ROV Plan Overview

Routine office visit documentation can be more succinct and direct than that of an initial visit for an episode of care. Examples of this are found in the plan section and the full treatment plan in the corresponding section of an initial visit. At the beginning of an episode of care, the provider lays out the plan for the full episode while the plan section of a routine office visit simply outlines what was completed that day and the services rendered to select the appropriate codes.

Parts of the Plan

The Plan section of an ROV note is usually the quickest and easiest to complete; it’s also the most important element for compliance because it determines the coding needed to ensure proper billing. Use this guide to ensure all required elements are included. The following ROV PLAN overview is a table with the 7 different Plan elements and their rationale. We have broken the list up into 2 pages, for ease of its’ digestion. This is not an exhaustive list, but a guide to help you identify any holes in your documentation that may need to be filled or resolved.

ROV PLAN Overview

Treatment
Includes Rationale
Primary: CMT/Technique

    • 1o Subluxations
    • 2o Incidental Subluxations
Primary Treatment:  Usually Chiropractic Manipulative Treatment (CMT) (98940-98943). The spinal regions that have been prescribed treatment are noted here. Indicate the specific segments adjusted. Best practice is to identify the medically necessary spinal segments separately from the compensatory, clinically appropriate spinal segments that were adjusted. This makes it easier to count spinal regions and apply correct CMT billing codes.
Secondary or Supportive Therapy:

    • Passive (attended/unattended)
    • Active therapies
    • Total therapy time
Supportive Therapies and Procedures: If ancillary services are rendered (e.g., modalities and procedures), record each according to best practices; documentation should include time spent, location, and intensity. If multiple timed codes are performed, include total time in the documentation. For therapeutic procedures, documentation may need to include the number of reps for exercises, or the muscle groups involved if providing muscular therapy. Always include who performed the service if other than the doctor. The services should follow the detail outlined in the treatment plan, simply list the service and details. Coding comes from the documentation so the appropriate code should be clear and based on the daily plan documentation.
DME Rx
Includes Rationale
Orthotics, heel lifts,
EMS units, etc.
Durable Good Dispensed: If any supplies or durable goods are dispensed (e.g., a pillow, a belt, prescribed orthotics, etc.) add the details to the plan section. List the item dispensed; include all orthotics (e.g., ankle braces, pedal arch supports, heel lifts, low back belt supports, shoulder braces, wrist braces, TMJ Splints, etc.), EMS or TENS units, Vaso pneumatic cryotherapy packs, etc.
Counseling
Includes Rationale
Diagnostic test results; prognosis, risk & benefits; instructions; compliance; risk factor reduction; patient and family education “Counseling” occurs when you discuss the following with a patient or their family member:

  • Diagnostic results (Radiology: Xray/MRI/CT/ Dexa Scan/US, blood labs, NCV, Needle EMG
  • Prognosis
  • Risks and benefits of the treatment options (conservative care options, more invasive options such as injections, surgical consults, or surgery). Be sure to know and communicate to the patient the threshold they need to reach to get to a referral for the more invasive options).
  • Instructions for treatment and/or follow up
  • Importance of compliance with chosen management option
  • Risk factor reduction (examples include):
    • Problems related to obesity, HBP, elevated cholesterol and/or Cardiac CRP; tobacco use and abuse, alcohol abuse, illicit drug use and abuse, other behaviors related to addiction.
    • Prescribed dietary changes, injury prevention practices.

Patient and family education (we may need to teach a spouse how to help or care for the patient, to help get them up and down from a chair or the bathroom, for example).