Physical & Occupational Therapy Encounter Form With Functional Limitation Reporting (Page 2 of 2) in pdf

Physical & Occupational Therapy Encounter Form With Functional Limitation Reporting Page 2

Instructions for Completing Encounter Form for FLR

Purpose: This encounter form is meant for multiple patients being seen on a single date of service for a

single type of therapy service. Please print out multiple sheets for different types of therapy and/or

multiple dates of service.

Service Date – Fill in the date the patients were seen

Prepared By – Fill in the name of the provider

Patient Name – Fill in the name of the patient

Type – Circle the appropriate therapy type

FLR Column – Fill in the relevant G-code by referencing the bottom-left table

For example, if you selected Self Care as the

functional limitation and this was an initial or

reporting period visit, you would reference the

appropriate column values for both rows associated

with a single patient.

(If this was at discharge, you would select “89”

instead of “87” if the FLR was Self Care.)

Mod. – Fill in the CX modifier by referencing the bottom-right table

For example, if the patient’s current FLR severity

was 75% with a goal of 10%, you would complete

the “C” modifier with the appropriate letter (H-N).

Treatment – Fill out the number of units on the appropriate blank line to the left of the CPT code.

Physical & Occupational Therapy Encounter Form With Functional Limitation Reporting Page 2