Service Record – Speech Therapy



Service Record – School Based Physical 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 CodeUnitsPhysical Therapy: Physician’s authorization on file. Must be identified on Service Plan.CodeProcedureService Unit*97161 GPPhysical Therapy Evaluation Low Complexity1 event per calendar year*97162 GPPhysical Therapy Evaluation Moderate Complexity1 event per calendar year*97163 GPPhysical Therapy Evaluation High Complexity1 event per calendar year97164 GPPhysical Therapy Re-evaluation2 events per calendar year97032 GPApplication of a modality to one or more areas; electrical stimulation (manual), each 15 minutes97110 GPTherapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility97112 GPNeuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities, each 15 minutes20 units per month 20 units per month 20 units per month97113 GPAquatic therapy with therapeutic exercises, each 15 minutes20 units per month97116 GPGait training (includes stair climbing) each 15 minutes20 units per month97140 GPManual therapy techniques (Mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes20 units per month97150 GPTherapeutic procedure(s), group (2 or more individuals), each 15 minutes.20 units per month97530 GPTherapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes97532 GPDevelopment of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes97533 GPSensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes*May only use one of the three evaluation codes per calendar year.Use 97150 GP for all procedures provided to a group (2 or more individuals).20 units per month 20 units per month20 units per monthDate123456789101112131415Start TimeEnd TimeDate16171819202122232425262728293031Start TimeEnd TimeSignature/CredentialsDateWVDE – BMS – SBHS – Appendix GEffective Date: January 1, 2017 ................
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