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Exam
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Initial Exam
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Re-Exam
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99202 E/M New Patient Office Visit 10 Min
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99203 E/M New Patient Office Visit 30-44
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99204 E/M New Patient Office Visit 45-59
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99205 E/M New Patient Office Visit 60-74
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99211
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99213
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99214
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Noncompliant/Patient Denies new trauma statement.
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Minor?
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Mechanism of Injury
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Previous Treatment
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Imaging
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Previous Treatment
• • •
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Imaging
• • •
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Medication
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Medication
• • •
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Helping
• • •
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SUBJECTIVE
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Headache
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Frequency
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Headache
• • •
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Quality
• • •
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VAS
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Headache History
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History of Illness
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Exacerbation
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Neck
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Frequency
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Neck
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Quality
• • •
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VAS
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Neck History
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History of Illness
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Exacerbation
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Mid Back
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Frequency
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Mid Back
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Quality
• • •
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VAS
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Mid Back History
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History of Illness
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Exacerbation
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Low Back
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Frequency
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Low Back
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Quality
• • •
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VAS
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Low Back History
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History of Illness
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Exacerbation
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Pelvis
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Frequency
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Pelvic
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Quality
• • •
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VAS
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Pelvis History
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History of Illness
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Exacerbation
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Extremity
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Upper Extremity
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TMJ
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Frequency
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TMJ
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Quality
• • •
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VAS
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TMJ History
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History of Illness
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Exacerbation
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Shoulder
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Frequency
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Shoulder
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Quality
• • •
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VAS
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Shoulder History
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History of Illness
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Exacerbation
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Arm
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Frequency
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Arm
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Quality
• • •
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VAS
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Arm History
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History of Illness
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Exacerbation
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Wrist
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Frequency
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Wrist
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Quality
• • •
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VAS
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Wrist History
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History of Illness
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Exacerbation
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Lower Extremity
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Hip
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Frequency
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Hip
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Quality
• • •
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VAS
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Hip History
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History of Illness
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Exacerbation
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Leg
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Frequency
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Leg
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Quality
• • •
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VAS
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Leg History
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History of Illness
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Exacerbation
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Knee
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Frequency
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Knee
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Quality
• • •
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VAS
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Knee History
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History of Illness
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Exacerbation
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Ankle
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Frequency
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Ankle
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Quality
• • •
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VAS
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Ankle History
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History of Illness
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Exacerbation
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Foot
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Frequency
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Foot
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Quality
• • •
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VAS
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Foot History
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History of Illness
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Exacerbation
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Rib & Other
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Rib
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Frequency
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Rib
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Quality
• • •
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VAS
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Rib History
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History of Illness
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Exacerbation
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Other
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Frequency
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Other
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Quality
• • •
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VAS
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Other History
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Aggravating Factors
• • •
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Relieving Factors
• • •
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Other History: Full Sentence
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Other Subjective Info:
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OBJECTIVE
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Exams
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Cervical Exam
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Flexion
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Extension
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Right Rotation
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Left Rotation
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Right Lateral Flexion
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Left Lateral Flexion
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Cervical Distraction Test
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Cervical Compression Test
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Jackson's Compression Test
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Maximum Cervical Compression Test
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Shoulder Depression Test
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Bakody's Sign
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Adson's Test
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Other Ortho Tests Performed
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Other Cervical Findings
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U.E. Dermatomes
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Left C4 Dermatome
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Right C4 Dermatome
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Left C5 Dermatome
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Right C5 Dermatome
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Left C6 Dermatome
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Right C6 Dermatome
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Left C7 Dermatome
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Right C7 Dermatome
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Left C8 Dermatome
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Right C8 Dermatome
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U.E. Myotomes (disc level)
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Left C4 Myotome
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Right C4 Myotome
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Left C5 Myotome
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Right. C5 Myotome
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Left C6 Myotome
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Right C6 Myotome
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Left C7 Myotome
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Right C7 Myotome
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Left T1 Myotome
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Right T1 Myotome
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UE DTRs
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Left Biceps Reflex
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Right Biceps Reflex
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Left Brachioradialis Reflex
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Right Brachioradialis Reflex
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Left Triceps Reflex
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Right Triceps Reflex
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Thoracic Exam
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Flexion
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Extension
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Right Rotation
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Left. Rotation
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Right Lateral Flexion
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Left Lateral Flexion: {{value}}
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Adam's Sign
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Schepelmann's Sign
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Beevor's Sign
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Other Ortho Tests Performed
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Other Thoracic Findings
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Lumbar Exam
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Flexion
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Extension
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Right Rotation
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Lt. Rot
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Right Lateral Flexion
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Left Lateral Flexion
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Straight Leg Raise Test
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Kemp's Test
• • •
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Lesegue's Test
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Dejerine's Triad
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Double Leg Raise Test
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Minor's Sign
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Braggards Test
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Toe Walk
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Milgram's Test
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Heel Walk
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Slump Test
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Nachlas
• • •
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Other Ortho Tests Performed
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Other Lumbar Findings
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L.E. Dermatomes
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Left L2 Dermatome
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Right L2 Dermatome
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Left L3 Dermatome
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Right L3 Dermatome
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Left L4 Dermatome
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Right L4 Dermatome
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Left L5 Dermatome
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Right L5 Dermatome
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Left S1 Dermatome
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Right S1 Dermatome
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L.E. Myotomes (disc level)
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Left L1, L2, L3 Myotome
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Right L1, L2, L3 Myotome
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Left L4 Myotome
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Right L4 Myotome
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Left L5 Myotome
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Right L5 Myotome
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LE DTRs
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Left Patellar Reflex
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Right Patellar Reflex
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Left Achilles Reflex
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Right Achilles Reflex
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Pelvis/SI Exam
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Rt Pelvis/SI Exam
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Anterior Innominate Test
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Nachlas Test
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Belt Test
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Laguerre's Test
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Gaenslen's Test
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Sacral Apex Test
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Gapping Test
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SI Resisted Abduction Test
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Goldthwait's Test
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Yeoman's Test
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Iliac Compression Test
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Hibb's Test
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Lt Pelvis/SI Exam
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Anterior Innominate Test
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Nachlas Test
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Belt Test
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Laguerre's Test
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Gaenslen's Test
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Sacral Apex Test
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Gapping Test
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SI Resisted Abduction Test
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Goldthwait's Test
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Yeoman's Test
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Iliac Compression Test
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Hibb's Test
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Other Ortho Tests Performed
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Other Pelvis Findings
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Extremity Exam
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Upper Extremity Exam
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TMJ Exam
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Rt. TMJ Exam
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Dorsal TMJ Capsule Palpation
• • •
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Lateral TMJ Capsule Palpation
• • •
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Interincisal Open Assessment
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Protrusive Jaw Motion Assessment
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Lateral Jaw Motion Assessment
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Other Right TMJ Findings
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Left TMJ Exam
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Dorsal TMJ Capsule Palpation
• • •
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Lateral TMJ Capsule Palpation
• • •
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Interincisal Open Assessment
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Protrusive Jaw Motion Assessment
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Lateral Jaw Motion Assessment
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Other Left TMJ Findings
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Shoulder Exam
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Right Shoulder Exam
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Flexion
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Extension
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Abduction
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Adduction
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Internal Rotation
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External Rotation
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Neer's Test
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Compression Test
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Speeds Test
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Empty Can Test
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Dawburns Test
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Yergason's Test
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Hawkin's - Kennedy Test
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Apley Scratch Test
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Mazion Shoulder Maneuver
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Dugas Test
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Other Ortho Tests Performed
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Other Right Shoulder Findings
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Left Shoulder Exam
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Flexion
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Extension
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Abduction
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Adduction
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Internal Rotation
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External Rotation
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Neer's Test
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Compression Test
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Speeds Test
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Empty Can Test
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Dawburns Test
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Yergason's Test
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Hawkin's - Kennedy Test
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Apley Scratch Test
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Mazion Shoulder Maneuver
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Dugas Test
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Other Ortho Tests Performed
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Other Left Shoulder Findings
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Elbow/ Exam
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Rt Elbow Exam
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Right Elbow Flexion
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Right Elbow Extension
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Right Elbow Supination
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Right Elbow Pronation
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Cozen's Test
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Mill's Test
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Golfer's Elbow Test
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Tennis Elbow Test
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Medial Ligamentous Instability Test
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Lateral Ligamentous Instability Test
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Kaplan's Sign
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Tinel's Sign
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Other Ortho Tests Performed
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Other Right Elbow Findings
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Lt Elbow Exam
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Left Elbow Flexion
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Left Elbow Extension
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Left Elbow Supination
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Left Elbow Pronation
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Cozen's Test
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Mill's Test
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Golfer's Elbow Test
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Tennis Elbow Test
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Medial Ligamentous Instability Test
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Lateral Ligamentous Instability Test
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Kaplan's Sign
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Tinel's Sign
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Other Ortho Tests Performed
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Other Left Elbow Findings
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Wrist Exam
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Rt Wrist Exam
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Right Wrist Flexion
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Right Wrist Extension
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Right Wrist Radial Deviation
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Right Wrist Ulnar Deviation
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Phalen's Test
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Reverse Phalen's Test
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Other Ortho Tests Performed
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Other Right Wrist Findings
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Lt Wrist Exam
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Left Wrist Flexion
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Left Wrist Extension
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Left Wrist Radial Deviation
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Left Wrist Ulnar Deviation
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Phalen's Test
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Reverse Phalen's Test
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Other Ortho Tests Performed
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Other Left Wrist Findings
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Lower Extremity Exam
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Hip Exam
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Rt Hip Exam
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Right Hip Flexion
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Right Hip Extension
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Right Hip Adduction
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Right Hip Abduction
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Right Hip Internal Rotation:
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Right Hip External Rotation
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Allis' Test
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Jansen's Test
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Anvil Test
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Ober's Test
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Gauvain's Test
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Patrick's Test
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Hip Telescoping Test
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Thomas Test
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Q-Angle Test
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Trendelenburg's Test
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Hibb's Test
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Other Ortho Tests Performed
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Other Right Hip Findings
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Lt Hip Exam
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Left Hip Flexion
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Left Hip Extension
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Left Hip Adduction
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Left Hip Abduction
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Left Hip Internal Rotation:
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Left Hip External Rotation
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Allis' Test
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Jansen's Test
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Anvil Test
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Ober's Test
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Gauvain's Test
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Patrick's Test
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Hip Telescoping Test
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Thomas Test
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Q-Angle Test
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Trendelenburg's Test
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Hibb's Test
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Other Ortho Tests Performed
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Other L Hip Findings
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Knee Exam
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Rt Knee Exam
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Right Knee Flexion
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Right Knee Extension
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Adduction Stress Test
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Anterior Drawer Test
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Abduction Stress Test
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Posterior Drawer Test
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Apley Compression Test
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Fouchet's Sign
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Patella Apprehension Test
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Lachman Test
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Clarke's Sign
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McMurray Sign
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Wilson's Sign
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Q-Angle Test
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Other Ortho Tests Performed
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Other R knee Findings
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Lt Knee Exam
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Left Knee Flexion
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Left Knee Extension
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Adduction Stress Test
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Anterior Drawer Test
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Abduction Stress Test
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Posterior Drawer Test
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Apley Compression Test
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Fouchet's Sign
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Patella Apprehension Test
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Lachman Test
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Clarke's Sign
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McMurray Sign
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Wilson's Sign
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Q-Angle Test
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Other Ortho Tests Performed
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Other Left Knee Findings
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Ankle
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Rt. Ankle
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Right Ankle Plantar Flexion
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Right Ankle Dorsiflexion
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Right Ankle Inversion
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Right Ankle Eversion
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Anterior Drawer Sign
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Posterior Drawer Sign
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Claudication Test
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Homan's Sign
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Duchenne's Sign
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Morton's Test
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Helbings' Sign
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Moses' Test
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Hoffa's Test
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Strunsky's Test
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Tinel's Foot Sign
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Thompson's Test
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Other Ortho Tests Performed
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Other Right Ankle Findings
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Lt. Ankle
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Left Ankle Plantar Flexion
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Left Ankle Dorsiflexion
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Left Ankle Inversion
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Left Ankle Eversion
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Anterior Drawer Sign
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Posterior Drawer Sign
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Claudication Test
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Homan's Sign
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Duchenne's Sign
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Morton's Test
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Helbings' Sign
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Moses' Test
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Hoffa's Test
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Strunsky's Test
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Tinel's Foot Sign
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Thompson's Test
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Other Ortho Tests Performed
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Other Left Ankle Findings
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Posture
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Observation
• • •
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Other Posture Findings
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Gait
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Gait
• • •
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Other Gait Findings
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Palpations
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Severity
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C Spasms:
• • •
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Severity
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T Spasms:
• • •
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Severity
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L Spasms:
• • •
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Severity
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Extremity Spasms:
• • •
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Severity
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Other Spasms
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Specific Muscles (Spinal)
• • •
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Specific Muscles (Extremity)
• • •
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Listings
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C Listings
• • •
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T Listings
• • •
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L/S Listings
• • •
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Other Listings
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Other Objective Findings
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Short Leg
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Length
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Right/Left
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Prone/Supine
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Xray Exam
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72040 Cervical Spine 2-3 Views
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72050 Cervical Spine 4-5 Views
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72052 Cervical Spine 6 Views
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72070 Thoracic Spine 2 Views
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72100 Lumbosacral Spine 2-3 Views
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72080 Entire Spine
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73560 Knee
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Imaging Findings
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XRAY Findings
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Significant Radiograph Findings
• • •
|
Findings
|
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MRI
|
|
|
Significant MRI findings
• • •
|
Findings
|
|
ASSESSMENT
|
|
|
Assessment
|
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Prognosis
• • •
|
Rationale
• • •
|
|
Comments Full Sentence
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PROCEDURE/PLAN
|
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Adjustment
|
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98940 1-2 Regios
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98941 3-4 Regions
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98942 5+ Regions
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Cervical Spine Adjustment
|
Thoracic Spine Adjustment
|
|
Lumbosacral Spine Adjustment
|
|
|
Extremity Adjustments
|
|
|
Extraspinal Adjustments
• • •
|
Technique
|
|
Therapy
|
|
|
Ice/Heat
|
|
|
Hot/Cold Pack
• • •
|
Region
• • •
|
|
Infrared Light Therapy
|
|
|
Infrared Therapy
• • •
|
Region
• • •
|
|
Electrical Stim Unattended
|
|
|
Electrical Stim Unattended
• • •
|
Region
• • •
|
|
Electrical Stim Attended
|
|
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Electrical Stim Attended
• • •
|
Region
• • •
|
|
Mechanical Traction
|
|
|
Mechanical Traction
• • •
|
Region
• • •
|
|
Manual Therapy (15 min)
|
|
|
Manual Therapy
• • •
|
Region
• • •
|
|
Therapeutic Ultrasound
|
|
|
Therapeutic Ultrasound
• • •
|
Region
• • •
|
|
Therapeutic Exercises Performed
|
|
|
Therapeutic Exercises
• • •
|
Region
• • •
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Therapeutic Activities
|
|
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Therapeutic Activities
• • •
|
Region
• • •
|
|
Review ADL, Exercises
|
|
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Therapeutic Exercises Reviewed
|
|
|
Review of Exercises
• • •
|
Other Exercises reviewed:
|
|
ADL Review
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|
|
Activities of Daily Living - 97535
• • •
|
Other ADL's reviewed:
|
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DME Prescribed
|
|
|
Tens Unit
|
Tens Supplies
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|
MD/MRI Referral
|
|
|
MRI Referral
• • •
|
Orthopedist
• • •
|
|
Pain Management
• • •
|
Neurologist
• • •
|
|
Other Referral Information
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|
|
Treated Without Incident
|
Symptoms Post Treatment
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|
Care Plan Frequency
|
Care Plan Length
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|
Release Comments
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