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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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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/.

Moshe Heller & Stephen Cowan

Harmonize the Earth To Treat Many Disorders

 

Hello and welcome to the show. I’d like to first thank the American Acupuncture Council for hosting this show. It’s great to be here and my name is Moshe Heller. For those of you who have seen me before here I teach, together with Dr. Cowan, a course on Chinese pediatric acupuncture. And today I’d like to speak about harmonizing the earth to treat many disorders. So let’s dive in. I hope that the slides are up.

When we talk about children especially, and we believe that children are born with a really weak digestive system and therefore the digestive disorders are usually the root of many childhood disorders. And so that’s an important thing to remember when we are treating children because although we may see various different disorders, the root cause or the reason that they are suffering from whatever, we’ll see a little later what these might be, are rooted in a weak digestive system so we have to support that in order to resolve the issue.

What we will see is since these kind of patterns of digestive dysfunctions cause different issues in the child such as accumulation disorders or exposure to foods that are not appropriate, those cause different issues of poor transformation and therefore affect the child’s ability to transform. And therefore this accumulation can cause heat and we can see that affecting the fire or the heart with overreacting and overstimulation. We can see also that it can affect the lung and cause issues of accumulation of dampness in the lung and also affecting the kidneys with cold. The cold foods can create different types of issues such as inability to resolve toxicity. And also we can affect, of course, the liver that will cause also wind and affect the emotional state of the child as having different anger issues and so on and so forth.

We can see that although the root cause is in the earth, it can affect any of the five other organs to cause issues of imbalance. I also wanted to point out and remember for those of you who have heard our previous lectures about this really important triad that we call the gastro immune, neuro triangle that each one of these parts are affected by or help to be regulated by the others. So when one part of this is not functioning correctly, then it can affect the others. We have the gastro part, which means that the gut, the digestive system, our gut biome, all that can affect our immune system and also our neurological function.

It can cause issues with either imbalanced immunity or different neurological disorders starting from having inability to focus, to even inability to communicate. So we can see that kind of triangle and really a very important triangle in treating children.

I also wanted to point out that there are many books starting with traditional books like the Pi Wei Lun where Li Dong Yuan talks about the importance of balancing spleen and stomach to resolve many, many disorders both in children and adults. This doesn’t stop at at the child. It can affect also many disorders in adults and I think that even if you are treating an adult and a really important aspect of of that is to look at their diet and see what’s going on in the digestive system to to support many of the treatment many of the conditions that you might be treating. I also wanted to point out that that Li Dong Yuan talks about another concept of what he determines is yin fire, which is a little bit like a yin vacuity of the spleen.

We don’t think of that in general, but also at the end of this I will point out an article by Steven Clavey, which is a really good source to read about this concept of a spleen yin vacuity. Also in more modern books we can see Bob Flaws in his handbooks of TCM pediatrics points out that a weak digestion is the cause for many childhood diseases such as colic, earache, cough, swollen glands, allergies and pediatric asthma and eczema. And that’s what we are going to see also as we continue. Julian Scott in his book on pediatric acupuncture points out that there are five really common patterns of illness that that are at the root of many disorders. And the interesting thing is that three of them are issues of spleen vacuity and all of them in the treatment, you will see that they’re really focused on supporting the spleen.

I’d like to stay with Julian a little bit and just to point out these five common patterns, he names them as spleen qi vacuity, hyperactive spleen qi vacuity, accumulation disorder, hyperactive kidney qi vacuity and lingering pathogenic factor. And if you look in his book and see each one of them addresses the spleen vacuity as the main treatment principle. So whichever one of these five disorders, you’ll see that spleen is something that’s in the treatment protocol.

But I want to look at two of them for this lecture. The first one of course is the diagnosis of spleen qi deficiency. So although when we see this diagnosis, we’ll see that the child will have a sallow complexion or being very pale. Their skin tones and limbs are flabby. By the way, one of the disorders that I see frequently in in my office is low muscle tone in kids and that’s very closely linked to spleen qi deficiency as of course, we know that the spleen is in charge of muscles and when the muscle tone is low, it does point for me, it’s a strong indication that there is a spleen deficiency that needs to be addressed.

The lips are pale. Another really important, very common thing that I note is that I look at the lips and if the lower lip is a little bit protruding or I call it flabby, it kind of falls forward and and a lot of times you will see that the child is drooling very easily because they’re not able to close the lips appropriately. That’s another really strong indication for a spleen qi vacuity. Of course we’ll see either frequent loose stools or constipation, diarrhea alternating. But one of the most important things is that when we have a spleen deficiency that is pure spleen deficiency, the stools don’t usually smell bad. And that’s an important differentiation because sometimes the spleen deficiency can be, or it can look like a spleen deficiency, but there’s actually an accumulation disorder and in this case the stools will have a stronger smell to them.

You’ll see that there’s also a lot of times issues of sleep. The pure spleen deficient child will prefer to sleep during the day and always have difficulty falling asleep and would all kinds of manipulations in order not to go to sleep. And another important thing to see when you have a spleen qi deficiency is that these children always have a lot of phlegm and dampness, so they’ll have a tendency to get colds, coughs and other illnesses that’s associated with phlegm or damp accumulation.

And now the really, really important issue too that needs a lot of times to be addressed is their very poor appetite and picky about food. They are the classical what we call mono diet. They only eat one thing. A lot of times it’s sweet and when I say sweet, it’s not necessarily candy or something like that, but even pasta that is called a sweet food, right? It’s something a lot of times I see they’ll only eat pasta, even not with cheese or anything, but that’s what we call a mono diet. They are not open to a variety of tastes. They’re very strict on on eating things that have a sweet property and that’s something we really need to work on, and we’ll see a little later about different things that help to open up that appetite and have a little more variety.

There’s also sometimes a tendency for vomiting and gag reflex being very easily created and we’ll see, of course, the body, the tongue will be pale. There may be a white or thick or greasy tongue coating and the pulse is usually weak or slippery. And one other thing is, especially if they’re young and below or under a two year old, I always look at the finger vein. Finger vein diagnosis is very helpful I think. And the differentiation between a spleen deficiency and something that involves more stagnation and heat will determine the shade of blue that you will see in the finger vein. As a reminder, when we look at the finger vein, we rub the finger a little bit and there are three gates. We call them the wind gate, the qi gate and the life gate. And we see how far the finger vein continues. If it passes the wind gate, it means that the pathogen is starting to affect the qi. If it passes the qi gate, it is affecting the qi. And if it is reaching the life gate, it means that it is actually life threatening, so we have to be careful of that.

But the most important thing is that when we look at the shade of the blue, if it’s a pale blue, that is considered more of a cold condition, whereas where it is more of a dark blue, then that’s a sign of heat. When it’s almost black, that’s really a sign that there’s a lot of heat going on. And if you see a black and purplish hue to it, that means there’s heat and stagnation. In this case, when it’s spleen qi deficiency, we’re talking about more of a cold condition.

When we look at treatment, the points are pretty standard and these are points we use a lot. And the important thing is that we have to understand, although they are points that are very common, they are very effective, especially with children. When we combine large intestine 10 for example, with stomach 36, we are tonifying both qi and blood and that’s a really important combination. Stomach 36, shou san li of course tonifies the qi and large intestine 10 helps to regulate the stomach and intestine and reduce digestive stagnation, which is a tendency that children have. This is a very, very important combination for kids who have spleen deficiency.

We also can consider using spleen six. It regulates and strengthens and tonifies the spleen and also regulates the stomach. This again supports this combination of large intestine 10 and stomach 36. We’re supporting it by adding spleen 6. I also really like using CV-12. It strengthens the spleen and again regulates and strengthens the function of the stomach. I wanted to point out a very helpful treatment protocol that was passed on to me by Alex Tiberi. He always used to say that when we can address our digestive capability or strengthen our digestion by using spleen one for problems with digesting fat, spleen two with problems for digesting protein and spleen three for problems with digesting carbohydrates.

These are things to remember because a lot of times you’ll see that children might have difficulty digesting fat or the parent will say every time he eats avocado, for example, you will see that his stomach is bloated or that there is some issues with bowel movements or every time they eat some type of protein. Then you can use these points appropriately to help in that digestion.

I really like the last combination that you’ll see here, which is a combination of spleen three and spleen eight for those children who really have these sugar cravings. Combining spleen three and spleen eight will help reduce sugar craving, according to Alex Tiberi, and I’ve seen it work really well throughout the years of using them.

I also wanted to remind you all of this four-needle technique. We sometimes call it the Korean four-needle technique in which when we recognize that there is a weakness or an excess in a channel or organ system, then we can use the four needle technique to support that. And sometimes you can use these four needle techniques as a take home treatment with using magnets, for example, because with magnets we can clearly create tonification or dispersion by using the bio north or bio south. And when we have the four needle technique ideas that when we have a spleen vacuity and we need to strengthen the spleen, we use supplementation on heart eight and spleen two and then we have to drain liver one and spleen one and we can do that by either leaving little magnets or by during the treatment just connecting these magnets to the points and then taking them off because heart eight for example, is a weird point to leave. I mean the child may peel it or won’t continue to leave it for the treatment and it will support during supplementing the spleen.

A lot of times the reason I like to use this combination is we’ll see that there is an imbalance between the spleen and the stomach where the spleen will be deficient yet the stomach will be excess and Li Dong Yuan talks a lot about this in the Pei Wei Lun about this kind of the stomach tends to be more excess, whereas the spleen tends to be more deficient and so you might need to combine a strengthening treatment combination for the spleen, whereas you will use a dispersing treatment for the stomach.

You can see those points all listed here and this is a great technique to use in the clinic. I also very frequently either perform or teach the parents Tuina or pediatric Tuina, and I really love this hand technique where you can see that there is actually the presentation of each of the organs at the tip of the fingers. So for example, you see here on the little finger, on the pinky, the top part is Shen Jing, meaning that represents the kidney. On the ring finger, it’s Fei Jing, which represents the lung and Shin Jing here is the heart, Guan Jing the liver and on the thumb this is where we see Pi Jing, which is the spleen.

Generally speaking, in this technique, when we do rotations, when we take the thumb and we rotate, usually with our thumb, this rotation is supplementation, whereas where we are pulling upwards, this is considered dispersion. So we can either disperse this spleen or strengthen the spleen and as we can see that the stomach is actually just below the spleen so we can disperse the stomach by pulling upwards and we can strengthen the spleen by doing rotations. I’ve noted this here and on the slide. You can see that. And the arrow is pointing downwards, but it could be upwards or downwards. It doesn’t really matter. I prefer upwards actually. And I combine that with clockwise rotation around the umbilicus, which is also a great way to support the spleen.

As in abdominal diagnosis, we know that the spleen is manifest around the umbilicus. Of course on the left side we will have the liver. On the right side, this is the lung, the heart is on top and kidney is below. I also always look at the abdomen while I’m working to see any issues and palpate it to see what I’m feeling to support the diagnosis.

I also wanted to mention one other thing is the use of tiger warmer. This is a great way to treat kids. You can create heat and pressure at the same time and they respond really, really well to tiger warmer and you can use both supplementation points. You can use, for example, when you see a spleen Qi deficiency strengthen bladder 20 or bladder 21, the [inaudible 00:26:29] of the spleen and stomach, CV 12 and stomach 36 this is a great way to work the points. We’re applying both heat and pressure and it is great way to stimulate the points and kids usually respond really well to it.

Also, you can use regular moxa salt, on spleen CV8 is a great supplementation of Yuan Qi and also this kind of connection between kidney and spleen where you can strengthen the kidneys’ relationship with the spleen by using salt moxa on the umbilicus.

Last thing when we were talking about spleen Qi vacuity of course we can use herbal treatment and there are many formulas, depending on the little symptoms that you want to address. For example, our classical strengthen the spleen formula is Liu Jun Zi Tang, although technically I always prefer to use the Xiang Sha with kids. Xiang Sha means that we have the Liu Jun Zi Tang plus [inaudible 00:28:04] and [inaudible 00:28:04] that is [inaudible 00:28:04] Xiang is the Qi moving. It helps to move the intestines, it moves Jian in the belly and that’s a great addition to this formula and Sha Ren is extremely important in promoting appetite and so it’s a really important herb, especially for those kids who have this mono diet where they are not open to to experiencing other tastes. I think of Sha Ren. Also Shen Ling Bai Zhu San, which is the best formula, I think, for spleen dampness. If you you see a damp spleen, so a combination of spleen Qi vacuity with dampness, there’s nothing like Shen Ling Bai Zhu San.It’s an amazing formula for that condition and the two main symptoms is diarrhea and soft stools and lack of appetite, low appetite. These are really the two main symptoms for Shen Ling Bai Zhu San.

Of course we can also use Gui Pi Tang, which is this kind of relationship between where the spleen is actually deficient, but the heart has some what we might see as a blood vacuity or a heart Qi vacuity with some irritability, difficulty sleeping, and the Gui Pi Tang combination addresses that kind of both heart and spleen.

Bu Zhong Yi Qi Tang, of course is for lifting the central Qi. That’s very important. And Xiao Jian Zhong Tang also is a great formula, a very simple formula for this kind of when the spleen is really deficient, the center is a week. I also want to point point out I’ve developed a combination of herbs, a line of herbs actually that I’ve called Moshen herbs. It plays on the word Moshen and the word Moshen and the word shen there is affecting the spirit. But the idea is that I’ve created a few pediatric formulas that are really helpful for… I’ve found them really effective for different disorders.

One of them I’ve called Digest and this is a combination that will address children with spleen Qi acuity and or the the next pattern that we will see, which is an accumulation disorder. It’s a formula that addresses both things and and very effectively. Please check it out on moshenherbs.com and you can read the ingredients and see how the functions of this formula. But it is a formula that I use for digestive disorders in children when those… it could be even that when I suspect that when a child comes in with eczema that I suspect comes from this weak spleen that we can use Digest to address that. And especially if they have a tendency to get asthma, for example, or a lot of phlegm disease, then we can still use Digest to resolve that.

Let’s move to the next common disorder and we call it accumulation disorder. It is pretty much similar to the concept of food accumulation in adults, but it’s manifestation in children is a little different and it is is associated with exposure to foods that are not appropriate to or are difficult for the child to digest. One of the most common reasons for an accumulation disorder, unfortunately, is the use of formula in kids. I think that the issues with the formula is that it is over rich. Therefore, it’s very hard on the digestive system and therefore it causes a lot of issues. I know sometimes we need to use it, but we have to recognize or realize that it can cause a problem. Another issue is that children are sometimes offered food too early when they’re not really ready for food and therefore that causes also issues.

It’s very common that we see accumulation disorders around six months of age. That’s when solids are being introduced to the diet. And this is a period where accumulation disorders can develop. One of the most important symptoms that I see for accumulation disorder is this redness in the cheeks. And I can almost see that, I can suspect it already when I see the patient in the waiting room and I see those two red lights as cheeks. They’re really red. I have a picture in the next slide so you will see that. And that’s a really common symptom. A lot of times you have to ask the parent, “Oh, does he have these red cheeks all the time, or is he just hot or something like that?”

A lot of times when it’s an accumulation disorder, they’re pretty much consistent. The cheeks are red most of the time. They’ll also suffer from a lot of irritability, insomnia and a lot of lingering illnesses, especially this green nasal discharge. When you see this little kid with the green nasal discharge in his nostril and that’s something that the parents are complaining about.They’ll say this child is always sick. Everything that’s around, he immediately gets it. And he immediately gets this kind of nasal green nasal discharge. That’s a another very typical accumulation disorder symptom.

The interesting thing is that this accumulation disorder pattern usually can transfer or develop into a lot of what we would categorize or Western doctors will categorize as food allergies. So we’ll see how that develops in a second. These are the main symptoms. We can see here that this kind of red cheek, you see this baby with these kind of red cheeks, looks really cute. You think this is a a healthy little kid, but actually this is sign of a problem a lot of times, especially when it’s been going on for a little bit, you’ll see that then the skin becomes a little bumpy around the the cheeks. And when you see this kind of little bumpy area as well as red cheeks, it’s pretty much a food accumulation involvement.

We can see that in babies, the reason why you’ll have an accumulation disorder is overfeeding cow milk formulas. As we said, poor sleep and and dysbiosis are really the major causes in babies. In children we look at poor quality of foods, cold, raw foods, sugars, or sugar can be a cause for an accumulation disorder and a lot of this kind of very what we call children food are usually like pizza. Amazing. A great way to cause food accumulation in a child is give them lots of pizza. That’s something that we have to pay attention to.

Definitely also a general poor eating habit and I think one of the things that we have to remember is that one of the things that’s really strengthening to the spleen is the creation of a routine of eating, so that eating at the regular times and creating this kind of a regular pattern of eating is something that is not necessarily something that we need to teach our kids. And I think that’s a problem with a lot of parents that they don’t enforce it so that the tendency is to feed children as they want or on demand as we call it, on demand feeding, where that actually sets the grounds or creating an accumulation disorder.

It’s about eating mindfully and creating these mealtimes and involving children in that process is really, really part of strengthening the spleen and preventing food accumulation. What we’ll see is this hunger with no real desire to eat. They’ll say, “I want this”, and then they won’t eat it. And then there’s this kind of sensation that you’re hungry but you don’t know what to eat. Never satisfied. Sometimes reflux. You’ll hear them eating and then they’ll have a lot of burping up of gas, these red cheeks, green stools babies. This is another really very important sign, yellow nasal discharge and congestion and also chronic ear infections, chronic cough, chronic or even asthma. Sometimes the breath sounds like a little sour, so it is affecting the stomach and you can actually smell it. Eczema, cradle cap. The skin is starting to be affected by that and a lot of restlessness, hyperactivity and sometimes behavioral issues develop from this kind of accumulation disorder. Although it starts out in the digestive system, it affects many, many areas of imbalance.

The best time to, to catch or to address this food accumulation is when the children are really young and the best treatment the Sifengwen points, the four points. And you can see their location here and the bends. I know that traditionally they’re saying that you need to prick it and squeeze it until some yellow fluid comes out. I just insert the needle in all four areas and I get great results. You don’t really need to stand and squeeze it. I also recommend to use these points at the end of the treatment so when it hurts and the baby’s not crying in the room, you can do it and have them go and that’s a really a good way to use these points.

I teach the parents this kind of a massage of the thenar eminence that helps to reduce food accumulation and then also disperse the stomach. These are all techniques that really help to resolve food accumulation. With older kids, we can look at using CB 12 and stomach 36 as we remember. Large intestine 10 also helps with this kind of regulating of the stomach. Oops, sorry about that. And another combination that I really like to use is the combination of CV10, CV12 and CV13 that helps to regulate the flow of stomach and opening and closing of the sphincters. This is a really important thing. Stomach 36 of course is a great point for stomach pain and if there’s a lot of phlegm we do need to use stomach 40. If there’s a lot of phlegm in the lung, I usually don’t start with using stomach 40. I start with using CV 22 to start kind of resolving the phlegm in the lungs and only then I will use stomach 40, so that’s another important thing to remember.

What herbs? There’s Bao He Wan. This is the classical formula for food accumulation and, as I said, if there’s a lot of them, if the spleen is deficient and there is accumulation of dampness, I always think of Shen Ling Bai Zhu San. In this case it’s mostly when there’s soft stool. So if there’s this kind of a stinky diarrhea most of the time then I would use Shen Ling Bai Zhu San. Otherwise I’ll use Bao He Wan if there’s this alternating constipation diarrhea. Then Digest, again, is the herbal formula that I developed and you can read about it in moshenherbs.com and I wanted to point out another formula that I’ve been working with. It’s called React. I called it React but it’s based on Wu Mae Wan and I know that Wu Mae Wan is usually a parasite formula, but I’ve used it very effectively for for for food allergies, food sensitivities and in general this kind of tendency to be very allergic, whether it’s allergic asthma or allergic skin reaction.

All these things are really very affected, can be addressed by the use of React, which is an herbal formula based on Wu Mei Chuan and I’ve changed it a bit to be very well used with children. Please take a look at that because it’s a very good tool to use for different types of conditions in pediatrics and also adults actually can use React in this case, especially where there’s food allergies as a basis for many problems.

I also wanted to point you to a very interesting article about this kind of spleen and stomach yin deficiency. It’s not something we see so frequently. But Stephen Clavey wrote a wonderful article about the differentiation and treatment of spleen and stomach yin vacuity, so please read it. It’s from the journal of Chinese medicine from January of 1995. I know it’s a while ago, but it’s a great article, and I wanted to point out that these are things that you will see very frequently with children is that they’ll have trouble digesting food, easily full after eating small amounts, typical right? Bloating and feeling of uncomfortable fullness after eating, loss of taste discrimination, so they only want to eat sweet things, dry lips, different type of ulcerations in the mouth.

Look at these symptoms. These are things that I see very frequently and in this article he will help you differentiate between them and the use of different formulas. So a very good resource. Okay. I think I went over time, but I’m not sure. Anyway, I want you to thank you for listening and being with me today. I have here, if you want more information about Moshen herbs, please go to moshenherbs.com and also I wanted to point out that this is the certification course that’s going to start in March, jingshenpediatrics.com.Thank you very much and I will see you again in, I think it is in February.

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/.

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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