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PROCEDURES
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MANIPULATIONS/MOBILIZATIONS
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Cervical/Head
• • •
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Manipulation or Mobilization
• • •
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Thoracic
• • •
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Manipulation or Mobilization
• • •
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Lumbar
• • •
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Manipulation or Mobilization
• • •
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Sacrum
• • •
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Manipulation or Mobilization
• • •
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Pelvis
• • •
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Manipulation or Mobilization
• • •
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Lower Extremity
• • •
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Manipulation or Mobilization
• • •
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Upper Extremity
• • •
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Manipulation or Mobilization
• • •
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Other
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Time
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Notes
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TRANSVERSE FRICTION MASSAGE (97140)
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Head/Neck/Upper Back
• • •
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Mid Back
• • •
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Low Back/Pelvis
• • •
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Hip
• • •
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Knee
• • •
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Ankle/Foot
• • •
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Shoulder
• • •
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Elbow
• • •
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Wrist/Thumb
• • •
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Other
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Time
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Notes
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TISSUE COMPLIANCE RESTORATION (97140)
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Head/Neck/Upper Back
• • •
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Mid Back
• • •
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Low Back/Pelvis
• • •
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Hip
• • •
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Knee
• • •
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Ankle/Foot
• • •
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Shoulder
• • •
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Elbow
• • •
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Wrist/Thumb
• • •
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Other
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Time
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Notes
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OTHER MANUAL THERAPIES (97140)
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List Area & Technique
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Time
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Notes
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DRY NEEDLING (20560/1)
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List Area & Technique
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Notes
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NEUROMUSCULAR RE-EDUCATION (97112)
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Neck
• • •
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Trunk
• • •
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Hip w/ Straight Leg
• • •
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Hip w/ Knee Bent
• • •
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Knee
• • •
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Ankle
• • •
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1st MTP
• • •
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Shoulder
• • •
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Elbow
• • •
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Wrist
• • •
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Other
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Time
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Notes
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MANUALLY RESISTED THER. EX. (97110)
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Neck
• • •
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Trunk
• • •
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Hip w/ Straight Leg
• • •
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Hip w/ Knee Bent
• • •
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Knee
• • •
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Ankle
• • •
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1st MTP
• • •
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Shoulder
• • •
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Elbow
• • •
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Wrist
• • •
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Other
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Time
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Notes
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THERAPEUTIC EXERCISES (97110)
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Exercise #1 & Parameters/Cues
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Intent of exercise (ROM, strength, etc)
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Exercise #2 & Parameters/Cues
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Intent of exercise (ROM, strength, etc)
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Exercise #3 & Parameters/Cues
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Intent of exercise (ROM, strength, etc)
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Exercise #4 & Parameters/Cues
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Intent of exercise (ROM, strength, etc)
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Exercise #5 & Parameters/Cues
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Intent of exercise (ROM, strength, etc)
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Exercise #6 & Parameters/Cues
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Intent of exercise (ROM, strength, etc)
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Exercise #7 & Parameters/Cues
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Intent of exercise (ROM, strength, etc)
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Exercise #8 & Parameters/Cues
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Intent of exercise (ROM, strength, etc)
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Other
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Time
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Notes
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THERAPEUTIC ACTIVITIES (97530)
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Activity #1 & Parameters/Cues
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Intent of activity (functional performance)
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Activity #2 & Parameters/Cues
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Intent of activity (functional performance)
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Activity #3 & Parameters/Cues
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Intent of activity (functional performance)
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Activity #4 & Parameters/Cues
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Intent of activity (functional performance)
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Activity #5 & Parameters/Cues
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Intent of activity (functional performance)
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Activity #6 & Parameters/Cues
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Intent of activity (functional performance)
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Activity #7 & Parameters/Cues
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Intent of activity (functional performance)
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Activity #8 & Parameters/Cues
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Intent of activity (functional performance)
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Other
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Time
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Notes
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NMR EXERCISES (97112)
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Exercise #1 and Parameters/Cues
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Intent of NMR (balance, coordination, kinesthetic sense, posture, proprioception)
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Exercise #2 and Parameters/Cues
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Intent of NMR (balance, coordination, kinesthetic sense, posture, proprioception)
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Exercise #3 and Parameters/Cues
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Intent of NMR (balance, coordination, kinesthetic sense, posture, proprioception)
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Exercise #4 and Parameters/Cues
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Intent of NMR (balance, coordination, kinesthetic sense, posture, proprioception)
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Exercise #5 and Parameters/Cues
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Intent of NMR (balance, coordination, kinesthetic sense, posture, proprioception)
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Exercise #6 and Parameters/Cues
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Intent of NMR (balance, coordination, kinesthetic sense, posture, proprioception)
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Exercise #7 and Parameters/Cues
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Intent of NMR (balance, coordination, kinesthetic sense, posture, proprioception)
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Exercise #8 and Parameters/Cues
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Intent of NMR (balance, coordination, kinesthetic sense, posture, proprioception)
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Other
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Time
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HOME EXERCISE PROGRAM
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HEP
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Time
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Notes
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MODALITIES
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List Modalities & Parameters
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Time
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Notes
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GAIT TRAINING (97116)
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Please list procedures performed here:
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Time
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Notes
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Total Manual Therapy Time (97140):
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Total Ther Ex Treatment Time (97110):
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Total Neuro Re-ed Treatment Time (97112):
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Total Therapeutic Activities Treatment Time (97530):
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Total Gait Training Time (97116):
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Total Dry Needling Time (20560/1):
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Total Billable Treatment Time
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Total Appointment Time
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