Mental Health Counseling Billing "*" indicates required fields HiddenYour Phone*Do not edit. Pre-filled for your convenience.HiddenEmail*Do not edit. Pre-filled for your convenience. Clinic Name* Practitioner Name* First Last Patient Name* First Last Diagnosis Given for This Patient Date of Care* MM slash DD slash YYYY Services Provided by Licensed Professional Counselor 90791 - Psychiatric Diagnostic Evaluation 90832 - Individual Psychotherapy 16-37 minutes 90834 - Individual Psychotherapy 38-52 minutes 90837 - Individual Psychotherapy 53 minutes plus 90846 - Family Therapy without patient 26 minutes plus 90847 - Family Therapy with patient 26 minutes plus 90853 - Group psychotherapy (interpersonal processing) 90785 - Interactive Complexity +99354 - Additional time for Diagnostic Evaluation Codes for Minnesota Medicaid only (and Minnesota Medicaid Managed Care Plans) 90899 U8 Clinical Care Consultation Face to Face 5 to 10 min 90899 U8 U4 Clinical Care Consultation Non Face to Face 5 to 10 min 90899 U9 Clinical Care Consultation Face to Face 11 to 20 min 90899 U9 U4 Clinical Care Consultation Non Face to Face 11 to 20 min 90899 UB Clinical Care Consultation Face to Face 21 to 30 min 90899 UB U4 Clinical Care Consultation Non Face to Face 21 to 30 min 90899 UC Clinical Care Consultation Face to Face 31 min plus 90899 UC U4 Clinical Care Consultation Face to Face 31 min plus H0031 UA Administrating and reporting standardized measures H0032 UA Treatment review and development Do you have another date of service for this patient? Yes No 2nd Date of Care* MM slash DD slash YYYY Services Provided by Licensed Professional Counselor 90791 - Psychiatric Diagnostic Evaluation 90832 - Individual Psychotherapy 16-37 minutes 90834 - Individual Psychotherapy 38-52 minutes 90837 - Individual Psychotherapy 53 minutes plus 90846 - Family Therapy without patient 26 minutes plus 90847 - Family Therapy with patient 26 minutes plus 90853 - Group psychotherapy (interpersonal processing) 90785 - Interactive Complexity +99354 - Additional time for Diagnostic Evaluation Codes for Minnesota Medicaid only (and Minnesota Medicaid Managed Care Plans) 90899 U8 Clinical Care Consultation Face to Face 5 to 10 min 90899 U8 U4 Clinical Care Consultation Non Face to Face 5 to 10 min 90899 U9 Clinical Care Consultation Face to Face 11 to 20 min 90899 U9 U4 Clinical Care Consultation Non Face to Face 11 to 20 min 90899 UB Clinical Care Consultation Face to Face 21 to 30 min 90899 UB U4 Clinical Care Consultation Non Face to Face 21 to 30 min 90899 UC Clinical Care Consultation Face to Face 31 min plus 90899 UC U4 Clinical Care Consultation Face to Face 31 min plus H0031 UA Administrating and reporting standardized measures H0032 UA Treatment review and development Do you have another date of service for this patient? Yes No 3rd Date of Care* MM slash DD slash YYYY Services Provided by Licensed Professional Counselor 90791 - Psychiatric Diagnostic Evaluation 90832 - Individual Psychotherapy 16-37 minutes 90834 - Individual Psychotherapy 38-52 minutes 90837 - Individual Psychotherapy 53 minutes plus 90846 - Family Therapy without patient 26 minutes plus 90847 - Family Therapy with patient 26 minutes plus 90853 - Group psychotherapy (interpersonal processing) 90785 - Interactive Complexity +99354 - Additional time for Diagnostic Evaluation Codes for Minnesota Medicaid only (and Minnesota Medicaid Managed Care Plans) 90899 U8 Clinical Care Consultation Face to Face 5 to 10 min 90899 U8 U4 Clinical Care Consultation Non Face to Face 5 to 10 min 90899 U9 Clinical Care Consultation Face to Face 11 to 20 min 90899 U9 U4 Clinical Care Consultation Non Face to Face 11 to 20 min 90899 UB Clinical Care Consultation Face to Face 21 to 30 min 90899 UB U4 Clinical Care Consultation Non Face to Face 21 to 30 min 90899 UC Clinical Care Consultation Face to Face 31 min plus 90899 UC U4 Clinical Care Consultation Face to Face 31 min plus H0031 UA Administrating and reporting standardized measures H0032 UA Treatment review and development Δ