Physical & Occupational Therapy Encounter Form With Functional Limitation Reporting

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Physical & Occupational Therapy Encounter Form with Functional Limitation Reporting
Therapist:
PT OT Massage
Service Date:
/
/
Type:
Patient Name
FLR
Mod
Treatment(s)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
Curr/Disc
G89 ____ C __
__ 97001 __ 97002 __ 97003 __ 97035 __ 97110 __ 97112 __ 97535
Goal
G89 ____ C __
__ 97140 __ 97150 __ 97140 __ 97750 __ 97530 __ G0283 __ 97140 (M)
FLR Category
Curr / Disc
Goal
Modifier
Impairment Limitation Restriction
Mobility
78 / 80
79
H
0% impaired, limited, or restricted
Body Pos
81 / 83
82
I
At least 1% but less than 20% impaired, limited, or restricted
Carry
84 / 86
85
J
At least 20% but less than 40% impaired, limited, or restricted
Self Care
87 / 89
88
K
At least 40% but less than 60% impaired, limited, or restricted
Other PT/OT
90 / 92
91
L
At least 60% but less than 80% impaired, limited, or restricted
Sub PT/OT
93 / 95
94
At least 80% but less than 100% impaired, limited, or restricted
M
N
100% impaired, limited, or restricted
Provided courtesy of Physicians Advantage Services, Inc. - Commercial Use Allowed. May not be rebranded or modified without explicit consent.

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