Documentation & Coding

The term “Routine Office Visit” describes 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 patients’ progress, or lack thereof, as they advance through the stated plan.

Now that we've had a month to settle into the new Evaluation and Management (E/M) coding rules that went into effect at the beginning of the year, the questions are getting more specific and refined.

We have been preparing all year for the inevitable start date in January, and now is the time to learn how the coding changes affect you!

Many of the doctors we meet tell us they’re not too worried about their documentation. “We’ve got that covered,” they say. “I think we’re probably fine.” “I’m fine, right?”

Just in the past few weeks, our Help Desk and our Solutions line have been inundated with calls from both members and non-members of KMC University indicating that they have received records requests for groups of patients. Folks, when this happens, it’s usually an audit. We have seen enough the past few weeks to confirm that audits are on the rise again.

Much of your training has focused on anatomy, terminology, biomechanics, techniques and all the things involved in moving segments and aligning spines. But what about your practice?

Whether performed by the doctor or appropriately delegated to qualified team members, all ancillary services must be recorded in the same way as the primary manipulative treatment.

A Hydro-Bed modality, aka hydrotherapy table, water massager, aqua table or hydro-massager, is a device in which water is used to administer a massage-type therapy. These devices are usually in a table format and are available in several variations.