Important Steps, Inc.-Session Note Instructions--NYCDOE-CPSE: 08-01-11
1. ASessionNotemustbecompletedforeachsession.
2. Completeallareasasfollows:
•Child’sName,DOB,andNYCID#:Makesurethisinformationisconsistentwiththeinformationin the NYCDOE system(donotusenicknames).
•Provider’s Name:Theindividualprovidingtherelated services.
•Discipline:Theappropriatedisciplineoftheinterventionist(e.g.,PT,ST, OT).
- Frequency and Duration: As per IEP and Assignment from Important Steps, Inc.
•LocationofService:Wherethesessiontookplace,(e.g.,home,school, or office)
•DateandTime:Thedateandtime duringwhichthesessiontookplace. Please circle “am/pm”.
•ServiceType:TheservicetypeaslistedontheIEP,(i.e. SpeechTherapy(ST))
•DateNoteWritten:Thedatethesessionnotewascompleted(shouldbethesameasthedateofservice).
- Make-up for: Indicate the date of missed session within the school year conducting make up for (i.e. Fall)
- SessionCancelled/Absent:a) Checkthisoffwhenthesessioniscancelled/notheld/child is absent; b) Indicatethereasonthereasonfor cancelation. (Note: no need for the following: CPT codes, activities, etc. Therapist signature is required. Caregiver signature is optional.)
- ICD-9 Code: The relevant ICD-9 code as indicated on the child’s evaluation for your discipline. This is pre-written for your convenience at the time of your assignment. Please contact main office for more info.
- CPT Codes: The relevant CPT (Current ProceduralTerminology) codes as indicated by the clinician’s professional association. IMPORTANT: CPT Codes MUST match its description & ICD-9 codes.
See list of suggested codes below as per each discipline scope of practice. Check the time interval consistent w/each CPT code and list as many as you have conducted during the mandated session interval.
If conducted same CPT code several times indicate # of same CPT codes. Example: if mandate is Basic (A) –(i.e. 30 min & up) and same CPT codes was conducted 2 times (15 min each) please put: 1) CPT# 97530 X 2
•IEP Outcome(s)Addressed:Thetargetoutcome(s)fromtheIEP,whichwas/werethefocusofthatsession’s intervention. These outcomes are taken directly from child’s current IEP (Note: this is the only section that can be pre-typed).
•ActivityDuringSession and Child’s Response:Briefdescriptionoftheclinician’s activities (at least 3)and child’s/family response to each activity duringthesession.These activities/descriptions MUST match CPT codes above.
•Parent/Caregiver Training/Carryover:
1. Indicatetheoneormoreactivitiesagreedupon by theinterventionistandtheparent/caregiverthatwill be usedduringdaily routinesinthe comingweek(s). Indicate: WHERE/WHEN/WHAT “homework” activities caregivers can do w/child during child’s daily routine. Forexample,iftheobjectiveisforthechildtoroll,theinterventionistcould write:“At bathorchangetime,theparentwillusea towelordiapertogentlylift onesideofthechild toassistinbeginningtoroll.”Parentwillrecordprogressinparent/therapistnotebook/calendar,etc.
2. Activitiesforparentsareexpectedtospana minimumofoneweek.However,a therapistmayseethe child/familymorethanonceperweek;oractivitiesmayberecommendedfor multipleweeks.
IndicateinthissectionifyouarecontinuingtoworkonanactivityfromtheaboveSessionNote.
3. Parent/CaregiverSignatureandRelationshiptoChild:Theparent/caregiverwhowaspresentduringthesession signscontemporaneously w/related service providerandindicateshis/herrelationshiptothechild (i.e. mother, babysitter, day care teacher, etc).
4. Provider’sSignature, Credentials License# :Theclinician’ssignaturefull credentials
(Ex: MA.CCC-SLP, #00921) . For CFs Supervisor’s signature &full credentials are required for each note.
5. Indirect Time: Indicate time (from-to) spend after the mandated direct service has concluded (i.e. paperwork, etc)
6. KeeptheSessionnotesw/original signatureinchild’sfileattheprovidersite. TheSessionnotesmaybereviewedorrequestedbytheparents; therapist’sQA supervisor;NYC DOE’svariousdepartmentssuchastheLocal District andProgramMonitoringand QualityImprovement; NYSDOEand OMIG.
7. Monthly Multidisciplinary Meeting: Please complete one at least per month.
8. Indicate NPI# on the bottom of each page as required for billing submission to NYCDOE.
Instructions for Completing CPT/ICD-9 Codes on Session Notes-2011-12_ above
Use the chart below to indicate the child’s type of delay (ICD-9 codes) (from evaluations) and the type of therapy you have provided (CPT codes).
Related Service: Occupational Therapy (OT)
CPT Code / Description / ICD-9 Code / Unit Definition / Restrictions97110 / Therapeutic Exercises to develop strength and endurance, range of motion and flexibility / 315.4 Developmental Coordination Disorder / 15 minutes / Session limit 4 units
97112 / Neuromuscular Reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing / 315.4 Developmental Coordination Disorder / 15 minutes / Session limit 4 units
97124 / Massage Therapy including effleurage, pertrissage, tapotement (stroking, compression, percussion) / 315.4 Developmental Coordination Disorder / 15 min / Session limit 4 units
97150 / Group Therapeutic (2 or more individuals) / 315.4 Developmental Coordination Disorder / Encounter / I unit per recipient
97530 / Kinetic therapy-Therapeutic activities, direct (1X1) patient contact by the provider (use of dynamic activities to improve functional performance) / 315.4 Developmental Coordination Disorder / 15 min / Session limit 4 units
97533 / Sensory Integration to enhance sensory processing and promote adaptive responses to environmental demands direct (1X1) patient contact by the provider. / 315.4 Developmental Coordination Disorder / 15 min / Session limit 4 units
97755 / Assistive Technology assessment / 315.4 Developmental Coordination Disorder / 15 minutes / With written report
In the event you require more codes please refer to:
Related Service: Speech Therapy- ST
CPT Code / Description / ICD-9 Code / Unit Definition / Restrictions92507 / Treatment of speech, language, voice, communication, &/or auditory processing disorder: individual / 315.3 – Developmental Speech-language disorder;
315.32-Mixed receptive-expressive language disorder
315.31-Expressive language disorder
315.39 Other
Developmental articulation disorder, Phonological disorder
Excludes: Lisping and lalling (307.9) / Encounter / 4 procedures per day
92508 / Speech Therapy Group, 2 or more individuals / 315.3 – Developmental Speech-language disorder;
315.32-Mixed receptive-expressive language disorder
315.31-Expressive language disorder
315.39 Other
Developmental articulation disorder, Phonological disorder
Excludes: Lisping and lalling (307.9) / Group Encounter
In the event you require more codes please refer to:
Related Service: Physical Therapy- PT
CPT Code / Description / ICD-9 Code / Unit Definition / Restrictions97110 / Therapeutic Exercises to develop strength and endurance, range of motion and flexibility / 315.4 Developmental Coordination Disorder / 15 minutes / Session limit 4 units
97112 / Neuromuscular Reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing / 315.4 Developmental Coordination Disorder / 15 minutes / Session limit 4 units
97116 / Gait training including stair climbing / 315.4 Developmental Coordination Disorder / Encounter / Session limit 4 units
97124 / Massage Therapy including effleurage, pertrissage, tapotement (stroking, compression, percussion) / 315.4 Developmental Coordination Disorder / 15 min / Session limit 4 units
97530 / Kinetic therapy-Therapeutic activities, direct (1X1) patient contact by the provider (use of dynamic activities to improve functional performance) / 315.4 Developmental Coordination Disorder / 15 min / Session limit 4 units
97755 / Assistive Technology assessment / 315.4 Developmental Coordination Disorder / 15 minutes / With written report
In the event you require more codes please refer to: