Important Steps



Important Steps, Inc.- Session Note Instructions-- NYC DOE-CPSE: 08-01-111. A Session Note must be completed for each session.2. Complete all areas as follows:?Child’s Name, DOB, and NYCID#: Make sure this information is consistent with the information in the NYCDOE system (do not use nicknames).?Provider’s Name: The individual providing the related services. ?Discipline: The appropriate discipline of the interventionist (e.g., PT, ST, OT).Frequency and Duration: As per IEP and Assignment from Important Steps, Inc. ? Location of Service: Where the session took place, (e.g., home, school, or office)?Date and Time: The date and time during which the session took place. Please circle “am/pm”. ?Service Type: The service type as listed on the IEP, (i.e. Speech Therapy (ST))?Date Note Written: The date the session note was completed (should be the same as the date of service).Make-up for: Indicate the date of missed session within the school year conducting make up for (i.e. Fall) Session Cancelled/Absent: a) Check this off when the session is cancelled/not held/child is absent; b) Indicate the reason the reason for cancelation. (Note: no need for the following: CPT codes, activities, etc. Therapist signature is required. Caregiver signature is optional.)ICD-9 Code: The relevant ICD-9 code as indicated on the child’s evaluation for your discipline. This is pre-written for your convenience at the time of your assignment. Please contact main office for more info. CPT Codes: The relevant CPT (Current Procedural Terminology) codes as indicated by the clinician’s professional association. IMPORTANT: CPT Codes MUST match its description & ICD-9 codes. See list of suggested codes below as per each discipline scope of practice. Check the time interval consistent w/each CPT code and list as many as you have conducted during the mandated session interval. If conducted same CPT code several times indicate # of same CPT codes. Example: if mandate is Basic (A) –(i.e. 30 min & up) and same CPT codes was conducted 2 times (15 min each) please put: 1) CPT# 97530 X 2?IEP Outcome(s) Addressed: The target outcome(s) from the IEP, which was/were the focus of that session’s intervention. These outcomes are taken directly from child’s current IEP (Note: this is the only section that can be pre-typed). ?Activity During Session and Child’s Response: Brief description of the clinician’s activities (at least 3) and child’s/family response to each activity during the session. These activities/descriptions MUST match CPT codes above.?Parent/Caregiver Training/Carryover:1. Indicate the one or more activities agreed upon by the interventionist and the parent/caregiver that will be used during daily routines in the coming week(s). Indicate: WHERE/WHEN/WHAT “homework” activities caregivers can do w/child during child’s daily routine. For example, if the objective is for the child to roll, the interventionist could write: “At bath or change time, the parent will use a towel or diaper to gently lift one side of the child to assist in beginning to roll.” Parent will record progress in parent/therapist notebook/calendar, etc.2. Activities for parents are expected to span a minimum of one week. However, a therapist may see the child/family more than once per week; or activities may be recommended for multiple weeks.Indicate in this section if you are continuing to work on an activity from the above Session Note.3. Parent/Caregiver Signature and Relationship to Child: The parent/caregiver who was present during the session signs contemporaneously w/related service provider and indicates his/her relationship to the child (i.e. mother, babysitter, day care teacher, etc). 4. Provider’s Signature, Credentials & License# : The clinician’s signature & full credentials (Ex: C-SLP, #00921) . For CFs Supervisor’s signature &full credentials are required for each note. 5. Indirect Time: Indicate time (from-to) spend after the mandated direct service has concluded (i.e. paperwork, etc)6. Keep the Session notes w/original signature in child’s file at the provider site. The Session notes may be reviewed or requested by the parents; therapist’s QA supervisor; NYC DOE’s various departments such as the Local District and Program Monitoring and Quality Improvement; NYS DOE and OMIG.7. Monthly Multidisciplinary Meeting: Please complete one at least per month. 8. Indicate NPI# on the bottom of each page as required for billing submission to NYCDOE.Instructions for Completing CPT/ICD-9 Codes on Session Notes-2011-12_ aboveUse the chart below to indicate the child’s type of delay (ICD-9 codes) (from evaluations) and the type of therapy you have provided (CPT codes). Related Service: Occupational Therapy (OT)CPT CodeDescriptionICD-9 CodeUnit DefinitionRestrictions97110Therapeutic Exercises to develop strength and endurance, range of motion and flexibility315.4 Developmental Coordination Disorder15 minutesSession limit 4 units97112Neuromuscular Reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing315.4 Developmental Coordination Disorder15 minutesSession limit 4 units97124Massage Therapy including effleurage, pertrissage, tapotement (stroking, compression, percussion)315.4 Developmental Coordination Disorder15 minSession limit 4 units97150Group Therapeutic (2 or more individuals)315.4 Developmental Coordination DisorderEncounterI unit per recipient97530Kinetic therapy-Therapeutic activities, direct (1X1) patient contact by the provider (use of dynamic activities to improve functional performance) 315.4 Developmental Coordination Disorder15 minSession limit 4 units97533Sensory Integration to enhance sensory processing and promote adaptive responses to environmental demands direct (1X1) patient contact by the provider. 315.4 Developmental Coordination Disorder15 minSession limit 4 units97755Assistive Technology assessment 315.4 Developmental Coordination Disorder15 minutesWith written report In the event you require more codes please refer to: Related Service: Speech Therapy- STCPT CodeDescriptionICD-9 CodeUnit DefinitionRestrictions92507Treatment of speech, language, voice, communication, &/or auditory processing disorder: individual315.3 – Developmental Speech-language disorder; 315.32-Mixed receptive-expressive language disorder315.31-Expressive language disorder315.39 OtherDevelopmental articulation disorder, Phonological disorderExcludes: Lisping and lalling (307.9)Encounter4 procedures per day92508Speech Therapy Group, 2 or more individuals315.3 – Developmental Speech-language disorder; 315.32-Mixed receptive-expressive language disorder315.31-Expressive language disorder315.39 OtherDevelopmental articulation disorder, Phonological disorderExcludes: Lisping and lalling (307.9)Group Encounter?In the event you require more codes please refer to: Related Service: Physical Therapy- PTCPT CodeDescriptionICD-9 CodeUnit DefinitionRestrictions97110Therapeutic Exercises to develop strength and endurance, range of motion and flexibility315.4 Developmental Coordination Disorder15 minutesSession limit 4 units97112Neuromuscular Reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing315.4 Developmental Coordination Disorder15 minutesSession limit 4 units97116Gait training including stair climbing315.4 Developmental Coordination DisorderEncounterSession limit 4 units97124Massage Therapy including effleurage, pertrissage, tapotement (stroking, compression, percussion)315.4 Developmental Coordination Disorder15 minSession limit 4 units97530Kinetic therapy-Therapeutic activities, direct (1X1) patient contact by the provider (use of dynamic activities to improve functional performance)315.4 Developmental Coordination Disorder15 minSession limit 4 units97755Assistive Technology assessment 315.4 Developmental Coordination Disorder15 minutesWith written reportIn the event you require more codes please refer to: ??? ................
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