Documentation Drives Coding

Far too often, we find a fancy code (maybe a new code) and want to find a way to charge for it. This is completely backward. Documentation must drive coding. This simple visual reminder outlines the process of starting with the documentation and coding from there. Utilize this concept to re-enforce the dependency that each...
OOPS, this page contains content reserved for KMC University members. We’d love to welcome you to the KMC University family because there is an amazing amount of helpful content in the trainings and resources of the KMC University Library. Click here to learn more.

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 of an established patient initial visit of an episode of care has a different look than a new patient initial visit. Also note the layout of a non-E/M visit note when the patient is receiving care and has an incident, which requires more than a routine office visit but not a full E/M service. Please remember that these samples are not meant to be used exactly but rather to help you form a picture in your mind of what a good note looks like.

The Anatomy of a CMT Routine Visit Note

The Anatomy of a Routine Visit Note – Preventative Maintenance

The Anatomy of a Routine Office Visit (ROV) Note
with Therapeutic Procedures

The Anatomy of a Subsequent Routine Office Visit (ROV)
Episodic Care (OV#2)

The Anatomy of a Subsequent Routine Office Visit (ROV) Episodic Care (OV#5)
The Anatomy of a
Wellness Encounter Treatment Note


Gain a Solid Command of Routine Office Visit (ROV) Documentation Requirements

This Rapid Tutorial sets the tone for this module and for the entire course focused on Documentation of Evaluation and Management. Start your training by better understanding what a routine office visit looks like in the context of your documentation.

Often, providers forget the ROV within “episodic care” must have a minimum set of targeted “updated” (comparative) subjective data components from the previous visit, or initial visit when applicable, of this episode. These routine visits provide the necessary elements to continue to prove the medical necessity for active treatment and the plan itself.


Gain a Solid Command of Initial Visit Documentation Requirements

This Rapid Tutorial sets the tone for this module, but also for the entire course focused on Documentation of Evaluation and Management.  Start your training by better understanding what an initial office visit looks like in the context of your documentation.

Often, providers forget when dealing with an insured patient, that the initial visit of an episode of care must have the same components as other initial visits. These foundational visits provide the necessary elements to establish medical necessity for active treatment.


Incident, Burst, or Episode

Download Support Tool The terms incident, burst and full episode were coined by us here at KMC University as a way for providers to consider 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 can be put...
OOPS, this page contains content reserved for KMC University members. We’d love to welcome you to the KMC University family because there is an amazing amount of helpful content in the trainings and resources of the KMC University Library. Click here to learn more.