Service Record – School Based Physical Therapy
Medicaid Number
00000000000
WVEIS #
590000001
Last Name
Doe
Diagnosis Code
First Name
Jane
Date of Birth
M25.571 M25.572 M67.00
01-01-1900
County
059
1 Beginning Date
09-02-2015
1 Ending Date
09-30-2015
1 Procedure Code
97110 GP
Units
10
School
2 Beginning Date
2 Ending Date
2 Procedure Code
Units
201
09-02-2015
09-30-2015
97150 GP
5
Provider Name
John Brown
3 Beginning Date
09-02-2015
3 Ending Date
09-30-2015
3 Procedure Code
97530 GP
Units
10
Physical Therapy: Physician’s authorization on file. Must be identified on Service Plan.
Code
97001 GP
Physical Therapy Evaluation
Procedure
Service Unit
1 event per calendar year
97002 GP
Physical Therapy Re-evaluation
2 events per calendar year
97032 GP
20 units per month
97113 GP
Application of a modality to one or more areas; electrical stimulation (manual),
each 15 minutes
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises
to develop strength and endurance, range of motion and flexibility
Neuromuscular reeducation of movement, balance, coordination, kinesthetic
sense, posture, and proprioception for sitting and/or standing activities, each 15
minutes
Aquatic therapy with therapeutic exercises, each 15 minutes
97116 GP
Gait training (includes stair climbing) each 15 minutes
20 units per month
97140 GP
Manual therapy techniques (Mobilization/manipulation, manual lymphatic
drainage, manual traction), one or more regions, each 15 minutes
Therapeutic procedure(s), group (2 or more individuals), each 15 minutes.
20 units per month
97110 GP
97112 GP
97150 GP
20 units per month
20 units per month
20 units per month
20 units per month
97530 GP
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of
dynamic activities to improve functional performance) each 15 minutes
97532 GP
Development of cognitive skills to improve attention, memory, problem solving,
(includes compensatory training), direct (one-on-one) patient contact by the
provider, each 15 minutes
97533 GP
Sensory 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
Use 97150 GP for all procedures provided to a group (2 or more individuals).
Date
Start
Time
End
Time
Date
Start
Time
End
Time
1
2
1)9:15
2)9:45
3)1:15
1)9:45
2)10:00
3)1:45
16
1)9:15
2)9:45
3)1:15
1)9:45
2)10:00
3)1:45
17
3
18
4
19
5
20
21
6
7
8
22
23
1)9:15
2)9:45
3)1:15
1)9:45
2)10:00
3)1:45
9
1)9:15
2)9:45
3)1:15
1)9:45
2)10:00
3)1:45
24
__________________________________________________
Signature/Credentials
WVDE – BMS – SBHS – Appendix G
25
26
10
27
20 units per month
20 units per month
20 units per month
11
28
12
29
13
14
30
3)8:00 1)9:15
2)9:45
3)8:30 1)9:45
2)10:00
9-30-2015
Date
Effective Date: August 1, 2015
15
31