Billing Log

Providers Name:*

Today's Date:*

Original Billing Log - First SubmissionCorrected Billing Log - Resubmission (please only indicate corrected information)

Billing Log:*

Rows	Client's Full Name	Date of Service	CPT Code	Place of Service	Diagnosis Code(s)	Payment Amount	Cash Check# CC
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Attach Files if needed:

Example: Office notes for auto or work comp claims

Signature*

CPT Code Referance:

90785 Interactive Complexity
90791 Initial Evaluation
90832 30 min Individual session
90834 45 min Individual session
90837 60 min Individual session
90839 60 min Crisis Session
90840 +60 min Crisis Session (used with 90839)
90846 Family Session without the client
90847 Family Session
90853 Group Session
96130 Psych Testing, evaluation by Psychologist, first 60 min
96131 Psych Testing each additional 60 min (used with 96130)
Late Cancel (Charge)
No Show (Charge)

** Important Note:

Please make sure you review your Billing Log before submission. Correct names, dates and billing codes are important for the billing process. Once billing is submitted, errors can not be corrected until the claim is fully processed by the insurance.