ENP - Important Steps



Important Steps, Inc. – EI Department Physical Therapy Division THERAPY MONTHLY LOG Month/Year: _______/________Child: ___________________________EI No.________________ IFSP Freq ___ Dur. ___IFSP Therapy Type: __PT Location: Home ___Daycare___ Facility___Provider Name:___________________________ Title/Credentials:___________________________DateDirect ServicesStart TimeDirect ServicesEnd TimeSession Type:R= regularM =makeup(indicate date of Missed SessionWithin 2 weeks)Indirect ServicesStart Time(immediately following the session)Indirect ServicesEnd Time(immediately following the session)1____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm2____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm3____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm4____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm5____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm6____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm7____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm8____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm9____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm10____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm11____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm12____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm13____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm14____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm15____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm16____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm17____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm18____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm19____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm20____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm21____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm22____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm23____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm24____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm25____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm26____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm27____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm28____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm29____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm30____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pm31____:____am/pm____:____am/pmR / M ____/____/_______:___am/pm___:___am/pmMonthly Multidisciplinary Meeting Date:___/___/___ Participants: Name/Title:_____________________________________________________________________________ (In narrative form, please describe what was discussed, any issues that have arisen, troubleshooting and problem solving.)Team Recommendations: Service Provider’s Signature:___________________________Date:___________ Total Billable Sessions:_______****Session Notes (Originals) Must be Attached and correspond to this Monthly Log-Page 1Page 2-(PT) Instructions for Completing Monthly Log:Complete ALL demographic information at the top of the page, including child’s name and ID #, frequency and duration, type of service, and provider’s name and credentials.Next to the corresponding date of Direct service, enter start and end time of the provided session and record whether it is a regular or make-up session (if it is a make-up session, you must provide the date of the missed session and have a corresponding blank session note for it).You must now also include any Indirect time spent on the case. For example, enter the time that you spent writing the session note (which must be after the completion of the session and at least 5 minutes in length). This excludes the travel time. Any time that you have spent on the case for that day EXCLUDING your time spent with the child/parent is considered INDIRECT time. Please note: basic sessions are 30-59 minutes; extended sessions are 60 minutes plus.Sign, date, and indicate the number of billable sessions.Instructions for Completing CPT/ICD-10 Codes on Session Notes_AttachedUse the chart below to indicate the child’s type of delay (ICD-10 codes) (from evaluations) and the type of therapy you have provided (CPT codes).CPT CodeDescriptionICD-9 Code-use til 09/30/15ICD-10 Code-Effective 10/1/15CPT Code-Unit DefinitionCPT Code-Restrictions97110Therapeutic Exercises to develop strength and endurance, range of motion and flexibility315.4 Developmental coordination disorder315.5 Mixed developmental disorder781.3 Lack of coordination (chose one only specific to child) 728.3 Other specific muscle disorders728.9 Unspecified disorder of muscle, ligament or fascia728.87 Muscle weakness783.42 Delayed milestonesF82 Specific developmental disorder of motor functionF82 Specific developmental disorder of motor functionR27.0 Ataxia Unspecified*orR27.8 Other lack of Coordination*orR27.9 Unspecified lack of coordinationM62.89 Other specified disorders of muscleM62.9 Disorder of muscle, unspecifiedM62.81 Muscle weakness (generalized)R62.0 Delayed milestone in childhood15 minutesSession limit 4 units97112Neuromuscular Reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing315.4 Developmental Coordination DisorderOr any of the codes above See ICD-10 codes above15 minutesSession limit 4 units97116Gait training including stair climbing315.4 Developmental Coordination DisorderOr any of the codes aboveSee ICD-10 codes aboveEncounterSession limit 4 units97124Massage Therapy including effleurage, pertrissage, tapotement (stroking, compression, percussion)315.4 Developmental Coordination DisorderOr any of the codes aboveSee ICD-10 codes above15 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 DisorderOr any of the codes aboveSee ICD-10 codes above15 minSession limit 4 units97755Assistive Technology assessment 315.4 Developmental Coordination DisorderOr any of the codes aboveSee ICD-10 codes above15 minutesWith written reportIn the event you require more codes please refer to: Monthly Log-PT-Page 3 ?? ................
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