POSt-REGULAR SESSION BILLING SUBMISSION FOR INSURANCE CLIENTS

Instructions for Therapists:

ESTIMATED TIME TO COMPLETE: 3 minutes

Please complete each item below the same day as an Initial Session. Reference the MMLHI and your session note in the development of your diagnosis. Contact the Clinical Director if you have questions!

Provider Name(Required)

Clinician Email(Required)

Please use your Change, Inc. Gmail Address! (Example: emily.changeinc@gmail.com)

Client Name(Required)

First Last

Today's Date/Session Date(Required)

Should be same date as session for which information is being submitted.

Exact Start Time(Required)

Exact End Time(Required)

ICD-10 Diagnosis(Required)

List is Alphabetical

Do you need to add additional data or specifiers?(Required)

Additional Data/Specifiers(Required)

For example, for a diagnosis of F34.1 – Persistent Depressive Disorder, specifiers could be: Moderate, with melancholic features, with moderate-severe anxious distress, with intermittent major depressive episodes, with current episode

Does the above diagnosis constitute a change from your original/other diagnoses you've given this client in the past?(Required)

Initial Session/Diagnosis Date(Required)

CPT Code(Required)

Do you need to submit an additional CPT Code?(Required)

Additional CPT Code(Required)

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