Superbill Audiology Form – Fill Out and Use This PDF

MODEL AUDIOLOGY SUPERBILL

PATIENT:

INSURED:

REFERRING PHYSICIAN:

ADDRESS:

FILE:

INSURANCE PLAN:

DATE:

INSURANCE PLAN #:

DATE INITIAL SYMPTOM:

DATE FIRST CONSULTATION:

PRIMARY (Audiology):

ICD-9 CODE:

SECONDARY (Medical):

ICD-9 CODE:

HEARING AID/EARMOLD DEFECT:

 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

 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),

automated analysis

92558

 Pure tone audiometry (threshold); air and

92553

 Distortion product evoked otoacoustic

bone

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

92556

emissions, with interpretation and report

92587

recognition

 Comprehensive audiometry threshold

 Distortion product evoked otoacoustic

evaluation and speech recognition

92557

emissions; comprehensive diagnostic

evaluation (quantitative analysis of outer hair

 Audiometric testing of groups

92559

cell function by cochlear mapping, minimum

 Bekesy audiometry; screening

92560

of 12 frequencies), with interpretation and

 Bekesy audiometry; diagnostic

92561

report

92588

 Evaluation of central auditory function, with

 Loudness balance test, alternate binaural or

92562

report; initial 60 minutes

92620

monaural



each additional 15 minutes

92621

 Tone decay test

92563

 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 exam and selection; monaural

92590

 Acoustic reflex testing, threshold

92568

 Hearing aid exam and selection; binaural

92591

 Acoustic immittance testing, includes

 Hearing aid check; monaural

tympanometry (impedance testing), acoustic

92592

reflex threshold testing, and acoustic reflex



Hearing aid check; binaural

92593

decay testing

92570

 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

 Synthetic sentence identification test

92576

Vestibular and Balance System Assessment Procedures

 Stenger test, speech

92577

 Spontaneous nystagmus, including gaze

92531

 Visual reinforcement audiometry (VRA)

92579

 Positional nystagmus test

92532

 Conditioning play audiometry

92582

 Caloric vestibular test, each irrigation

 Select picture audiometry

92583

(binaural, bithermal stimulation constitutes 4

 Electrocochleography

92584

tests)

92533

 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

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

 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

 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

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

V5269

outside the operating room (remote or

 Assistive listening device, television amplifier,

nearby) or for monitoring of more than one

case while in the operating room, per hour

any type

V5270

 Assistive listening device, television caption

(List separately in addition to code for primary

procedure)

95941

decoder

V5271

 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

 Assistive learning device not otherwise

V5274

service provided by a qualified nonphysician

specified

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, direct audio input receiver

V5285

11-20 minutes of medical discussion

98967



 Personal blue tooth FM/DM receiver

V5286

21-30 minutes of medical discussion

98968

 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,

guardian, or health care provider not

listening device

V5288

originating from a related assessment &

 Personal FM/DM adapter/boot coupling

management service provided within the

device for receiver, any type

V5289

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

Electrophysiology Procedures

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

 Nerve conduction studies; 1-2 studies

95907

family, 30 minutes or more; participation by

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

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

professional

99368



13 or more studies

95913



the central nervous system; in upper limbs

95925

in lower limbs

95926

Total Charges: $



in upper & lower limbs

95938



in the trunk or head

95927