WA Psychology, Counseling, and Nursing Log



|Student name: |      |Student #: |      |MA # / Client ID #: |      |DOB: |      |

|School district: |      |Service month/year: |      |

|Provider name (print): |      |NPI #: |      | Psychology Counseling Nursing |

|Supervising Nurse (print) |      |NPI #: |      | | |

|Service date |Time in |Time out |Total time |CPT code |Progress |Treatment notes |

| | | |in minutes | |code | |

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|Provider and Supervisor (if applicable) signature required below. |

|Provider’s signature: | |Title: |      |Date: |      |

|Supervisor’s signature: | |Title: |      |Date: |      |

|CPT codes |Progress codes |3. Is progressing toward objective(s) |

|Please see reverse |1. Same |4. Mastery of objective(s) |

| |2. Requires assistance when working toward objective(s) | |

|CPT codes |

|96101 – Psychology testing by psych/phys, each 60 minutes |

| |

|S9445 – Counseling, individual |

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|S9446 – Counseling, group |

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|T1001 – Nursing assessment/evaluation |

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|T1002 – RN services, each 15 minutes |

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|T1003 – LPN/LVN services, each 15 minutes |

|Minutes |Units |

|0 min - 7 mins |0 units |

|8 mins - 22 mins |1 unit |

|23 mins - 37 mins |2 units |

|38 mins - 52 mins |3 units |

|53 mins - 67 mins |4 units |

|68 mins - 82 mins |5 units |

Nursing service minutes for the day are totaled and the minutes table for timed codes from the Medicaid Provider Guide is used to determine billable units.

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