by Meridel I. Gatterman, MA, DC, MEd,
ACA Wellness Subcommittee on Education; and
Marion W Evans Jr., DC, PhD, CHES
Chiropractic physicians as autonomous practitioners offer first-contact care. In addition to managing acute and chronic conditions, they are well-situated to promote the health and wellness of both patients (people seeking care for health problems) and clients (apparently healthy people).  Individuals increasingly are seeking active participation in their own health care. To effectively fulfill the role of health promotion and wellness practitioners, chiropractors must assess the needs for health promotion and wellness in their individual communities. Factors that should be considered when assessing a community’s health-promotion and wellness needs include: access to health-promotion and wellness resources, risk exposure, income levels, cultural norms, health insurance coverage and barriers to access.
Access to Health-Promotion and Wellness Resources
Online: We cannot assume that all individuals in a community have access to Internet resources. Assessment of the need for dissemination of information that provides the location of Internet cafes, libraries and other facilities that offer online services is important so that resource information becomes available. A list of Web sites for specific foundations and societies can provide patients with resources specific to health promotion and wellness related to their specific conditions. Some examples are the Arthritis Foundation, Diabetes Foundation and the American Cancer Society. The American Public Health Association (APHA) now has a Chiropractic Health Care section and offers a host of resources to aid in the delivery of community health information. With National Public Health Week held every spring, the organization focuses on a topic of interest that the doctor can participate in by delivering health education messages to your community. A variety of advocacy and wellness topics are available from APHA as well. For more information on the APHA, go to www.apha.org. 
Brochures and Books: Assessment of individual and community needs related to health risks can identify areas where health-promotion information can be provided. A variety of brochures dealing with disease prevention and health promotion can be made available to patients in office waiting rooms. Smoking cessation brochures are available from the American Heart Association and American Lung Association Chapters, along with booklets that can be downloaded from the Centers for Disease Control and National Lung Association that will help patients take action. More information is available at www.cdc.gov  by following the tobacco control links. The NIH 5-A-Day program has undergone major changes recommending that Americans eat more servings of fruits and vegetables than the original “Get 5” stated. This site has numerous color pamphlets available for free or a small fee. From these, patients can learn how to increase their fruit and vegetable servings. These brochures are tested for effectiveness by health education specialists and it has been demonstrated that patients like them. You can visit their site at www.fruitsandveggiesmore.org or contact your state coordinator for more information. Many counties across the U.S. have public health departments with a variety of resources that can be passed on to patients.
Some doctors provide a lending library of books, tapes and DVDs for patients to check out. Some may provide copies of pertinent articles, for example, those related to weight control, diet and fitness or those specifically designed to promote a healthy back. These may be provided, not only for a patient’s condition, but for family members and friends who may benefit from health promotion and wellness counseling.
Regular physical activity throughout life is important for maintaining a healthy body, enhancing psychological well-being and preventing premature death. In 1999, 65 percent of adolescents engaged in the recommended amount of physical activity. Only 40 percent of adults performed the recommended amount of physical activity.  Physical inactivity, as described by the Surgeon General, is “less than 30 minutes of moderate physical activity most, if not all, days of the week.” This definition is used as the representative level to classify the percentage of physically inactive adults. Populations with low rates of physical activity tend to include more women than men, people with lower incomes and less education, with African Americans and Hispanics generally less physically active than whites. By age 75, one in three men and one in two women engage in no regular physical activity.  Printouts are available from the APHA and the CDC that explain different levels of physical activity. Why not make your community, as well as every patient, aware of the current recommendations for regular exercise? Why wait until they are overweight or have a health condition? Primary prevention is the effort to keep people healthy and not wait until they have a condition or disease. With the current epidemic of obesity and diabetes, most communities will profit from an active education program that emphasizes the benefits of physical activity.
Exposure to health risks often is a community problem. An estimated 25 percent of preventable illnesses worldwide can be attributed to poor environmental quality.  In the U.S. alone, air pollution is estimated to be associated with 50,000 premature deaths and an estimated $40 to $50 billion in health-related costs annually. Each community has identifiable health risks that can be assessed and addressed by the conscientious chiropractor interested in promoting health and wellness.
Health Impact of Poor Air Quality: It has been demonstrated that poor air quality contributes to respiratory illness, cardiovascular disease and some cancers.  The overall death rate from asthma steadily is increasing (overall, 57 percent between 1980 and 1993 and 76 percent for children).
Air Pollution: Millions of tons of toxic pollutants are released into the air each year from automobiles, industry and other sources. What is your community doing to address this problem? Compared with Caucasians, a disproportionate number of Hispanics, African Americans and American Indians or Alaska Natives live in areas that fail to meet standards that provide healthy air.  The air quality of each community should be assessed and addressed.
Tobacco Smoke: Exposure to environmental tobacco smoke (ETS), or second hand smoke, among nonsmokers is widespread. ETS increases the risk of heart disease and respiratory infections in children and is responsible for an estimated 3,000 cancer deaths of adult nonsmokers. Banning smoking in public places varies from community to community, and the status should be assessed as a preventable health risk in all areas.
Exposure to Hazardous Substances: Assessment of high-risk industries can determine low-level exposures to hazardous substances. Those living in agricultural areas such as vineyards may have a high risk of exposure to toxic sprays or poor water quality from chemical fertilizers. Other areas may be exposed to hazardous chemicals from the mining industry.
Workplace Wellness: Workplace wellness can be promoted through onsite visits and follow-up assessment. Identification of high-risk employees can lead to promotion of healthier lifestyles. Personalized reports, followed by health coaching, can empower workers to reduce health risks and encourage them to take steps toward better health. Employers can be provided with an aggregate risk profile for their industry based on screening and job analysis assessments.
Surveys and samples can be used to determine what employees want in a health-promotion program. The Wellness Councils of America (WELCOA) offers examples of these materials, along with educational resources available at www.welcoa.org.  A PowerPoint presentation, titled “What Exercise Will Do For You,” also is available. This straightforward, no-nonsense type of program can be presented to employee populations along with employee handouts. Review of the mechanisms related to industrial injuries and development of prevention programs can be highlighted. Ergonomic solutions to industrial injuries can be presented, along with means of avoiding repetitive-motion and lifting injuries. In addition to injury prevention, other health promotion and wellness strategies can be presented, such as nutrition and smoking cessation.
Overcoming Barriers to Community Health-Promotion and Wellness Services
Financial, structural and personal barriers can limit access to health-promotion and wellness services. Financial barriers include not having insurance that covers health-promotion and wellness services or not having the financial resources to pay for these services outside a health plan or insurance program. Increasingly, insurance plans now provide coverage for preventive services. Preventive medicine services (PMS) under the CPT codes were revised in 2002, and billing under PMS is appropriate if the patient has an insignificant or absent problem.  The CPT codes define preventive medicine as “The branch of medical science concerned with the prevention of disease and with promotion of physical and mental health, through study of etiology and epidemiology of disease processes.”
A comprehensive examination definition for PMS is not synonymous with the definition of office visit codes. The comprehensive history obtained as part of the preventive medicine service is not problem-oriented, and does not involve a chief complaint or present illness. It does include a comprehensive or interval past, family and social history, as well as a comprehensive assessment/history of pertinent risk factors. The comprehensive examination performed as part of preventive medicine service is multi-system, but the extent of the examination is based on age and gender of the patient and the risk factors identified. If a problem or abnormality is encountered, and if it requires additional work and the performance of the key component of a problem-oriented evaluation and management service, the two codes may be reported on the same day. In addition to the preventive service billed, the regular E/M office code is billed with the modifier-25 added. An insignificant or trivial problem that does not require additional work should not be reported separately. The actual performance of diagnostic tests/studies for which specific test CPT codes are available should be reported separately, in addition to the appropriate E/M code.  Preventive medicine codes are summarized in Table 1.
Counseling and/or Risk-Factor Reduction Intervention: New or Established Patient
Preventive medicine counseling and risk-factor reduction interventions provided as a separate encounter will vary with age and should address issues such as family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter.
These codes are not to be used to report counseling and risk-factor reduction interventions provided to patients with symptoms or established illness. For counseling individual patients with symptoms or established illness, use appropriate office E/M codes (Table 2). For counseling groups of patients with symptoms or established illness, use 99078. Not all insurance carriers will pay for health-promotion and wellness services and often may not understand that chiropractors are health-promotion and wellness practitioners even when such services are covered. Uninsured patients may not have the financial capacity to cover services outside a health plan or insurance program. 
Structural barriers include the lack of health care professionals to meet the health-promotion and wellness needs of the community. This, along with our conservative philosophy and training, makes a strong case for chiropractors to serve as health-promotion and wellness specialists, given that most communities are served by chiropractors.  Patients who already seek regular chiropractic care should be receiving health-promotion and wellness messages to show them how to stay healthy or return to optimum health.
Table 1: CPT Codes for Preventive Medicine Services
|Early childhood (ages 1-4 years)
Late childhood (ages 5-11 years)
Adolescent (ages 12-17 years)
65 years and older
|Early childhood (ages 1-4 years)
Late childhood (ages 5-11 years)
Adolescent (ages 12-17 years)
65 years and older
Table 2: Counseling and/or Risk-Factor Reduction Intervention
New or Established Patient
Individual Preventive Medicine Counseling (PMC) and/or risk-factor reduction for interventions use the following codes:
Group Preventive Medicine Counseling (PMC) and/or risk-factor reduction for interventions use the following codes:
Based on the community in which you live, various cultural barriers may exist. Every community won’t have the same needs or the same resources. Health is an unequal world and in rich countries as well as poor countries, people lead poor quality lives and die unnecessarily. In rich countries, autonomy and social inclusion influence health behaviors such as nutrition, smoking and alcohol use as well as through neuroendocrine pathways (i.e., chronic stress) just as they do in poor countries.  This should be taken into account. After all, no one wants to design or offer something that no one wants. Practitioners should be aware of the barriers that may exist in their community, so that promoting healthier lifestyles for their patients can be identified up-front and removed or reduced where possible. Access to chiropractors is readily available in most communities. As physicians, we seek not only to understand but to make things better. Our sphere of action should include public health that acts collectively, as well as focusing on individual behaviors. Before redesigning your intake forms to account for health promotion and wellness, it is important to assess your community’s needs for health promotion and wellness.
- Jamison JR. Health Promotion for Chiropractic Practice. Gaithersburg, Md.: Aspen, 1991, p 29.
- Available at www.apha.org. Accessed August 2007.
- Available at www.cdc.gov. Accessed August 2007.
- Healthy People 2010: Understanding and Improving Health. U.S. Department of Health and Human Services. November 2000.
- Available at www.welcoa.org. Accessed August 2007.
- CPT 2008 AMA (2007) Chicago: American Academy of Professional Coders Contexo Media.
- Gatterman MI. Chiropractic and Health Promotion and Wellness. Sudbury, MA: Jones and Bartlett, 2007;p 30.
- Marmot M. Health is an unequal world. Lancet, 2006;368:2081-94.