Asha Superbill Form PDF Details

The Asha Superbill Form is used to bill Medicaid and other insurance providers for services provided to patients. The form is used to record the date of service, the service provided, and the amount charged. The form also includes fields for the provider's information and the patient's insurance information. The Asha Superbill Form can be used to bill for a single service or for multiple services provided on a single date.

QuestionAnswer
Form NameAsha Superbill Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namessuperbill asha, patient pathology model, model pathology, speech procedure model

Form Preview Example

MODEL SUPERBILL

FOR SPEECH-LANGUAGE

PATHOLOGY

The following is a model of a superbill which could be used by a speech-language pathology practice when billing private health plans. This sample is not meant to dictate which services should or should not be listed on the bill. Most billable codes are from the American Medical Association (AMA) Current Procedural Terminology (CPT)© 2013. Prosthetic and durable medical equipment codes, such as speech generating device codes, are published by the Centers for Medicare and Medicaid Services (CMS) as the Healthcare Common Procedure Code System (HCPCS).

The superbill is a standard form which health plans use to process claims. For the professional rendering services, it provides a time efficient means to document services, fees, codes, and other information required by insurance companies, (i.e., certification and licensure). The patient uses this form to file for health plan payment.

NOTE: This is only a model, therefore some procedures, codes, or other pertinent information may not be found on the following model. A complete list of speech- language pathology related codes is available in the 2014 Coding & Billing for

Audiology and Speech-Language Pathology. You can purchase this product through ASHA’s Online Store or by calling ASHA’s Product Sales at 1-888-498-

6699.

More information on coding for speech-language pathology services can also be found on ASHA’s billing and reimbursement website.

P a g e | 1

MODEL SPEECH-LANGUAGE PATHOLOGY SUPERBILL

PATIENT:

INSURED:

REFERRING PHYSICIAN:

ADDRESS:

FILE:

INSURANCE PLAN:

DATE:

INSURANCE PLAN #:

DATE INITIAL SYMPTOM:

DATE FIRST CONSULTATION:

PLACE OF SERVICE: HOME OFFICE OTHER:

DIAGNOSIS:

 

PRIMARY (Speech-Language Pathology):

ICD-9 CODE:

 

 

SECONDARY (Medical):

ICD-9 CODE:

 

 

 

 

 

 

 

 

 

SERVICES:

PROCEDURE

CPT

CHARGE

 

PROCEDURE

CPT

CHARGE

Swallowing Function

 

 

 

Behavioral and qualitative analysis of voice

92524

 

 

Treatment of swallowing dysfunction and/or

 

 

 

 

and resonance

 

 

92526

 

 

Evaluation of auditory rehabilitation status,

 

 

 

 

oral function for feeding

 

 

 

first hour

92626

 

 

Evaluation of oral & pharyngeal swallowing

 

 

 

 

 

92610

 

 

each additional 15 minutes

92627

 

 

 

function

 

 

 

 

Motion fluoroscopic evaluation of swallowing

 

 

 

Auditory rehabilitation; pre-lingual hearing

 

 

 

 

 

 

 

 

 

function by cine or video recording

92611

 

 

 

loss

92630

 

 

Flexible fiberoptic endoscopic evaluation of

 

 

 

Auditory rehabilitation; post-lingual hearing

92633

 

 

 

 

 

 

 

swallowing by cine or video recording

92612

 

 

 

loss

 

 

interpretation and report only

92613

 

 

Assessment of aphasia with interpretation

 

 

 

 

 

 

 

Flexible fiberoptic endoscopic evaluation,

 

 

 

 

and report, per hour

96105

 

 

 

 

 

 

 

 

 

 

Developmental screening, with interpretation

 

 

 

 

laryngeal sensory testing by cine or video

 

 

 

 

and report, per standardized instrument form

96110

 

 

 

recording

92614

 

 

 

 

 

 

 

Developmental testing, (includes assessment

 

 

 

 

 

 

 

 

 

 

interpretation and report only

92615

 

 

 

of motor, language, social, adaptive and/or

 

 

 

Flexible fiberoptic endoscopic evaluation of

 

 

 

 

cognitive functioning by standardized

 

 

 

 

 

 

 

developmental instruments) with

 

 

 

 

swallowing and laryngeal sensory testing

92616

 

 

 

 

 

 

interpretation and report only

92617

 

 

 

interpretation and report

96111

 

 

 

 

Standardized cognitive performance testing

 

 

 

Speech and Language

 

 

 

 

 

 

 

 

 

 

(eg, Ross Information Processing

 

 

 

Treatment of speech, language, voice,

 

 

 

 

Assessment) per hour of a qualified health

 

 

 

 

communication, and/or auditory processing

 

 

 

 

care professional’s time, both face-to-face

 

 

 

 

disorder, individual

92507

 

 

 

time administering tests to the patient and

 

 

 

group, two or more individuals

92508

 

 

 

time interpreting these test results and

 

 

 

 

 

 

preparing the report

96125

 

 

Development of cognitive skills to improve

 

 

 

 

 

 

 

 

 

Laryngoscopy; flexible fiberoptic; diagnostic

31575

 

 

 

attention, memory, problem solving, direct

 

 

 

 

 

 

one-on-one patient contact by the provider;

 

 

 

Laryngoscopy; flexible or rigid fiberoptic, with

31579

 

 

 

each 15 minutes

97532

 

 

 

stroboscopy

 

 

Sensory integrative techniques to enhance

 

 

 

Augmentative and Alternative Communication

 

 

sensory processing and promote adaptive

 

 

 

Evaluation for use/fitting of voice prosthetic

 

 

 

 

responses to environmental demands; each

 

 

 

92597

 

 

 

 

 

 

 

device to supplement oral speech

 

 

 

15 minutes

97533

 

 

 

 

 

 

 

 

Evaluation for prescription of non-speech

 

 

 

Nasopharyngoscopy w/ endoscope

 

 

 

 

 

 

92511

 

 

 

generating augmentative and alternative

 

 

 

Laryngeal function studies

92520

 

 

 

communication device, face-to-face with the

 

 

 

 

 

 

patient;

 

 

 

Evaluation of speech fluency (eg, stuttering,

 

 

 

 

 

 

 

 

 

 

 

first hour

92605

 

 

 

cluttering)

92521

 

 

each additional 30 minutes

92618

 

 

 

 

 

 

 

Evaluation of speech sound production (eg,

 

 

 

 

 

 

articulation, phonological process, apraxia,

 

 

 

Therapeutic service(s) for the use of non-

 

 

 

 

dysarthria);

92522

 

 

 

speech generating augmentative and

 

 

 

Evaluation of speech sound production (eg,

 

 

 

 

alternative communication device, including

 

 

 

 

 

 

 

programming and modification

92606

 

 

 

articulation, phonological process, apraxia,

 

 

 

 

 

 

 

dysarthria) with evaluation of language

 

 

 

 

 

 

 

 

 

comprehension and expression (eg, receptive

 

 

 

 

 

 

 

 

 

and expressive language)

92523

 

 

 

 

 

 

 

 

M o d e l S p e e c h - L a n g u a g e P a t h o l o g y S u p e r b i l l

 

 

P a g e | 2

 

PROCEDURE

CPT

CHARGE

PROCEDURE

CPT

CHARGE

 

Evaluation for prescription for speech-

 

 

 

Online assessment & management service

 

 

 

 

 

generating augmentative and alternative

 

 

 

provided by a qualified nonphysician health

 

 

 

 

 

communication device; face-to-face with the

 

 

 

care professional to an established patient,

 

 

 

 

 

patient;

 

 

 

guardian, or health care provider not

 

 

 

 

 

first hour

92607

 

 

originating from a related assessment &

 

 

 

 

each additional 30 minutes

92608

 

 

management service provided within the

 

 

 

 

 

 

previous 7 days, using the Internet or similar

 

 

 

 

Therapeutic services for the use of speech-

 

 

 

98969

 

 

 

 

 

 

electronic communications network.

 

 

 

 

generating device, including programming

 

 

 

Medical team conference with

 

 

 

 

 

 

 

 

 

 

 

 

 

and modification

92609

 

 

 

 

 

 

Repair/Modification of AAC device (excluding

 

 

 

interdisciplinary team of health care

 

 

 

 

 

 

 

 

 

 

 

V5336

 

 

professionals, face-to-face with patient and/or

 

 

 

 

 

adaptive hearing aid)

 

 

family, 30 minutes or more; participation by

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Procedures

 

 

 

nonphysician qualified health care

 

 

 

 

 

 

 

professional

99366

 

 

 

Otorhinolaryngological service or procedure

92700

 

 

 

 

 

 

 

Medical team conference with

 

 

 

 

Telephone assessment and management

 

 

 

 

 

 

 

 

 

 

interdisciplinary team of health care

 

 

 

 

 

service provided by a qualified nonphysician

 

 

 

professionals, patient and/or family not

 

 

 

 

 

health care professional to an established

 

 

 

 

 

 

 

 

 

 

 

present, 30 minutes or more; participation by

 

 

 

 

 

patient, parent, or guardian not originating

 

 

 

 

 

 

 

 

 

 

 

nonphysician qualified health care

 

 

 

 

 

from a related assessment and management

 

 

 

 

 

 

 

 

 

 

 

professional

99368

 

 

 

 

service provided within the previous seven

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

days nor leading to an assessment and

 

 

 

 

 

 

 

 

 

management service or procedure with the

 

 

 

 

 

 

 

 

 

next 24 hours or soonest available

 

 

 

 

 

 

 

 

 

appointment;

 

 

 

Total Charges: $

 

 

 

 

5-10 minutes of medical discussion

98966

 

 

 

 

 

 

 

 

 

 

 

 

11-20 minutes of medical discussion

98967

 

 

 

 

 

 

 

21-30 minutes of medical discussion

98968

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BILLING INFORMATION

 

PREVIOUS BALANCE:

$

 

 

 

 

 

 

 

TODAY’S CHARGES:

$

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL DUE:

 

$

 

 

 

 

 

 

 

PAID TODAY:

$

 

 

 

 

 

 

 

PAID BY: CASH

 

CREDIT

CHECK

 

 

 

VISA MC

OTHER

AUTHORIZATIONS

I hereby authorize direct payment of benefits to Speech Services, Inc.

SIGNATURE:

DATE:

I hereby authorize Jane Smith, MA, CCC-SLP to release any information acquired in the course of treatment.

BALANCE:

$

SIGNATURE:

DATE:

Jane Smith, MA, CCC-SLP

Speech Services, Inc.

999 Anywhere Street

Rockville, MD 00000

(999)999-9999 PHONE

(888)888-8888 FAX

NPI # 1234567890 TAX ID # 22-22222 MARYLAND LICENSE # 3333

White Copy: Office

Canary Copy: Insurance

Pink Copy: Patient

How to Edit Asha Superbill Form Online for Free

By using the online PDF editor by FormsPal, you may complete or alter speech procedure model right here and now. The tool is constantly maintained by us, receiving additional features and growing to be greater. Here's what you will need to do to get started:

Step 1: First of all, open the editor by clicking the "Get Form Button" at the top of this site.

Step 2: Once you open the editor, you will get the form ready to be filled in. In addition to filling out various fields, it's also possible to do various other things with the Document, such as writing any textual content, modifying the initial text, inserting graphics, placing your signature to the form, and a lot more.

As for the blanks of this specific document, this is what you need to do:

1. While filling in the speech procedure model, be certain to complete all necessary fields in the relevant section. This will help facilitate the process, making it possible for your details to be processed quickly and properly.

Stage no. 1 for filling out model speech language

2. The next step is usually to submit all of the following blank fields: PATIENT, REFERRING PHYSICIAN, FILE, DATE, DATE INITIAL SYMPTOM, PLACE OF SERVICE, DIAGNOSIS, INSURED, ADDRESS, INSURANCE PLAN, INSURANCE PLAN , DATE FIRST CONSULTATION, HOME, OFFICE, and OTHER.

Stage # 2 for filling in model speech language

3. Completing PROCEDURE Swallowing Function , function by cine or video recording, swallowing by cine or video, interpretation and report only , interpretation and report only , interpretation and report only, communication andor auditory, group two or more individuals , Sensory integrative techniques to, Nasopharyngoscopy w endoscope , each additional minutes , and report per hour, loss, Developmental testing includes, and of motor language social adaptive is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

swallowing by cine or video, and report per hour, and of motor language social adaptive inside model speech language

4. You're ready to begin working on the next form section! In this case you've got all of these Nasopharyngoscopy w endoscope , cluttering, Evaluation of speech sound, Evaluation of speech sound, Augmentative and Alternative, each additional minutes , and speech generating augmentative and blank fields to fill in.

Stage # 4 for filling in model speech language

People often make some mistakes while filling in Evaluation of speech sound in this area. Remember to double-check what you type in right here.

5. Finally, the following final segment is precisely what you'll want to complete before using the document. The blank fields in this case include the next: CPT, CHARGE, PROCEDURE Evaluation for, generating augmentative and, each additional minutes , RepairModification of AAC device, adaptive hearing aid, Other Procedures , service provided by a qualified, CPT, CHARGE, PROCEDURE Online assessment , Medical team conference with, interdisciplinary team of health, and Medical team conference with.

Step number 5 of filling out model speech language

Step 3: Confirm that the details are correct and click on "Done" to finish the project. Find the speech procedure model the instant you sign up for a 7-day free trial. Conveniently get access to the pdf file within your FormsPal account, along with any edits and changes automatically synced! Here at FormsPal, we do our utmost to ensure that your details are kept private.

Asha Superbill Form isn’t the one you’re looking for?

Related Documents