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Education Toolbox

 Look for the star CCoE Star in the education materials below for Centers of Excellence education.

Audit Protection

Establishing Medical Necessity

Presented by Dr. Evan Gwilliam, Vice President of ChiroCode Institute, presents the following insight to what auditors look for when reviewing documentation and recordkeeping, such as:

  • Establishing medical necessity
  • Treatment plan development and re-evaluation
  • Demonstrating patient progress

Dr. Gwilliam is a licensed chiropractic physician, certified coder, compliance specialist, and medical auditor. He has published numerous articles in ACA News and Chiropractic Economics, and is known for making challenging and dry topics engaging and easy-to understand.

CCoE Star Establishing Medical Necessity

Why is the Chain of Medical Necessity is a critical component to effectively documenting the necessity of your treatment?

The Chain of Medical Necessity includes:

  • History of onset
  • Patient complaint
  • Exam findings
  • Diagnosis
  • Treatment plan
  • Progress (using measurable outcome goals)

CCoE Star Treatment Plans Part 1

Constructing a treatment plan:

  • Create care plans that establish need for care
  • Learn how payers and auditors use treatment plans and measurable goals to determine if care is payable

CCoE Star Treatment Plans Part 2

Treatment plans updates:

  • Learn how and why to update treatment plans at a re-evaluation
  • Tell the story of ‘patient progress’ using measurable goals of Outcome Assessment Tools

CCoE Star Showing Patient Progress

Understanding payer and auditor requirements:

  • Learn how to document patient progress
  • Assessments updates for daily visits
  • Recording the ‘patient progress’ story with your SOAP notes


Included in this section is a case study presentation (posted below) and a series of case study exercises to be reviewed using the General Patient Audit Form (also provided below). The General Patient Audit Form can also be used in the clinic setting to conduct a self-audit and evaluate the thoroughness of one’s documentation and recordkeeping.

Case Study Presentation I PDF

Case Study Presentation | Video

Developed by Dr. Evan Gwilliam, Vice President of ChiroCode Institute, this presentation covers modalities and therapeutic procedure coding for Chiropractic, such as:

  • Knowing the basics of E&M codes and how Auditors view them
  • Learn to audit the history component of E&M
  • Learn to audit the exam component of E&M
  • Learn to audit the medical decision of E&M

Dr. Gwilliam is a licensed chiropractic physician, certified coder, compliance specialist, and medical auditor. He has published numerous articles in ACA News and Chiropractic Economics, and is known for making challenging and dry topics engaging and easy-to understand.

E&M Audit Tool

The E&M Audit Tool is designed to be helpful with identifying which E&M code is properly supported and should be used in conjunction with the 5-part E&M video series.

Download Audit Tool

E&M I Video 1

E&M I Video 2

E&M I Video 3

E&M I Video 4


This webinar by Dr. Gwilliam covers best practices in documentation and coding for Chiropractic Manipulative Therapies (CMT).

After watching this video you will:

  • Be familiar with CMT codes
  • Diagnose, document and select the proper CMT code
  • Avoid common CMT mistakes

Dr. Gwilliam, Vice President of ChiroCode Institute is a licensed chiropractic physician, certified coder, compliance specialist, and medical auditor. He has published numerous articles in ACA News and Chiropractic Economics, and is known for making challenging and dry topics engaging and easy-to understand.”

Developed by Dr. Evan Gwilliam, Vice President of ChiroCode Institute, this presentation covers a best-practice approach in the utilization and coding for passive modalities and active procedures.

Dr. Gwilliam is a licensed chiropractic physician, certified coder, compliance specialist, and medical auditor. He has published numerous articles in ACA News and Chiropractic Economics, and is known for making challenging and dry topics engaging and easy-to understand.

Passive Modalities Introduction

Passive Modalities Part 2

Passive Modalities Part 3

Active Procedures

Active Procedures Part 2


Practice Improvement

We do not have any Active Care Certification classes scheduled at this time.

CCoE StarFulcrum is committed to preparing is network providers for the evolving health care environment by providing them with the tools and information needed to successfully promote active care in their practice.

A key component of this support is the Active Care Chiropractic Certification Program. The program is provided several times each year and is offered at no cost to ChiroCare network chiropractors. The program offers Continuing Education Units through Northwestern Health Sciences University for some of the courses.

Health care in the United States is changing, especially as it relates to patient care. Passive care alone is no longer enough. Patients need to take ownership in their own treatment, and studies are confirming active care as an emerging new best practice for physicians.

Chiropractors must teach and assist their patients in appropriate self-care/active care by developing the patient’s coping skills and motivating them to resume activities. Studies over the past several years show that active care is helpful in returning a patient to pre-morbid functional capacity. The new model no longer focuses on pathology or symptomatology. Pain is being used less as an indicator of patient progress; function is the measure of patient recovery.

Introduction to Active Care: Program 1 | PPT

Coding and Compliance for Active Care: Program 3 | PPT

Patient satisfaction surveys have demonstrated, patients care that their safety is protected by providers washing their hands and sanitizing tables.  To explore efficient and effective methods of infection control in a chiropractic clinic, Fulcrum partnered with CLIPS, a consulting group who are experts in the infection prevention field to develop a series of products and recommendations for clinics.  We also developed four short presentations on infection prevention.  These presentations are great for new doctors or staff, or just general reminders.

The educational presentations cover the topics: Hand Hygiene, Surface Disinfection, Skin Infection such as MRSA, and Blood Draw Recommendations. They are designed to be an introduction to best practices in infection prevention and include a pre-test and post-test for each presentation to help measure understanding of the content. 

Clinic Product Recommendations

Ecolab QuikCare Foam & moisturizer

  • Foam product
  • 5% Alcohol
  • Aerosol container
  • Mounts to wall
  • Easy to use
  • Comes with drip cup to protect floor, carpet, or walls
  • Check instructions for the correct amount of foam for each use
  • 2yr shelf life
  • Dye and fragrance free
  • Formulated for sensitive skin

3M Avagard Hand Antiseptic Sanitizer and Lotion

  • Hand Sanitizer/Lotion
  • 61% Alcohol
  • Pump dispenser
  • One pump per use
  • 3 year shelf life
  • Fragrance, dye, and preservative free
  • Contains no paraben
  • Contains no oils, mineral oil or petrolatum

Disinfectant Wipes

Contact Time: Contact time is the amount of time required for a product to remain wet on a surface to be effective. We recommend educating your staff to keep the product wet on the surface for the required time, which may include using additional wipes.

Glove use: Disinfectant wipes are typically safe for skin contact, however, it is recommended that staff uses gloves while using disinfectant wipes to reduce the risk of hands becoming contaminated from the surface being cleaned.

Equipment cleaning: We recommend checking the manufacturer’s instructions before cleaning equipment to ensure cleaning product does not cause damage.

Oxivir TB wipes (1-Minute contact time)

  • Active Ingredient: Hydrogen Peroxide
    • Effective against most organisms
    • Environmentally friendly
  • Contact time – 1 Minute
  • Kills in 1-minute:
    • HBV
    • HCV
    • HIV-1
  • No VOC’s, added fragrance
  • Active ingredient breaks down to water and oxygen
  • Non-irritating to skin

PDI AF3 wipes

  • Bactericidal, Tuberculocidal, Viricidal
  • No fragrance added, alcohol, bleach, acid, phenol acetone and ammonia
  • Ideal for cleaning equipment and nonporous surfaces sensitive to alcohol
  • 3 minute contact time

Blood Draw/Acupuncture Products

Sterile Individually Packaged Alcohol Wipes

  • Individual package for one-time use
  • Easy to clean up
  • 100% Isopropyl Alcohol

Sterile Gauze Pads

  • Individual package for cleanliness
  • Easy to clean up
  • Multiple uses

Mail Back Medical Waste Kit

  • Convenient Sharps disposal system
  • Pre-paid postage for disposal of sharps container
  • Instructions included

Lessons Learned

  1. Do not refill sanitizers or soap containers – replace empty containers with new ones instead
  2. Pay attention to contact time of disinfectant wipes – the time can vary from one to several minutes, depending on the brand of wipes
  3. Discard sanitizers with expired dates

Education Presentations

Education presentation 1: Hand Hygiene

Participants with this education presentation will:

  • Be able to identify infection risks
  • Understand basic steps to hand hygiene using CDC guidelines
  • Learn effective and efficient methods to sanitize hands
  • Learn how to engage your clinic with infection prevention initiatives

Download Education Module

Download Answer Sheet

Education presentation 2: Surface and Equipment Disinfection

Participants with this education presentation will:

  • Identify clinic surfaces vulnerable to contamination
  • Learn about contact time
  • Review patient and staff safety tips
  • Determine how frequently infection control should be used on surfaces

Download Education Module

Download Answer Sheet

Education 3: Skin Infections MRSA & Athletes

Participations with this education presentation will:

  • Identify risk factors for individuals who may have skin infections
  • Recognize prevention strategies for skin infections in healthcare settings
  • Identify risks and prevention strategies related to skin infections in athletes

Download Education Module

Download Answer Sheet

Education 4: Blood Draws and Acupuncture

Participants with this education presentation will:

  • Recognize key components of the Federal and MN – OSHA bloodborne pathogen standard
  • Identify required elements for compliance with the exposure control plan (ECP)
  • Understand the requirements for staff who perform acupuncture, blood draws, sharps handling or specimen handling related to an ECP
  • Define bloodborne pathogen exposure

Download Education Module

Download Answer Sheet


Best Practice Guidelines for Radiology

Standards for high-value, patient-centered care are continually changing as ongoing research reveals new findings and insights. This is also true of radiology for musculoskeletal conditions. We tend to see that doctors with high radiology services are those practicing with outdated standards.

Today’s clinical research strongly suggests that X-rays in the first six weeks of care is not necessary, unless there are red flags present. While it may be convenient to have X-rays as a reference, doctors practicing high-quality, patient-centered care should always use caution when exposing patients to radiation, and expose patients only when it is medically necessary.

In the absence of red flags, many guidelines recommend not imaging for adult low back pain within the first six weeks of care. Technique, office protocols or philosophy are not sufficient reasons to support taking x-rays. For additional information and recommendations, check out the following resources:

Fulcrum’s Radiology Guideline for ChiroCare providers

CCoE Star Shared Decision Making

Best Practices with Shared Decision Making

Shared decision making involves a partnership between patient and care provider to develop a treatment strategy with engagement and shared goals.  The care focus changes from doing something TO the patient towards doing something WITH the patient

Implementing shared decision making involves an in depth conversation with the patient to better understand their previous experiences, expectations, fears, current knowledge and other circumstances which could enable or limit their success.  It includes providing the patient with possible options of care and discussing their needs to select optimal services and practitioner.  The information gathered is used to refer or create a focused treatment plan with patient-centered goals that increases patient understanding and engagement. 

Patient understanding and participation in their goals and decision making process can lead to:

  • Increased patient engagement
  • More realistic expectations and goals
  • Feel better about their choices
  • Reduction in anxiety about condition
  • Reduction in indecisiveness

Providers who implement shared decision making should include this information in the chart as a compliment to the specific measurable goals and informed understanding of treatment options, risks, and benefits of the treatment plan.

For example:

              We discussed possible treatment options and risks with chiropractic care.  The patient selected chiropractic care (or other practitioner when indicated).  We have identified shared treatment goals of care as……… 1) to be able to read to her grandchildren for 1 hour instead of 15 minutes without neck pain and 2) walk for 30 minutes a couple times per day – up from 15 minutes she is currently limited to by her pain. She also expressed concern about aggressive manual manipulation to her cervical spine. We will modify our treatment to provide productive outcomes while respecting her concerns.

Additional resources can be found at:

CCoE Star Coordination of Care

Coordination of Care between Practitioners or Facilities

Communication between practitioners or facilities who are involved with the treatment of a specific patient is an important component for the application of patient-centered care.  While this may be relatively simple for practitioners who are within the same care system and EHR, it can be an added challenge to outside practitioners.  

To implement best-practice care coordination, providers would communicate with Primary Care physician, specialist, or imaging center to:

  1. Refer patients at the appropriate time
  2. Assist patient with appointment scheduling and ensuring the patient completes the appointment
  3. Follow up with any further referral or testing required
  4. Communication with patient and other practitioners involved with the patient’s care. For example sharing complaint, treatment plan overview, and expected results with primary care can build relationships with these practitioners and assist the patient with their condition updates.
  5. Communicate potential follow-up should treatment plan change

Additional resources are available at: 

CCoE Star Care Management

Management of the patient care plan

Care management is a collaborative process between the patient and providers involved with a treatment plan to meet the patient’s health needs through communication and available resources to achieve the expected results from the treatment plan. 

Care management is a patient-centered process by which the provider clearly communicates to the patient how each step of the treatment plan will support the patient achieving the desired outcomes.  Providers work to ensure patient understanding and agreement with each part of the treatment plan.

Providers who practice patient-centered care management should document such events as

  1. Missed appointments
  2. Follow-up calls on patients not complying to treatment plan for patient update or if a referral is needed
  3. Appropriate intervals for re-exams and updates to assessment of progress and update treatment plans
  4. Document discussions regarding compliance to the treatment plan if patients are not compliant
  5. Providing assistance with care outside the scope of chiropractic care that may involve other health care providers: Preventative health discussions (mammograms, depression, high blood pressure, diabetes, etc.)
  6. Documenting the patient compliance with home/self-care measures