Transcript 3x week for 4 weeks

The PMTP
•
•
•
•
•
•
Phases of Care
Active and Passive Care
Prognosis
MMI
Adjusting Goals, Duration, and Frequency
Physiotherapy selection
3-1-06
4/3/06
Care Status
Phase of Healing
Stage of Care
• Phase I Acute Inflammatory
• Phase II Repair / Regeneration
• Phase III Rehab / Remodeling
Phase I
Acute
Inflammation
Mild 2 days
Moderate 3-4 days
Moderate to severe 7
days
Phase II
Regeneration
Repair
Mild to moderate 6 weeks
Moderately severe up to
16 wks.
Phase III
Remodeling
Rehab
Mild 2-3 weeks
Moderate 4-8 weeks
Moderately severe up to
1 yr.
Medicine and Science in
Sports and Exercise
Examples of Time frames for mild, moderate, and
moderately severe conditions and phases of healing.
Phase I
Acute
Inflammatory
Phase II
Repair
Regeneration
PASSIVE CARE
Phase III
Remodeling
Rehab
decreases
increases
ACTIVE CARE
Time / Number of Visits
Passive / Active Care Examples
3-1-06
4/3/06
Zeroing
in on
Prognosis
Prognosis
Prognosis: What your patient can expect. You forecast as to
the probable outcome of their condition.
One word descriptions (Good -Poor) are inadequate, offer
no explanation as to evidence to support the prognostic
conclusion, and are unacceptable.
Prognosis
Arriving at a technically certain prognosis after the initial
exam may not be possible especially during the acute phase.
3-1-06
This patient is in the acute phase of care. Prognosis is deferred until the
response to the initial therapeutic trial is determined by progress exam in 4
wks
4/3/06
Prognosis deferral
Acute Phase
Prognosis is deferred until the patient’s
response to the initial therapeutic trial
has been determined by progress
examination in approximately 4
weeks.
Good Prognosis Example
• The prognosis is good and is based upon
– excellent patient compliance in keeping
appointments (11/12 kept) and performing
home therapy
– reduction in pain scores from 6 to 3,
– improvement in the NDI from 42% to 18%,
– and substantially improved cervical range of
motion.
Fair Prognosis Example
• The prognosis in this case is currently considered
fair based upon the following:
– There were (4) previous episodes of low back pain
resulting in loss of work time and light duty restrictions
over the past 3 years.
– Mild obesity, deconditioning syndrome, and smoking 2
packs of cigarettes / day for past 5 years.
– Pain score improvement from 6/10 to 3/10.
– Low back Oswestry score improved from 48% to
30%.
– 9/12 appointments kept over the last therapeutic
trial
Poor Prognosis Example
• The prognosis in this case is poor in consideration
of the following:
– Non-compliance with the agreed upon treatment plan,
missing 6/10 appointments.
– Non-compliance with the agreed upon home exercise
program.
– Obesity and moderately severe de-conditioning
syndrome.
– Diabetes and non-compliance with diet and nutritional
recommendations.
• Document in SOAP notes
Poor Prognosis Example
• The prognosis in this case is poor due to the
following:
– Low back Oswestry score is 58% , indicating a
moderately severe patient perception of disability
performing routine activities of daily living.
– Moderately severe degenerative disc disease L5/S1
with attendant radiculopathy of the right lower
extremity
– Decreased coordination, strength, sensation, and
proprioreception of the right lower extremity.
UNACCEPTABLE
PROGNOSIS
EXAMPLE
• The prognosis in this case is good with
patient compliance
• The above Prognosis is unacceptable
• MUST ANSWER THE QUESTION: WHY?
Prognosis
• One word prognosis is unacceptable.
• Prognosis is good with patient compliance is
unacceptable
– ADD THE WORD “BECAUSE”
– THINK OF THE PHRASE “BECAUSE OF THE
FOLLOWING”
– …DUE TO THE FOLLOWING FACTORS /
OBJECTIVE FINDINGS
– YOU MUST DOCUMENT YOUR REASON(S).
3-1-06
This patient is in the acute phase of care. Prognosis is deferred until the response
to the initial therapeutic trial is determined by progress exam in 4 wks
In some cases, if you cannot reasonably
forecast the patient’s anticipated response to
care (the PROGNOSIS) especially during he
acute phase based upon a one time exam,
how can one be reasonably certain regarding
the date of MMI?
MMI
Maximum Medical Improvement
• The patient’s condition is static and stable.
• Patient symptoms, your objective exam findings, and
Outcome Assessments show little or no improvement
after 2 progress exams..
• When further care does not bring about
OBJECTIVE MEASURABLE IMPROVEMENT!
• The patient may then be a candidate for supportive
care.
Supportive / Palliative Care
• Treatment rendered after achieving
maximum medical / therapeutic benefit.
• Periodic trials of withdrawal from care fail
to sustain previous treatment gains.
• Excluded from Medicare coverage. Not
considered medically necessary.
– Excluded from most insurance policy coverage
MMI DOES NOT MEAN
• RELEASING THE PATIENT WITH A PAIN
SCORE OF 0,
• OR AN OSWESTRY SCORE OF 0%,
• OR WITH NORMAL R.O.M MEASUREMENTS
CONFIRMED BY YOUR INCLINOMETER!
• Maximum Therapeutic Benefit (MMI?): when
there are NO DETECTABLE measurable
changes (improvements) identified over the
course of 2 therapeutic trials as determined by
2 progress exams AND OUTCOME
ASSESSMENTS
MMI Uncomplicated Case
• An uncomplicated mild to moderate ankle
sprain
– 6 WEEKS OF CARE ESTIMATED
– OPPORTUNITY TO SEE THE PATIENT
THROUGH THE 3 PHASES OF HEALING
– ESTABLISH THE MMI DATE ABOUT 6 WEESK
OUT FROM THE BEGINNING CARE.
MMI Date for Complicated Case
• Low back pain 6/10, Oswestry score 50%
• Moderately severe DDD L5S1 with weakness of the R
LE
• Overweight smoker with significant deconditioning
• Acute on chronic condition with PMHX of multiple
disabling events,
• Compliance to home therapy, nutrition, and in-office
care is fair, keeping 7/10 appts.
• Anticipated MMI date 16-24 weeks out from initial
care, pending results of further diagnostic testing,
referrals, and measurable change to Outcome
Assessments.
Establishing an MMI date
1. Determine if it is a mild, moderate, or
moderately severe condition.
2. Are there complicating factors that adversely
affect prognosis?
3. Is the patient compliant with home care and
keeping appts?
4. It is better to select an MMI date a little further
out and releasing the patient early, than to
repeatedly miss the mark you select (target date)
DOCUMENT THE PROGNOSIS AND
MMI DATE AS SOON AS
REASONABLY POSSIBLE
1. During the initial exam or
2. At the time of the the first progress exam
3. The prognosis may be updated / changed
based upon the availability of new
information
MMI
• Maximum Medical (Chiropractic) Improvement is
determined by the results of all of the components
of your examination
–
–
–
–
–
Ortho
Neuro
ROM
Strength
Outcome Assessments / effects on ADL
• AS WELL AS HOW YOU SET UP YOU
TREATMENT PLAN AND TX GOALS!
3 times per week for 3 weeks
Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (739.1) and the lumbar spine at L5 (739.3). Begin Diversified
adjusting week 2, after acute pain and spasm have been reduced
3 times per week for 3 weeks
Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (7391.) and the lumbar spine at L5 (739.3). Begin Diversified
adjusting 2nd week of treatment after acute pain has been reduced and stabilized.
Joint mobilization
97140
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
3x week for 1 week
3 times per week for 3 weeks
Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (7391.) and the lumbar spine at L5 (739.3). Begin Diversified
adjusting 2nd week of treatment after acute pain has been reduced and stabilized.
Joint mobilization
97140
Ultrasound-pulsed
97035
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
Reduce acute inflamm / swelling
3x week for 1 week
3x week for 1 week
3 times per week for 3 weeks
Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (7391.) and the lumbar spine at L5 (739.3). Begin Diversified
adjusting 2nd week of treatment after acute pain has been reduced and stabilized.
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
3x week for 1 week
Joint mobilization
97140
Ultrasound
97035
Reduce acute inflamm / swelling
3x week for 1 week
EMS- Interferential
97014
High and low frequency for pain modulation and swelling
/ inflammation, and muscle spasm
3x week for 2 weeks
3 times per week for 3 weeks
Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (7391.) and the lumbar spine at L5 (739.3). Begin Diversified
adjusting 2nd week of treatment after acute pain has been reduced and stabilized.
Joint mobilization
Ultrasound
EMS- Interferential
97140
97035
97014
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
3x week for 1 week
Reduce acute inflamm / swelling
3x week for 1 week
High and low frequency for pain modulation and swelling
/ inflammation, and muscle spasm
3x week for 2 weeks
Muscle Spasm
Violent involuntary contraction of muscle attended by pain and interference of function. An
ACUTE phenomenon.
Mostly commonly seen the 1st week post trauma, and resolved within a few weeks.
Possibly seen and palpated during an acute on chronic episode.
If muscle spasm is commonly documented during the subacute (repair regeneration) phase
and the rehab (remodeling) phase, it lessens the credibility of the provider and may trigger a
fraud investigation by 3rd party payors.
Muscle spasms that occur 4, 6, and 10 weeks into the treatment plan would be extremely
rare and may require referral, and minimally an advanced neurological examination
3 times per week for 3 weeks
Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (7391.) and the lumbar spine at L5 (739.3). Begin Diversified
adjusting 2nd week of treatment after acute pain has been reduced and stabilized.
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
3x week for 1 week
Joint mobilization
97140
Ultrasound
97035
Reduce acute inflamm / swelling
3x week for 1 week
EMS- Interferential
97014
High and low frequency for pain modulation and swelling
/ inflammation, and muscle spasm
3x week for 2 weeks
97014 EMS unattended
97032 EMS attended / manual- applied by the hand of the therapist
requiring constant attendance for therapy to take place
3 times per week for 3 weeks
Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (7391.) and the lumbar spine at L5 (739.3). Begin Diversified
adjusting 2nd week of treatment after acute pain has been reduced and stabilized.
Joint mobilization
97140
Ultrasound
EMS- Interferential
97014
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
3x week for 1 week
Reduce acute inflamm / swelling
3x week for 1 week
High and low frequency for pain modulation and swelling
/ inflammation nd muscle spasm
3x week for 2 weeks
Soft foam cervical collar.Verbal and written
instructions supplied
Cold pack. Written and verbal
instructions supplied
DATE
DATE
DATE
DATE
ALWAYS
Intern signature legible!
7 + 6 + 8 = 21 / 3 = 7 QVAS score
3 times per week for 3 weeks
Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (7391.) and the lumbar spine at L5 (739.3). Begin Diversified
adjusting 2nd week of treatment after acute pain has been reduced and stabilized.
Joint mobilization
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
97140
Ultrasound
EMS- Interferential
97014
Reduce acute inflamm / swelling
3x week for 1 week
High and low frequency for pain modulation and swelling
/ inflammation
3x week for 2 weeks
Soft foam cervical collar.Verbal and written
instructions supplied
Cold pack. Written and verbal
instructions supplied
7/10
See entire acute care tx plan above
3x week for 1 week
DATE
DATE
DATE
DATE
Reduce QVAS from 7 to 5 in 4 weeks (achieve this goal on or before the progress
exam
D
C
3
2
C
D
2
3
F
D
5
3
D
C
3
2
D
3
D
3
My back and neck hurt me more when I
try to get in and out of my car
Intern legible signature
D
C
3
2
27 pts X 2= 54
C
D
54% Oswestry
Disability Score
2
3
F
D
5
3
D
C
3
2
D
3
D
3
My back and neck hurt me more when I
try to get in and out of my car
Intern legible signature
Joint mobilization
Ultrasound
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
97140
Reduce acute inflamm / swelling
97035
EMS- Interferential
3x week for 1 week
High and low frequency for pain modulation and swelling
/ inflammation
97014
3x week for 1 week
3x week for 2 weeks
DATE
DATE
Soft foam cervical collar.Verbal and written
instructions supplied
Cold pack. Written and verbal
instructions supplied
7/10
DATE
DATE
DATE
Reduce QVAS from 7 to 5 in 4 weeks (achieve this goal on or before the progress
exam
See entire acute care tx plan above
Oswestry Low Back Disability Score
ADL training
54%
Improve patient comfort and safety transfer in and out of their car
97535
1x per week for 2 weeks
DATE ALWAYS
Legible intern signature
DATE ALWAYS
28 pts X 2 =
56% NDI score
Legible intern signature
Joint mobilization
Ultrasound
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
97140
Reduce acute inflamm / swelling
97035
EMS- Interferential
3x week for 1 week
High and low frequency for pain modulation and swelling
/ inflammation
97014
3x week for 1 week
3x week for 2 weeks
DATE
DATE
Soft foam cervical collar.Verbal and written
instructions supplied
Cold pack. Written and verbal
instructions supplied
7/10
DATE
DATE
DATE
Reduce QVAS from 7 to 5 in 4 weeks (achieve this goal on or before the progress
exam
See entire acute care tx plan above
Oswestry Low Back Disability Score
54%
ADL training
Neck Disability Index
Improve patient comfort and safety transfer in and out of their car
97535
56%
1x per week for 2 weeks
Goal to achieve by progress
exam date
currently
There are a lot of Activities of Daily Living issues with this case as
documented by the Oswestry and NDI. In the ACUTE phase, it is
better to focus on helping them with the reachable and critical
necessities
•Self care
•Driving – transfer in and out of vehicle
•Sitting- getting in and out of chair
Recreational activities and lifting heavier objects are examples that may be
addressed in later phases with active care / rehab.
Joint mobilization
Ultrasound
Gently increase intersegmental ROM, pump out
inflamm exudates, prepare joints for grade V
manipulation / adustment
97140
Reduce acute inflamm / swelling
97035
EMS- Interferential
3x week for 1 week
High and low frequency for pain modulation and swelling
/ inflammation
97014
3x week for 1 week
3x week for 2 weeks
DATE
DATE
Soft foam cervical collar.Verbal and written
instructions supplied
Cold pack. Written and verbal
instructions supplied
7/10
DATE
DATE
DATE
Reduce QVAS from 7 to 5 in 4 weeks (achieve this goal on or before the progress
exam
See entire acute care tx plan above
Oswestry Low Back Disability Score
54%
ADL training
Neck Disability Index
ADL Training-verbalize
and demonstrate ability
to perform
Improve patient comfort and safety transfer in and out of their car
97535
56%
1x per week for 2 weeks
To look after herself normally despite pain by the next progress exam
97535
1x and re-evaluate in 1 week. See SOAP notes
for additional ADL info.
Acute Inflammatory Phase
• Activity restrictions / work restrictions
– Based upon exam findings, outcome assessments, job
description etc.
• Short term immobilization and bracing
– Collar, belt, rest
• Reduce inflammation and pain
– Home therapy
– Physiotherapy
– Nutritional intervention
• Document advice / ADL instructions
• Adjusting vs. mobilization (joint motion w/o
thrust)
PMTP Example
Phase II Repair- Regeneration
PMTP Example
• Repair Regeneration Phase II
• Low back patient
– Prognosis
– Adjusting goals
– Outcome Assessments
• Treatment plan
• Treatment goals
ALWAYS
Intern signature legible!
4 + 4 + 7 = 15 / 3 = 5 QVAS score
2
2
1
1
40% Oswestry Score
3
4
2
1
2
2
My back hurts more and
feels weak when I lift and
care for my 2 y/o baby
Legible signature
Prognosis to date is good based upon excellent compliance to the treatment plan, approx 50% improvement in
ROM, fewer + orthopedic tests, reduction in pain , Oswestry, and Neck Disability Index scores.
Biomechanical and structural
pathology from Rad report goes here.
Will this info affect the prognosis? Are
any of these findings worthy of making
it up to the Diagnosis section
Prognosis to date is good based upon excellent compliance to the treatment plan, approx 50%
improvement in ROM, fewer + orthopedic tests, reduction in pain , Oswestry, and Neck Disability
Index scores.
CVA/ cardiovascular risk
Safety issues collected from outcome assessment data.
Work / recreational issues – re-injury / joint protection
Biomechanical and structural
pathology from Rad report goes here.
Will this info affect the prognosis? Are
any of these findings worthy of making
it up to the Diagnosis section
3x week for 4 weeks
Reduce moderately severe alterations in joint endplay hypomobility (739.3) at L4.
3x week for 4 weeks
Reduce moderately severe alterations in joint endplay hypomobility (739.3) at L4.
EMS - Interferential
97014
For pain control
3x week for 2 weeks
3x week for 4 weeks
Reduce moderately severe alterations in joint endplay hypomobility (739.3) at L4. Increase
intersegmental and global ROM per clinical exam and inclinometry ROM testing
EMS - Interferential
Therapeutic exercises
97014
97110
For pain control
Increase ROM and, strength
3x week for 2 weeks
2x week for 4 weeks
97110
therapeutic exercises to develop strength and
endurance, range of motion and flexibility, one
or more areas, each 15 minutes
If your examination documents loss of strength, endurance, range of
motion, or flexibility, the selection and performance of 97110 may be
considered medically (chiropractically) necessary.
It would not be appropriate to select 97110 to decrease pain.
3x week for 4 weeks
Reduce moderately severe alterations in joint endplay hypomobility (739.3) at L4. Increase
intersegmental and global ROM per clinical exam and inclinometry ROM testing
EMS - Interferential
Therapeutic exercises
97014
97110
5
EMS – Interferential
For pain control
Increase ROM, flexibility, strength
3x week for 2 weeks
2x week for 4 weeks
Reduce QVAS score to 3. Decrease pain at its worst from 7 to 5 in 4 wks.
97014
3x week for 2 weeks
2
2
1
1
40% Oswestry Score
3
4
2
1
2
2
My back hurts more and
feels weak when I lift and
care for my 2 y/o baby
Legible signature
EMS - Interferential
Therapeutic exercises
97014
For pain control
97110
Increase ROM, flexibility, strength
5
Oswestry Score
ADL training
40%
3x week for 2 weeks
2x week for 4 weeks
Reduce QVAS score to 3. Decrease pain at its worst from 7 to 5 in 4 wks.
The pt. will demonstrate the ability to safely lift her 2 y/o baby using proper
mechanics and joint protection
97535
1x per week for 2 weeks
ADL
Issues
*Lifting
*Walking
*Standing
Legible signature
Don’t Ignore Documented ADL issues
• It would be appropriate to address some of
these ADL issues during Phase II Repair
Regeneration Phase of Care / Healing
– Walking
– Standing
– Lifting?
Oswestry Score
40%
ADL training
Oswestry Low Back Score 40%
Therapeutic exercises
The pt. will demonstrate the ability to safely lift her 2 y/o baby using proper
mechanics and joint protection
97535
1x per week for 2 weeks
Improve walking and standing tolerances (endurance). Demonstrate ability to lift
1.5 x the weight of her baby from the floor and various elevations up to waist level.
97110
2x week for 4 weeks
Improve walking and standing tolerances (endurance). NOTE: LIFTING
HEAVIER WEIGHTS MAY BE AN INNAPROPRIATE GOAL DURING
PHASE II HEALING AND CAUSE FURTHER INJURY. PHASE II SHOULD
BE PREPARATION FOR MORE AGGRESSIVE EXERCISE IN PHASE III
Phase II Repair Regeneration Phase
• Adjustments
• Physiotherapy
–
–
–
–
EMS
Microcurrent
Traction
Soft tissue work – ischemic compression
• Therapeutic exercises
– Home therapy / stretches
– ROM exercises, isometrics
– ADL activity improvements
• This phase represents a combination of passive
and active care.
Phase III Rehab Remodeling
PMTP Example
• Rehab / Remodeling Phase Example
– Prognosis
– Adjusting goals
– Outcome Assessments
• Treatment plan
• Treatment goals
PMTP Example
• Areas involved: Lumbar spine
• Severity: Mild to Moderate
• Outcome Assessments
– QVAS (Quadruple Visual Analog Scale)
– Oswestry (Low back)
Prognosis is good based upon a 50% improvement in the pain score and Oswestry score the past 4 weeks.
ROM has improved in all planes except lumbar extension. Lumbar neural tension signs are negative. This
patient is ready for an aggressive rehab / conditioning program.
1x week for 4 wks
Cervical spine joint dysfunction (739.1) has resolved. Continue CMT to lumbar spine level L5
(739.3) to improve intersegmental ROM and reduce the 2mm retrolisthesis at this level.
1x week for 4 wks
Cervical spine joint dysfunction (739.1) has resolved. Continue CMT to lumbar spine level L5
(739.3) to improve intersegmental ROM and reduce the 2mm retrolisthesis at this level.
Therapeutic exercises
97110
Develop strength, ROM and flexibility
3x week for 4 wks
1x week for 4 wks
Cervical spine joint dysfunction (739.1) has resolved. Continue CMT to lumbar spine level L5
(739.3) to improve intersegmental ROM and reduce the 2mm retrolisthesis at this level.
Therapeutic exercises
97110
Develop strength, ROM and flexibility
3
CMT-Adjustment
Improve pain at its worst from a 6 to a 3
98940
1x week for 4 weeks
1
2
1
0
1
4
2
1
3
1
32% Oswestry
Legible signature
It is common for OT’s and PT’s to
select the next letter or two up as a
target goal to achieve by the next
progress exam
?
For post workout soreness,
home stretches etc?
3
98940
CMT - adjusting
Oswestry Score
Therapeutic exercises
Improve pain at its worst from a 6 to a 3
32%
1x week for 4 weeks
Improve to lifting heavier objects that are conveniently positioned. Improve
walking tolerance to ½ mile or 20 mins; improve sitting tolerance to 1 hour
97110
3x week for 4 weeks. Gradually increase exercise
time to 30 minutes. See SOAP notes for addtl data
Phase III Rehab Remodeling
Phase
• Adjustments less frequent. Generally not in
the 3x week mode.
• Minimal to no physiotherapy modalities
• Active care:
•
•
•
•
•
ROM exercises, stretches
Weight machines
Tubing exercises, exercise ball
Balance boards, proprioreception,
Treadmill, exercise bike, upper body ergonometer
Phase I
Acute
Inflammatory
Phase II
Repair
Regeneration
PASSIVE CARE
Phase III
Remodeling
Rehab
decreases
increases
ACTIVE CARE
Acute on Chronic
• Reduce and stabilize the acute episode
• Move the patient through the phases of care
/ healing.
• Get them to the rehab phase as quickly as
possible, not jeopardizing pt. health, joint
integrity, or cause further re-injury.
Clinic Fee Update Examples
Police
Fire
Active Duty
• 98940 CMT 1-2 areas
• 98941 CMT 3-4 areas
• 98942 CMT 5-6 areas
$10
$12
$13
$20
$23
$26
• 98943 CMT extraspinal $10
$16
Clinic Fee Update Examples
• Therapy
–
–
–
–
–
–
97010 hot pack / cold pack
97012 posture pump / wedge
97014 muscle stim unattended
97032 muscle stim attended
97035 ultrasound
97140
• Myofascial trigger point
• Percussor
–
$7
$7
$7
$7
$7
$10
$10
$10
$10
$13
$7 $13
$7 $13
Clinic Fee Update Examples
• Active Therapy
– 97110 therapeutic exercise
– 97112 neuromuscular re-ed.
– 97535 ADL / self care
$7
$7
$7
$15
$15
$15
ROF Visit
• The ROF is typically performed on the 2nd
or possibly in some cases the 3rd visit.
• Performing a Report of Findings on the
initial visit may be possible and advisable in
rare cases, and would represent the
exception, not the rule.
Clinic Fee Update
• 99213 E/M code for Report of Findings
– To be used if the ROF is performed on the 2nd or 3rd visit
– SOAP notes must be documented thoroughly
• Total time spent. Begin time and end time
• What was discussed?
– Hx, CC, exam, x-ray, restrictions, nutrition, exercise, DX,
prognosis
• Document patients questions and concerns
• Acceptance of tx plan
– A one line sentence indicating that a ROF was
performed is inadequate documentation and will no
longer be accepted. Credit will not be approved for
that visit unless the ROF visit is thoroughly
documented.
Report of Findings Visit
– SOAP notes must be documented thoroughly
• Total time spent. Begin time and end time
• What was discussed?
– Hx, CC, exam, x-ray, restrictions, nutrition,
exercise, DX, prognosis
• Document patients questions and concerns
• Acceptance of tx plan
– A one line sentence indicating that a ROF
was performed is inadequate documentation
and will no longer be accepted. Credit will
not be approved for that visit.
Clinic Update
Dr. Thomas
•
•
Professional Behavior
Physical Contact
–
–
Clinic Staff
Patients