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 |
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|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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