|
Demographics
|
|
|
Pt Name
|
Date of Service
|
|
Diagnosis
|
|
|
Tx Approved
|
Auth#
|
|
Start
|
End
|
|
E&M
|
|
|
E&M
|
|
|
Mod/Proc
|
|
|
Traction
|
Time
|
|
|
Area
|
|
EMS
|
Time
|
|
|
Area
|
|
Paraf. Bath
|
Time
|
|
|
Area
|
|
Whirpool
|
Time
|
|
|
Area
|
|
Ultrasound
|
Time
|
|
Units
|
Area
|
|
Masage
|
Time
|
|
|
Area
|
|
Exercise
|
Time
|
|
Units
|
Area
|
|
Gait training
|
Time
|
|
|
Area
|
|
Aquatic training
|
Time
|
|
Units
|
Area
|
|
Neuromusc Re-edu
|
Time
|
|
Units
|
Area
|
|
Home/Self care
|
Time
|
|
|
Area
|
|
CMT (1-2 areas)
|
Area
|
|
CMT (3-4 areas)
|
Area
|
|
WC Init
|
Area
|
|
WC additional
|
Time
|
|
|
Area
|
|
WH Init
|
Area
|
|
WH Add.
|
Time
|
|
|
Area
|
|
Trigger Point Therapy
|
Area
|
|
Provider
|
|
