Time Log & Billing Attestation (Neuropsychological Services)

Patient: [Patient full name], DOB: [YYYY-MM-DD], MRN: [Medical record number]

Referring Provider: [Name, credentials]

Reason for Referral: [Brief statement of referral question]

Service Episode: [Start date - YYYY-MM-DD] through [End date - YYYY-MM-DD]

Billing Date of Service: [YYYY-MM-DD]

Place of Service: [Location type], [Facility name if applicable]

Time Log

(Add one row per discrete work segment. For multi-day episodes, include all dates with their respective segments. If a session is interrupted, log each continuous segment separately or note interruption minutes excluded. Do not infer or estimate time values; leave fields blank if not provided. Each row must have exactly one Code Bucket Assignment. Explicitly log non-billable administrative tasks with Code Bucket = "Non-Billable." If any row lacks Start Time, Stop Time, or Duration, flag it as INCOMPLETE - NOT BILLABLE until corrected.)

Date (YYYY-MM-DD)	Start Time	Stop Time	Duration (min)	Service Component	Person Performing	Role	Code Bucket	Brief Work Note	Supervising Clinician	Supervision Level	Supervisor Available	Status
[YYYY-MM-DD]	[HH:MM]	[HH:MM]	[Minutes]	[clinical interview / test administration / scoring / record review / collateral review / interpretation and integration / report writing / interactive feedback / non-billable administrative]	[Name, credentials]	[QHP / Technician]	[Neuropsych Evaluation / Test Administration-QHP / Test Administration-Technician / Non-Billable]	[Brief description of work performed]	(Technician rows only) [Name, credentials]	(Technician rows only) [general / direct]	(Technician rows only) [Yes / No]	[OK / INCOMPLETE - NOT BILLABLE]
[Additional rows as needed]

Unit Calculation Summary

(Summarize minutes and derived units across the entire episode. Display the exact minutes-to-units conversion rule used for each code bucket. Exclude Non-Billable time from units.)

Code Bucket	Total Minutes	Units Derived	Time-to-Unit Rule Applied
Neuropsych Evaluation	[Total minutes]	[Units]	[First unit threshold: __ min; Additional unit increment: __ min; Rounding rule: __]
Test Administration-QHP	[Total minutes]	[Units]	[First unit threshold: __ min; Additional unit increment: __ min; Rounding rule: __]
Test Administration-Technician	[Total minutes]	[Units]	[First unit threshold: __ min; Additional unit increment: __ min; Rounding rule: __]
Non-Billable	[Total minutes]	0	N/A
Episode Totals (Billable)	[Sum of billable minutes]	[Total billable units]	[Rule set or policy reference]

Tests Administered

(List each test, or reference the neuropsychological report if the complete list appears there.)

• [Test name] — [paper / computerized / automated], Administrator: [QHP / Technician / automated], Date(s): [YYYY-MM-DD]
• [Additional tests as needed]
• (Alternative) See neuropsychological report [Document ID] for complete test list.

Documentation References

• Report: [Report type], Signed: [YYYY-MM-DD], [Document location or ID]
• Feedback Session: [YYYY-MM-DD], [Participants], [in-person / telehealth / phone] (Include only if performed)
• Results Communication: Sent [YYYY-MM-DD] via [EHR message / fax / secure email / mail]

Attestations

Rendering Clinician Attestation: I attest that this time log accurately reflects the time I personally spent performing the services described; time has been assigned to a single appropriate code bucket per segment without duplication; non-billable administrative time has been recorded as such; and supporting documentation is maintained in the medical record.

[Signature], [Credentials], [Date]

(Include only if any time log row has Role = Technician)

Technician Attestation: I attest that I personally performed the test administration and scoring activities listed above and that the logged time reflects active professional work related to these services and not clerical tasks.

[Signature], [Credentials], [Date]

(Include only if any time log row has Role = Technician)

Supervisor Attestation: I attest that I served as the supervising clinician for the technician services rendered in this episode, that supervision met applicable payer requirements as documented above, and that I was available as required during the service.

[Signature], [Credentials], [Date]