Date

MM

DD

YYYY

I/P

Evals

Do not count evals as treatments

Treatments

# of CPT Codes Billed (excluding eval)

For example 2 units of therapeutic exercise, 1 unit of gait training, 1 unit of electrical stimulation = 4 CPT codes billed

O/P

Evals

Do not count evals as patient visits

Patient Visits

# of CPT Codes Billed (excluding eval)

For example 2 units of therapeutic exercise, 1 unit of gait training, 1 unit of electrical stimulation = 4 CPT codes billed