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