang when I see a spleen deficient at the background of the phlegm accumulation. If there’s spleen deficiency at the background, Er Chen Tang is what I would think for.

Ban Xia Hou Po Tang, another really important formula for phlegm. The difference between that and Er Chen Tang is that Er Chen Tang is more spleen-y, and whereas Ban Xia Hou Po Tang is more liver-y. If the spleen is really deficient and is the cause of the phlegm accumulation, then we can use Shen Ling Bai Zhu San. Or, if there’s an accumulation disorder at the background, Bao He Wan is the choice. As I mentioned, you can check my variation of Bao He Wan in the motion herbs website.

There’s other two formulas I just want to mention that is related to cough. Qing Qi Hua Tan Wan is the famous phlegm heat, or sometimes called Pinellia Expectorant. That clears phlegm heat from the lung. That’s when you have a lot of this cough, which is productive with yellow phlegm. But, if there’s more phlegm dryness, we think of Bei Mu Gua Lou San as the formula for resolving phlegm and dryness.

I think that’s about the time that I have for this presentation. Thank you very much for joining me, and I hope we will meet again in our next session.

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Poney Chiang Thumb

Wear Your Heart on Your Sleeve: Neuro-anatomy of HT-4 to HT-7 – Poney Chiang

Hi, good afternoon. My name is Poney Chiang. I’m a practitioner of acupuncture and traditional Chinese medicine from Toronto, Canada. Welcome to today’s American Acupuncture Council live Facebook podcast show. I’m your host for today. And since this video is taking place on the week of Valentine’s Day, I thought I would do something fun and present something that is heart-related or heart region-related. So, let’s get started with today’s presentation.

The title of my presentation is Wear Your Heart on Your Sleeve. And the subtitle, Neuro-Anatomy of Heart-Four to Heart-Seven. It’s kind of a tongue-in-cheek idea that Heart-Four and Heart-Seven are very close to our wrist, so it’s very close to the sleeve and obviously because it’s Valentine’s Day, I chose to talk about the heart meridian.

The painting you’re looking at is the painting that was done in the year 1900, and it was painted by artist named Edmund Leighton. It is, as you can see, a princess or a fair lady tying a scarf or handkerchief to the sleeve or the arm of a knight. This is supposedly one of the origins behind the English expression to wear one’s heart on your sleeve, which of course means somebody who speaks their mind, somebody has no agenda, who is very direct. What you see is what you get. And here, this knight, by wearing the sleeve from the lady, from the princess, means that he is fighting for the princess’ honor. And therefore, he is identified as vouching or speaking or defending the lady pictured here in the painting.

What we’re going to do first is we’re going to look at the historical development of these points, particularly heart meridian points in the early classics. What I mean by early classics are works around the time of the Han Dynasty or shortly after. So, as you know, the LingShu or the Yellow Emperor’s Classic of internal medicine has two volumes, the plain question, which is the Suwen and the LingShu, which is spiritual pivot. And in chapter 10 the spiritual pivot we learn about the channel theory… And the channel pathways of the different channels on the body. And there is one paragraph that is focuses on the heart channel. Now in this paragraph, on the chapter 10 of the LingShu, entitled Channel Vessel, it says that there is a Luo Channel or what the classic described as a separation.

So if you look at the second bullet under it says “Pathway: the separation of the hand, lesser yin or shao yin is named Heart Five”. And so here we actually have a point identified by its name. Of course then there’s your classic, it would be called Tong Li, the Chinese name of the point instead of heart-five. It says that it’s located one and a half cun from the wrist, separates and course upwards, follow the channel enters into the heart, connects to the tongue root, joins the eye connection and so on and so forth.

Now if you are very good at point location, you might be scratching your head a little bit and wondering, hey, wait a minute. Tong Li, it’s not one point five cun, it’s actually supposed to be one cun from the wrist. So this is an example, a lot of discrepancies we see in the classics at the time of the LingShu, heart-five was actually considered a one point five cun on their wrist, as opposed to the way it is currently taught as one cun from the wrist crease.

But that’s another reason why I’m talking about this. That’s just kind of interesting trivia. I’m introducing to the idea that in the time of the suspicion pivot, we’re starting to have a little bit of introduction to certain points in the heart Meridian, and we know at least our heart file Tong Li is supposed to be in the heart meridian or the hand lesser yin meridian. But you may be surprised that very few points from the heart Meridian are actually recognize by name and location at the time of the yellow in person internal medicine. The only other place that hints at a location of a heart point from the heart Meridian is in the insert chapter 52. The title of that chapter is called Wei Qi as in defensive Qi and there they talk about, if you look at the fourth bullet on the page: the root of the hand shao yin, it’s at the tip of the sharp bone manifest at the back shu.

So here are the top of the hand shao yin, which is the heart meridian and that the root of this Meridian, it’s at the tip of the sharp bone. We modern scholars believe that the sharp bone refers to the pisiform bone in the wrist, in the carpals of the hand which has a bony protrusion and what I want you to notice is that they’ve located this point where we would consider a heart-seven but there’s no mention of shenmen or the name or the Chinese name for heart-seven itself.

And so what that means is that at the time of the Yi Jing, we only have one point for the heart Meridian mentioned by name and location, which happened to even be in disagreement with what is taught later on. And even heart-seven or shenmen, it’s simply just described by location and as names are not mentioned at all.

So that’s only a two out of the nine points in the heart meridian that has been passed down to us today. So the other seven points and not even mentioned by name or location. They don’t actually appear in the knowledge of Chinese medicine textual history until, if you look at the last final bullet in the Jia Yi Jing. This is the meta classic of acumoxa [inaudible 00:07:49] which is probably around the third century.

I put down eight points because heart-seven wasn’t actually mentioned by name. This is why it’s a meta classic where Jia Yi Jing considered the first complete acupuncture manual. There are points that are not described at the time of the of the yellow emperor.

This a nice little zoomed in view of the points on the wrist and the center of the photo is as you can see, heart-four, five, six, seven closely juxtaposed to each other. In fact, heart-seven is right on the crease line. Heart-six said to be half a cun from the crease line, heart-five is one cun from the crease line, and heart-four is one point five cun from the crease line.

And we just saw that even that is disputed because back in chapter 10 where the LingShu, they actually say heart-five is one and a half cun, which is where we look at heart-four today. So the reason why I decided to talk about the heart Meridian points in the wrist. You know obviously you tongue in cheek play on words about the one issue one wears the heart on one’s sleeve and it happens to be Valentine’s day.

But I love examples like this because it really highlights for us the specificity and the lack of redundancy that goes behind how ancient acupuncturists and who I like to call ancient anatomist pass down these points. A lot of people would ask me in my workshops is heart-four or five, six, seven just one point. Because one looks at them as so close and any reasonably educated person would ask that question, why would you have four points? That’s such a tiny little space. Now this is where the brilliance of the ancient acu-anatomist comes in. They pass on these points for very specific reasons is because in fact they are different anatomically. And this is the focus of our presentation today.

Before we jump into very new anatomical, I’d like to just acknowledge William Shakespeare in his work, the Othello at point scene 1. Is this the first textual? A record of the saying wearing my heart upon my sleeve. So there’s a character in the play, Othello’s play, who says that “when my outward action doth demonstrate the native act and figure of my heart in compliment extern, ’tis not long but I will wear my heart upon my sleeve, for daws to peck at”, daws are apparently some kind of Ravens and not what I am.

So if I am not consistent internally and externally I’m not what I seem to be, I am therefore not worthy and deserve to be pecked at by these ravens or and as such. So just in case you were wondering what the expression means and I like to share these kind of food for thought information. It gives a little more context and also helps give us some association when we think about these points.

Now we’re going to jump into the real anatomical and this diagram here comes from Grey’s Anatomy and I would like you to note that there’s two red boxes here on the very top of the page is the ulnar nerve box. And then in the lower box if you read closely, there’s actually two different branches here. One says superficial branch ulnar nerve, the other one says the deep branch of the ulnar nerve. So what I would like you to appreciate is that if you follow the deep branch of the ulnar nerve, you can see that it kind of plunges into the thin arm muscles. And then it actually kicks across towards the left side of the slide, that horizontal branch, that is as also labeled, it’s called deep branch ulnar nerve, it innovates the interior osseous muscles.

These are the muscles that allow you to abduct and adduct the fingers. And it actually makes it all the way into the abductor pollicis muscle. And that’s the muscle that allows you to abduct the thumb. So just another [inaudible 00:12:26] muscle. But because it’s associated with the thumb we call it abductor pollicis instead of interosseous pollicis. So all these branches become important because in a moment we’re going to see how brilliant ancient acupuncturists are in their knowledge of this anatomy and assign different points to each of these specific branches.

So in this video I’m going to show you the needle is inserted into heart-four, and heart-four is assigned the ulnar nerve trunk. Obviously you can stimulate heart, the nerve channel front, I’d say small intestine eight in the elbow, but at that level, the anatomy, it also innovates some wrist extensor muscles. But once you come distally to the level of heart-four it is sort of the first stop before it branches into this deep and superficial branches I just mentioned.

Now because it is superior to the deep motor branch, which I just described, innovates the interosseous muscles, when the electric stimulates that it would stimulate everything downstream of it. So including the superficial branch, which is responsible for the cutaneous sensation of the palmar in the back of the hand, but only for the median one half fingers. Okay, so according to ulnar nerve distribution, but unfortunately because the video cannot demonstrate parasthesia or tingling sensation that the subject is feeling. All we’re going to see is the motor aspect of this mixed nerve trunk at heart-four.

So when I play this video, you’re going to see that there is movement of the fingers. The thumb is moving. In fact, when they sustain a stimulation, what you can see is that there’s an opposition. So the thumb and fingers are coming together by virtue of contraction of the Athena and hypothenar muscles. Sorry, by virtue of the contraction of the hypothenar and abductor pollicis muscles, not the hypothenar muscles. That actually is in fact innovative of the meridian, not the ulnar nerve. I’ll play the video one more time, so you can see. But in addition to the motor aspect you’re seeing with interosseous muscles moving, this subject is feeding tremendous paresthesias or numbness and tingling into the palmar side of the hypothenar and also into the dorsal side of the median one half fingers.

So this color coded image is meant to remind everybody how the ulnar nerve and median nerve covers different terrain in the hand. If I can draw your attention to the left side of the slide, you’ll see the dorsal aspect of the hand. And you can see that in pink, that’s the distribution of the meat of the radial nerve. Now, whereas in green is a distribution of the ulnar nerve. But if you look closely at the dotted line that’s pointing to the back of the hand in the green section, it actually says the dorsal branch. So we haven’t talked about that branch yet. There’s a dorsal cutaneous branch that goes to the back of the hand, but only the one and half fingers. In some people it can be two and a half fingers. Okay. As you can see by the separation where the pink and green separates in the center of the middle finger in this diagram.

Now if I can draw your attention to the right side, now we’re looking at the palmer side of the hand, and you will notice that the palmer side is innovated not by the radial nerve anymore in Brown color. We see that is innovated by the median nerve. So the median nerve is in fact responsible for the palmer innovation, including the palm and fingers of the lateral, three and a half fingers. And then whereas in green you see that the ulnar nerve, if you look at where the dotted line is pointed to the palm, you’ll see that there’s actually two sections. There’s a cross hatch section closer to the heel of the hand that is labeled as the ulnar nerve palmer branch. But when we look at the dotted line as pointing to more kind of the ball of the palm, that is innovative as the ulnar nerve digital branches.

So all in all we have seen palmer branches, digital branches, dorsal branches. Let’s take a look at how these all perfectly super impose on these acupuncture points around the wrist. This slide talks about heart-five and heart-five is also the low point, which means that it’s supposed to connect into an exterior relationship. So the exterior relationship to the heart is there is none other than the small intestine the hand tai Yin. So as a point, it is supposed to traverse from the yin side of the wrist and hand into the yang side of the wrist and the hand going from in other words, the heart to the small intestine or from the shao yin to the [foreign language 00:17:38]. And now what’s very beautiful is that there is exactly a nerve branch of the ulnar nerve that does that.

If you look at the black and white photo on the bottom portion of the slide, you can see on the left side, I have two points as labeled heart-five and small intestine five. The dotted white line on the left side of the photo here represents the outer contours of the ulnar bone. And you can see that the ulnar nerve is labeled in white here with the arrow, is continued into the hypothenar, but on its way to doing that, we have this brand exactly where heart-five is located, where the red dot is on a slide. It branches towards small intestine five in other branches from the yin side to the yang side of the body. So this branch is called the dorsal cutaneous branch and it perfectly satisfies channel theory that is a low meridian point.

This is a dissection. That is from The work that we’d done, the nerves are not naturally yellow like this. They’ve been colored in by an artist to make it more easily visible. And so I want to just start by helping you orientate yourself. You look at the legend on the bottom right, you’ll see that the arrow pointing down is distal. Arrow pointing up is proximal. So imagine this is somebody’s arm pointing downwards and then the ulnar side is actually the right side of the slide and the left side of the slide is the radial side. Let me just help orient you again. This metallic probe you see towards the left side of the wrist here is lifting up the tendon of flexor carpi ulnaris to expose the neurovascular bundle of the ulnar nerve and artery.

In this slide here, C would be the flexor carpi ulnaris muscle. B is pointed to the neurovascular bundle and A is pointing to that [inaudible 00:19:53] branch that is now going to become heart-five. Just as an aside, [inaudible] is actually ultimately bifurcates and becomes small intestine six and small intestine five later on. But that’s beyond the scope of our [inaudible 00:20:08] and discussion for today. If I can draw your attention to heart-six, the arrow heart-six, you’ll see that it is centered over the vessel and we’ll talk more about that. And then heart-seven is on the wrist line.

What’s interesting about the heart-six is that this point has an unusual location. Remember I said these points other than heart-five was just identified by name or location in the special pivot. Points like heart-four, heart-six and seven are not even mentioned by name in the yi jang. So the first time that heart-six ever appears is in the jia yi jang systematic classic and its location is kind of unusual. If you look at the description at the top of the slide I’ve bolded it and highlight it for you in red. It tells us that this point is in the pulse behind the palm, five fen towards the wrist. A fen is a 0.1 cun so, five fen basically means half a cun. But it’s interesting is that is located at a pulse. Now if you can take a look at this black and white photo.

This photograph is taken from the article, The Nerve of Henle: An anatomical & immunohistochemical study for the general hand surgery. And these hand surgeons were interested in finding out more about the anatomy of the ulnar nerve. And you can see it labeled in this diagram here. A, if you look at the left side of the black and white photo, A is the ulnar artery, n is the ulnar nerve. But you see that there’s a star labeled. That star, see how I try for a case on the right side of the photo, that’s actually the branch that goes to the palm and if you remember the colored photo of the distribution of the nerves in the hands, I talked about a cross hash portion around the heel portion of the hand. That’s in fact where those three branches towards the right side goes through.

That’s called a palmer branch. But notice that they’re asterix in addition to the star in this photo and notice how those small branches that represent labeled by the asterix are actually intimately touching the ulnar artery itself. So the significance of this is that the ulnar nerve gives innovations to the ulnar artery. What kind of innovations? Sympathetic innovations, a type of autonomic innovation that controls the smooth muscles of the ulnar artery to control its vasal constriction. And that the classics is the meta classic, we’ve mentioned that this point is in the pulse is telling us that they are more concerned about stimulation of the rich autonomic fibers associated with the artery.

Now it is of no coincidence then that we have learned through pre-occurring experience and knowledge passed on by our mentors that heart-six is one of the most important points to regulate sweating inside of body together with kidney-seven. And why would that be? Because these points are intimately related, associated with the vessels and by stimulating the vessel you are stimulating the sympathetic aspect of the nervous system and sweating is indeed a part of our physiology that is controlled by the sympathetic nervous system. Isn’t that very interesting how the function and anatomy and the historical point locations all perfectly intersect.

The last point is heart-seven. If you look at the color photo on the bottom of the slide here, you’ll see heart-seven clearly labeled. But if you just look a little bit to the right of where heart-seven’s located, you’ll see that there are three branches, right? So the letter C is pointed to two branches that corresponds to the digital branches of the palmer side of the ring, the index and the pinky finger. And then there’s our breads B. That B branch is actually that deep motor branch, the one that actually innovates interosseus muscles.

We saw how stimulation of the the mixed nerve trunk, which contains a sensory and motor aspect. What activate the interosseous and adductor pollicis muscles. So the significance of heart-three or seven, my apologies, is that it is the beginning of the superficial branches of the ulnar nerve. I hope you can see that every single location differ slightly in terms of what nerve has already left the main trunk. So that there is very, very high degree of specificity in the rationale behind why these points are passed down individually and so close to each other.

So I’d just like to finish by giving you a little bit of clinical applications. Anatomy is interesting, exciting, but at the end of the day, that information is to give us more intention, clarity and specificity in our needling. And so we want to talk about how that can be used in a day to day situation. If you are familiar with the type of nerve entrapment called Guyon’s Canal Entrapment. If you look at the picture on the bottom right, it’s also called a handlebar entrapment it’s very common in cyclists that might press the weight of their entire upper body onto the heel of their hand. And as you can see if on the red little lightening symbols, that’s where the pressure and people can feel a nervy electrical sensation. And so if you have some understanding of the… it can differentiate diagnose this type of entrapment.

One way for you to deirritate and improve neural conductance, restore proper neural conductance back into his nerves because it was impeded by pressure. You can needle points like heart-seven, points like heart-four and apply electricity to help deirritate this nerve that has been impinged. One situation that often used the heart-four point for is actually is for restoration of fine motor function. This can happen in patients who have multiple sclerosis. This can happen in patient who has suffered a stroke and they lose the ability to do fine opposition movements and I have found that electrical stimulation of their mixed nerve trunk allows a reactivation of the interosseous muscles and the adductor muscles and hypothenar muscles so that patients can increase their motor control or motor activation of these muscles so that when they do occupational therapy exercises or hand specific fine motor exercises or games, they are going to get more out of those exercises because now the nervous system is firing at it’s optimal efficiency.

Heart-five, it’s name is called Tongli which translates, that’s penetrating interior. It’s traditionally associated with the treatment of aphasia because as you know, the heart orifice is the tongue and the channel theory pathway tells us that heart-five has control and dominance on the heart. But because these points are so close, heart-four to seven, how do you know you actually stimulate heart-five? What if you stimulate heart-seven instead, right? Heart-seven stimulation would feel like palm numbness and parasthesia in the pinky and the ring finger and the palmer side. But whereas heart-five there’s just sensation or parasthesia, ought to feel like numbness and sensation on the dorsal side because of the dorsal cutaneous branch that covers that territory.

So if you are really wanting to use this point to benefit aphasia and tongue and speech and so forth, or to just open the lower vessel, the proper sensation needs to be parasthesia and numbness on the dorsal part of the hand as opposed to the Palmer side of the hand. Finally, heart-seven is called shenmen or a spirit gate, is associated with calming the nervous system. And we already talked about how things like… Points like heart-six because close association to the vessel as very rigid RNI fibers. We saw that how we can conceptualize how that can have effect on sweating, which is a sudomotor response where they get regulated by the automatic nervous system. But similarly heart-seven being able to calm their shenmen, helping insomnia means that by regularly the automatic nervous system is somehow puts the body into a parasympathetic state to improve various type of autonomic dysfunctions.

I want to finish that up this last slide as example of how to use this for a neuro rehab situation. So what you’re still about to see is a patient who has multiple sclerosis at a time that she saw me in the clinic, it’s been about four or five years. She’s developing a lot of spasticities. She has some drop foot happening and upon physical examination we noticed that she was losing fine motor dexterity of her hand. So the top video I will play to you, will demonstrate to you that she’s been instructed to open and close her fingers. The effected side is her right side and then she’s instructed to open and close her fingers. Then she’s going to be instructed to abduct and adduct her fingers. And you can notice that there’s some contracture in the index and middle finger. That’s her attempt to abduct and look at how well the left side works.

The right side cannot abduct at all. And now she’s shaking out her hand because you’d probably be embarrassed. Okay, so just play that one more time so you can just compare for yourself. I’ll stop talking. There’s not much abduction and adduction of the fingers whereas the left hand side is completely normal. And this is important because the deep motor branch of the ulnar nerve is that responsible for the innovation of those interosseous muscles. And so what I did is I put needle heart-four, apply electrical current and because heart-four is the mixed nerve trunk, it will get everything downstream. They’ll get the sensation on the palmer side, on the dorsal side. You’ll get the deep motor branch, you’ll get the supervision branches and immediately after the first treatment and there is that. Now the ability abduct and adduct the fingers is immediately improved.

And that just goes to show you how adaptive are plastic our nervous system is even for something that’s been going on for several years. One treatment, as long as you’re able to have high specificity, you can really do a lot to help these patients. So that’s all I have prepared for you guys today. I hope you enjoyed that. I hope you learn something interesting about the heart points around the wrist and that they are in fact not the same point. They are very, very specific information that ancients have passed down for us. I hope that inspires you to review anatomy. Because I firmly believe that the more you understand neural anatomy, the more specificity you can have with your needling and then the better outcome you can deliver to your patients. Thank you very much everybody for listening. I wish you have a happy Valentine’s Day and don’t forget to join us next week. Our speaker for next week is Sam Collins. Thank you.

Please subscribe to our YouTube Channel (http://www.youtube.com/c/Acupuncturecouncil ) Follow us on Instagram (https://www.instagram.com/acupuncturecouncil/), LinkedIn (https://www.linkedin.com/company/american-acupuncture-council-information-network/) Periscope (https://www.pscp.tv/TopAcupuncture). If you have any questions about today’s show or want to know why the American Acupuncture Council is your best choice for malpractice insurance, call us at (800) 838-0383. or find out just how much you can save with AAC by visiting: https://acupuncturecouncil.com/acupuncture-malpractice-quick-quote/.

Sam Collins for HJ Ross

Medicare and Acupuncture 2020 American Acupuncture Council

Hi, everyone. This is Samuel Collins, your coding and billing expert for acupuncture at the American Acupuncture Council, our seminars, our networks, and all that. And I welcome you to another program of To The Point. In fact, let’s do that. Let’s get to the point. My goal, as always, is to make sure to give you information that’s up-to-date, current, and keep your office practice going strongly.

So what’s going on? Well, of course, what’s going on right now, of course, is Medicare. And of course, Medicare and acupuncture has had a lot of confusion, and I want to clear up that confusion and kind of give you some insight as to where you can fit what we can do and what we can do for the future. So where are we going with Medicare and acupuncture? Well, let’s take a look, go to the slides.

So we start off with just simply Medicare and acupuncture. Always know that my email is here for you as well. But let’s talk about what has occurred for Medicare. July 15th of last year, the Trump administration proposed a plan to cover acupuncture for Medicare patients with chronic low back pain, framing it as a step that could more safely treat pain without supplying patients with opioids. And of course, this is kind of what happened because of the VA. Opioids have become a big problem. They’re looking for something else that can be helpful. So credit to that, we’re working towards a proposal.

So this is what happened in July. The Trump administration proposed this for patients with chronic low back pain, so they could safely treat without using opioids. Okay. So what does safely treat mean? Well, acupuncture. The proposal released, though, would only be for patients enrolled in clinical trials. So this is what initially happened, just clinical trials and under the National Institute of Health. In its statements, CMS acknowledged the evidence base for acupuncture has grown in recent years. However, questions remain.

So what they did was they said “We’re going to open up a dialogue,” and they allowed everyone to send in information to see whether or not it would be helpful. And the idea first, and as I was told by many people in NIH, it was solely going to be just a study. They were going to put a few people in a clinical trial. Well, after all this information, lo and behold, I put fireworks here, January 21st, what I thought wasn’t going to happen happened.

But I’ll give a note. Marilyn Allen, who many of you may be aware of, and I had spoken with a few people at NIH that said something the week before. They said, “When you get acupuncture.” They didn’t say, “If,” they said, “When.” And we thought that was a little puzzling because we thought, “Okay, it’s going to be a study. We have to see where it’s going to go.”

Well, what happened on January 21st is they made this announcement. “The Centers for Medicare and Medicaid services finalized a decision to cover acupuncture for Medicare patients with chronic low back pain. Before this final National Coverage reconsideration, acupuncture was nationally non-covered by Medicare. CMS conducted evidence reviews and examined the coverage policies of private payers to inform today’s decisions.” So what they did was they got enough information from private payers and others to just decide, “We’re going to cover it.” They didn’t need to do a study. They’re just flat out going to cover it for chronic low back pain.

So what does this mean for us? Well, the decision regarding coverage takes into account the assessment benefits and the harms of opioids. It says, “While a small number of adults age 65 or older have been enrolled in published acupuncture studies, patients with chronic low back pain in these studies showed improvements in function and pain. The evidence reviewed for this decision supports clinical strategies that include nonpharmacologic therapies for chronic low back pain.” While there is variations in indications, the bottom line is they said, “No, we’re going to cover chronic low back pain for acupuncture.”

This decision was published in a memo, if you will, and it’s the CAG-00452N, so if you want to look it up. But here’s it in a nutshell, and what it says is this. “The Centers for Medicaid & Medicare Services will cover acupuncture for chronic low back pain under section 1862(a)(1)(A),” which is the Social Security Act, that will cover up to 12 visits in 90 days covered for Medicare beneficiaries so long as the following circumstances are met.

For the purpose that means chronic low back pain is defined by Medicare means it’s lasting longer than 12 weeks, so you’ve got to make sure in the chart notes and history, this patient didn’t just wake up with back pain, but it’s some back pain they’ve had off and on for 12 weeks or greater.

It’s nonspecific that it has no identifiable systemic cause, not associated with metastatic inflammatory infections or other diseases of course, not associated with surgery, and not associated with pregnancy. Now, I will say this, I doubt we’re going to have very many 65 year olds with pregnancy, but that of course is based on some of the other guidelines.

However, beyond the 12 visits they will authorize within in the first 90, an additional eight sessions will be covered for those patients demonstrating improvement, but it says no more than 20 acupuncture treatments may be administered annual. Bear in mind that these 12 visits or initial 12 visits are within 90 days. If you use those up, you certainly could get approved for more. The exciting part here is that the acceptance and how quickly it was to deal with acupuncture and low back pain.

Now, some of you are aware, I have a chiropractic background, but technically if you look at some of the studies, by a small percentage, acupuncture has shown potentially greater outcomes for back pain than does chiropractic adjustments alone. That being said, it also indicates treatment must be discontinued if patient is not improving or regressing. Well, here’s the good news. When someone comes to an acupuncturist with back pain, generally what happens within one to three visits, they’re already showing some levels of improvement. So I don’t think it’s going to be very difficult, though you want to focus on two things: pain reduction and increase in function.

Now, in general, this is the guideline under section 30.3 for acupuncture in Medicare that never covered it. And it says, “Acupuncture,” of course, “is a selection and manipulation of specific acupuncture points.” And it says effective for dates of service January 21st. So actually, when did this begin? January 21st.

Now, the good news is yes, but there are some restrictions, and this is what most people assume that maybe an acupuncturist could bill directly. Well, let’s talk about what is the billing provider versus the performing provider? Because under this provision, this still does not give any indication that an acupuncturist can join Medicare. That’s something that’s going to require an act of Congress. But the billing provider must still be a provider that’s enrolled in Medicare. So that’s going to be a physician as defined by Medicare, which means essentially an MD. So a physician as [inaudible 00:07:08] by 1861 is going to be your medical doctors within their state requirements.

However, it’s also going to allow physician assistants, nurse practitioners, clinical nurse specialists, and other auxiliary personnel to furnish acupuncture if they meet the applicable state requirements. So remember, acupuncturists are going to fit under this auxiliary personnel, which means yes, you can work on Medicare, but under the supervision or direction of the MD as so long as the person, and this is the nurse practitioner, has a master’s or doctoral level or degree in acupuncture or Oriental Medicine by an accredited school or a current, full, and active, unrestricted license to practice in a state or a territory of the United States.

In other words, they must be a licensed acupuncturist, if not an MD. An MD can do acupuncture should they choose. Obviously, most won’t. They’re going to refer to someone. So that referral could go to a nurse practitioner, but of course, the nurse practitioner can only do it if they also are licensed for acupuncture. Therefore, this is the opportunity for acupuncturists to work within an MD setting where the MD prescribes, the acupuncturist performs, and it’s billed directly to Medicare.

Now, auxiliary persons performing it must be under, and I’ve underlined it, “the appropriate level of supervision.” Now, what’s important to see here is this distinction. The term “appropriate level” is a little bit different from what others will often state. Generally, what it’ll say is “direct supervision,” and of course, it needs supervision, but “appropriate level” doesn’t mean that you need as much intervention by the doctor, if you will, the medical doctor in order to provide the service. That’s going to still be more up to the practitioner of acupuncture.

But this can be the supervision, bear in mind, of a physician assistant, a nurse practitioner, or a clinical nurse specialist. So this certainly could be an opportunity where you may have a nurse practitioner that practices with an MD overseeing them, but then has a separate business where you work with them, either they come to your office or you go to theirs, and can furnish these services.

The bottom line is the type of supervision required was changed at the request of the acupuncture profession from direct to appropriate level. This accommodation adds a tremendous amount of latitude for collaborative agreements between LAcs and MD providers or even DOs, nurse practitioners and all. While nurse practitioners and clinical nurse specialists and physicians assistant may not practice acupuncture, their supervisory availability also vastly expands the potential for collaborative agreements, which means it doesn’t necessarily need to be an MD. It could be under a nurse practitioner, physician assistant, and so forth. So it means you don’t necessarily have to work directly for an MD but might be working in a clinic setting where there’s a nurse practitioner or other type of provider that can be registered with Medicare.

The difference here, though, is it’s obviously, an acupuncturist cannot bill directly, so you’re going to hear this term a lot called “incident to.” So in order to bill acupuncture, an acupuncturist must be working incident to this provider. So what does “incident to” mean? It means the service must take place in a noninstitutional setting, which in simple terms means not in a hospital. Number two, it must be a Medicare-credentialed physician that must initiate the patient’s care. So we have to make sure the supervising personnel, if you will, examines, determines, “Yes, I believe they can be helped by acupuncture.”

Subsequent to the initial encounter to which the physician can arrive at the diagnosis, this nonphysician practitioner, meaning auxiliary personnel, may provide the follow-up care. So then the acupuncturer does their work, and then once every thirty days or approximately thereof, this supervising person will just check to see how the patient’s improving or not improving.

Then the next step is the care must occur with direct supervision or the appropriate level. Per the Benefit Policy of Medicare, what does that actually mean? Does that mean you could have someone just give you a referral for acupuncture and you do it in your office? The answer to that is no. Direct supervision in the office setting does not mean the physician must be present in the same room with his or her aide or auxiliary personnel. However, the practitioner must be present in the office suite or immediately available to provide assistance and direction throughout the time the aide is performing the services.

So now this is going to get a little bit different here because notice it says, “Immediately available.” For instance, under auxiliary personnel such as a nurse practitioner, it doesn’t necessarily mean in the office. Under this guise, I’m going to state at this point, you want to make sure you’re working with direct supervision, they’re in the facility, and I think you’re going to be at your safest bet.

However, Medicare will begin paying for acupuncture. And I have not any practitioners yet, but I certainly have a few that are already working with the MD setting, so I’m waiting to see the bills come in.

Ultimately, this. The physician or the supervisor must be actively participating and must be working in the management in the course of care. They can’t just prescribe and not be involved at all. Both the credentialed and physician may qualify for this incident to so long as you’re employed by the group. So remember, you’re going to be working as an employee in some way to this person. You’re not going to be working as an independent contractor. In order to be supervised, you have to work as an employee. Independent contractor means it’s billed under your own name; therefore, that’s not going to fit here.

Now, is this as good as everyone was hoping or wanting? I would say not. However, bear in mind this. This was only supposed to be a study, and it started in July, but by January they decided, “Nope, we don’t need the study. We’re just going to cover it.” So I see this as neither a slight to the profession nor an error in any way. Provider types outside of Medicare are by the CMS definition of auxiliary personnel, must be supervised by Medicare providers. But remember, it doesn’t necessarily have to be an MD. This is the maximum freedom that can be granted until the Social Security Act is amended to include acupuncturists.

Now, here is the big problem for us. We need to make sure that acupuncturists, by an act of Congress, can become providers under Medicare. Once that happens, there will be direct billing, and I think that certainly will be the area that we’re looking towards that’s going to be more cost effective. The bigger issue for us, though, the power does not rest with CMS as much, it rests with our profession and dealing with Congress, meaning we need to make sure as a profession we have some type of national certification where we make sure that they can be trusted, that these services are under a guideline that’s standardized on a national level. Not to say that you can’t do things differently, but that we’re going to have to have some national standards, if you will.

The excellent news here is that they’re going to cover acupuncture. Now, some people are going to wonder, “Well, what do they mean by cover?” Well, they’re going to cover the acupuncture codes themselves, meaning they’re going to cover 97810 to 97814. And you may question, what would be the prices of these codes? Well, to give you an idea, the Medicare uses a conversion factor for their codes. The conversion factor is roughly between 37 to $40 depending on the region you’re in, and they base it on the relative value unit. The relative value unit for manual acupuncture is about 1.03, and for electroacupuncture is about 1.15, which means you can assume the first set is going to be paid somewhere in the $40-plus range, the additional sets likely in the $30 range. For many of you, that generally is going to mean what you’re seeing for VA in many instances.

This is a real great step forward, but I do want to warn that it is not for direct billing. We still cannot join Medicare. However, what about working collaboratively? What about talking to some MDs in your area where possibly you work in their office a few hours a week or even just a few hours a month, if you will, to start treating some of these patients to see how they’re doing? Remember, Medicare is a big insurer. Everyone over 65. And how many people that have Medicare probably have a little back pain? It’s a tremendous number. And what they’re trying to do is to give persons an alternative.

Here’s what I will say. Acupuncture works well. Once we start getting more and more of these services provided, you’re going to see where Medicare is going to come on board, allow acupuncturists to join and bill directly. But as of now, what about working collaboratively? So is Medicare perfect for us? No. But think of this step. Who could have imagined even a few years ago that this would have occurred?

I want to thank you for spending some time with me. Please take a note, if you go to our website, the American Acupuncture Council Network, and go to our news section, we have this information and much more on upcoming changes and things happening with coding. I suggest go there, sign up for our email service. What we provide are lots of news items.

I’m going to give you a couple of quick items that are occurring. UnitedHealthcare is requiring modifier GP on all physical medicine codes regardless of the profession. As of note for any practitioner in the New York area, New York Empire is also now beginning this GP modifier. And as I’m sure you’re aware, the VA is doing so as well. In addition, of course, things are changing for the VA. Of course, on the East Coast, they’re now using a company called OptumHealth. The West Coast continues with TriWest.

As always, we want to be the most effective place for your information. Take a look at all of our sites. And I welcome you to always come in and say hi to me. Also, coming up next week will be Moshe Heller. And I wish you all the best, and continue your practices strong. We want to be with you and To The Point. This is Sam Collins.

Please subscribe to our YouTube Channel (http://www.youtube.com/c/Acupuncturecouncil ) Follow us on Instagram (https://www.instagram.com/acupuncturecouncil/), LinkedIn (https://www.linkedin.com/company/american-acupuncture-council-information-network/) Periscope (https://www.pscp.tv/TopAcupuncture). Twitter (https://twitter.com/TopAcupuncture) If you have any questions about today’s show or want to know why the American Acupuncture Council is your best choice for malpractice insurance, call us at (800) 838-0383. or find out just how much you can save with AAC by visiting: https://acupuncturecouncil.com/acupuncture-malpractice-quick-quote/.

Yair Maimon thumbnail

The Spark and Evidence of Acupuncture


Hello, everybody. My name is Yair Maimon. I want, first of all, to thank the American Acupuncture Council to be kind to put up this show. It’s the first show for me on this platform, so it’s great to be here. I’ve called the show the Spark and Evidence of Acupuncture. Later, you will see why. I think I want to focus the show a lot on the evidence and on the confidence we should have in this medicine, but even more on the spark, I think on the uniqueness of Chinese medicine.

I’ve been a student and an inspirer of Chinese medicine for over 30 years. So it’s quite a while. I’m doing different things. My interest in is on two extremes. One is cancer, where I’m a head of a cancer research institute in the biggest hospital in Israel, in Sheba Medical Center, when I researched the effect of herbal medicine even to the molecular level, both on cancer and the immune system. I’ve published more than 20 peer-reviewed medical journals, so papers. So you can read them up. Although this show, and especially today, will be focused more on acupuncture, but also on the clinical thing.

I’ve been teaching also worldwide, I think, in the last more than 20 years. I have also my own clinical center in Israel, I’m from Israel, where we are about a group of 20 practitioners working together. I must say that, still, the practice is my passion, although teaching and researching all building up the full approach and understanding of Chinese medicine.

So I’m glad to be on this special show and share with you some of my experience, which I hope you will find useful for yourself, for your own clinic today or tomorrow. The idea is really to do a practical and in the same time I hope a little bit magical show. So I’ll put some slides. So please can you put this first slide on? That will be great.

This lecture is called What Do You Do When You Don’t Know What To Do? I chose this topic for a reason. I’ve been practicing, as I said, for 30 years, and I think it’s almost a daily phenomenon, not just for acupuncturist but for any healthcare provider. There is a lot of situation when you don’t know what to do.

So I set up on this small mission of asking colleagues who are at least 15 years in practice. I’ve asked 25 colleagues what they do when they don’t know what to do, and try to conclude something from my experience and other people’s experience. I’ve put it eventually all into one presentation and divided it a bit, I hope, in a special way. I took, I can say, the essence of what my colleagues are practicing Chinese medicine for many years, have kind of were willing to share.

I think, as we know, it is a great clinical dilemma. One of our problems is to move from uncertainty to certainty. We wish sometimes in the clinic we’ll have this kind of crystal ball that can look into the future. If we’ll do this point, this will happen. If we’ll do another point, this will happen. Therefore, let’s choose this one.

But that’s not the clinical reality. We have to take the pulse, check the patients, and then decide upon the diagnosis. What will be the best treatment and the best way to do it? We’d love to be certain. As I say, I put a dice, yes, no, maybe, on each dilemma, but this seems not seems to work.

In western medicine, it’s much easier. As I said, I’ve been all my life also in western medical setups. The thinking is linear, so there’s a much more comfortable solution, like in oncology, one of the fields that I’m excelling in in Chinese medicine and working in Chinese medicine.

In western medicine, eventually there is a diagnosis, there is a protocol, and there is some comfortability about it, which is very different to the way in Chinese medicine, because in western medicine, once you have a diagnosis, you have a protocol, and you proceed in what seems the linear way, which makes the physician comfortable and more feeling certain.

In Chinese medicine, the situation is very different. We’ll look at system, we’ll look at a much wider picture. So for us, there is much more options to make a clinical decision. This is really what the lecture is focusing on. In this kind of what seems to be very open space, how do we make the best clinical decision for patients, especially when we feel that I would say not uncertain, but we feel we don’t really know. We don’t have a final decision of what is the best to do.

I divided this lecture on purpose to three levels, to heaven, man, and earth kind of approach, because in the science of Chinese medicine, we divide things to a number, to one, two. When we reach three, we are really on the place of men on earth and we are on the real dilemma of human life. So in a man situation, we are between heaven and earth making our decisions.

As you will see, when I looked at the three layers of approaching this uncertainty, there will be a different answer. On a heavenly level, there’ll be an answer which more relates to the dao into a path. On a man level, more to the movement, into the qi. And on the earth level, more in material solution. Sometimes we need all of them together. Sometimes we choose one solution to the situation in the clinic. Therefore, we can look at the shen affecting the shen or affecting the qi or affecting the jing.

Each one has a different play in the clinic, and usually we are trying to affect this model, the three layers model, and get the best benefit to the patient. That’s why the shen, qi, and jing are called the three treasures.

When we manage to put them all together, we have a three-dimensional picture of the patient. I always say when you look at the past, then we see all the problems and pains that the patient bring. When we look at the present, we look at their symptoms. But when we look at the future, we look at their healing. So when we can put past, present, and future together in the clinic at one point, we are reaching the depth of treatments and the depths of human experience.

So let’s start with the solution of what do we do when we don’t know what to do in a heavenly level, on the shen level. That means that on that level, we’re allowing a presence of the shen, because for us, shen is one of the five substances in Chinese medicine.

So the spirit to us is not something strange or unreal. It’s a real essence of the body. It’s the most young, the most strong, the most effective, the one that connects us to oneness into the strongest abilities. Therefore, it’s present in the clinic and it’s present in creating healing. It’s definitely one of the key things.

When we are reaching the level of the shen and we don’t know what to do, we listen and we wait. We allow something which we understand is the dao, or the dao or the path of the patient to be present. We do, I think, the most interesting waiting. To me, the Chinese science present I think one of the most mind-blowing idea, is you do nothing. Wu wei means doing a non-doing.

So in a way, when we want to look deeper, we allow this moment of just not being involved, of just being present. In the clinic, it happens many time when I tell … And every practitioner is always … Have this experience. You decide on a certain point, you get to the patient, and you do something else. You realize that this change was exactly what the patient was needed.

So this doing a non-doing, it’s a new concept for us as western people, but it’s embedded in the core of Chinese medicine and Chinese medicine thinking. So on that level, we listen and wait. We allow something of the presence, the presence of the patient, his own path to be there. We’re just waiting.

Waiting is not just a Chinese medical idea because to me wu wei’s the source and essence of Chinese medicine. I took this slide and put also Bion [inaudible 00:10:23], who was a psychologist talking about nonverbal communication, and very much focused on this aspect of just seeing and listening and being present in a nonverbal way, which is strongly affecting the clinical situation. He called this book A Beam of Intense Darkness, because we always talk about light, but actually darkness allows everything to come out and appear in it.

So to me this idea is very strong in the clinic because when I don’t know what to do, I must say my own first thing is just to sit and wait, to put this beam of darkness or to put this endless space and to see what is coming up, and always something will come up.

But this practice, I think it’s one of the best way to start when you don’t know what to do. Instead of convincing yourself, “Oh, there is dampness, there is cold,” or something that you see in the patient and immediately jumping on a diagnosis when, in reality, there is a lot of option at that moment, and we don’t know which one to choose from.

So on the shen level, I think getting this inspiration also from the nonverbal communication, just waiting there, is perfect. I teach a lot what I call one minute diagnosis, because there’s so much we see in one minute. This is the one minute that we allow the whole complexity of the patient just to be present there and us being totally empty and trying to understand and connect and seeing the whole full layers of the patient.

A lot of time in this space, we move from uncertainty to certainty. We move from this deep darkness. Everything is possible into light and into something very specific. This space is a very healing space because in the silent, something comes up. This thing that comes out in the spur of the moment is probably a key for the healing and for the treatment.

A healing environment is very sacred and special. If it allows something happens there, sometimes we know what to do. It’s like almost obvious that this lecture focuses on this space, which is always important to hear, but definitely important when we want to see what’s the most core to the patient at this point when we treat him.

So to summarize this level and the way we can approach it is we start from darkness. We still remain uncertain, and we are fine with it. That’s not always easy to remain fine with uncertainty. We don’t move to certainty. We will use wu wei. We are not doing anything and we are not expecting anything. We’re not putting any pressure.

Then the second step usually comes. There is some movement to light. There is some kind of something that is emerging and coming up. I call it an insight and, a new word in English, enlight. Suddenly something emerging and suddenly we have some certainty in the direction of what to do.

This is really a place when we stay in stillness and something emerge and we approach it or we allow it. To me this level is one of the core levels when we don’t know what to do, and to allow this level in a kind of very, oh, we say almost scientific or didactic or diagnostic way, because we live in the western world. Everything needs to be certain, and uncertainty leaves us a kind of suddenly uncomfortable. I think that allowing this uncomfortable feeling and emerging from it with healing is the key for the level of the shen.

Now we’ll move to the second level, to the level of man. So to the level of man, we move to qi and we move to the movement of qi. In a basic way, when we move to this movement, I got a lot of response from the people I interviewed, and then they realize that a lot of great masters actually created different formulas to what to do and they don’t know what to do, or create different formulas of points that are moving the qi, harmonizing the qi in a very wide way that allows healing.

So when we move to the second level, I actually look upon different masters along the history of Chinese medicine, and I will present some kind of idea from us to tung and maybe even stop with the four command points.

The four command points are very simple and very easy. We can easily understand them. They are each directed to an area. Like we do stomach 36, if there’s something in the abdomen, if there’s something in the head and neck, you do lung seven. If there is a back, especially lower back, bladder 40. If there is something in the face and mouth, you do large intestine four. So you don’t know what to do, but you know these points will guide you to an area or will move qi in an area.

Therefore, it’s a good place to start when you don’t know what to do, because sometimes it’s like peeling an onion. We just move the qi, we peel this first layer, and then something deeper emerges or better clarity comes.

There’s two additional points usually for the four command points. For the chest and the heart, pericardium six. For fainting and collapse, actually also for lower back pain, DU-26. So this will be like a set of point. When you don’t know what to do and you want to move a qi in a certain area in a larger way, this is a good resource to start with in just generally moving the qi.

I looked very deeply at the five points, the 10 needles that Professor Tung suggested, and Miriam Lee, who was one of the first practitioners actually in the States, who was a very, very active practitioner, she saw about hundred patients a day and mainly treating just with this formula. This is the formula that she was using. Very known point, but if we go deeper, very clever point.

I think with acupuncture, we can be very elaborated with points. I’m doing a project, learning the points in depth, but sometimes using a simple point when we know why we are using them is extremely powerful. When we use them all the time, I think we are losing the sense of acupuncture and the fine-tuning of needling. But this lecture more focuses, you don’t know what to do, so this is a very interesting prescription.

It’s not superficial. It allows harmonizing the qi on that level in many ways. So stomach that is six, spleen six, large intestine for large intestine 11, and lung seven are the points of the five points and there’s 10 needles that can be used.

I’ll go very quickly point-by-point to explain how they are combined together. Sometimes we can use the whole five or inner combination, obviously with additional point, a bit like what we do in herbal medicine.

I’ll start with spleen six. Obviously, everybody know and use this points. It’s the meeting of the three yin of the leg. This point, if you look at the combination of them, we’ll see that the sum of the combination will be lung and spleen. We have stomach 36, spleen six. We have large intestine and stomach. So we have TaiYin and we have YangMing. So we have large intestine for large intestine 11 and lung seven. So we have this TaiYin, YangMing combination. We have a specific earth yin and yang combination and metal yin and yang combination. So we have both the qi, the yin qi and the wei qi presented in this combination.

I’ll briefly introduce my two colleagues there, Rani Ayal and Bartosz Chmielnicki. Together, we formed the group called the CAM team. We are producing the special book called The Gate of Life. The Gate of Life book goes deeper into the understanding of acupuncture points with a painter from Poland, Martina [Yankee 00:18:54]. She is painting these points.

Actually, here you can see the whole picture. This is a meridian, so all the meridians are painted. This is the spleen meridian. As you can see, it will start with spleen one and slowly, slowly we go through different points to the point that we are talking now, spleen six, when we have the three yin meeting.

Here you can see them. You can see the three yin women meeting and all the interaction with other meridians, et cetera, and turtle because it’s to do with the deep aspects of yin. I won’t go into all the symbolization, but just to give you this general sense of this book and the points. Probably in future shows, I’ll show some more pictures and going into different less known points and try to explain the dynamic of qi there.

So as we know, spleen six has a very strong dynamic. It both works on postnatal qi, working on the blood and damp. It’s connected with the liver and the kidney. So it will move blood. It will work on yin and jing. So we get a wide variety of effects on the body just using this point, when we don’t know what to do and we … Or we want to affect an area rather than a specific diagnosis. So we are moving from working on a specific diagnosis into affecting a whole area.

It will work on the lower jiao and the energy and everything that’s on the lower part of the body and, specifically this point and especially when combined with the stomach, will also affect especially the dampness in the lower jiao.

So this tung combination, when we look at this point, will be stomach 36 and spleen six working on earth. But not just working on the earth element, but also stabilizing, vitalizing the earth, affecting digestion in a big way, affecting the metabolism of fluids and dampness.

So you can see there’s already inherent combination that works on earth, and another combination that works … So it works on earth and digestion and another combination that works on breathing. Obviously, when we come to life, the first thing we do is we breathe and we need to eat.

So this combination affects this two fundamental aspect of postnatal life, of digestive system, and of the lung system. The combination of spleen six and lung seven will affect breathing and will affect the wei qi. We work also on the RenMai meridian in this respect. So from the tung combination, you can see how wide it is. The same with large intestine four.

I won’t go into each point in too many details because I think some of the points are more familiar, but it’s yuan point, so it’s a command point that affect, as we see, the face and mouth. It’s also a LU point, so it works closely with large intestine four, lung seven. Again, a great combination.

So we’re slowly moving into this tung combination system, and understanding this inner combination of large intestine four and lung seven, like this two command point, releasing also exterior, working on wind, working on the sweat. Our large intestine four and large intestine 11 working on the head, face, also affecting all the orifices and also releasing heat.

So you see how this tung combination, the deeper we go into it, the more and more we see how clever it is and how it affects so many aspects when we don’t know what to do, or sometimes just because there’s a lot of things present, and we want to affect all of them.

So large intestine 11, being in earth and he, uniting point, and taking also heat and affecting deeply the metal and the large intestine. Large intestine 11 and stomach 36 tonifies the qi and blood. It’s the Yang Ming meridian, which is so rich in qi and blood and, with large intestine four, also taking heat out. Again, you can add another points like Du-14 if there is extreme heat. Lung seven, one of the almost last points that I want to present here, again a luo point, opening of the RenMai. In a way, we are even tapping an extra meridian system.

Lastly, we are moving with stomach 36 into this kind of final part of this combination, looking at stomach 36, which is an earth point. But it’s not the normal earth point. It’s an earth point of the earth. I think this is the key of understanding this point.

By the way, this is the picture from our book. It always remind me because when I look at a picture, when I was taught stomach 36, suddenly everybody was saying it’s a three li. If somebody is tired, you puncture this point, and there’s the story. People can walk another three miles, three li. But in reality, the three li have different meanings. One of the li is like a small village that can sustain itself. So three lis is actually three villages that can sustain themselves. It talks about the vitality in this point.

Also, it talks about the three parts, as we can see here, of the abdomen, which are the avenues of the yuan qi that goes to the triple warmer. The three li can also refer to this very deep vitality in the body. But obviously being the earth of earth is the reason why this point is doing so much and it has so many indication, clinical indication.

So we looked at these points, and now I would like to move to the last part. We look at the shen part. We look at moving the qi in a general way, like in one combination, I think, which summarize it nicely and, the last one, through stomach 36, we move to the earth level.

Tapping into the yuan qi, tapping into the earth and the fundamental part of living on earth, because all the elements are surrounding the earth. So whenever we use points of the earth element, especially the yuan source points, we are really helping to stabilize human on earth and we are able to tap on some deep authenticity. We are able to tap on the resource of both qi, blood, and jing to help the patient to recover and regain health.

Stomach 36, that’s the reason why this point is so effective. As I said, it’s the earth of earth. Otherwise, there’s no other explanation why the use of this point is so strong and so critical. Then if you look at all the yin points on the yuan points on the yin meridians, the zang meridian, all of them are earth points and all of them are soul-balancing points.

Again, when we don’t know what to do, yuan points will be the first one we will consider affecting directly the element itself, but also deeply the qi and the yuan qi. Here I’m just showing a simple combination. Liver three, stomach 36, lung nine, all earth point. So we work on this axis. The same way can be heart seven and kidney three with stomach 36, working on the creation axis. So both we can work on the formation or creation axis, just using yuan points, and achieving something very deep.

So to finalize, when we don’t know what to do in the clinic, we can relax. Nothing is under control. It’s a normal situation. But I think if we follow this kind of deep logic of looking at shen, qi, and jing, something unfolds. Then we move from uncertainty to certainty.

So I would like to thank you for watching this. I hope you enjoyed it. Be well. Thank you very much. All the best to you. I want to add maybe some … I can stop the slideshow and maybe just add some final note.

First of all, I want to mention that next week on this show, there’ll be a good friend of mine, Moshe Heller. Also, you can follow the next shows that I will do on the American Acupuncture Council. I hope you enjoyed it. Do write comments. I promise I’ll try to answer. All the very best to you and be well. Thank you very much.

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Sam Collins for HJ Ross

Proving Medical Necessity Dr. Sam Collins & HJ Ross

 

Hi, everyone. Happy New Year and welcome to 2020 and to the first episode of To the Point for the American Acupuncture Council. I welcome you in, and I want to make sure we have a clear vision for the year. Of course, I’m going to probably overuse the 2020 reference, but nonetheless, let’s make this a good year and let’s make sure we’re understanding what’s going on [inaudible 00:01:16] make sure our practices are doing okay and better, but also how do we make sure we’re dealing with when someone says, “Are your services medically necessary?” How do we determine that? What does an insurance look for? What does it really mean? I think ultimately we know what it means in the sense that we have to show the patient is better, but ultimately what does an insurance company want? So let’s really focus on that today.

So let’s go to the slides. Take a look here, and I start off with insurance medical necessity for acupuncture. And this is really based upon an insurance company. Whether we agree, disagree for the most part doesn’t matter because it’s what the insurance companies say. So here are the medical necessity factors as per insurance, and this is specifically through Cigna, though you’ll see this is a repeat with almost every insurance. It says “Medically necessary services must be delivered toward defined, reasonable, and evidence-based goals.” In other words, they want to see that we’re going towards something that we can have an expectation of reaching a specific goal.

“Decisions must be based on patient presentation, including diagnosis, severity, and documented clinical findings.” So if you think of it, diagnosis and severity are only a part. The clinical findings help determine the severity and the diagnosis. So what I will say is it’s always ultimately best to have something that you can quantify clinical findings to show the patient is better.

One of those clinical findings could be a pain scale, but that’s not as accurate because I’m sure you’ve noticed, some people will tell you their pain is a nine, but yet clearly it’s not a nine based on their function. So I want to focus a little bit more than that. It goes on to say, “Continuation of treatment is contingent upon progression towards defined treatment goals and evidenced by specific significant objective functional improvements.” And I think it’s interesting to note here it doesn’t really focus as much on pain as we might think, but more about functional change or outcome assessments. And the reason why I think is that’s something we can measure. A pain scale, though it’s something that gives us a feeling of where the patient is at, it’s subjective. We want to try to focus more on objective factors, so outcome assessment scales and range of motion certainly will do that.

In addition, realize that certain conditions could be severe enough, maybe they’re going to be co-managed. By example, the company Evercore, which manages a lot of the Anthem policies, now covers things like mental disorders, post-traumatic stress disorders, anxiety, but you probably won’t be treating that just by yourself, but part of a co-treating. So, in those instances, making sure if you’re getting a diagnosis of say post-traumatic stress disorder, you’re not making it alone but co-managing along with another healthcare professional.

But it says, “Medically necessary services, including monitoring of outcomes and progress with a change in treatment or withdrawal of treatment if the patient is not improving or regressing.” So the idea is that the patient should get better with care, and if we withdraw care, they’re not getting any better or worse, clearly it shows the care as not medically necessary.

So that all sounds well and good, but really what are they looking for? They’re looking for the patient to have a treatment plan individualized. Now, obviously there’s going to be a lot of similarities with similar conditions, but it should correlate with the clinical findings. The more severe condition, the longer the plan may be, the more intense the care. Think of someone with simple back pain. They just woke up with a little back pain. It’s not going to require as much care as someone with say cervical disc degeneration. That’s chronic. So realize that some of those goals are going to be based on some of those factors as well and how much.

So ultimately, those should be this. Treatment is expected to result in significant therapeutic improvement over a clearly defined period of time. So, when you’re making a treatment plan, please make a plan. Tell me how many visits you’re expecting to see this patient. For instance, you might say, “I want to see them two times a week for four weeks,” meaning a total of eight visits. But then what are the expectations of that? Make sure you’re defining what do you expect to see? Do you expect 100% improvement or maybe a 50%? And that’s kind of where you want to go with it. Don’t have expectations that always says, “I expect the patient to be pain-free within X number of visits.” But you should see a clearly defined improvement.

So, by example, maybe after three to six visits, a 25 to 50% improvement in the pain, as well as a 25 to 50% improvement in function. The difficulty is the pain scale is easy, but how do we define function? And that’s what I really want to emphasize, what insurances will look for.

So, when planning, they say they want therapeutic goals that are functionally oriented, realistic, measurable, and evidence-based. So my takeaway here is to make sure that, when we’re writing a treatment plan, don’t simply focus on the patient having a decrease in pain. That’s certainly fine, but it’s not enough because they want something that they can measure, and it’s evidence-based. And again, the pain scale is too subjective to really accomplish that.

There should also be kind of a proposed release date or end time. That doesn’t mean that’s going to be the absolute. If I say I’m going to treat someone two times a week for four weeks, certainly, hopefully I’ll get them well sooner than four weeks or at least by four, but that’s not carved in stone. Realize potentially, after four weeks, the patient may have improved 75% but may still have a little bit more. The point here is have at least something that kind of gives an approximation.

What insurances are leery of is when someone says, “Well, I don’t know, I’m just going to treat until they get better.” There should be something that kind of gives you some type of feeling towards what are your expectations, and a lot of that is just based on your good old experience as a practitioner. What has been your practical experience for when patients have similar conditions how long it takes to respond? And, of course, there’s always all types of complicating factors.

So here’s what we need to do. In fact, this is what is directly stated in the Cigna guideline for medical necessity. It says, “Functional Outcome Measures, when used, demonstrates Minimal Clinically Important Differences from the baseline results through periodic reassessments.” So, in other words, what an outcome assessment does, it’s an easy way of measuring function. It’s not so much how much does the pain hurt, but how does the pain affect you doing certain tasks, maybe getting in and out of bed, sitting for long periods, doing your work, doing home chores, and those are things that we can certainly measure and manage.

And then it says, of course, “Documentation substantiates the practitioner’s diagnosis and treatment.” That’s kind of a given. Certainly what we’re going to be treating with the exam should demonstrate that. What I’m going to emphasize to you today is start implementing something beginning this year where every patient that you’re going to treat with insurance and going to treat for any extended period of time, you want to begin using outcome measures, and these are things like [inaudible 00:07:40], neck disabilities, which frankly are a little complicated for most patients. But nonetheless, you want to have some type of instrument to help you do that because here’s what they want is demonstration of progress towards an active home care, meaning the patient gets to a point where they can help themselves at home. Maybe you’re going to start with back pain and then eventually get to where they’re going to do more stretching, yoga, Tai Chi, so they can really kind of deal with it on their own, or they really maximize it.

Ultimately, they want to make sure that, if you’re going to continue care, maximum therapeutic benefit has not been reached. How can we measure that maximum therapeutic benefit has not been reached without an outcome assessment? Think of it much like a person on a diet. If you put someone on a diet, the only way to show that they’re losing weight is to measure that, and you want to measure it in a way that is quantified. So clearly, the simplest thing for weight loss would be putting someone on a scale, and that scale will say they weigh 150 pounds, and as they lose weight, they obviously will lose weight, 150 to 145.

The key is it has to be significant. We can’t certainly say the patient weighed 150 pounds, and now they weigh 149 and eight ounces. That’s really not going to be a significant amount. So we want to have something a little bit more than just that, but something that we can measure.

So here’s another example. Now, I just gave you what was Cigna’s. This is the one from the company Evercore. So, if any of you deal with a lot of the Anthem Blue Crosses, and I’ll let you know also United Healthcare and Optum Health use this company. And here’s what they say for when it comes to functional assessment. And it says, “Documentation of a patient’s level of function is an important aspect of patient care. The documentation is required in order to establish the medical necessity of ongoing acupuncture treatment.” And they go on to state, “The patient’s specific functional scale is a patient-reported outcome assessment that is easy and appropriate for acupuncturists to use. This so-called PSFS has been studied in peer-reviewed scientific literature and has been proven to be a valid, reliable, and responsive measure for a variety of pain symptoms, including neck, back, knee.” I would say you name it. It probably works with anything, even headaches.

But notice that they’re giving us a tool. They’re saying they want to see the patient’s specific functional scale. So my rule would be, if that is the type of protocol they want to see, let’s make sure we give that because notice they’re going to give you the objective findings that they also want to see. Notice it says, “inspection, palpation, range of motion, motion palpation of spine, orthopedic testing, neurologic testing.” Now, this, of course, would be a person with back pain, but I want you to notice none of this really focuses on the pain as much as the result of pain, their level of dysfunction.

So I’ll give one more. The veterans program, I’m sure you’re familiar. Many of you are probably treating VA patients through the PC3 program, formerly known as Veterans Choice. And here’s the two things they say on the standard episode of care for acupuncture. It says, “The result of care should result in significant durable pain intensity decrease,” and they actually say on a VAS scale of zero to 10, so that’s good. We still want to use that. But to go beyond that, we have to have a little bit more because notice the next thing they want is also “functional improvement by clinically meaningful improvement on validated disease specific and outcome instruments or return to work or improvement in activities of daily living.”

So you’ll notice the pain scale is a part, and when that pain scale is positive, we’re going to have improvements here. So, at the very least, even if you’re not using a validated form, please make sure you’re documenting maybe three or four activities that are being affected by their condition and as that condition improves, how those improve as well.

Do always make sure you compare apples to apples. I used earlier the example of weight loss. So let’s say you put someone on a diet, and week one you put them on a scale, and you weigh them. But then week two, you don’t weigh them. You measure their waist circumference. Well, unfortunately, because we’re doing two different types of measurements, comparing those two will give us no idea of how the patient’s changed. So do be consistent. If you’re going to do some functional things that are not on a validated scale, please make sure to make them consistent. Whether or not it’s the activity you come up with or the patient does, so long as we have some consistency, it’s going to show the functional change.

The other thing the VA says though, and this is something that is worthwhile to do with any patient as well, is “documented decrease utilization of pain-related medications.” Now, of course, we’re not going to tell a patient that they should or should not take them, but we want to monitor the levels. When a patient’s in a lot of pain, they’re probably taking many more. As they’re getting your care and improving, all of a sudden they may say, “Hey, I’m no longer taking it at all, or maybe taking far, far less.” Notice all these demonstrate the changes of the patient. Instead of relying on “I feel better,” let’s rely on something that we can measure that no one can dispute.

So, by example, here is the patient-specific functional scale. And you’ll see here it’s simply just a questionnaire. And what this questionnaire does, it talks about your initial assessment, followup assessments. But what I want to focus on, notice it has a scale here that says “patient-specific activity scheme.” If it’s a zero, they can’t perform it at all. If it’s a 10, they can perform it fully.

But what’s nice here is notice you’re just going to score this maybe every two weeks, but you have to indicate what type of activity. The activity could be sleeping. The activity could be how long you’re sitting, lifting, bending, carrying for home activities, any of those. It’s your choice to come up with it, but notice what this allows you to do is to take something specific to your patient and then beginning to grade their changes because all they’re looking for is did you make the patient better? The easiest way is by function.

So this is the patient-specific functional scale. I like it, but because it takes a little bit of extra work to come up with those activities, you may well like something like this one. This is called a general pain index. Now, general pain index, you’ll notice at the top, it says, “We would like to take a moment to see how your pain presently prevents you from doing what you would normally do.” Notice it’s not talking about how much it hurts but activities.

But just like the patient-specific functional scale, you’ll notice this one already has the activities listed. Notice, family, recreation, social, employment, self-care and so forth, and if you go to the bottom here, life support. The one thing that is different though with this one, completely able to function is a zero, unable to function is a 10, so it’s a little bit opposite from that standpoint. But notice what it simply does is give us a way of measuring how the patient is doing. I really like this one because I pretty much don’t care what I’m treating the patient for. Whatever you have, even abdominal pain is going to affect these things, and as those get better, the function’s going to improve.

Now, along with that, the VA has given us, of course, a pain scale. The one thing about this pain scale that I think you want to see is it’s not the traditional pain scale many of you are used to about, well, the 10 is when its at its worse. But I’ll just have you notice these indicate things more about activities. Look at number five. Their pain level is five because it interrupts some activities, whereas number seven, the focus of attention of the pain prevents you from doing daily activities. So it’s not that it’s not pain, but it’s more functionally based. And what’s very nice about this type of form, it’s two-sided, and there’s four questions on the back that goes over how it affects your activity, your sleep, your mood, or your stress from a zero to 10 scale.

Now I’m going to offer you this one, if you’d like. Just text AAC Network. You’re going to text to the number you see 714-332-6926. And when you text that number, you’ll get a little bounce back that’s saying, “Hi, how are you, what’s your email?” And then once you send your email, we will then send you a copy of this form, and then that way what I would suggest to do is print it out and use this now as your pain scale, which means you’re getting away from talking about how much it hurts, but also how much it hurts and how the patient is functioning as a result of that.

And I do like this one quite a bit because it doesn’t just focus on activities of daily living, but sleep, the patient’s mood, their stress level, and those all certainly are going to play a factor, and I think many acupuncturists ask those questions. So certainly, if you have a moment, go ahead and text us. We’ll send you a free copy, no charge to you. It’ll be in color. I suggest print it out, maybe blow it up to a poster size.

Ultimately, do keep one thing in mind. Acupuncture is considered not medically necessary for these two things, and do bear in mind treatment intended to improve or maintain general physical condition. Now, as a person that likes to keep himself healthy, I think this is the thing most people should do, but this is just not something that we do directly with treatment. But this is lifestyle. So once a patient has reached a point where you’re doing this, certainly you want to put them on maintenance. And I do believe there’s a benefit to getting care, but it has to be paid by the patient, not insurance.

And then, of course, it says maintenance services when significant therapeutic is not expected. Now, one thing I would suggest on this last one, there are times that could be supportive care, so by example, the VA even indicates this and will allow chronic care. Let’s say you withdraw the services. When you withdraw the services, maybe after two to four weeks, the symptoms get much worse. They may well allow supportive care. And I want to be clear, I’m saying supportive, not maintenance.

Ultimately, medical necessity for acupuncture, in my opinion, is quite simple. Acupuncture really helps a patient decrease their level of pain, and as a result an increase in function. If you focus on both factors, the pain and the function, that is the easiest way to demonstrate true medical necessity because it’s not just the reliance on “I feel better.”

So I wish you the best. Please take a moment to download some of those forms. Ultimately, American Acupuncture Council is here for you. We offer lots of programs, whether it’s coding, billing online, whether it’s a live seminar with [inaudible 00:17:45]. but we also are online. If you want to go to Instagram or Facebook, we’re there, and we put out news. We’re not there just to promote a program, but to really make sure that you’re doing well. Our goal at American Acupuncture Council is to make sure you’re successful. Ultimately, if you’re not successful, we don’t have our own ways of dealing with making sure we have a business. We want to make sure this profession moves forward, and to give you a highlight, the acupuncture towards Medicare is still moving forward, so there’s a lot of positive things happening. And I’ll see you next time. This is Sam Collins, the coding and billing expert for the American Acupuncture Council, and I wish you the best.

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