Professional Documents
Culture Documents
BALANCE
DESCRIPTION
CHARGES
PAYMENTS
ADJUSTMENTS
NAME
BALANCE
CREDITS
A. NEUROMUSCULAR PROCEDURES:
(Include report)
1. Initial Visit with Evaluation, 30 days
2. Muscle Testing Limb or Trunk
(Excluding Hand)
3. Muscle Testing, Hand
4. Range of Motion Measurements
Each Limb (Excl. Hand) .
5. Range of Motion Measurements,
Hand
B. PHYSICAL MODALITIES:
1. Hot or Cold Pack, 1 or more areas
_____________________________
2. Traction, Mechanical ..
3. Electrical stimulation (unattended) ..
4. Vasopneumatic devices .
5. Paraffin Bath
6. Microwave
7. Whirlpool ..
8. Diathermy .
9. Infrared .
10. Ultraviolet
11. Electrical Stimulation (manual) 15 min.
12. Iontophoresis (each 15 min.)
13. Contrast Baths (each 15 min.)
14. Ultrasound (15 min.)
15. Hubbard Tank
16. Unlisted Modality
C. PHYSICAL PROCEDURES
17. Therapeutic Exercises or Procedures
1 or more areas
18. Neuromuscular Re-education
19. Gait Training
CPT
$ FEE
90060 _______
95831 _______
95832 _______
95851 _______
95852 _______
97010
97012
97014
97016
97018
97020
97022
97024
97026
97028
97032
97033
97034
97035
97036
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
______________________________
E. EVALUATION & MANAGEMENT
1. Office Service, New ..
97110 _______ 2. Office Service, Estab. ..
97112 _______ 3. ______________________________
97116 _______
DATE OF SERVICE:__________________________
CPT
97118
97120
97122
97124
97126
97128
$ FEE
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
99050 _______
99054 _______
97039 _______
_______
99201
99211
PREVIOUS
BALANCE
DESCRIPTION
CHARGES
PAYMENTS
ADJUSTMENTS
NAME
BALANCE
CREDITS
A. NEUROMUSCULAR PROCEDURES:
(Include report)
1. Initial Visit with Evaluation, 30 days
2. Muscle Testing Limb or Trunk
(Excluding Hand)
3. Muscle Testing, Hand
4. Range of Motion Measurements
Each Limb (Excl. Hand) .
5. Range of Motion Measurements,
Hand
B. PHYSICAL MODALITIES:
1. Hot or Cold Pack, 1 or more areas
_____________________________
2. Traction, Mechanical ..
3. Electrical stimulation (unattended) ..
4. Vasopneumatic devices .
5. Paraffin Bath
6. Microwave
7. Whirlpool ..
8. Diathermy .
9. Infrared .
10. Ultraviolet
11. Electrical Stimulation (manual) 15 min.
12. Iontophoresis (each 15 min.)
13. Contrast Baths (each 15 min.)
14. Ultrasound (15 min.)
15. Hubbard Tank
CPT
$ FEE
90060 _______
95831 _______
95832 _______
95851 _______
95852 _______
97010
97012
97014
97016
97018
97020
97022
97024
97026
97028
97032
97033
97034
97035
97036
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
97039 _______
97116 _______
______________________________
E. EVALUATION & MANAGEMENT
1. Office Service, New ..
97110 _______ 2. Office Service, Estab. ..
97112 _______ 3. ______________________________
DATE OF SERVICE:__________________________
CPT
97118
97120
97122
97124
97126
97128
$ FEE
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
99050 _______
99054 _______