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Understanding the difference between the initial visit of an episode of care, and the subsequent visits in the episode helps define the documentation requirements. The Routine Office Visits (ROV) are those visits where the prescribed treatment plan is executed. Usually these will be in a SOAP format for documentation.
The great news about ROVs is that the documentation is usually much more succinct and to the point. Their purpose is to document changes since the last visit and statements about the patient’s progress. Of course, the services performed are also clearly documented here to drive the CPT coding.
In this helpful video, KMC addresses the most common questions we get about what goes in the documentation for an ROV. She explains what auditors are looking for in this documentation, and as usual, makes it easy to understand and to duplicate.
Watch this short explanatory video and watch the documentation of ROVs in your practice go from good to great!