Documentation & Coding Archives

Anatomy of Routine Office Visit (ROV) Documentation Samples

Download Reference Documents These documentation samples are provided not only as examples of the necessary components of a note but also to indicate in the sidebar the reasoning for the individual pieces needed to create the best possible note to document and relay the information essential for various patient case types. Notice that the look…

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PART-Routine Visit Documentation

Documenting PART During ROV The PART Process initials are an acronym for the required elements of examination that quantify the existence of a subluxation to meet Medicare requirements. The elements of PART are Pain, Asymmetry or Misalignment, Range of Motion Abnormalities, and Tissue Tone Changes. These elements are generally present in the initial examination by…

Medicare Documentation Requirements and Guidelines

Download Reference Document Download, review and use this extremely helpful tool that outlines Medicare’s requirements and explanations for documenting the initial evaluation and management note and the daily visit note. Save this tool and use it to guide you as you strive to create compliant documentation, especially when lacking any other guidance from third party…

Distinguish Between an Initial and Routine Office Visit

This brief overview further solidifies the distinction between these two basic formats of your documentation. As you review this, consider your own documentation style, and confirm that there is a difference that clearly distinguishes between initial and routine office visits.

Incident, Burst, or Episode

Download Reference Document The terms incident, burst and full episode were coined by us here at KMC University as a way for providers to consider and clearly define the length of an episode of care. When sitting down to document the initial visit of a new episode, consideration of the potential length of the episode…

The Purpose and Form of an ROV

ROV Components The term “Routine Office Visit” describes the treatment visits where the patient is being seen for the execution of the written treatment plan at the beginning of the Episode of Care. The documentation of these visits contains the details of the patient’s progress, or lack thereof, as they advance through the stated plan….