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Har
vey
Rich
man
, OD
, FAA
O, F
COVD
Dip
lom
ate
ABO
Codi
ng B
asic
sc-s-D
on’t
Fall
Asl
eep
Visi
on T
hera
py E
xam
inat
ions
Fund
amen
tal al
diff
eren
ce: m
edic
al
alalvs
. wel
l vis
ion
Fund
amen
taFu
ndam
entaa
lalff
eren
ce:
ffer
ence
:didi
care
vs.
ther
apy
exam
s
Chie
f com
plai
nt a
nd d
etai
l nee
ded
Chie
f com
plai
nt a
nM
edic
al d
ecis
iont a
non
-d
deta
il ne
eded
ndt a
nn-
mak
ing
com
plex
Med
ical
dec
isM
edic
alde
cisi
oRi
sk in
crea
sed si
osi
o d–
akin
g co
mpl
exak
ing
com
plex
mmmmmmooononnn –––
mor
bidi
ty/m
orta
lity
Risk
incr
ease
dRi
skin
crea
sedd d
mor
bidi
ty/m
mor
bidi
ty/m
mo
mo
mmmmEx
amin
atio
n m
ore
deta
iled
Codi
ng S
yste
ms
The
prop
er u
se o
f a c
odin
g gsy
stem
s is
Th
e pr
oan
op
er u
se o
f a c
odin
gg ys
tem
sye
pro
nim
port
ant c
ompo
nent
for
anann n
mpo
rtan
mpo
rtan
tco
imimpa
rtic
ipat
ion
ompo
nent
ompo
nennt
font
co
ntco
n nin
any
hea
lth
r r fo
rfo
rfo h h
care
pa
rtic
ipat
part
icip
atar
tisy
stem
.
Wha
t is
Doc
umen
tatio
n an
d W
hy Is
It Im
port
ant?
Med
ical
reco
rd d
ocum
enta
tion
is
isre
quir
ed to
M
edic
al re
cord
doc
umen
tatio
ni
reco
rd p
ertin
ent f
acts
, fin
ding
s,
equi
red
to
ren
iisr
san
d ob
serv
atio
ns
pre
cord
pert
inen
t fac
ts,
abou
t an
indi
vidu
al’s
g
findi
ngs,s,
d ob
serv
atio
ndan,
cts,
’s
heal
th h
isto
ry in
clud
ing
ns
atio
gg pa
st
abou
t an
indi
vian
d pr
esen
t id
ual’’s
ea
lth
hisst
ory
hend
ivi
ntill
ness
es, e
xam
inat
ions
clud
inyry
inry ns
, tes
t,
pan
d pr
esenn
t ne
ssill
ntr
eatm
ents
, and
,
sees,
exa
min
es, e
ness
dou
tcom
es.
The e
med
ical
reco
rd c
hron
olog
ical
ly d
ocum
ents
ts
the
Thee
edic
al re
cord
chr
onol
ogic
ally
doc
umm
care
of t
he p
atie
nt a
nd is
an
impo
rtan
t m
entts
he
thoc
umnt
elem
ent
pca
rre o
f the
pat
ient
and
is a
n im
por
re o
cont
ribu
ting
to h
igh
qual
ity c
are
rtppo
rre
.
Wha
t is
Doc
umen
tatio
n an
d W
hy Is
It Im
port
ant?
The
abili
ty o
f the
phy
sici
an a
nd o
ther
hea
lth
care
Th
e ab
ility
of t
he p
hysi
cian
and
oth
er h
ealt
h ca
re
prof
essi
onal
s to
eva
luat
e an
d pl
an th
e pa
tient
’s im
med
iate
pr
ofes
sion
als
to e
valu
ate
and
plan
the
patie
nt’s
imm
edia
te
prof
essi
onal
s to
eva
luat
e an
d pl
an th
e pa
tient
’s im
mtr
eatm
ent,
and
to m
onito
r his
/ he
r hea
lth
care
ove
r tim
e.
Com
mun
icat
ion
and
cont
inui
ty o
f car
e am
ong
phys
icia
ns a
nd
Com
mun
icat
ion
and
cont
inui
ty o
f car
e am
ong
phys
icia
ns a
nd
othe
r hea
lth
care
pro
fess
iona
ls in
volv
ed in
the
patie
nt’s
car
e.
Acc
urat
e an
d tim
ely
clai
ms
revi
ew a
nd p
aym
ent
App
ropr
iate
util
izat
ion
revi
ew a
nd q
ualit
y of
car
e A
ppro
pria
te u
tiliz
aev
alua
tions
; and
Colle
ctio
n of
dat
a th
at m
ay b
e us
eful
in re
sear
ch a
nd
Colle
ctio
n of
educ
atio
n.
Prin
cipl
es o
f Med
ical
al
Rec
ord
Doc
umen
tatio
nTh
e pr
inci
ples
of d
ocum
enta
tion
are ee
appl
icab
le to
ooal
l Th
e pr
inci
ples
of d
ocum
enta
tion
are
type
s of
med
ical
and
sur
gica
l ser
vice
s pl
icab
ppap es
esin
all
le too
ca
bll ll
sett
ings
l al
lgsgs
.
For or
Eval
uatio
n an
d dM
anag
emen
t ser
vice
ses, t
he n
atur
e Foo
r va
luat
ion
anEv
and
amou
nt o
f ndd
an
agem
ent
Mn
anof
phys
icia
n w
ork
serv
icees
he n
atur
e ,t
ent
kan
d do
cum
enta
tion
and
amou
nt o
annd
amou
nto
ndam
vari
es b
y ty
pe
hysi
cia
hhysi
cian
why
sic
phphooofof
ppee
of s
ervi
cew
orw
ork k
nd d
ocum
enta
tion
nddo
cuum
enta
tion
ume
ananan
wan
wcece
, pla
ce o
f ser
vice
and
the
vari
es b
y ty
pva
ries
byty
pe ee
fsfsfofofpa
tient
’s s
tatu
s
Prin
cipl
es o
f Med
ical
Rec
ord
Doc
umen
tatio
n
Med
ical
reco
rd s
houl
d be
com
plet
e an
d le
gibl
e
Doc
umen
tatio
n of
eac
h pa
tient
enc
ount
er s
houl
d in
clud
e:p
Reas
on fo
r the
enc
ount
er a
nd re
leva
nt h
isto
ry, p
hysi
cal
Reas
on fo
r the
enc
ount
er a
nd re
leva
nt h
isto
ry, p
hysi
cal
exam
inat
ion
findi
ngs
and
prio
r dia
gnos
tic te
st re
sult
s;ex
amin
atio
n fin
ding
s an
d pr
ior d
iagn
ostic
test
Ass
essm
ent,
clin
ical
impr
essi
on o
r dia
gnos
ist r
test
isis;
Ass
essm
ent,
clin
ica
Plan
of C
are;
and
Plan
of C
are;
and
Dat
e an
d le
gibl
e id
entit
y of
the
obse
rver
Prin
cipl
es o
f Med
ical
Rec
ord
Doc
umen
tatio
n
The
patie
nt’s
pro
gres
s, re
spon
se to
oan
d dch
ange
s in
Th
e pa
tient
s pr
ogre
ss, r
espo
nse
toondan
d ha
nges
inch
trea
tmen
t, an
d re
visi
ons
of d
iagn
osis
sho
uld
be
trea
tmen
t, an
ddo
cum
ente
dd
and
eded.
The e
CPT
and
ICDCD
.10.0.0CM
cod
es o
n th
e he
alth
Th
eePT
and
ICCP
CD.100
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cod
es o
n th
e he
alth
CM
insu
ranc
e cl
aim
form
or b
illin
g st
atem
ent s
houl
d in
sura
nce
clai
m fo
rm o
r bill
ing
stat
emen
t sho
uld
be s
uppo
rted
by
the
docu
men
tatio
n in
the
med
ical
be
sup
pore
cord
.
Acc
urat
e Co
ding
: Ess
entia
lM
ost p
ayer
s ar
e fu
lly c
ompu
teri
zed
Com
pute
rs p
roce
ss c
laim
s by
:o
pute
sp
oces
sc
as
Reco
gniti
on o
f Cod
esec
ogn
too
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atch
ing
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edur
es to
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gnos
isat
cg
poc
edu
esto
dag
oss
Det
erm
inin
g ap
prop
riat
enes
s of
cla
im
Paye
rs li
nk d
iagn
osis
and
ser
vice
s
Acc
urat
e Co
ding
: Es
sent
ial
Code
to h
ighe
st le
vel o
f spe
cific
ityg
py
Refl
ect i
nfor
mat
ion
in m
edic
al re
cord
for
Refl
ect i
nfor
ma
clai
m v
alid
ityyW
ithst
ands
any
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ity
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w ti
mel
y cl
aim
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oces
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ng S
yste
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edur
e Co
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edur
e Co
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ICD
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iagn
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gnos
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hat Y
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ind
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odes
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odes
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su u
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ifier
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odifi
ers
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hat’s
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eren
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Proc
edur
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des
Iden
tifie
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ysic
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and
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Copy
righ
t hel
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Am
eric
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edic
al A
ssoc
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ated
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ugh
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cess
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ges
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r
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odify
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vice
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d pr
oced
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es
whe
n pr
imar
y M
odify
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vice
s an
d pr
oced
ure
rvic
esan
dpr
oced
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es
hen
prim
ary
hen
prim
arww
code
doe
s no
t acc
urat
ely
refl
ect w
hat w
as d
one.
Unu
sual
alal
Proc
edur
e (
e e-
y((-2
2)U
usuaa
oced
ue
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()2
Prof
essi
onal
Com
pone
nt (tt
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oes
so
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ile
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orld
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Spec
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O
phth
alm
oSe
rvic
es92
060
Sens
orim
otor
exa
min
atio
n w
ith m
ultip
le
Sens
orim
otor
exa
min
atio
n w
ith m
ulti
mea
sure
men
ts o
f ocu
lar d
evia
tion
(m
ulti
n(e
ge
iple
ti geg,
mea
sure
men
ts o
f ocu
lar d
evia
tionn
(egeg
, re
stri
ctiv
e or
par
etic
mus
cle
with
dip
lopi
a)
rest
rict
ive
or p
aret
ic m
uscl
e w
ith d
iplo
pia)
w
ith in
terp
reta
tion
and
repo
rt (s
epar
ate
with
inte
rpre
proc
edur
e)
Q. W
hat i
s a se
nsor
imot
or e
xam
?
CPT
lists
bas
ic s
enso
rim
otor
exa
m a
s a
requ
ired
exa
m
CPT
lists
bas
ic s
enso
rim
otor
exa
m a
s a
requ
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elem
ent o
f a c
ompr
ehen
sive
eye
exa
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20quir
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uire
00××4)
;
it is
an
inci
dent
al c
ompo
nent
and
not
sep
arat
ely
it is
an
inci
dent
reim
burs
ed.
A q
uant
itativ
e se
nsor
imot
or e
xam
inat
ion,
util
izin
g A
qua
ntita
tive
sens
orim
otor
exa
min
atio
n, u
tiliz
ipr
ism
s to
mea
sure
ocu
lar d
evia
tion,
is a
mor
e pr
ism
s to
mea
sure
ocu
lar d
evia
tion,
is a
mor
e ex
tens
ive
exam
and
may
be
sepa
rate
ly b
illab
le.
Q. W
hat i
s a se
nsor
imot
or
t is a
sens
oex
am?
A
exam
?ex
am?
Aba
sic
sens
orim
otor
exa
m e
valu
ates
ocu
lar r
ange
of
AAas
ic s
enso
rim
otor
exa
m e
valu
ates
ocu
lar r
ange
of
mot
or e
xam
eva
luat
eba
mot
ion
to d
eter
min
e if
the
eyes
mov
e to
geth
er in
the
mot
ion
to d
eter
min
e if
the
eyes
mov
e to
geth
er in
the
min
e if
the
eyes
mov
mve
toge
ther
inth
em
otio
nto
dete
rmmin
eif
the
eyes
mov
mot
vari
ous
card
inal
pos
ition
s of
gaz
e (1
2:00
, 1:3
0, 3
:30,
vava
rio
etc
ous
card
inal
pos
ition
s of
gaz
e (1
2:00
, 1:3
0, 3
:30,
ou
sca
rdin
alpo
sitio
nsof
gaze
(12:
00,1
:30,
3:30
,ar
ioar
iotc
). Th
is e
xam
ele
men
t is
com
mon
ly n
oted
as
ocul
ar
etettctc
This
eTh
isex
am). ).
mot
ility
, or
m e
lem
enm
elem
enti
exam
exam
orex
trao
cula
rs
com
mon
ly n
oted
as
ocul
ar
sco
mm
only
note
das
ocul
arnt
int
iar
mus
cles
(EO
M),
in th
e ch
art
mot
ility
, omm
otili
ty,o
mot
ilor
or
xtra
ocul
axt
raoc
ula
exexarar
mus
cles
(EO
M),
in th
e ch
art
mus
cles
(EO
M),
inth
ech
art
mmno
te. A
nor
mal
rang
e of
mot
ion
is o
ften
not
ed a
s no
te. A
nor
mal
rang
e of
mot
note
.Anoo
rmal
rang
eo
orm
aof
mot
ion
ofm
"ful
l" o
r "w
ithin
nor
mal
lim
itsisis
tion
tion
tsts.”
Q. W
hat i
s a se
nsor
imot
or e
xam
?D
ocum
enta
tion
of a
lignm
ent,
usua
lly in
pri
mar
y ga
ze,
Doc
umen
tatio
n of
ais
oft
en n
oted
as
alig
nmen
t, u
of a
asor
thop
hori
at, u a(
ually
isu
, u a(o
rtho
n pr
imar
ylly
iho
) in
olde
r is
oft
en n
oted
ais
ofte
nno
ted
aas
asrt
hoph
ori
rtho
phor
ioror
aaaa((
rth
rth
ororoohoho
n ol
der
nol
der
) i)ich
ildre
n an
d ad
ults
. For
ped
iatr
ic p
atie
nts,
"CS
M"
for
child
ren
and
adul
ts. F
or p
edia
tric
pat
ient
s,CS
M fo
child
ren
and
aduul
ts.F
orpe
diul
tsiaa
tric
pat
ric
atr
atie
nts,
CSM
atie
"cen
tral
, ste
ady,
mai
ntai
n" a
nd "
F&F"
for "
fix a
nd
cent
ral,
stea
dy, m
aint
ain
and
F&F
for
fix a
nd
cent
ral,
stea
dy,m
aint
ain
and
F&F
for
fixan
dfo
llow
" ar
e of
ten
used
to d
enot
e bo
th v
isua
l acu
ity
follo
war
e of
ten
used
to d
enot
e bo
th v
isua
l acu
ityfo
llow
are
ofte
nus
edto
deno
tebo
thvi
sual
acui
tyan
d gr
oss
mot
ility
. Abn
orm
al c
ondi
tions
are
not
ed a
s an
d gr
and
gros
sph
oria
soss
oss
asasor
ot
ilit
otili
ty.A
s m
os
mo
ss r rorortr
opia
sAA
ty. A
ty.A
asas.
Q. W
hat i
s a se
nsor
imot
or e
xam
?
CPT
desc
ribe
s th
is d
iagn
ostic
test
as
9206
0, S
enso
rim
otor
CP
T de
scri
bes
this
dia
gnos
tic te
st a
s 92
060,
Sen
sori
mo
exam
inat
ion
with
mul
tiple
mea
sure
men
ts o
f ocu
lar
pex
amin
atio
n w
ith m
ultip
le m
easu
rem
ents
of o
cula
r p
devi
atio
n (e
.g.,
rest
rict
ive
or p
aret
ic m
uscl
e w
ith d
iplo
pia)
de
viat
ion
(e.g
., re
stri
ctiv
e or
par
etic
mus
cle
with
dip
lop
devi
atio
n(e
.g.,
rest
rict
ive
or p
aret
ic m
uscl
e w
ith d
iplo
with
inte
rpre
tatio
n an
d re
port
(sep
arat
e pr
oced
ure)
.
Fund
amen
tallylyy
, thi
s te
st re
quir
es th
e cl
inic
ian
to a
sses
s Fu
ndam
enta
llyhi
s te
st re
quir
es th
e cl
inic
ian
to a
sses
s, tyy
qbo
th e
yes
(i.e.
, bila
tera
l); it
sho
uld
not b
e bi
lled
per e
ye.
y(
,);
pbo
th e
yes
(i.ee.
, bila
tera
l); it
sho
uld
not b
e bi
lled
per e
e., b
iPe
rtin
ent d
iagn
oses
incl
ude
but a
re n
ot li
mite
d to
: Pe
rtin
entd
dipl
opia
, g
iagn
oses
int
da
exot
ropi
ases
iia
, nc
lude
but
ines
ia,,
esot
ropi
abut
ia,
are
not l
imite
t abu
ta,,
hype
rtro
pia
ed to
: m
itea
and
para
lytic
p
pdi
plop
ia,a,
xot
exst
rabi
smus
.
Q. W
hat i
s a se
nsor
imot
or
t is a
sens
oex
am?
exam
?ex
am?
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????????Th
e A
mer
ican
Ass
ocia
tion
for P
edia
tric
Oph
thal
mol
ogy
and
The
Am
eric
an A
ssoc
iatio
n fo
r Ped
iatr
ic O
phth
alm
olog
y an
dia
tion
for P
edia
tric
OSt
rabi
smus
(AA
POS)
issu
ed a
pos
ition
sta
tem
ent i
n 19
99.
"Sen
sori
mot
or e
ye e
xam
incl
udes
mea
sure
men
t of o
cula
r Se
nsor
imot
or e
ye e
xam
incl
udes
mea
sure
men
t of o
cula
r al
ignm
ent i
n m
ore
than
one
fiel
d of
gaz
e at
dis
tanc
e an
d/or
al
ignm
ent i
n m
ore
than
one
fiel
d of
gaz
e at
dis
tanc
e an
d/or
gn
men
tin
mor
eth
anon
efie
ldof
gaze
atdi
stan
cean
d/or
near
, and
incl
usio
n of
at l
east
one
app
ropr
iate
sen
sory
test
in
near
, and
incl
usio
n of
at l
east
one
app
near
,and
incl
usio
nof
atle
asto
neap
ppa
tient
s w
ho a
re a
ble
to re
spon
d.”
Mea
suri
ng o
nly
prim
ary
gaze
at d
ista
nce
wou
ld n
ot s
atis
fy
Mea
suri
ng o
nly
prim
ary
gaze
at d
ista
nce
wou
ld n
ot s
atis
fth
e re
quir
emen
ts. Y
ou s
houl
d in
clud
e oc
ular
alig
nmen
t th
e re
quir
emen
ts. Y
ou s
houl
d in
clud
e oc
ular
alig
the
requ
irem
ents
.You
shou
ldin
clud
eoc
ular
alig
mea
sure
men
ts in
mor
e th
an o
ne fi
eld
of g
aze.
Q. W
hat i
s a se
nsor
imot
or
t is a
sens
oex
am?
Exam
ples
of s
enso
ry fu
nctio
n te
stin
g in
clud
e W
orth
4
Exam
ples
of s
enso
ry fu
ndo
t, M
addo
x ro
d, a
nd
nctio
n te
sy
fun
dd Ba
golin
ist
ing
inc
n te
sni
lens
es.
The
asse
ssm
ent o
f sen
sory
func
tion
is
The
asse
ssm
ent o
f sen
sory
func
tion
isco
mpl
emen
tary
to th
e ev
alua
tion
of th
e m
otor
co
mpl
emen
tary
to th
e ev
alua
tion
of th
e m
otor
co
mpl
emen
tary
to th
e ev
alua
tion
of th
efu
nctio
n as
the
term
"se
nsor
imot
or"
impl
ies.
It is
no
func
tion
as th
e te
rmse
nsor
imot
orim
plie
s. It
is n
ofu
nctio
n as
the
term
sens
orim
otor
impl
ies.
It is
less
impo
rtan
t and
an
esse
ntia
l par
t of t
he s
ervi
ce
Cove
r Tes
t
Q. H
ow is
the
sens
orim
otor
exa
m d
ocum
ente
d in
the
patie
nt's
m
otor
exa
m d
ocum
em
edic
al re
cord
?A
n or
der f
or th
e te
st s
houl
d be
not
ed in
the
char
t.
Test
st
resu
lts
for m
otor
func
tion
are
typi
cally
doc
umen
ted
in a
"tici
-c-ta
ca-c-to
e" fo
rmat
to
Tesst
esu
lts
for m
otor
func
tion
are
typi
cally
doc
umen
ted
in a
t
reic
ataac
oe fo
rmat
to
otore
pres
ent d
iffer
ent f
ield
s of
gaz
e. R
esul
ts o
f the
sen
sory
func
tion
test
are
not
ed, t
ooo oooo.
Exam
iner
s no
te e w
hat t
ype
of s
tere
opsi
s te
st w
as u
sed
and
the
scor
e th
at th
e pa
tient
Ex
amin
ers
rece
ived
A p
ositi
ve s
tere
o te
st o
n a
nonv
erba
l pat
ient
mig
ht b
e re
pres
ente
d by
the
patie
nt's
A
pos
itive
ste
reo
test
on
a no
nver
bal p
atie
nt m
ight
be
repr
esen
ted
by th
e pa
tient
sat
tem
pt to
touc
h or
pic
k up
the
fly'
s w
ings
. Res
ults
of a
Wor
th 4
dot
oft
en n
ote
whi
ch
atte
mpt
to to
uch
orat
tem
ptto
touc
hor
light
s w
ere
seen
.
An n
inte
rpre
tatio
n of
the
test
resu
lts
and
the
effe
ct o
n th
e pa
tient
's c
ondi
tion
and
Ann
terp
reta
tion
of th
e te
st re
sult
s an
d th
e ef
fein
tco
urse
of t
reat
men
t sat
isfy
the
inte
rpre
tatio
n ec
t on
the
patie
effe
nnre
quir
emen
tse
patie
tsts.
Q. H
ow is
the
sens
orim
otor
exa
m d
ocum
ente
d in
is
the
sens
orim
otor
exa
m d
ocum
the
patie
nt's
med
ical
reco
rdm
ecu
mrdrd
?p
Take
car
e th
at th
e no
tatio
ns fo
r the
test
are
cle
arly
iden
tifia
ble
Take
car
e th
at th
e no
tatio
ns fo
r the
test
are
cle
arly
iden
tifia
be
that
the
nota
tions
fort
hete
star
ecll
earl
yle
arly
and
dist
inct
from
the
offic
e vi
sit n
otes
(e.g
., st
amp,
box
ed
and
dist
inct
from
the
offic
e v
and
dist
inct
from
the
offic
ev
entr
y, s
epar
ate
page
, etc
.).
Repe
ated
test
ing
is in
dica
ted
whe
n m
edic
ally
nec
essa
ry fo
r Re
peat
ed te
stin
g is
indi
cate
d w
hen
med
ical
ly n
eces
sary
for
new
sym
ptom
s, d
isea
se p
rogr
essi
on, n
ew fi
ndin
gs, u
nrel
iabl
e ne
w s
ympt
oms,
dis
ease
pro
gres
sion
, new
find
ings
, unr
elia
blne
wsy
mpt
oms,
dise
ase
prog
ress
ion,
new
findi
ngs,
unre
liabl
prio
r res
ults
or a
cha
nge
in th
e tr
eatm
ent p
lan.
In g
ener
al,
prio
r res
ults
or a
cha
nge
in th
e tr
eatm
entp
lan.
In g
ener
al,
prio
rres
ults
ora
chan
gein
the
trea
tmen
tpla
n.In
gene
ral,
addi
tiona
l tes
ting
is w
arra
nted
whe
n th
e in
form
atio
n ga
rner
ed
addi
tiona
l tes
ting
is w
arra
nted
whe
n th
e in
form
atio
n ga
rner
addi
tiona
ltes
ting
isw
arra
nted
whe
nth
ein
form
atio
nga
rner
from
the
eye
exam
is in
suff
icie
nt to
ade
quat
ely
asse
ss th
e fr
om th
e ey
e ex
from
the
eye
exam
patie
nt's
dis
ease
m
mxa
mxa
msese
.
Spec
ial O
torh
inol
aryn
golo
gic
Serv
ices
Vest
ibul
ar F
unct
ion
Test
s, w
ith O
bser
vatio
n an
d Ev
al
by P
hysi
cian
, w/o
Ele
ctric
al R
ecor
ding
9235
1Sp
onta
neou
s ny
stag
mus
, inc
ludi
ng g
aze
9235
2Po
sitio
nal n
ysta
gmus
test
9235
4O
ptok
inet
icny
stag
mus
test
Spec
ialO
torh
inol
aryn
golo
gic
Serv
ices
DO
N’T
GO
TH
ERE?
DO
N’T
GO
HER
E EI
THER
Vest
ibul
ar F
unct
ion
Test
s, w
ith R
ecor
ding
(eg,
EN
G, P
ENG
), an
d M
edic
al D
iagn
ostic
9254
1
Spon
tane
ous
nyst
agm
uste
st, i
nclu
ding
gaz
e an
d fix
atio
n ny
stag
mus
, w
ith re
cord
ing
9254
2
Posi
tiona
l nys
tagm
us te
st, m
inim
um o
f 4 p
ositi
ons,
with
reco
rdin
g (C
alifo
rnia
Pos
t Rot
ary
Nys
tagm
us)-
9254
4
Opt
okin
etic
nys
tagm
us te
st, b
idire
ctio
nal,
fove
al o
r per
iphe
ral
stim
ulat
ion,
with
reco
rdin
g
9254
5O
scill
atin
g tr
acki
ng te
st, w
ith re
cord
ing
Cent
ral N
ervo
us S
yste
m A
sses
smen
ts/T
ests
en
tra
(ntra ((egal
Nra ggegeg
, er
vous
Ne
al N
gg, ,N
eurovo
usroro
-Sy
stem
Ass
essm
ents
/Tes
ts
ous
oo-Co
gniti
ve, M
enta
l Sta
tus)
The e
follo
win
g co
des
are
used
to re
port
the
serv
ices
Th
ee ol
low
ing
code
s ar
e us
ed to
repo
rt th
e se
rvic
esfo
prov
ided
dur
ing
test
ing
of th
e co
gniti
ve fu
nctio
n of
the
pg
gg
proov
ided
dur
ing
test
ing
of th
e co
gniti
ve fu
nctio
n o
ovid
cent
ral n
ervo
us s
yste
m. T
he te
stin
g of
cog
nitiv
e y
gg
cent
ral n
ervo
us s
yste
m. T
he te
stin
g of
cog
nitiv
e pr
oces
ses,
vis
ual m
otor
resp
onse
s, a
nd a
bstr
activ
e p
oces
se, v
isua
l mot
or re
pons
e, a
nd a
bstr
activ
e pr
oces
ses,
vis
ual m
otor
resp
onse
s, a
nd a
bstr
activ
eab
ilitie
s is
acc
ompl
ishe
d by
the
com
bina
tion
of s
ever
al
py
abili
ties
is a
ccom
plis
hed
by th
e co
mbi
natio
n of
sev
era
type
s of
test
ing
proc
edur
es. I
t is
expe
cted
that
the
ypg
pp
type
s of
test
ing
proc
edur
es. I
t is
expe
cted
that
the
adm
inis
trat
ion
of th
ese
test
s w
ill g
ener
ate
mat
eria
l tha
t g
adm
inis
trat
ion
of th
ese
test
s w
illg
will
be
form
ulat
ed in
to a
repo
rt.
Cent
ral N
ervo
us S
yste
m A
sses
smen
ts/T
ests
en
tra
(ntra ((egal
Nra ggegeg
, er
vous
Ne
al N
gg, ,N
eurovo
usroro
-Sy
stem
Ass
essm
ents
/Tes
ts
ous
oo-Co
gniti
ve, M
enta
l Sta
tus)
9610
1 Psy
chol
ogic
al
alte
stin
g (in
clud
es
esps
ycho
diag
nost
ic96
101 P
sych
olog
icaal
est
ing
(incl
ude
tees
sych
odia
gno
psas
sess
men
t of e
mot
iona
lity,
inte
llect
ual a
bilit
ies,
y,
asse
ssm
ent o
f em
ootio
nalit
y, in
telle
cot
iope
rson
ality
and
psy
chop
atho
logy
, llec
yeg
,al
abi
litie
s,a
tua
cct geg, M
MPI
, Ror
scha
ch,
py
py
pgy
pers
onal
ity a
nd p
sych
opat
holo
gyy,y, e
gggegM
MPI
, Ror
scha
ch,
MM
PI, R
orsc
h,, M
py
py
pgyy
ggW
AIS
), pe
r hou
r of t
he p
sych
olog
ist's
or p
hysi
cian
's ti
me,
),
pW
AIS
), pe
r bo
th fa
cepper
ce-
pper
etor to
-p
yg
py
,ur
of t
he p
sych
ologg
istt'
s or
phy
sici
an's
tim
e,
t's
ot'
uho
uh ooo
face
tim
e ad
min
iste
ring
test
s to
the
patie
nt
both
faccee
-ttoooo-
gp
ce ti
me
adm
inis
teri
ng te
sts
to th
e pa
tient
afa
and
time
inte
rpre
ting
thes
e te
st re
sult
s an
d pr
epar
ing
the
and
timee
repo
rt
Cent
ral N
ervo
us S
yste
m
Cent
ral N
ervo
Ass
essm
ents
/Tes
ts (er
vos
(s
(egou
so ggegeg
, Sy
stem
s S
ous
gg,,N
eurote
mroro
-
mte
moo-
Cogn
itive
, ts
/Tes
tss (e
gegg,
eur
Ne
Nroo
Men
tal S
tatu
s)
9611
0 D
evel
opm
enta
l tes
ting;
lim
ited
(d
(eggeg
, 96
110
Dev
elop
men
tal t
estin
g; li
mite
dd(e
geg,
Dev
elop
men
tal S
cree
ning
Tes
t II,
Earl
y La
ngua
ge
Dev
elop
men
tal S
cree
ning
Tes
t II,
Earl
y La
ngua
ge
Dev
elop
men
tal S
cree
ning
Tes
t II,
Earrl
yLa
ngLa
ngL
Mile
ston
e Sc
reen
), w
ith in
terp
reta
tion
and
repo
rt
9611
1 ext
ende
d (in
clud
es a
sses
smen
t of m
otor
, 96
111 e
xten
ded
(incl
udes
ass
essm
ent o
f mot
or,
lang
uage
, soc
ial,
adap
tive
and/
or c
ogni
tive
func
tioni
ng
lang
uage
, soc
ial,
adap
tive
and/
or c
ogni
tive
func
tioni
nla
ngua
ge, s
ocia
l, ad
aptiv
e an
d/or
cog
nitiv
e fu
ncti
by s
tand
ardi
zed
deve
lopm
enta
l ins
trum
ents
) with
by
sta
dad
edde
eop
eby
sta
ndar
dize
d de
velo
pme
inte
rpre
tatio
n an
d re
port
Cent
ral N
ervo
us S
yste
m A
sses
smen
ts/T
ests
en
tra
(ntra ((egal
Nra ggegeg
, er
vous
Ne
al N
gg, ,N
eurovo
usroro
-Sy
stem
Ass
essm
ents
/Tes
ts
ous
oo-Co
gniti
ve, M
enta
l Sta
tus)
9611
6 N
euro
beha
vior
al s
tatu
s ex
am (c
linic
al a
sses
smen
t of t
hink
ing,
96
116
Neu
robe
havi
oral
sta
ture
ason
ing
and
judg
men
t, stat
ut,
egex
am (c
linic
al a
sses
smen
t of t
hink
ing,
us
etu geg
, acq
uire
d kn
owle
dge,
att
entio
n, la
ngua
ge,
reas
onin
g an
d ju
dgm
ent
reas
onin
gan
dju
dgm
entt,t,
eeggegegac
quir
ed k
now
ledg
e, a
tten
tion,
lang
uage
, ac
quir
edkn
owle
dge,
atte
ntio
n,la
ngua
ge, a,a
mem
ory,
pla
nnin
g an
d pr
oble
m s
olvi
ng, a
nd v
isua
l spa
tial a
bilit
ies)
, per
m
emor
y, p
lann
ing
and
prob
lem
sol
vin
mem
ory,
plan
ning
and
pprob
lem
solv
ing,
blem
bho
ur o
f the
phy
sici
an's
tim
e, b
oth
facenng
,ce
-ng
,ng
,e-
to, , to-
d vi
sual
spa
tial a
bilit
ies)
, per
d
visu
alsp
atia
labi
litie
s),p
erdd
and
and
aa ooo-fa
ce ti
me
with
the
patie
nt a
nd
hour
of t
he p
hysi
cian
s tim
e, b
oth
fac
hour
ofth
eph
ysic
ian
stim
e,bo
thfa
cceceeetttotooooooo
ce
ceti
me
aafafatim
e in
terp
retin
g te
st re
sult
s an
d pr
epar
ing
the
e w
ith
ew
ith
time
time
e ere
port
9612
5 5St
anda
rdiz
ed c
ogni
tive
perf
orm
ance
test
ing
(g
(eggeg
, Ros
s In
form
atio
n 96
125
tand
ardi
zed
cogn
itive
per
form
ance
test
ing
Stg
(egeg
Ross
Info
rmat
ion
, RPr
oces
sing
Ass
essm
ent)
per
hou
r of q
ualif
ied
heal
th c
are
prof
essi
onal
’s
Proc
essi
ng A
sses
smen
t) p
er h
our o
f qua
lifie
d he
alth
car
e pr
ofes
sion
als
Procc
essi
ngA
sses
smen
t)pe
rhou
rofq
ualif
ied
heal
cess
ith
care
prof
essi
onal
sca
rec
time,
bot
h fa
ce to
face
tim
e ad
min
iste
ring
test
s to
the
patie
nt a
nd ti
me
time,
bot
h fa
ce to
face
tim
e ad
min
iste
ring
test
s to
the
pati
time,
both
face
tofa
cetim
ead
min
iste
ring
test
sto
the
pati
inte
rpre
ting
thes
e te
st re
sult
s an
d pr
epar
ing
the
repo
rt
Prol
onge
d Se
rvic
e Co
des
9935
499
354
Prol
onge
d ph
ysic
ian
serv
ice
in th
e of
fice
or o
ther
Pr
olon
ged
phys
icia
n se
rvic
e in
the
offic
e o
Prol
ong
outp
atie
nt s
ettin
g re
quir
ing
dire
ct (f
acece
oce
-ce
oe-
too to-
ther
otrooro ooo-fa
ce)
outp
atie
nt s
ettin
g re
quir
ing
dire
ct (f
acou
tpat
ient
sett
ing
requ
irin
gdi
rect
(facc
eceeepa
tient
con
tact
bey
ond
the
usua
l ser
vice
ffa
eetttotooooooo e efir
st
) )ceceaafafa st
ststho
ur
p List
y
ststse
para
tely
in a
dditi
on to
cod
e fo
r ser
vice
of
Lisst
ep
arat
ely
in a
dditi
on to
cod
e fo
r ser
vice
of
seot
her o
utpa
tient
Eva
luat
ion
and
man
agem
ent
othe
r out
othhe
rout
her
Serv
ice
Prol
onge
d Se
rvic
e Co
de99
355
9935
5Pr
olon
ged
phys
icia
n se
rvic
e in
the
offic
e or
oth
er
Prol
onge
d ph
ysic
ian
serv
ice
in th
e of
fice
oPr
olon
gou
tpat
ient
set
ting
requ
irin
g di
rect
(fac
ece o
ce-
ce o
e-too to
-th
er
otrooro ooo-fa
ce)
outp
atie
nt s
ettin
g re
quir
ing
dire
ct (f
acou
tpat
ient
sett
ing
requ
irin
gdi
rect
(facc
eceeetttotooooooo
ce)
ace)
aafafapa
tient
con
tact
bey
ond
the
usua
l ser
vice
eac
h pa
tient
con
tact
bey
ond
patie
ntco
ntac
tbey
ond
addi
tiona
l 30
min
utes
Prol
onge
d Se
rvic
e Co
des
9935
8588-88-
Prol
onge
d N
on F
ace
to F
ace
99355
gPr
olon
ged
eval
uatio
n an
d m
anag
emen
t ser
vice
o
oge
de
aua
toa
da
Prool
oonge
d ev
alua
tion
and
man
agon
ged
onge
befo
re a
nd/o
r aft
er d
irec
t (fa
cenag
ce-agnag
e-togg to
-e
tse
ceen
t ser
vice
e
me
eemeegg ooo-fa
ce) p
atie
nt
befo
befo
rea
care
(ore
ore
ae
(eg
d/or
aft
er d
irec
t (fa
cd/
oraf
terd
irec
t(fa
cceceeetttotooooooo
ce) p
atie
ntce
)pat
ient
aafafaan
dan
de
ae
a geg, r
evie
w o
f ext
ensi
ve re
cord
s an
d te
sts,
ca
reca
ree (e(ee
ggegegre
view
of e
xten
sive
reco
rds
and
test
s,
revi
ewof
exte
nsiv
errre
ccoord
san
dte
sts,
ords
ord
oo, r,r
com
mun
icat
ion
with
oth
er p
rofe
ssio
nals
and
/or
com
mun
icat
ion
with
oth
er p
rof
comm
muun
icat
ion
with
othe
rpro
fun
icu
the
patie
nt/f
amily
); fir
st h
our
Prol
onge
d Se
rvic
e Co
des
9935
99
59-9-
Prol
onge
d N
on F
ace
to F
ace
993
99g
Prol
onge
d ev
alua
tion
and
man
agem
ent s
ervi
ce
Prol
onge
d ev
alua
tion
and
man
Prol
onge
d on
ged
eval
uatio
nan
dm
anag
dng
edbe
fore
and
/or a
fter
dir
ect (
facenna
gce
-na
gna
ge-
togg to-
ent s
ervi
ce
ents
ervi
cem
em
eememeegg ooo-
face
) pat
ient
be
fore
and
/or a
fter
dir
ect (
fac
befo
rean
d/or
afte
rdir
ect(
facceceee
tttotoooooooca
re; e
ach
addi
tiona
l 30
min
utes
Care
Pla
n O
vers
ight
Ser
vice
s99
367
Med
ical
team
con
fere
nce
with
inte
rdis
cipl
inar
y te
am
Med
ical
team
con
fere
nce
with
inte
rdis
cipl
inar
y te
amof
hea
lth
care
pro
fess
iona
ls, p
atie
nt a
nd/o
r fam
ily
of h
ealt
h ca
re p
rofe
ssio
nals
, pat
ient
and
/or f
amily
of
heal
thca
repr
ofes
sion
als,
patie
ntan
d/or
fam
ilyno
t pre
sent
, 30
min
utes
or m
ore;
par
ticip
atio
n by
no
t pre
sent
,no
tpre
sent
,ph
ysic
ian
9206
5O
rtho
ptic
and
/or p
leop
tic tr
aini
ng, w
ith c
ontin
uing
O
rtho
ptic
and
/or p
leop
tic tr
aini
ng, w
med
ical
dir
ectio
n an
d ev
alua
tion.
9206
5Fr
om a
n A
MA
Cur
rent
Pro
cedu
ral T
erm
inol
ogy
(CPT
®) c
odin
g pe
rspe
ctiv
e, c
ode
9206
5 w
ould
be
repo
rted
for e
ach
indi
vidu
al
trai
ning
ses
sion
pro
vide
d by
the
phys
icia
n. T
he p
hysi
cian
pre
scri
bes
exer
cise
s to
cor
rect
ocu
lar p
robl
ems
(eg,
ocu
lar m
otor
m
isal
ignm
ent)
. The
phy
sici
an th
en tr
ains
the
patie
nt to
per
form
th
erap
eutic
exe
rcis
es to
try
to c
orre
ct th
e m
isal
ignm
ent.
The
re is
no
spec
ific
time
allo
tted
to th
e pr
oced
ure
by C
PT®
.
9206
5 Su
perv
isio
n 92
065
Sup
Gui
delin
esSup
ee-
ervi
sion
pe
Sup
ss-CM
S Le
vel 1
Gen
eral
sup
ervi
sion
mea
ns th
e pr
oced
ure
is fu
rnis
hed
unde
r G
ener
al s
uper
visi
on m
eaan
roce
dure
is fu
rnis
hed
upr
ns th
e p
the
phys
icia
n’s
over
all d
irec
tion
and
cont
rol,
but t
he
the
phys
icia
ns
over
all d
irec
tion
and
cont
rol,
but t
he
the
phys
icia
ns
over
alld
irec
tion
and
cont
rol,
butt
heph
ysic
ian’
s pr
esen
ce is
not
requ
ired
dur
ing
the
perf
orm
ance
ph
ysic
ian
s pr
esen
ce is
not
requ
ired
dur
ing
the
perf
orm
ance
ph
ysic
ian
spr
esen
ceis
notr
equi
red
duri
ngth
epe
rfor
mof
the
proc
edur
e. U
nder
gen
eral
sup
ervi
sion
, the
trai
ning
of
of th
e pr
oced
ure.
Und
er g
ener
al s
uper
visi
on, t
he tr
aini
ngof
the
proc
edur
e.U
nder
gene
rals
uper
visi
on,t
hetr
aini
ngth
e no
nphy
sici
an p
erso
nnel
who
act
ually
per
form
s th
e th
e no
nphy
sici
an p
erso
nnel
who
act
ually
per
form
s th
e th
eno
nphy
sici
anpe
rson
nelw
hoac
tual
lype
rfor
ms
the
diag
nost
ic p
roce
dure
and
the
mai
nten
ance
of t
he n
eces
sary
di
agno
stic
pro
cedu
re a
nd th
e m
aint
enan
ce o
f the
nec
essa
rydi
agno
stic
proc
edur
ean
dth
em
aint
enan
ceof
the
nece
ssa
equi
pmen
t and
sup
plie
s ar
e th
e co
ntin
uing
resp
onsi
bilit
y of
eq
uipm
ent a
nd s
equi
pmen
tand
sth
e ph
ysic
ian.
9249
9U
nlis
ted
opht
halm
olog
ical
ser
vice
or p
roce
durere
—U
nlis
ted
opht
halm
olog
ical
ser
vice
or p
roce
durre
Phys
icia
ns m
ay u
se th
is c
ode
to re
port
ser
vice
s th
at
Phys
icia
ns m
ay u
se th
is c
ode
to re
port
ser
vice
s th
at
have
not
bee
n gi
ven
a m
ore
spec
ific
code
by
CPT®
. ha
ve n
ot b
een
give
n a
mor
e sp
ecifi
c co
de b
y CP
T®H
owev
er, i
nsur
ers
are
likel
y to
reje
ct c
laim
s fo
r H
owev
er, i
nsur
ers
are
likel
y to
reje
ct c
laim
s fo
r se
rvic
es re
port
ed w
ith 9
2499
and
/or r
eque
st fu
rthe
r se
rvic
es re
port
ed w
ith
9249
9 an
d/or
requ
est f
urth
er
clar
ifica
tion
and
supp
ortin
g do
cum
enta
tion
rela
tive
clar
ifica
tion
and
supp
ortin
gto
the
serv
ices
pro
vide
d.
Phys
ical
Med
icin
e Co
des
ySt
ate
Boar
d Li
mita
tions
Thir
d Pa
rty
Lim
itatio
ns
CMS
App
rove
d Co
des
CMS
App
ro97
112pp
ro11
-ve
d Co
des
ovpp
ro 22-N
euro
mus
cula
r Ree
duca
tion
97111
297
5302 3030
-euro
mus
cula
r Ree
duca
tion
e2
eN
eN 00--Fu
nctio
nal P
erfo
rman
ce T
hera
py97
5397
532330 333
-un
ctio
nal P
erfo
rman
ce T
uuu00
F222--
Cogn
itive
Ski
lls T
hera
py97
5397
53333 33333
-og
nitiv
e Sk
ills
Ther
apoo
2C
333--Se
nsor
y Pr
oces
sing
py
erap
g gTh
erap
y
97XX
X Su
perv
isio
n CM
S
The
phys
icia
n or
ther
apis
t is
requ
ired
to h
ave
The
phys
icia
ndi
rect
(oneic
ian
nene-
cian ee-onnn nnoo
-th
erap
ist i
s re
quir
ed to
hav
e r
n or
n nnnn-on
e) p
atie
nt c
onta
ct.
This
doe
s di
rect
(onnee
ononnne
)pat
ient
con
tano
not u
sual
ly a
llow
for “
inci
denton
tann
-ac
t. T
his
doe
aon
tantnt
-to”
billi
ng.
not u
sual
ly a
llow
for
inci
dennnt
obi
lling
. oto
Furt
herm
ore,
doc
umen
tatio
n gu
idel
ines
are
Fu
rthe
rmor
e, d
ocum
enta
tion
guid
very
spe
cific
and
fair
ly c
ompl
ex
Ther
apeu
tic p
roce
dure
sIn
ord
er fo
r the
rape
utic
act
iviti
es to
be
cove
red,
all
of th
e fo
llow
ing
In o
rder
for t
hera
peut
ic a
ctiv
ire
quir
emen
ts m
ust b
e m
et:
-qu
irem
ents
mus
t be
met
:qu
irem
ents
mus
tbe
met
:re
qre
q-T
he p
atie
nt h
as a
con
ditio
n fo
r whi
ch th
erap
eutic
act
iviti
es c
an
he p
atie
nt h
as a
con
ditio
n fo
r whi
ch th
erap
eutic
act
iviti
es c
an
hepa
tient
has
aco
nditi
onfo
ThTh reas
onab
ly b
e ex
pect
ed to
rest
ore
or im
prov
e fu
nctio
ning
; and
-as
onab
ly b
e ex
pect
ed to
rest
ore
or im
prov
e fu
nctio
ning
; and
ason
ably
beex
pect
edto
rest
ore
orim
prov
efu
nctio
ning
;and
rea
rea
-The
pat
ient
’s c
ondi
tion
is s
uch
that
he/
she
is u
nabl
e to
per
form
he
pati
ent
s co
nditi
on is
suc
h th
at h
e/sh
e is
una
ble
to p
erfo
rm
hepa
tient
sco
nditi
onis
such
that
he/s
heis
unab
leto
perf
orm
ThTh ther
apeu
tic a
ctiv
ities
exc
ept u
nder
the
dire
ct s
uper
visi
on o
f a
ther
apeu
tic a
cth
erap
eutic
acth
ecl
inic
ian
and
-ni
cian
and
nici
anan
dcl
incl
in-T
here
is a
cle
ar c
orre
latio
n be
twee
n th
e ty
pe o
f exe
rcis
e pe
rfor
med
he
re is
a c
lear
cor
rela
tion
betw
een
the
type
of e
xerc
ise
perf
orm
here
isa
clea
ThTh and
the
patie
nt’s
und
erly
ing
func
tiona
l def
icit(
s) fo
r whi
ch th
e an
d th
e pa
tient
s un
derl
ying
func
tiona
l dan
dth
epa
tient
sun
derl
ying
func
tiona
ldan
dth
erap
eutic
act
iviti
es w
ere
pres
crib
ed.
Ther
apeu
tic P
roce
durere
-e-97
110
Ther
apeu
tic p
roce
dure
, one
or m
ore
area
s,
Ther
apeu
tic p
roce
dure
, one
or m
ore
area
s,ea
ch 15
min
utes
; the
rape
utic
exe
rcis
es to
ea
ch 15
min
utes
; the
rape
utic
exe
rcis
es to
de
velo
p st
reng
th a
nd e
ndur
ance
, ran
ge o
f de
velo
p st
reng
th a
nd e
nm
otio
n an
d fl
exib
ility
Neu
rom
uscu
lar R
eRe-e-ed
ucat
ion
9711
2
This
ther
apeu
tic p
roce
dure
is p
rovi
ded
to im
prov
e Th
is th
erap
eutic
pro
cedu
re is
pro
vide
d to
impr
ove
bala
nce,
coo
rdin
atio
n, k
ines
thet
ic s
ense
, pos
ture
, ba
lanc
e, c
oord
bala
nce,
coor
dina
tm
otor
ski
ll, a
nd
tion,
kin
esth
tion,
kine
sthe
ticdi
nat
dina
td d
prop
rioc
eptio
ncc
hetic
hetic
onon.
Ecce
ntri
c Fi
xatio
n Tr
aini
ng
Gai
t Tra
inin
gng-g-97
116
Ther
apeu
tic A
ctiv
itytyt-y-ga
it tr
aini
ng
Ther
apeu
tic A
ctiv
ittyy
ait t
ag(in
clud
es s
tair
clim
bing
)
-71
1679
ng
Gro
up T
hera
pypy-y-97
150
Ther
apeu
tic p
roce
dure
(s),
grou
p (2
or m
ore
indi
vidu
als)
(Rep
ort 9
7150
for e
ach
mem
ber o
f gro
up)
(Gro
up th
erap
y pr
oced
ures
invo
lve
cons
tant
att
enda
nce
of th
e ph
ysic
ian
or th
erap
ist,
but b
y de
finiti
on d
o no
t req
uire
one
-on-
one
patie
nt c
onta
ct b
y th
e ph
ysic
ian
or th
erap
ist)
Func
tiona
l Per
form
ancece
-e-97
530
This
pro
cedu
re in
volv
es th
e us
e of
func
tiona
l Th
ispr
oced
ure
invo
lves
the
use
of fu
nctio
nal
activ
ities
to im
prov
e fu
nctio
nal p
erfo
rman
ce in
a
activ
ities
to im
prov
e fu
nctio
nal p
erfo
rman
ce in
apr
ogre
ssiv
e m
anne
r. Th
e ac
tiviti
es a
re u
sual
ly
prog
ress
ive
man
ner.
The
activ
ities
are
usu
ally
di
rect
ed a
t a lo
ss o
r res
tric
tion
of m
obili
ty, s
tren
gth,
di
rect
ed a
t a lo
ss o
r res
tric
tion
of m
obili
ty, s
tren
gth,
ba
lanc
e, o
r coo
rdin
atio
n. T
hey
requ
ire
the
skill
s of
a
bala
nce,
or c
oord
inat
ion.
The
y re
quir
e th
e sk
ills
ocl
inic
ian
and
are
desi
gned
to a
ddre
ss a
spe
cific
cl
inic
ian
and
are
desi
gned
to a
ddfu
nctio
nal n
eed
of th
e pa
tient
.
Cogn
itive
ski
lls th
erap
ypy-y-97
532
This
cod
e de
scri
bes
inte
rven
tions
TTh
is c
ode
desc
ribe
s in
terv
entio
ns
T used
to e
nhan
ce c
ogni
tive
skill
s,
used
to e
nhan
ce c
ogni
tive
skill
s,
used
toen
hanc
eco
gniti
vesk
ills,
(e.g
., at
tent
ion,
mem
ory,
pro
blem
(e
.g.,
atte
ntio
n, m
emor
(e.g
.,at
tent
ion,
mem
ory,
pso
lvin
g) w
ith d
irec
t (on
eryry,p
ne-y, p
y,p
e-onpprpp no
-le
m
lem
bbro
bro
brr nn-
one)
so
lvin
g) w
ith d
irec
t (on
solv
ing)
with
dire
ct(o
nneneee-oo
nnoonnnn-
ne)
ne)
nnoopa
tient
con
tact
by
the
clin
icia
n.
Sens
oryy
inte
grat
ivee
ther
apyy
9753
3
This
act
ivity
focu
ses
on s
enso
ry in
tegr
ativ
e Th
is a
ctiv
ity fo
cuse
s on
sen
sory
inte
grat
ive
tech
niqu
es to
enh
ance
sen
sory
pro
cess
ing
tech
niqu
es to
enh
ance
sen
sory
pro
cess
inan
d to
pro
mot
e ad
aptiv
e re
spon
ses
to
and
to p
rom
ote
adap
tive
resp
onse
s to
en
viro
nmen
tal d
eman
ds, w
ith d
irec
t (on
enene-ee-onnno
-en
viro
nmen
tal d
eman
ds, w
ith d
irec
t (o
one)
pat
ient
con
tact
by
the
clin
icia
n.
Requ
ired
Doc
umen
tatio
n eq
uire
d D
ocum
enta
tiofo
r Reh
abili
tatio
nPh
ysic
ian
Pres
crip
tion
for R
ehab
ilita
tion
Initi
al E
valu
atio
n an
d Pl
an o
f Car
e
Dai
ly P
rogr
ess
Not
es
Mon
thly
Pro
gres
s N
otes
Dis
char
ge S
umm
ary
Dur
atio
n an
d Fr
eque
ncy
of
and
Freq
Visi
tsEs
timat
ed L
engt
h of
Ses
sion
g30
Min
utes
usu
al (u
p to
2 h
ours
)
Estim
ated
Fre
quen
cy o
f Tre
atm
ent
qy
2 tim
es p
er w
eek
usua
l (ca
n be
less
)
Phys
ical
Med
icin
e an
d Re
habi
litat
ion
sica
l Med
icin
e an
d Re
habi
lita
Code
s fo
r Vis
ion
Ther
apy
Code
s fo
r Vis
ion
Ther
apy
Doc
umen
tatio
n fo
r pro
visi
on o
f vis
ion
ther
apy
shou
ld b
e D
ocum
enta
tion
for p
rovi
sion
of v
isio
n th
erap
y sh
ould
be
enta
tion
for p
rovi
sion
of v
isio
n th
erap
y sh
oul
iden
tifie
d in
the
indi
catio
ns se
ctio
n of
the
char
t. O
nce
they
are
id
entif
ied
in th
e in
dica
tions
sect
ion
of th
e ch
art.
Onc
e th
ey a
rid
entif
ied
inth
ein
dica
tions
sect
ion
ofth
ech
art.
Onc
eth
eyes
tabl
ishe
d, a
n in
divi
dual
reha
bilit
atio
n pl
an (I
RP) m
ust b
e es
tabl
ishe
d, a
n in
divi
dual
reha
bil
esta
blis
hed,
anin
divi
dual
reha
bilit
aten
tere
d in
to th
e pa
tient
's re
cord
. tio
n pl
an (I
RP) m
ust b
e tio
npl
an(I
RP)m
ustb
elit
atlit
atd.
Min
imum
doc
umen
tatio
n en
tere
d in
to th
e pa
tient
s rec
ord
ente
red
into
the
patie
ntsr
ecor
dd.
d.M
inim
um d
ocum
enta
tioM
inim
umdo
cum
enta
tioMM
requ
irem
ents
in th
e IR
P an
d se
ssio
ns e
xecu
ting
the
plan
Thir
d Pa
rty
Reim
burs
emen
tIn
sura
nce e
Pays
for F
unct
iona
l Act
iviti
es a
s In
sura
ncee
ays
for F
unct
iona
l Act
iviti
es a
Path
ey R
elat
e to
Act
iviti
es o
f Dai
ly L
ivin
ggg.
Phys
ical
Med
icin
e an
d Re
habi
litat
ion
Code
s es fo
rci
ne a
nd R
ehab
ilita
tVi
sion
The
rapy
CPT®
Def
ines
Reh
abili
tatio
n as
“A
man
ner o
f CP
T® D
efin
es R
ehab
ilita
tion
asA
man
ner o
fef
fect
ing
chan
ge th
roug
h th
e ap
plic
atio
n of
clin
ical
ef
fect
ing
chan
ge th
roug
h th
e ap
plic
atio
n of
cl
skill
s &
/or s
ervi
ces
that
att
empt
to im
prov
e sk
ills
&/o
r se
func
tion.
”
Phys
ical
Med
icin
e an
d Re
habi
litat
ion
sica
l Med
icin
e an
d Re
habi
lita
Code
s fo
r Vis
ion
Ther
apy
1.Pa
tient
's
'spe
rcep
tions
of v
isua
l fun
ctio
n an
d 1.
Patie
ntP
ser
cept
ions
of v
isua
l fun
ctio
n an
d pe
mea
sure
s of
hea
lth
rela
ted
qual
ity o
f life
(HRQ
OL)L)L
.
2.D
urin
g ex
ecut
ion
of th
e tr
eatm
ent p
lan,
the
2.D
urin
g ex
ecut
ion
of th
e tr
eatm
eD
prog
ress
shou
ld b
e do
cum
ente
d.
Phys
ical
Med
icin
e an
d Re
habi
litat
ion
sica
l Med
icin
e an
d Re
habi
lita
Code
s fo
r Vis
ion
Ther
apy
3.33333Sp
ecifi
c go
als
base
d up
on a
nsw
ers t
he p
atie
nt h
as p
rovi
ded
to
3.333Sp
ecifi
c go
als
base
d up
on a
nsw
ers t
he p
atie
nt h
as p
rovi
ded
to
Squ
estio
ns a
bout
con
cern
s; fo
r exa
mpl
e “t
o in
crea
se re
adin
g sp
eed
ques
tions
abo
ut c
once
rnqu
eestio
nsab
outc
once
rns;
foes
tto
100
wor
ds p
er m
inut
e”oo
ns; f
ons
;fo
ee”.
4.A A
desc
riptio
n of
the
met
hod
whi
ch w
ill b
e em
ploy
ed to
ach
ieve
AAA
escr
iptio
n of
the
met
hod
whi
ch w
ill b
e em
deea
ch g
oal s
houl
d be
in th
e tr
eatm
ent p
lan
mbe
em
anan.
Phys
ical
Med
icin
e an
d Re
habi
litat
ion
sica
l Med
icin
e an
d Re
habi
lita
Code
s fo
r Vis
ion
Ther
apy
55.py
Qua
ntita
tive
mea
sure
men
ts o
f cur
rent
per
form
ance
5.
Qua
ntita
tive
mea
sure
men
ts o
f cur
rent
per
form
ance
an
titat
ive
mea
sure
men
ts o
f cur
rent
per
form
ance
mea
sure
men
ts a
t eac
h se
ssio
n sh
ould
be
com
pare
d to
bas
elin
e m
easu
rem
ents
at e
ach
sess
ion
shou
ld b
e co
mpa
red
to b
asel
ine
mea
me
sure
men
tsat
each
sess
ion
shou
ld b
e co
mpa
red
to b
asel
inpe
rfor
man
ce m
easu
rem
ents
. A
trea
tmen
t pla
n m
ay c
all f
or a
chie
ving
pe
rfor
man
ce m
easu
rem
ents
. A
trea
tmen
t pla
n m
ay c
all f
or a
chie
ving
perf
orm
ance
mea
sure
men
ts.
A tr
eatm
ent p
lan
may
cal
l for
ach
iego
als
in a
sequ
entia
l man
ner.
Ther
efor
e, q
uant
itativ
e pe
rfor
man
ce
goa
sa
sequ
eta
ae
eef
oe,
qua
ttat
epe
foa
cego
als
in a
sequ
entia
l man
ner.
Ther
efor
e, q
uant
itativ
e pe
rfor
man
ce
mea
sure
men
ts o
f onl
y th
e go
als
curr
entl
y be
ing
addr
esse
d w
ould
be
easu
ee
tsm
easu
rem
ents
appr
opria
te
66.Su
ffic
ient
tim
e be
twee
n vi
sits
is n
eces
sary
for t
he p
atie
nt to
6.
Suff
icie
nt ti
me
betw
een
visi
ts is
nec
essa
ry fo
r the
pat
ient
toap
ply
visi
on tr
aini
ng to
thei
r act
iviti
es o
f dai
ly li
ving
. The
vis
ion
appl
y vi
sion
trai
ning
to th
eir a
ctiv
ities
of d
aily
livi
ng. T
he v
isio
n ap
pap
py
visi
on tr
aini
ng to
thei
r act
iviti
es o
f dai
ly li
ving
. The
vis
ion
spec
ialis
t can
ass
ess t
he p
atie
nt’s
impr
ovem
ent f
ollo
win
g pr
actic
e by
sp
ecia
list c
an a
sses
s the
pat
ient
s im
prov
emen
t fol
low
ing
prac
tice
spec
ialis
t can
ass
ess t
he p
atie
nts i
mpr
ovem
ent f
ollo
win
gpr
actic
eth
e pa
tient
with
tech
niqu
es to
max
imiz
e pe
rfor
man
ce. T
his m
ay
te
pate
tt
tec
ques
toa
epe
foa
cesm
ath
e pa
tient
with
tech
niqu
es to
max
imiz
e pe
rfor
man
ce. T
his m
ay
requ
ire p
erio
ds o
f at l
east
two
(2) t
o fiv
e (5
) day
s be
twee
n vi
sitsayay
tsts
.
Phys
ical
Med
icin
e an
d Re
habi
litat
ion
sica
l Med
icin
e an
d Re
habi
lita
Code
s fo
r Vis
ion
Ther
apy
7.py
Whe
n th
ere
is n
o pr
ogre
ss in
a q
uant
itativ
e 7.
Whe
n th
ere
is n
o pr
ogre
ss in
a q
uant
itativ
e W
hen
ther
eis
nopr
ogre
ssin
aqu
antit
atm
easu
rem
ent o
f per
form
ance
on
two
occa
sion
s m
easu
rem
ent o
f per
form
ance
on
two
occa
sion
sm
easu
rem
ent o
fper
form
ance
on
two
occa
sion
sfo
llow
ing
the
max
imal
mea
sure
of p
erfo
rman
ce,
fg
fpf
,fo
llow
ing
the
max
imal
mea
sure
of p
erfo
rman
ce,
subs
eque
nt tr
eatm
ent f
or th
at g
oal w
ill b
e co
nsid
ered
su
bsqu
ent t
reat
men
tfor
that
gal
will
be
cons
ider
edsu
bseq
uent
trea
tmen
t for
that
goa
l will
be
cons
ider
mai
nten
ance
and
will
be
cons
ider
ed b
y m
ost i
nsur
ers t
o m
aint
enan
be a
nonen
anon
-y
ce a
nd w
ill b
e co
nsid
ered
by
mos
t ins
urer
ncna
nn-
cove
red
bene
fit, p
ayab
le b
y th
e pa
tient
.
888.A
writ
ten
prog
ress
repo
rt o
f eac
h se
ssio
n is
a
8.A
writ
ten
prog
ress
repo
rt o
f eac
h se
ssio
n is
a
requ
ired
elem
ent o
f E&
M se
rvic
e, a
nd sh
ould
iden
tify
requ
ired
elem
ent o
f E&
M se
rvic
e, a
nd sh
ould
iden
tify
requ
req
ired
elem
ent o
f E&
M se
rvic
e, a
nd sh
ould
iden
tify
chan
ges
in g
oals
, the
rapy
sch
edul
es, o
r tre
atm
ent p
lan.
Phys
ical
Med
icin
e an
d Re
habi
litat
ion
sica
l Med
icin
e an
d Re
habi
lita
Code
s fo
r Vis
ion
Ther
apy
99.Ea
ch se
ssio
n us
ing
a se
rvic
e w
hose
def
initi
on in
clud
es sp
ecifi
c tim
e 9.
Each
sess
ire
quire
men
ts,
ion
usin
g a
serv
ice
who
se d
efin
ition
incl
udes
spec
ific
time
essi
s,ei
ther
ther
apeu
tic p
roce
dure
s or p
rolo
nged
serv
ices
, mus
t re
quire
men
requ
req
irem
ents
have
the
facetts ce
-tstss
,s, e--toto
-he
r the
rape
utic
pro
cedu
res o
r pro
long
ed se
rvic
es, m
ust
hert
hera
peut
icpr
oced
ures
orpr
olon
ged
serv
ices
,mus
thh
eith
eith
eeeeee ooo-fa
ce ti
me
betw
een
the
patie
nt a
nd p
hysi
cian
or l
icen
sed
have
the
fac
have
the
facceceee
tttotoooooooce
tim
e be
twee
n th
e pa
tient
and
phy
sici
an o
r lic
ense
dce
time
betw
een
the
patie
ntan
dph
ysic
ian
orlic
ense
daafafa
ther
apis
t doc
umen
ted
to th
e m
inut
e. U
nits
are
cal
cula
ted
as d
escr
ibed
in
ther
apis
t doc
umen
ted
to th
e m
inut
e. U
nits
are
cal
cula
ted
as d
escr
ibed
in
ther
apis
tdooc
uummen
ted
toth
em
inut
e.U
nits
are
calc
ulat
edas
desc
ribed
inm
enm
enmm
prol
onge
d se
rvic
es. I
n th
e ca
se o
f the
rape
utic
serv
ices
, 975
30, 9
7532
, and
pr
olon
ged
serv
ices
. In
the
case
of t
hepr
olon
ged
serv
ices
.In
the
case
ofth
erap
e97
533
a m
inim
um o
f 15
min
utes
of f
ace
ererap
ece
-ra
pra
pee-
toppe to-
ic se
rvic
es, 9
7530
, 975
32, a
nd
icse
rvic
es,9
7530
,975
32,a
ndtiti
eut
eut
eepepe ooo-fa
ce ti
me
for e
ach
unit
of se
rvic
e 97
533
a m
inim
um o
f 15
min
utes
of f
ac97
533
am
inim
umof
15m
inut
esof
facceceee
tttotoooooooce
tim
e fo
r eac
h un
it of
serv
icce
time
fore
ach
unit
ofse
rvic
aafafam
ust b
e bi
lled.
If le
ss th
an 15
min
utes
of t
hera
peut
ic p
roce
dure
tim
e is
m
ust b
e bi
lled.
If le
ss th
an 15
min
utes
of t
hera
peut
ic p
roce
dure
tim
e is
m
ustb
ebi
lled.
Ifle
ssth
an15
min
utess
offth
erap
eutic
proc
edur
etim
eis
ther
the
ttin
volv
ed n
o th
erap
eutic
serv
ice
may
be
bille
d. If
less
than
30
min
utes
of a
in
volv
ed n
o th
erap
eutic
ser
invo
lved
noth
erap
eutic
serv
ice
ther
apeu
tic se
rvic
e co
de fa
cevrvic
ece
-vi
cvi
ce e-toee to
-ay
be
bille
d. If
less
than
30
min
utes
of a
ay
bebi
lled.
Ifle
ssth
an30
min
utes
ofa
aam
am
ae eee ooo-
face
tim
e is
reco
rded
onl
y on
e un
it m
ay b
e th
erap
eutic
serv
ice
code
fac
ther
apeu
ticse
rvic
eco
defa
cceceeetttotooooooo
ce ti
me
is re
cord
ed o
nly
one
unit
may
cetim
eis
reco
rded
only
one
unit
may
beaafafa
bille
d. T
hree
uni
ts o
f the
rape
utic
serv
ice
requ
ire 4
5 to
60
min
utes
of f
aceyybe
cece-
yb
ybe ee-toe eee oooototo
-bi
lled.
Tbi
lled.
Thre
face
tim
eee
Thre
Thre
me
me.
Mod
ifier
GO
Serv
ices
del
iver
ed u
nder
an
outp
atie
nt o
ccup
atio
nal
Serv
ices
del
iver
ed u
ndth
erap
y pl
an o
f car
e
GO
ther
apy
mod
ifier
s ar
e re
quir
ed to
be
appe
nded
to
GO
ther
apy
mod
ifith
erap
y se
rvic
es
Cont
ract
ors
shal
l ens
ure
that
ther
e is
at l
east
on
Cont
rac
clai
mntra
cmm
-to
rs s
hall
ensu
re th
at th
ere
is a
t le
ctr
acmm
-leve
l ref
erri
ng p
rovi
der i
dent
ified
Mod
ifier
KX
Prov
ider
att
ests
that
the
serv
ices
are
Reas
onab
le a
nd N
eces
saryy
Doc
umen
ted
med
ical
nec
essi
ty in
the
reco
rd
Sect
ion
451(
c) re
quir
es fi
nanc
ial l
imita
tions
to
Sect
ion
451(
c) re
quir
es fi
nanc
ial l
imita
tial
l ou
tpat
ient
reha
bilit
atio
n se
rvic
es.
p$3
700
for 2
017
Ask
the
Codi
ng E
xper
tsI IIa
m lo
okin
g to
ope
n a
sepa
rate
vis
ion
I m
look
ing
to o
pen
a se
para
te v
isio
n am th
erap
y of
fice
dow
nsta
irs
but u
se a
diff
eren
t th
erap
y of
fice
dow
nsta
irs
but u
se a
diff
eren
tta
x ID
num
ber.
Som
eone
told
me
that
I ca
n ta
x ID
num
ber.
Som
eone
told
me
that
I ca
do th
at to
avo
id h
avin
g to
take
pat
ient
do
that
to a
void
hav
ing
toin
sura
nce.
Is
that
lega
l?
Just
bec
ause
you
got
pai
d
