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Patients Name *

First

Last

Patients D/O/B *

Time Seen *

Patients Diagnosis *

New Patient? *

Yes No

Primary Holder Name - If not the patient *

Primary Holder D/O/B- if not the patient *

INITIAL EVALUATION - CPT CODES *

10 min initial evaluation - 99201 20 min initial evaluation - 99202 30 min initial evaluation - 99203

RE-EVALUATION - CPT CODES *

5 min re-evaluation - 99211 10 min re-evaluation - 99212 15 min re-evaluation - 99213

How Many Re-evaluations done? *

NEW PATIENT *

Low to moderate severity - 99202 Moderate severity - 99203 Moderate to high severity - 99204

ESTABLISHED PATIENT *

low to moderate severity - 99212 Moderate severity - 99213 Moderate to high severity - 99214 Home Visit - 99056

E- Stim *

Initial unit (15 min) with Stim - 97813 Additional unity with stim- 97814 First 15 min (no e-stim) -97810 Extra 15 min (no e-stim) - 97811

EXTRA SERVICE *

Cupping - 97016 Manual Therapy - Body Work - 97140 Hot/Cold Pack- 97010 Infrared Therapy - 97026 Mechanical Traction - 97012 Neuromuscular reeducation - 97112 Massage each 15 min - 97124 Therapeutic Proc each 15 min - 97110

PAIN-RELATED ICD-10 CODES - Midline *

M54.2 Cervicalgia- Back/Neck Pain M54.6 Pain in Thoracic Spine M54.5 Lower Back Pain M54.41 Lumbago with Sciatica Right Side M54.42 Lumbago with Sciatica, Left Side

Length of time for body work if done *

PAIN-RELATED ICD-10 CODES - Lower Extremity *

M25.551 Pain in the Right Hip M25.552 Pain in the Left Hip M79.651 Pain in the Right Thigh M79.652 Pain in the Left Thigh M25.561 Pain in the Right Knee M25.562 Pain in the Left Knee M79.661 Pain in the Right Lower Leg M79.662 Pain in the Left Lower Leg M25.571 Pain in the Right Ankle and Joints of the Right Foot M25.572 Pain in the Left Ankle and Joints of the Left Foot M79.671 Pain in the Right Foot M79.672 Pain in the Left foot

PAIN-RELATED ICD-10 CODES - Upper Extremity *

M25.511 Pain in the Right Shoulder M25.512 Pain in the Left Shoulder M79.621 Pain in the Right Upper Arm M79.622 Pain in the Left Upper Arm M25.521 Pain in the Right Elbow M25.522 Pain in the Left Elbow M79.631 Pain in the Right Forearm M79.632 Pain in the Left Forearm M25.531 Pain in the Right Wrist M25.532 Pain in the Left Wrist M79.641 Pain in the Right Hand M79.642 Pain in the Left Hand

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