ENP - Important Steps



Important Steps, Inc. – EI DepartmentOccupational Therapy DivisionTHERAPY MONTHLY LOG Month/Year: _______/________Child: _____________________EI No._____________IFSP Freq___Dur. ___Location: Home__Daycare__Facility___IFSP Therapy Type: __OT __OT/feeding: Individual ____Group______Provider Name:___________________________ Title/Credentials:___________________________COTA’s Sup-r Name:______________________Title/Credentials:______________Supervision Date:____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-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-9 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 CodeDescriptionUnit DefinitionRestrictionsICD-9 Code-Use til 09/30/15ICD-10 Code-Effective October 1, 201597110Therapeutic Exercises to develop strength and endurance, range of motion and flexibility15 minutesSession limit 4 units315.4 Developmental coordination disorder315.5 Mixed developmental disorder315.9 Developmental Delay NOS781.3 Lack of coordination (Chose only one ICD-10-as 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 functionF81.9 Developmental disorder of scholastic skills, unspecified*orF89 Unspecified disorder of psychological developmentR27.0 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 childhood97112Neuromuscular Reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing15 minutesSession limit 4 unitsSee above codesSee above codes97124Massage Therapy including effleurage, pertrissage, tapotement (stroking, compression, percussion)15 minutesSession limit 4 unitsSee above codesSee above codes97150Group Therapeutic (2 or more individuals)EncounterI unit per recipientSee above codesSee above codes97530Kinetic therapy-Therapeutic activities, direct (1X1) patient contact by the provider (use of dynamic activities to improve functional performance) 15 minutesSession limit 4 unitsSee above codesSee above codes97533Sensory Integration to enhance sensory processing and promote adaptive responses to environmental demands direct (1X1) patient contact by the provider. 15 minSession limit 4 unitsSee above codesSee above codes97532Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (1x1) patient contact by the provider, each 15 minutes15 min.Session limit 4 unitsSee above codesSee above codes97755Assistive Technology assessment 15 minutesWith written reportSee above codes In the event you require more codes please refer to: Monthly Log-OT-Page 3 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download