Superbill Audiology Form – Fill Out and Use This PDF

The Superbill Audiology form is designed to streamline the billing process for audiology practices, facilitating the documentation and submission of claims to private health insurance plans. Incorporating a wide array of procedures and codes from the AMA's Current Procedural Terminology (CPT) and the HCPCS published by the CMS, it serves as a crucial tool for both the provider and the patient in the insurance claim process. To ensure accurate and prompt filing, click the button below to fill out the form.

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Superbill Audiology Form PDF Details

In the intricate landscape of healthcare billing and insurance claims, the Superbill plays a pivotal role, especially within specialized fields such as Audiology. Crafted as a comprehensive document, the Superbill contains detailed listings of services provided by audiologists, including diagnostic tests, assessments, and equipment fitting, all of which are essential for insurance claim processing. It leverages codes from the American Medical Association's Current Procedural Terminology (CPT) and the Healthcare Common Procedure Coding System (HCPCS) by the Centers for Medicare and Medicaid Services (CMS), ensuring accuracy and standardization in billing practices. This form not only facilitates a smoother transaction between healthcare providers and insurance entities by detailing services rendered, licensure information, and fees but also empowers patients in filing claims with their health plans. The model Superbill for audiology, while a template, underscores the diversity of audiologic services ranging from audiometric testing, vestibular assessment, to hearing aid fitting and rehabilitation services, offering a detailed matrix for audiologists to customize based on the specific needs and services of their practice. Understanding the Superbill's functioning and nuances can markedly enhance the efficiency of billing processes, making it a vital tool for both providers and patients in navigating the complexities of healthcare reimbursements.

Question	Answer
Form Name	Superbill Audiology Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	audiology model superbill, speech therapy superbill template, hearing superbill, superbill audiology

Form Preview Example

MODEL SUPERBILL

FOR AUDIOLOGY

The following is a model of a superbill which could be used by an audiology 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)© 2012. Prosthetic and durable medical equipment codes, such as hearing aid 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. For a complete list of CPT and ICD-9 codes, the ASHA Health Plan Coding & Claims Guide is available through ASHA’s Online Store or by calling ASHA’s Product Sales at 1-888-498- 6699.

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	MODEL AUDIOLOGY 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 (Audiology):	ICD-9 CODE:
	SECONDARY (Medical):	ICD-9 CODE:
	HEARING AID/EARMOLD DEFECT:

SERVICES:

 PROCEDURE	CPT	CHARGE		PROCEDURE	CPT	CHARGE
Audiological Assessment Procedures				Auditory evoked potentials, comprehensive	92585
 Tympanometry and reflex threshold	92550		 Auditory evoked potentials, limited		92586
measurements	92550		 Evoked otoacoustic emissions, screening
 Screening test, pure tone, air only			 Evoked otoacoustic emissions, screening
 Screening test, pure tone, air only	92551			(qualitative measurement of distortion product
 Pure tone audiometry (threshold);air only	92552			or transient evoked otoacoustic emissions),
 Pure tone audiometry (threshold);air only	92552			automated analysis	92558
 Pure tone audiometry (threshold); air and				automated analysis	92558
 Pure tone audiometry (threshold); air and	92553		 Distortion product evoked otoacoustic
bone	92553			emissions; limited evaluation (to confirm the
 Speech audiometry threshold				emissions; limited evaluation (to confirm the
 Speech audiometry threshold	92555			presence or absence of hearing disorder, 3-6
 Speech audiometry threshold; w/speech				frequencies) or transient evoked otoacoustic
 Speech audiometry threshold; w/speech	92556			emissions, with interpretation and report	92587
recognition	92556			emissions, with interpretation and report	92587
 Comprehensive audiometry threshold			 Distortion product evoked otoacoustic
 Comprehensive audiometry threshold			 Distortion product evoked otoacoustic
evaluation and speech recognition	92557			emissions; comprehensive diagnostic
evaluation and speech recognition	92557			evaluation (quantitative analysis of outer hair
 Audiometric testing of groups	92559			evaluation (quantitative analysis of outer hair
 Audiometric testing of groups	92559			cell function by cochlear mapping, minimum
 Bekesy audiometry; screening				cell function by cochlear mapping, minimum
 Bekesy audiometry; screening	92560			of 12 frequencies), with interpretation and
 Bekesy audiometry; diagnostic	92561			report	92588
 Bekesy audiometry; diagnostic	92561		 Evaluation of central auditory function, with
 Loudness balance test, alternate binaural or			 Evaluation of central auditory function, with
 Loudness balance test, alternate binaural or	92562			report; initial 60 minutes	92620
monaural				each additional 15 minutes	92621
monaural
 Tone decay test	92563
 Tone decay test	92563		 Assessment of tinnitus (includes pitch,
 Short increment sensitivity index (SISI)	92564		 Assessment of tinnitus (includes pitch,
 Short increment sensitivity index (SISI)	92564			loudness matching, and masking)	92625
 Stenger test, pure tone	92565		Hearing Aid Assessment and Fitting Procedures
 Tympanometry (impedance testing)	92567		Hearing Aid Assessment and Fitting Procedures
 Tympanometry (impedance testing)	92567		 Hearing aid exam and selection; monaural		92590
 Acoustic reflex testing, threshold	92568		 Hearing aid exam and selection; monaural		92590
 Acoustic reflex testing, threshold	92568		 Hearing aid exam and selection; binaural		92591
 Acoustic immittance testing, includes			 Hearing aid exam and selection; binaural		92591
 Acoustic immittance testing, includes			 Hearing aid check; monaural
tympanometry (impedance testing), acoustic			 Hearing aid check; monaural		92592
reflex threshold testing, and acoustic reflex				Hearing aid check; binaural	92593
decay testing	92570			Hearing aid check; binaural	92593
decay testing	92570		 Electroacoustic evaluation for hearing aid;
 Filtered speech test	92571		 Electroacoustic evaluation for hearing aid;
 Filtered speech test	92571			monoaural	92594
 Staggered spondaic word test	92572			binaural	92595
 Sensorineural acuity level test	92575		 Ear protector attenuation measurements		92596
 Sensorineural acuity level test	92575		 Ear protector attenuation measurements		92596
 Synthetic sentence identification test	92576
 Synthetic sentence identification test	92576		Vestibular and Balance System Assessment Procedures
 Stenger test, speech	92577		Vestibular and Balance System Assessment Procedures
 Stenger test, speech	92577		 Spontaneous nystagmus, including gaze		92531
 Visual reinforcement audiometry (VRA)	92579		 Spontaneous nystagmus, including gaze		92531
 Visual reinforcement audiometry (VRA)	92579		 Positional nystagmus test		92532
 Conditioning play audiometry			 Positional nystagmus test		92532
 Conditioning play audiometry	92582		 Caloric vestibular test, each irrigation
 Select picture audiometry			 Caloric vestibular test, each irrigation
 Select picture audiometry	92583			(binaural, bithermal stimulation constitutes 4
 Electrocochleography	92584			tests)	92533
				tests)	92533
			 Optokinetic nystagmus test		92534
			 Optokinetic nystagmus test		92534

M o d e l A u d i o l o g y S u p e r b i l l
 PROCEDURE	CPT CHARGE

Basic vestibular evaluation, incl. spontaneous nystagmus test w/eccentric gaze fixation nystagmus, w/recording, positional nystagmus test, min. of 4 positions, w/recording, optokinetic nystagmus test, bidirectional foveal & peripheral stimulation,

w/recording, & oscillating tracking test,
w/recording	92540

Spontaneous nystagmus test, incl. gaze and

fixation nystagmus, with recording

92541

Positional nystagmus test, minimum of four

positions

92542

Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes

four tests), with recording	92543
 Optokinetic nystagmus test, bi-directional,	92544
foveal or peripheral stimulation, w/ recording	92544
 Oscillating tracking test, with recording	92545
 Sinusoidal vertical axis rotational testing	92546

Use of vertical electrodes in any or all of the

above tests	92547
 Computerized dynamic posturography	92548

Vestibular and Balance Rehabilitation Services

Canalith repositioning procedure(s) (eg, Epley

maneuver, Semont maneuver) per day.

95992

Cerumen Management Services

Removal of impacted cerumen, one or both

ears

69210

Auditory Implant Services

 Cochlear implant follow-up exam <7 years of
age	92601
 Reprogram cochlear implant <7 years of age	92602
 Cochlear implant follow-up exam >7 years of	92603
age	92603
 Reprogram cochlear implant > 7 years of age	92604

Diagnostic analysis with programming of

auditory brainstem implant, per hour

92640

Habilitative and Rehabilitative Services

 Evaluation of speech, language, voice,		92506
	communication, and/or auditory processing	92506
 Treatment of speech, language, voice,
	communication, and/or auditory processing
	disorder; individual	92507
	group, two or more individuals	92508

Evaluation of auditory rehabilitation status,

	1st hour	92626
	each additional 15 minutes	92627

Auditory rehabilitation; pre-lingual hearing

loss

92630

Auditory rehabilitation; post-lingual hearing

loss

92633

Hearing Aids/FM Systems (HCPCS Level II Codes)

 Assessment for Hearing Aid	V5010
 Fitting/Orientation/Checking of Hearing Aid	V5011
 Repair/Modification of a Hearing Aid	V5014
 Conformity Evaluation	V5020

Hearing aid, Monaural, body worn,

air conduction

V5030

			P a g e \| 2
 PROCEDURE		CPT	CHARGE
	bone conduction	V5040
 Hearing Aid, Monaural, in the ear (ITE)		V5050
 Hearing Aid, Monaural, behind the ear (BTE)		V5060
 Glasses, air conduction		V5070
 Glasses, bone conduction		V5080
 Dispensing fee, Unspecified Hearing Aid		V5090
 Hearing Aid, bilateral, body worn		V5100
 Dispensing fee, bilateral		V5110
 Binaural, body		V5120
 Binaural, ITE		V5130
 Binaural, BTE		V5140
 Binaural, glasses		V5150
 Dispensing fee, binaural		V5160
 Hearing Aid, CROS, ITE		V5170
 Hearing Aid, CROS, BTE		V5180
 Hearing Aid, CROS, glasses		V5190
 Dispensing fee, CROS		V5200
 Hearing Aid, BICROS, ITE		V5210
 Hearing Aid, BICROS, BTE		V5220
 Hearing Aid, BICROS, glasses		V5230
 Dispensing Fee, BICROS		V5240
 Dispensing Fee, Monaural Hearing Aid		V5241
 Hearing Aid, Analog, monaural, completely in
	the ear canal (CIC)	V5242
 Hearing aid, analog, monaural, in the canal
	(ITC)	V5243
 Hearing aid, digitally programmable analog,
	monaural, CIC	V5244
 Hearing aid, digitally programmable analog,
	monaural, ITC	V5245
 Hearing aid, digitally programmable analog,		V5246
	monaural, ITE
 Hearing aid, digitally programmable analog,
	monaural, BTE	V5247
 Hearing aid, analog, binaural, CIC		V5248
 Hearing aid, analog, binaural, ITC		V5249
 Hearing aid, digitally programmable analog,		V5250
	binaural, CIC
 Hearing aid, digitally programmable analog,
	binaural, ITC	V5251
 Hearing aid, digitally programmable, binaural,		V5252
	ITE
 Hearing aid, digitally programmable, binaural,
	BTE	V5253
 Hearing aid, digital, monaural, CIC		V5254
 Hearing aid, digital, monaural, ITC		V5255
 Hearing aid, digital, monaural, ITE		V5256
 Hearing aid, digital, monaural, BTE		V5257
 Hearing aid, digital, binaural, CIC		V5258
 Hearing aid, digital, binaural, ITC		V5259
 Hearing aid, digital, binaural, ITE		V5260
 Hearing aid, digital, binaural, BTE		V5261
 Hearing aid, disposable, any type, monaural		V5262

M o d e l A u d i o l o g y S u p e r b i l l							P a g e \| 3
 PROCEDURE		CPT	CHARGE	 PROCEDURE		CPT	CHARGE
 Hearing aid, disposable, any type, binaural		V5263		 Visual evoked potential (VEP) testing central
 Earmold/insert, not disposable, any type		V5264			nervous system, checkerboard or flash	95930
					nervous system, checkerboard or flash	95930
				 Neuromuscular junction testing (repetitive
 Earmold/insert, disposable, any type				 Neuromuscular junction testing (repetitive
 Earmold/insert, disposable, any type		V5265			stimulation, paired stimuli), each nerve, any 1
 Battery for use in hearing device		V5266			method	95937
 Battery for use in hearing device		V5266		 Continuous intraoperative neurophysiology
 Hearing aid or assistive listening				 Continuous intraoperative neurophysiology
 Hearing aid or assistive listening					monitoring in the operating room, one on one
	device/supplies/accessories, not otherwise				monitoring requiring personal attendance,
	specified	V5267			monitoring requiring personal attendance,
	specified	V5267			each 15 minutes (List separately in addition to
 Assistive listening device, telephone amplifier,					each 15 minutes (List separately in addition to
 Assistive listening device, telephone amplifier,					code for primary procedure)	95940
	any type	V5268		 Continuous neurophysiology monitoring, from
 Assistive listening device, alerting, any type				 Continuous neurophysiology monitoring, from
 Assistive listening device, alerting, any type		V5269			outside the operating room (remote or
 Assistive listening device, television amplifier,					nearby) or for monitoring of more than one
 Assistive listening device, television amplifier,					case while in the operating room, per hour
	any type	V5270			case while in the operating room, per hour
 Assistive listening device, television caption					(List separately in addition to code for primary
 Assistive listening device, television caption					procedure)	95941
	decoder	V5271			procedure)	95941
 Assistive listening device, TDD		V5272		Other Procedures
 Assistive listening device, TDD		V5272		Other Procedures
 Assistive listening device, for use with		V5273		 Otorhinolaryngological service or procedure		92700
	cochlear implant			 Telephone assessment and management
	cochlear implant
 Assistive learning device not otherwise
 Assistive learning device not otherwise		V5274			service provided by a qualified nonphysician
	specified				service provided by a qualified nonphysician
	specified				health care professional to an established
 Ear impression, each		V5275			health care professional to an established
 Ear impression, each		V5275			patient, parent, or guardian not originating
 Personal FM/DM system, monaural (one					from a related assessment and management
	receiver, transmitter and microphone)	V5281			service provided within the previous seven
 Personal FM/DM system, binaural (two					days nor leading to an assessment and
	receivers, transmitter and microphone)	V5282			management service or procedure with the
 Personal FM/DM neck, loop induction					next 24 hours or soonest available
	receiver	V5283			appointment; 5-10 minutes of medical
 Personal FM/DM, ear level receiver		V5284			discussion	98966
 Personal FM/DM, ear level receiver		V5284		
 Personal FM/DM, direct audio input receiver		V5285			11-20 minutes of medical discussion	98967
 Personal FM/DM, direct audio input receiver		V5285		
 Personal blue tooth FM/DM receiver		V5286			21-30 minutes of medical discussion	98968
 Personal FM/DM receiver, not otherwise				 Online assessment & management service
 Personal FM/DM receiver, not otherwise				 Online assessment & management service
	specified	V5287			provided by a qualified nonphysician health
 Personal FM/DM transmitter assistive					care professional to an established patient,
 Personal FM/DM transmitter assistive					guardian, or health care provider not
	listening device	V5288			guardian, or health care provider not
	listening device	V5288			originating from a related assessment &
 Personal FM/DM adapter/boot coupling					originating from a related assessment &
 Personal FM/DM adapter/boot coupling					management service provided within the
	device for receiver, any type	V5289			management service provided within the
	device for receiver, any type	V5289			previous 7 days, using the Internet or similar
 Transmitter microphone, any type					previous 7 days, using the Internet or similar
 Transmitter microphone, any type		V5290			electronic communications network.	98969
 Hearing Service, Miscellaneous		V5299		 Medical team conference with
					interdisciplinary team of health care
					interdisciplinary team of health care
Electrophysiology Procedures					professionals, face-to-face with patient and/or
 Nerve conduction studies; 1-2 studies		95907			family, 30 minutes or more; participation by
 Nerve conduction studies; 1-2 studies		95907			nonphysician qualified health care
					nonphysician qualified health care
	3-4 studies	95908			professional	99366
	5-6 studies	95909		 Medical team conference with
	7-8 studies	95910			interdisciplinary team of health care
					interdisciplinary team of health care
					professionals, patient and/or family not
	9-10 studies	95911			present, 30 minutes or more; participation by
	11-12 studies	95912			nonphysician qualified health care
					nonphysician qualified health care
					professional	99368
	13 or more studies	95913

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from

	the central nervous system; in upper limbs	95925
	in lower limbs	95926
			Total Charges: $

	in upper & lower limbs	95938
	in upper & lower limbs	95938
	in the trunk or head	95927

M o d e l A u d i o l o g y S u p e r b i l l

BILLING INFORMATION

PREVIOUS BALANCE:	$

TODAY’S CHARGES:	$

TOTAL DUE:	$
TOTAL DUE:	$

PAID TODAY:	$

PAID BY:  CASH	 CREDIT	 CHECK
	 VISA  MC	 OTHER


BALANCE:	$

P a g e | 4

AUTHORIZATIONS

I hereby authorize direct payment of benefits to Audiology & Hearing Center, Inc.

SIGNATURE:

DATE:

I hereby authorize John Smith, PhD, CCC-A to release any information acquired in the course of treatment.

SIGNATURE:

DATE:

John Smith, PhD, CCC-A

Audiology & Hearing Center, 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

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