The Mechanics of Assessment in Routine Office Visits (ROV)

This Rapid Tutorial provides a high-level overview of the purpose and intention of this important part of a daily SOAP note. Assessment is not just a restating of the diagnosis. It’s where the doctor explains the patient’s progress or lack thereof. It provides the context for HOW the patient is doing, and WHY s/he may or may not need more care.

Because the assessment can seem redundant when there are multiple visits in one week, this brief training outlines the best practices for including the most important, specific elements. A well-written daily assessment provides the perspective needed as one works through the active episode of care to tell the story of the patient’s return to health.

CMS Job Aid Chiro Services Fact Sheet

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Medicare publishes helpful documents and alerts to keep providers in the know about important topics. We’ve included the document below that relates specifically to documenting Chiropractic care and medical necessity. This tool relates to the elements of Chiropractic documentation and the rulebook for Medicare policy (The Benefit Policy Manual).

CMS Job Aid Chiro Services Fact Sheet

PART Documentation for Medicare

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For approximately two decades, Chiropractic practice has used PART for objective evaluations of the Vertebral Subluxation Complex. PART can be used in conjunction with the PART Applied to the ROV Objective Documentation webpage or as a stand-alone tool.  It deconstructs PART into its components and gives the doctor a selection of options to objectively substantiate and document his/her findings for subluxation(s).

This tool provides general guidance for the requirements needed to establish the episode of care. Please download, review, and save this tool with your documentation training materials. You may also consider placing a copy in a sheet protector or laminating it for easy reference.

PART Documentation for Medicare

PART Applied to the ROV Objective Documentation

PART and ROV

The PART process, an examination method intended to quantify the presence of a subluxation for Medicare, has been used for over two decades. The application of PART, as noted below, is critical in the initial visit of an episode of care to formulate the basis for medical necessity. However, when documenting the evaluation on an ROV, the components of PART provide a useful guideline to record the findings. Remember, the object of objective is to document comparison of the findings to the previous visit. This data maintains the consistency of basic findings from visit to visit and uses a nationally accepted format.

PART is not required every visit, per Medicare, and is never specifically required outside of Medicare; but this simple process can be valuable as a documentation standard for all patients.  Medicare’s minimum PART findings require at least 2 elements, one from the “A” or “R” in PART to aid in proving the existence of a subluxation and medical necessity. Documenting these findings helps cover your bases and supports your Assessment of the day’s visit. You must document these findings for each region treated to show both clinical appropriateness and medical necessity.

Why A.R.?

The two most common and accepted forms of evaluation of Spinal Subluxation(s) in the profession are Static and Motion palpation, 89.2% and 86.5% respectively[1].  Therefore, it seems both easy and familiar for providers to include these minimum evaluation techniques in their records. How do these techniques relate to PART?

In the ROV-O’s most basic form, the doctor can show changes in the A.R. of PART since the previous visit with respect to:

    • Patient’s condition
    • Treatment effectiveness

What does this look like in your records?

PART Minimum for ROV-O Documentation Example
Asymmetry Static Palpation:  Left rotated C7, mildly less prominent or severe
Range of Motion (segmental or area, C5-6 or Cervical area) Motion Palpation: segmental motion restriction: C7 right rotation, mildly less severe restriction
Doctor’s objective note on treatment response not necessary but may help Noted decreased severity C7 VSC* post CMT
Medicare requires a primary VSC* Primary VSC* C7
*Vertebral Subluxation Complex

In the example above, the provider determined the A.R. of P.A.R.T. simply from palpation. It allows a provider to quickly arrive at A and/or R during each visit using different senses or tools:

    1. Observation/Visual
    2. Palpation/tactile
    3. Other Testing: standardized objective data with interpretation from specialists. Note: this is the S of the expanded “PARTS”
      1. Radiological Imaging (X-rays, CT, MRI with or without contrast, US Doppler studies, Dexa Scan)
      2. Neurological: NCV, Needle EMG, Evoked potentials, Reflex testing, Sleep Study)
      3. Blood testing (CRP, Ferritin, Transferrin, RA factor, CBC with diff, Thyroid)
      4. Pulmonary Function Tests

Note: for some of the above, connect the visceral/vascular problem to the spinal area and segment(s) of complaint

PART on Observation

The example above reviewed the A and R through palpation; next, explore these elements using only Observation. Begin the patient evaluation the very moment you see him/her. Below are some examples that may be appropriate for the Objective section of the daily note:

Observation of Asymmetry

    • Seated position, T-L-S leaning moderately less to the left.
    • Weight bearing, increased head tilt to the right, 45 degrees.
    • Improving gait, a bit more weight bearing on Rt leg, mild pain with less (approx. 30 degrees) Lt lumbar antalgia.

Observation of ROM

    • Increasing Rt shoulder ROM, up to 90 degrees with mild pain while getting on and off the treatment bench.
    • 25% increase cervical Lt rotation ROM with mild pain at C6-7 (Did the patient turn his/her neck more to talk to you while you were to his/her side, or did s/he turn his/her body?)
    • Mild decrease T L S flexion with mild pain local at Rt SI (Could the patient bend forward to pick up the keys you accidentally dropped? Patients usually want to be helpful even when they are in pain.)

Observation of Asymmetry

    • Mild Rt T-L-S convexity, decreasing severity, apex at L3

Observation of ROM

    • 50% decrease Right Lateral Flexion ROM T-L-S spine, no pain, maximal restriction at L3
    • 25% decrease Lumbosacral extension ROM, elicits mild-moderate pain at L5-S1.

These are just examples of things to consider. They are not intended to be copied and pasted into your records.  Furthermore, these examples use AR of PART only to meet the minimum requirements.  Other minimum options are PA, PR, RT, AT, of PART.

Tell the story of your patient’s progress with solid documentation of objective findings on a day-to-day basis. From there, medical necessity is sure to follow.

[1] Beliveau et al) “The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided,” Chiropr Man Ther 2017; 25(35):1-17

Documentation of Objective Findings Daily ROV

If a primary goal of a practice is to help people get better and achieve their functional goals, how can you determine if a patient is improving, regressing, or staying the same? You can’t rely solely on what the patient tells you as some patients unwittingly under report while others over report problems or progress.  It is important to examine the patient and then document your findings. What do Best Practices say?

Tune in to this Rapid Tutorial to see how you can easily track the patient through the ROV Objective.  In this lesson, we provide direction on how to convert your Objective findings into reliable, standardized language to address the minimum necessary through PART for different types of treatment plans, Active, Wellness, Supportive Maintenance, etc. Follow along here to learn the most critical elements of recording the ROV Objective assessment.

Use of the AT Modifier in Chiropractic

Medicare publishes helpful documents and alerts to keep providers in the know about important topics. The use of the AT modifier in Medicare is one of the most critical billing issues providers face. Absence of the AT modifier indicates that the service is maintenance in nature…and therefore, is not payable. Statistics show that overuse of...
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