Chiropractic Superbill Template PDF Details

Chiropractic superbill templates are useful for chiropractors and their staff. The template is a great way to stay organized, as it provides space for recording information such as patient name, date of service, starting time and ending time of the appointment, diagnosis code(s), insurance company and policy number (if applicable), co-pay or any other out-of-pocket costs paid by the patient, total charges including adjustments and treatment plan. It also includes space for signatures from both the chiropractor and the patient at the end.

Below is the details relating to the PDF you were in search of to fill out. It can show you the span of time you'll need to fill out chiropractic superbill template, what parts you need to fill in, and so on.

QuestionAnswer
Form NameChiropractic Superbill Template
Form Length1 pages
Fillable?Yes
Fillable fields3
Avg. time to fill out51 sec
Other nameschiropractic superbill online, chiropractor receipt, chiropractic superbill template, chiropractic superbill

Form Preview Example

PATIENT NAME:_____________________________________ DATE OF SERVICE: ____________________

CODE

DESCRIPTION

FEE

CODE

DESCRIPTION

FEE

OFFICE VISITS - NEW PATIENT

 

PASSIVE MODALITIES

 

99201

BRIEF

 

97124

Massage

 

99202

LIMITED

 

97035

Ultrasound

 

99203

INTERMEDIATE

 

97014

Electric Stim

 

99204

EXTENDED

 

97016

Vasopneumatic

 

99205

COMPREHENSIVE

 

97033

Iontophoresis

 

CNPO NEW PATIENT

 

97010

Hot/Cold Pack

 

 

 

 

97024

Diathermy

 

OFFICE VISITS - ESTABLISHED PATIENT

 

64660

Neurostimulator

 

99211

MINIMAL

 

97012

Mechanical Traction/ Intersegmental

 

99212

BRIEF

 

97140

Manual Therapy Units ________

 

99213

LIMITED

 

 

 

 

99214

INTERMEDIATE

 

ACTIVE MODALITIES

 

99215

EXTENDED, COMPREHENSIVE

 

97112

Neuromuscular Re-education

 

CEPO EXISTING PATIENT

 

97110

Therapeutic Exercise

 

 

 

 

97530

Kinetic Activity

 

 

 

 

97535

ADL Home

 

CMT PROCEDURES

 

97537

ADL Work

 

98940

CMT 1-2 REGIONS

 

97116

Gait Training

 

98941

CMT 3-4 REGIONS

 

 

 

 

98942

CMT 5 REGIONS

 

 

 

 

98943

CMT - EXTREMITIES

 

XRAY

 

 

CADJ ADJUSTMENT

 

72020

Single View, Cervical

 

 

 

 

72040

Cervial 2 views

 

 

 

 

72050

Cervial, 4 views

 

MISCELLANEOUS

 

72052

Cervical 7 views

 

E0230

Ice Pack

 

72070

Thoracic, 2 views

 

99070

Biofreeze

 

72100

Lumbar, 2 views

 

99070

Electric Stim Pads

 

72110

Lumbar, 4 views

 

99070

Vitamins

 

73020

Shoulder, 1 view

 

E0643

Cervial Pillow

 

73030

Shoulder, 2 views

 

L0500

Lumbar Support

 

73060

Humerus, 2 views

 

A4556

Stim leads

 

73070

Elbow, 2 views

 

E0730

TENS Unit Rental

 

73080

Elbow, 3 views

 

E0730

TENS Unit Purchase

 

73090

Forearm, 2 views

 

L2020

Orthotics

 

73110

Wrist, 3 views

 

 

 

 

73120

Hand, 2 views

 

 

 

 

73130

Hand, 3 views

 

 

 

 

73550

Femur, 2 views

 

 

 

 

73560

Knee, 2 views

 

 

 

 

73562

Knee, 3 views

 

 

 

 

73590

Tib/Fib, 2 views

 

 

 

 

73610

Ankle, 3 views

 

 

 

 

73620

Foot, 2 views

 

 

 

 

73630

Foot, 3 views

 

 

 

 

73650

Calcaneous, 2 views

 

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