Service Record – School Based Occupational Therapy
Medicaid Number
Last Name
First Name
00000000000
Doe
Jane
WVEIS #
Diagnosis Code
Date of Birth
R27.9
01-01-1900
590000001
M25.341 R62.50
County
059
1 Beginning Date
09-01-2015
1 Ending Date
09-30-2015
1 Procedure Code
97110 GO
Units
15
School
201
2 Beginning Date
09-01-2015
2 Ending Date
09-30-2015
2 Procedure Code
97116 GO
Units
5
Provider Name
3 Beginning Date
3 Ending Date
3 Procedure Code
Units
Jill Brown
09-01-2015
09-30-2015
97533 GO
10
Occupational Therapy: Physician’s authorization on file. Must be identified on Service Plan.
Code
Procedure
Service Unit
97003 GO
Occupational Therapy Evaluation
1 event per calendar year
97004 GO
Occupational Therapy Re-evaluation
2 events per calendar year
97032 GO
20 units per month
97113 GO
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 each 15 minutes
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 GO
Gait training (includes stair climbing) each 15 minutes
20 units per month
97150 GO
Therapeutic procedure(s), group (2 or more individuals), each 15 minutes.
20 units per month
97110 GO
97112 GO
97140 GO
Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage,
manual traction), one or more regions each 15 minutes
97530 GO
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of
dynamic activities to improve functional performance) each 15 minutes
97532 GO
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 GO
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 GO for procedure(s) provided to a group (2 or more individuals)
Date
Start
Time
1
1)8:00
2)8:45
End
Time
1)8:45
2)9:00
Date
Start
Time
16
17
2
3
3)2:00
4
5
20
21
6
7
3)2:30
18
19
End
Time
22
1)8:00
2)8:45
3)10:30
1)8:45
2)9:00
3)11:00
8
1)8:00
2)8:45
3)10:30
1)8:45
2)9:00
3)11:00
23
24
___________________________________________________
Signature/Credentials
WVDE – BMS – SBHS – Appendix F
9
25
10
11
26
27
20 units per month
20 units per month
20 units per month
20 units per month
20 units per month
20 units per month
20 units per month
12
28
13
14
29
1)8:00
2)8:45
3)10:30
1)8:45
2)9:00
3)11:00
15
1)8:00
2)8:45
3)10:30
1)8:45
2)9:00
3)11:00
30
31
__9/30/2015___________
Date
Effective Date: August 1, 2015