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Billing and Collections Coding Compliance Documentation Medicare Patient Finances Therapy and Active Care

PS-101
Documentation of Modalities and Procedures

Learn how to properly outline the medical necessity and results from modalities and procedures to meet the minimum necessary documentation for these ancillary services.

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Documentation of services other than CMT within the initial and routine office visit notes is often lacking. Just because we documented and commented on the response to the adjustment, it doesn’t mean that we’ve properly outlined the medical necessity and results from modalities and procedures. State licensing boards and insurance carriers have outlined the minimum necessary documentation for these ancillary services. This lesson helps you as you update your minimum standards for documenting these elements of a visit.

  • List the components of the initial visit documentation necessary to validate and justify ordering modalities and procedures in the patient’s treatment plan
  • Provide a clear description of the documentation requirements for routine visit (ROV) documentation for both supervised and constant attendance modalities and for therapeutic procedures
  • Explain the rules and regulations for counting and documenting timed treatment codes
  • Offer guidance on and implement rules for people that can provide modalities and procedures regarding how to document their involvement

Documentation of Modalities and Procedures Implementation Guide

Fact Sheets:

  • Documentation When Prescribing Modalities and Procedures
  • Documenting Ancillary Services in Routine Office Visit Notes
  • Who Can Provide Ancillary Services to Patients Other Than the DC?

Rapid Tutorials:

  • Documenting Physical Medicine
  • Documenting Modalities and Procedures in Routine Office Visit Notes

Sample Policy:

  • Documenting Modalities and Procedures

Support Tool:

  • Guidelines for Delegating Ancillary Services
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