Documentation & Coding of Physical Medicine- ROV Now that we’ve learned the importance of properly ordering and providing rationale for modalities and procedure in the initial visit, let’s explore best practices for documenting which services were performed on daily visits. Various regulations exist that point toward what type of information must be included to qualify…

Documentation Samples These documentation samples are provided not only as examples of the necessary components of the treatment plan in a note, but also to indicate in the sidebar the reasoning for the individual pieces needed to create the best possible note—one that will document and relay the information essential for an initial and routine…

Documenting Rationale for Physical Medicine The saying goes that where much is given, much is required. That is especially true with Chiropractic documentation. Practices that elect to include ancillary, supportive services in the patient treatment plan have a more rigorous requirement for establishing medical necessity. Part of that process includes defining the rationale for each…

Know Your Regulations! Delegation or Incident-To? We often hear the terms “incident to” and “delegating services” used interchangeably; however, there are many differences between the two. Both refer to the doctor or other qualified healthcare practitioner having someone else in the office to render patient services. It is important to note that Medicare has a…

Delegating Requires Prior Research  Every team member plays an important role in a patient’s healthcare experience. Proper and compliant delegating of services requires you to: Consider your workforce members and their job title and/or qualifications. Some job titles are created based on the practice’s needs and require that other credentials be earned. Knowing these roles,…

An Overview of Delegating Services The process of delegating services, either to another provider or a chiropractic assistant, is a tricky one. This brief training brings to light the most important factors to consider when providing services that may be billed to a 3rd-party payer. Both state law and the consideration of the payer are…