Important Steps, Inc.- Session Note Instructions-- NYC DOE-CPSE: 08-01-11
1. A Session Note must be completed for each session.
2. Complete all areas as follows:
• Child’s Name, DOB, and NYCID#: Make sure this information is consistent with the information in the
NYCDOE system (do not use nicknames).
• Provider’s Name: The individual providing the related services.
• Discipline: The appropriate discipline of the interventionist (e.g., PT, ST, OT).
 Frequency and Duration: As per IEP and Assignment from Important Steps, Inc.
• Location of Service: Where the session took place, (e.g., home, school, or office)
• Date and Time: The date and time during which the session took place. Please circle “am/pm”.
• Service Type: The service type as listed on the IEP, (i.e. Speech Therapy (ST))
• Date Note Written: The date the session note was completed (should be the same as the date of service).
 Make-up for: Indicate the date of missed session within the school year conducting make up for (i.e. Fall)
 Session Cancelled/Absent: a) Check this off when the session is cancelled/not held/child is absent; b) Indicate
the reason the reason for cancelation. (Note: no need for the following: CPT codes, activities, etc. Therapist
signature is required. Caregiver signature is optional.)
 ICD-9 Code: The relevant ICD-9 code as indicated on the child’s evaluation for your discipline. This is prewritten for your convenience at the time of your assignment. Please contact main office for more info.
 CPT Codes: The relevant CPT (Current Procedural Terminology) codes as indicated by the clinician’s
professional association. IMPORTANT: CPT Codes MUST match its description & ICD-9 codes.
See list of suggested codes below as per each discipline scope of practice. Check the time interval consistent
w/each CPT code and list as many as you have conducted during the mandated session interval.
If conducted same CPT code several times indicate # of same CPT codes. Example: if mandate is Basic (A) –
(i.e. 30 min & up) and same CPT codes was conducted 2 times (15 min each) please put: 1) CPT# 97530 X 2
• IEP Outcome(s) Addressed: The target outcome(s) from the IEP, which was/were the focus of that
session’s intervention. These outcomes are taken directly from child’s current IEP (Note: this is the only section
that can be pre-typed).
• Activity During Session and Child’s Response: Brief description of the clinician’s activities (at least 3) and
child’s/family response to each activity during the session. These activities/descriptions MUST match CPT
codes above.
• Parent/Caregiver Training/Carryover:
1. Indicate the one or more activities agreed upon by the interventionist and the parent/caregiver that will
be used during daily routines in the coming week(s). Indicate: WHERE/WHEN/WHAT “homework”
activities caregivers can do w/child during child’s daily routine. For example, if the objective is for the
child to roll, the interventionist could write: “At bath or change time, the parent will use a towel or
diaper to gently lift one side of the child to assist in beginning to roll.” Parent will record progress in
parent/therapist notebook/calendar, etc.
2. Activities for parents are expected to span a minimum of one week. However, a therapist may see the
child/family more than once per week; or activities may be recommended for multiple weeks.
Indicate in this section if you are continuing to work on an activity from the above Session Note.
3. Parent/Caregiver Signature and Relationship to Child: The parent/caregiver who was present during the session
signs contemporaneously w/related service provider and indicates his/her relationship to the child (i.e. mother, babysitter,
day care teacher, etc).
4. Provider’s Signature, Credentials & License# : The clinician’s signature & full credentials
(Ex: MA.CCC-SLP,
#00921) . For CFs Supervisor’s signature &full credentials are required for each note.
5. Indirect Time: Indicate time (from-to) spend after the mandated direct service has concluded (i.e. paperwork, etc)
6. Keep the Session notes w/original signature in child’s file at the provider site. The Session notes may be
reviewed or requested by the parents; therapist’s QA supervisor; NYC DOE’s various departments such as the
L o c a l D i s t r i c t and Program Monitoring and Quality Improvement; NYS DOE and OMIG.
7. Monthly Multidisciplinary Meeting: Please complete one at least per month.
8. Indicate NPI# on the bottom of each page as required for billing submission to NYCDOE.
Instructions for Completing CPT/ICD-9 Codes on Session Notes-2011-12_ above
Use the chart below to indicate the child’s type of delay (ICD-9 codes) (from evaluations) and the type of therapy you have
provided (CPT codes).
Related Service: Occupational Therapy (OT)
CPT Code
Description
ICD-9 Code
Unit
Definition
Restrictions
97110
Therapeutic Exercises to
develop strength and
endurance, range of motion
and flexibility
315.4 Developmental
Coordination Disorder
15 minutes
Session limit 4 units
97112
Neuromuscular Reeducation
of movement, balance,
coordination, kinesthetic
sense, posture, and/or
proprioception for sitting
and/or standing
315.4 Developmental
Coordination Disorder
15 minutes
Session limit 4 units
97124
Massage Therapy including
effleurage, pertrissage,
tapotement (stroking,
compression, percussion)
315.4 Developmental
Coordination Disorder
15 min
Session limit 4 units
97150
Group Therapeutic (2 or more
individuals)
315.4 Developmental
Coordination Disorder
Encounter
I unit per recipient
97530
Kinetic therapy-Therapeutic
activities, direct (1X1) patient
contact by the provider (use
of dynamic activities to
improve functional
performance)
315.4 Developmental
Coordination Disorder
15 min
Session limit 4 units
97533
Sensory Integration to
enhance sensory processing
and promote adaptive
responses to environmental
demands direct (1X1) patient
contact by the provider.
315.4 Developmental
Coordination Disorder
15 min
Session limit 4 units
97755
Assistive Technology
assessment
315.4 Developmental
Coordination Disorder
15 minutes
With written report
In the event you require more codes please refer to:
http://occupational-therapy.advanceweb.com/Article/Everything-You-Wanted-to-Know-About-Coding.aspx
Related Service: Speech Therapy- ST
CPT
Code
Description
ICD-9 Code
Unit
Definition
Restrictions
315.3 – Developmental Speechlanguage disorder;
315.32-Mixed receptive-expressive
language disorder
315.31-Expressive language disorder
315.39 Other
92507
Treatment of speech, language, voice,
communication, &/or auditory
processing disorder: individual
Developmental articulation disorder,
Phonological disorder
Excludes: Lisping and lalling (307.9)
Encounter
315.3 – Developmental Speechlanguage disorder;
315.32-Mixed receptive-expressive
language disorder
315.31-Expressive language disorder
315.39 Other
92508
Speech Therapy Group, 2 or more
individuals
Developmental articulation disorder,
Phonological disorder
Excludes: Lisping and lalling (307.9)
Group
Encounter
In the event you require more codes please refer to:
http://www.asha.org/practice/reimbursement/medicare/SLP_coding_rules.htm
4 procedures
per day
Related Service: Physical Therapy- PT
CPT Code
Description
ICD-9 Code
Unit Definition
Restrictions
97110
Therapeutic Exercises to
develop strength and
endurance, range of motion
and flexibility
315.4 Developmental
Coordination Disorder
15 minutes
Session limit 4 units
97112
Neuromuscular Reeducation
of movement, balance,
coordination, kinesthetic
sense, posture, and/or
proprioception for sitting
and/or standing
315.4 Developmental
Coordination Disorder
15 minutes
Session limit 4 units
97116
Gait training including stair
climbing
315.4 Developmental
Coordination Disorder
Encounter
Session limit 4 units
97124
Massage Therapy including
effleurage, pertrissage,
tapotement (stroking,
compression, percussion)
315.4 Developmental
Coordination Disorder
15 min
Session limit 4 units
97530
Kinetic therapy-Therapeutic
activities, direct (1X1) patient
contact by the provider (use
of dynamic activities to
improve functional
performance)
315.4 Developmental
Coordination Disorder
15 min
Session limit 4 units
97755
Assistive Technology
assessment
315.4 Developmental
Coordination Disorder
15 minutes
With written report
In the event you require more codes please refer to:
http://www.physicaltherapytoolbox.com/pdfs/cpt.pdf