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PREVIOUS

BALANCE

DESCRIPTION

CHARGES

PAYMENTS

ADJUSTMENTS

NAME

BALANCE

CREDITS

STATEMENT OF ATTENDING MASSAGE THERAPIST

A. NEUROMUSCULAR PROCEDURES:
(Include report)
1. Initial Visit with Evaluation, 30 days…
2. Muscle Testing Limb or Trunk
(Excluding Hand)………………………
3. Muscle Testing, Hand………………
4. Range of Motion Measurements
Each Limb (Excl. Hand) …………….
5. Range of Motion Measurements,
Hand …………………………………
B. PHYSICAL MODALITIES:
1. Hot or Cold Pack, 1 or more areas
_____________________________
2. Traction, Mechanical …………………..
3. Electrical stimulation (unattended) …..
4. Vasopneumatic devices ……………….
5. Paraffin Bath ……………………………
6. Microwave ………………………………
7. Whirlpool ………………………………..
8. Diathermy ……………………………….
9. Infrared ………………………………….
10. Ultraviolet
11. Electrical Stimulation (manual) 15 min.
12. Iontophoresis (each 15 min.)
13. Contrast Baths (each 15 min.)
14. Ultrasound (15 min.)
15. Hubbard Tank
16. Unlisted Modality
C. PHYSICAL PROCEDURES
17. Therapeutic Exercises or Procedures
1 or more areas
18. Neuromuscular Re-education
19. Gait Training

CPT

$ FEE

90060 _______
95831 _______
95832 _______
95851 _______
95852 _______
97010
97012
97014
97016
97018
97020
97022
97024
97026
97028
97032
97033
97034
97035
97036

_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

C. PHYSICAL PROCEDURES (cont.)
20. Electrical stimulation (manual)
21. Iontophoresis
22. Traction, manual
23. Massage
24. Contrast Baths
25. Ultrasound
26. Unlisted Procedure ______________
______________________________
27. Myofascial Release / Soft Tissue
Mobilization, 1 or more regions …
28. Kinetic Activities
29. Training in activities of daily living
30. Work Hardening
D. SPECIAL SERVICES:
1. After Hours, Up to 10 p.m. ………..
2. Sunday or Holiday ____/____/____
3. Other Location: _________________
______________________________
4. Supplies & Materials _____________
______________________________
5. Educational Supplies _____________
______________________________
6. Special Reports ……………………….
7. Hypothermia; regional ……………….
8. Hypothermia; Total Body …………….
9. Other Services __________________

______________________________
E. EVALUATION & MANAGEMENT
1. Office Service, New …………………..
97110 _______ 2. Office Service, Estab. ………………..
97112 _______ 3. ______________________________
97116 _______

DATE OF SERVICE:__________________________

CPT
97118
97120
97122
97124
97126
97128

$ FEE
_______
_______
_______
_______
_______
_______

PRESCRIBED BY REFERRING PHYSICIAN:
_______________________________________
Previous Diagnosis: _____________________
_______________________________________

97139 _______ _______________________________________
97250
97530
97540
97545

_______
_______
_______
_______
_______
99050 _______
99054 _______

Additional Information: __________________
_______________________________________
_______________________________________
_______________________________________

99056 _______ TOTAL FEE
FOR TODAYS SERVICES: $____________
99070 _______
99071 _______
99080 _______ X______________________________________
Signature of ATTENDING MASSAGE THERAPIST
99185
99186 _______ _______________________________________
_______

97039 _______

_______
99201
99211

John Doe, R.M.T.
123 Any Street
Anytown, USA 12345
(000) 111-2222
ID#:

NEXT APPOINTMENT: ___________________________________________ ______/______ AT _____:_____ AM/PM

PREVIOUS
BALANCE

DESCRIPTION

CHARGES

PAYMENTS

ADJUSTMENTS

NAME

BALANCE

CREDITS

STATEMENT OF ATTENDING MASSAGE THERAPIST

A. NEUROMUSCULAR PROCEDURES:
(Include report)
1. Initial Visit with Evaluation, 30 days…
2. Muscle Testing Limb or Trunk
(Excluding Hand)………………………
3. Muscle Testing, Hand………………
4. Range of Motion Measurements
Each Limb (Excl. Hand) …………….
5. Range of Motion Measurements,
Hand …………………………………
B. PHYSICAL MODALITIES:
1. Hot or Cold Pack, 1 or more areas
_____________________________
2. Traction, Mechanical …………………..
3. Electrical stimulation (unattended) …..
4. Vasopneumatic devices ……………….
5. Paraffin Bath ……………………………
6. Microwave ………………………………
7. Whirlpool ………………………………..
8. Diathermy ……………………………….
9. Infrared ………………………………….
10. Ultraviolet
11. Electrical Stimulation (manual) 15 min.
12. Iontophoresis (each 15 min.)
13. Contrast Baths (each 15 min.)
14. Ultrasound (15 min.)
15. Hubbard Tank

CPT

$ FEE

90060 _______
95831 _______
95832 _______
95851 _______
95852 _______
97010
97012
97014
97016
97018
97020
97022
97024
97026
97028
97032
97033
97034
97035
97036

_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

16. Unlisted Modality
C. PHYSICAL PROCEDURES
17. Therapeutic Exercises or Procedures
1 or more areas
18. Neuromuscular Re-education

97039 _______

19. Gait Training

97116 _______

C. PHYSICAL PROCEDURES (cont.)
20. Electrical stimulation (manual)
21. Iontophoresis
22. Traction, manual
23. Massage
24. Contrast Baths
25. Ultrasound
26. Unlisted Procedure ______________
______________________________
27. Myofascial Release / Soft Tissue
Mobilization, 1 or more regions …
28. Kinetic Activities
29. Training in activities of daily living
30. Work Hardening
D. SPECIAL SERVICES:
1. After Hours, Up to 10 p.m. ………..
2. Sunday or Holiday ____/____/____
3. Other Location: _________________
______________________________
4. Supplies & Materials _____________
______________________________
5. Educational Supplies _____________
______________________________
6. Special Reports ……………………….
7. Hypothermia; regional ……………….
8. Hypothermia; Total Body …………….
9. Other Services __________________

______________________________
E. EVALUATION & MANAGEMENT
1. Office Service, New …………………..
97110 _______ 2. Office Service, Estab. ………………..
97112 _______ 3. ______________________________

DATE OF SERVICE:__________________________

CPT
97118
97120
97122
97124
97126
97128

$ FEE
_______
_______
_______
_______
_______
_______

PRESCRIBED BY REFERRING PHYSICIAN:
_______________________________________
Previous Diagnosis: _____________________
_______________________________________

97139 _______ _______________________________________
97250
97530
97540
97545

_______
_______
_______
_______
_______
99050 _______
99054 _______

Additional Information: __________________
_______________________________________
_______________________________________
_______________________________________

99056 _______ TOTAL FEE
FOR TODAYS SERVICES: $_____________
99070 _______
99071 _______
99080 _______ X______________________________________
Signature of ATTENDING MASSAGE THERAPIST
99185
99186 _______ _______________________________________
_______
_______
99201
99211

John Doe, R.M.T.
123 Any Street
Anytown, USA 12345
(000) 111-2222
ID#:

NEXT APPOINTMENT: ___________________________________________ ______/______ AT _____:_____ AM/PM