Service Record – Speech Therapy



Service Record – School Based Occupational TherapyMedicaid NumberLast NameFirst NameWVEIS #Diagnosis CodeDate of BirthCounty1 Beginning Date1 Ending Date1 Procedure CodeUnitsSchool2 Beginning Date2 Ending Date2 Procedure CodeUnitsProvider Name3 Beginning Date3 Ending Date3 Procedure CodeUnitsOccupational Therapy: Physician’s authorization on file. Must be identified on Service Plan.CodeProcedureService Unit*97165 GOOccupational Therapy Evaluation Low Complexity1 event per calendar year*97166 GOOccupational Therapy Evaluation Moderate Complexity1 event per calendar year*97167 GOOccupational Therapy Evaluation High Complexity1 event per calendar year97168 GOOccupational Therapy Re-evaluation2 events per calendar year97032 GOApplication of a modality to one or more areas; electrical stimulation (manual), each 15 minutes20 units per month97110 GOTherapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility each 15 minutes20 units per month97112 GONeuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities, each 15 minutes20 units per month97113 GOAquatic Therapy with therapeutic exercises, each 15 minutes20 units per month97116 GOGait training (includes stair climbing) each 15 minutes20 units per month97150 GOTherapeutic procedure(s), group (2 or more individuals), each 15 minutes.20 units per month97140 GOManual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions each 15 minutes20 units per month97530 GOTherapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes20 units per month97532 GODevelopment of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider each 15 minutes20 units per month97533 GOSensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes20 units per month*May only use one of the three evaluation codes per calendar year.Use 97150 GO for procedure(s) provided to a group (2 or more individuals)Date1 Start Time End TimeDate2163174181952062172282324925102611271228132914153031Start TimeEnd TimeSignature/CredentialsDateWVDE – BMS – SBHS – Appendix FEffective Date: January 1, 2017 ................
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