Superbill Template Psychotherapy Details

Mental health is one of the most important aspects of our lives, and yet it can be one of the most difficult things to discuss openly. For many people, seeking mental health care can feel like a daunting task. But thanks to the Superbill for Mental Health Form, that process just got a little bit easier. This form provides an easy way for mental health professionals to bill their clients, making it simpler than ever before to get the treatment you need. So if you're struggling with mental health issues, be sure to talk to your doctor about using this form. It could make all the difference.

Below are a few facts you may want to read just before you start using the superbill for mental health.

QuestionAnswer
Form NameSuperbill For Mental Health
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmental health superbill template, sample superbill for mental health fill online printabl, superbill example mental health, psychotherapy superbill template

Form Preview Example

ANON Medical Group

Attending Provider’s Statement

 

Main Office

Alternate Clinic

 

 

Physician1, MD; Physician 2, MD;

Physician 3, MD, Physician 4, MD

 

1 Legacy Drive, Anywhere, ST zip

5 N. Mill St, #6, Somewhere, ST zip

 

(555) 555-1125 FAX (555) 555-5550 Tax I.D. xx-1234567

(555) 555-5555 FAX (555) 555-5550

GUARANTOR: Name, Address, Phone

Visit #

Patient Name

Age D.O.B.

Provider

Patient #

Name of Insurance

S.S.N.

Co-Pay

Date

 

OFFICE

NEW FEE

 

 

ESTAB. FEE

 

OTHER CHARGES

 

 

 

CONSULTATION

 

 

 

Complete Physical

 

NEW FEE

 

 

ESTAB.FEE

 

 

 

 

 

 

 

 

 

 

 

 

ER Visit

 

 

99058 _____

 

 

 

 

 

 

 

 

 

< 1 year

99381 ____

 

 

99391 ____

 

 

 

 

 

 

 

 

 

 

 

 

After Hours

 

99050 _____

 

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL 1

99201 _____

 

 

99211 _____

 

 

 

 

 

LEVEL I

99241 15 min

 

1-4

99382 ____

 

 

99392 ____

 

 

 

 

 

Sunday/Holiday

99054 _____

 

 

 

 

 

 

 

 

LEVEL 2

99202 _____

 

 

99212 _____

 

 

 

 

LEVEL II

99242 30 min

 

5-11

99383 ____

 

 

99393 ____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL 3

99203 _____

 

 

99213 _____

 

 

COUNSELING

 

 

 

LEVEL III

99243 40 min

 

12-17

99384 ____

 

 

99394 ____

 

 

LEVEL 4

99204 _____

 

 

99214 _____

 

LEVEL

I

 

99213 - 15 min

 

 

 

LEVEL IV

99244 60 min

 

18-39

99385 ____

 

 

99395 ____

 

 

LEVEL 5

99205 _____

 

 

99215 _____

 

LEVEL

II

 

99214 - 25 min

 

 

 

LEVEL V

99245 80 min

 

 

40-64 yrs

99386 ____

 

 

99396 ____

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL

III

 

99215 - 40 min

 

 

 

 

 

 

 

 

65 +

99387 ____

 

 

99397 ____

 

 

 

LABORATORY

 

ICD-9

 

 

 

 

PROCEDURES

 

 

 

 

 

 

 

 

SUPPLIES

 

 

 

36415

Drawing

 

 

 

Anoscopy 46600

 

 

 

 

 

 

 

 

A4570 Wrist or Thumb Splint

 

 

 

 

 

 

 

 

 

82947

Glucose [ Fast/Non Fast]

 

 

Flex Sig

w/out Bx 45330

with Bx 45331

 

A4460 Ace Bandage

 

 

 

 

 

 

 

 

 

83036 Hgb A1C

 

 

PFT 94060

 

 

 

 

 

 

 

 

 

L4350 Air Brace – Ankle

 

 

 

 

 

 

 

 

 

82043

Microalbumin

 

 

 

VO2 Max 94621

 

 

 

 

 

 

 

 

A4580 Cast Supplies

 

 

 

 

 

 

 

 

 

80048

Basic Panel Chem 7

 

 

 

Stress Test 93015

 

 

 

 

 

 

 

 

L3650 Clavicle Strap

 

 

 

 

 

 

 

 

 

80053

Chem 13

 

 

EKG/Interpretation 93000

 

 

 

 

 

L4360 Fracture Air Walker

 

 

 

 

 

 

 

 

 

80076 LFT

 

82977 GGT

 

 

Tympanogram 92567

 

 

 

 

 

 

 

29505 Long Leg Splint

 

 

 

 

 

 

 

 

 

82150

Amylase

 

 

 

Irrigation: Ear / 69210

 

Eye / 66999

 

 

 

 

29515

Short Leg Splint

 

 

 

 

 

 

 

 

 

80061

Lipids [ Fast/Non Fast]

 

 

 

Foreign Body Removal:

 

Ear/69200

 

 

Eye/65205

 

90780

I.V. Setup & Administration

 

 

 

83721

Direct LDL

 

 

 

Foreign Body Skin:

Simple/10120

Complicated/10121

J7120 Ringers Lactate (up to 1,000cc)

 

 

 

82270

Hemoccult

 

 

Debridement; skin, partial thickness

11040

 

J7030

Normal Saline (up to 1,000cc)

 

 

 

84153

PSA

 

 

 

 

 

 

 

 

Burn Care 16020

 

 

 

 

 

 

 

 

94640

Nebulizer Treatment

 

 

 

 

 

 

 

 

 

86140

C-Reactive Protein

 

 

 

Paring/Cutting Callous/Corn: Single/11055 2-4/11056

94665 Nebulizer Follow-Up

 

 

 

 

 

 

 

 

 

82131

Homocysteine

 

 

 

Wart Tx (cryo, acid, etc) <15 = 17110

>=15 = 17111

A4550 Surgical Tray

 

 

 

 

 

 

 

 

 

83735

Magnesium

 

 

Benign/Premalignant Lesion Tx (ie AK) (cryo, etc)

 

99070

Peak Flow Meter

 

 

 

 

 

 

 

 

 

84550

Uric Acid

 

 

 

Lesion 1 -- 17000

 

Lesions 2-14 – 17001

 

L3800 Finger Splint

 

 

 

 

 

 

 

 

 

88150

Pap

 

 

 

 

 

 

 

Trigger Point Injection 20550

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

88142

Thin Prep / Pap

 

 

 

Nail Removal 11730

 

 

 

 

 

 

 

 

 

IMMUNIZATION ADMINISTRATION

 

 

87800

GC/Chlamy DNA Probe

 

Aspiration Cyst 10160

 

 

 

 

 

 

 

90471 ______

 

 

90472 x ___ ______

 

 

87252-87274 Herpes Culture

 

 

 

Aspiration Joint

20600

 

 

 

 

 

 

 

90702

DT (child)

90634 Hep A (child)

 

 

86703

HIV

 

 

 

 

 

 

 

I&D Abscess - Simple/Single/10060

 

 

 

 

 

90718

Td (Adult Tetanus)

90632 Hep A (adult)

 

 

86592 RPR/VDRL

 

 

 

I&D Abscess - Complicated/Many/10061

 

90700

DTaP

90744 Hep B (Birth - 11 yo)

 

 

80074

Hepatitis Panel

 

 

 

Endometrial Biopsy 57500

 

 

 

 

 

90720

DTaP and Hib

90745 Hep B (11-19 yo)

 

 

85025

CBC/Complete

 

 

 

Colposcopy:

w/ Bx/57454

w/out Bx/57452

 

90669

Prevnar (Conj-Pneumo)

90746 Hep B (>=20 yo)

 

 

 

 

 

 

90707

MMR, (live)

90659 Influenza

 

 

 

85651

Sed Rate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

90713

Poliomyelitis (inject)

90732 Pneumovax (adult)

 

 

83540

Iron

 

82728 Ferritin

 

 

Skin Tag Removal < 15 Lesions 11200

 

 

 

 

 

 

 

90716

Varicella, (live)

90733 Meningococcal

 

 

83550

Iron Panel

 

 

Skin Lesion Excision:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

95115

Allergen Injxn: single

86580 PPD

 

 

 

83520

BNP

 

 

 

 

 

 

 

 

Repair:

Simple

 

Complex

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

95117

Allergen Injxn: >=2

Other:

 

 

 

86038

ANA

 

86431 RF

 

 

 

Size: <0.5cm

 

0.6-1.0cm

 

1.1-2.0cm

 

 

MEDICATION

 

 

 

X-RAY EXAM

 

 

84439

T4, Free

 

 

 

 

2.1-3.0cm 3.1-4.0cm

 

>4.0cm

 

90782 _____

 

 

 

 

 

 

 

 

 

84443

TSH

 

 

 

 

 

 

 

 

Site:

face, ears, eyelids, nose, lips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

84481

Free T3

 

 

 

 

scalp, neck, hands, feet, genitalia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

81000

Urine Dip

 

 

 

 

trunk, arm, leg

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

81001

Urinalysis

 

 

 

*** Hold for Pathology ***

 

 

 

 

 

BILLING INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

87088

Urine Culture

 

 

 

 

 

 

LACERATIONS

 

 

 

 

BALANCE FORWARD

 

 

 

 

87880

Rapid Strep Test

 

 

 

 

Scalp, Neck, Trunk, Arms, Feet

 

TODAY’S CHARGES

 

 

 

 

87070

Strep Culture

 

 

 

 

 

 

 

 

Simple

 

 

 

Intermediate

ADJUSTMENTS

 

 

 

 

 

 

86308

Mono Spot

 

 

 

0-2.5 cm

 

 

 

 

12001

 

 

12031

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

84703

Pregnancy (Serum)

 

 

 

2.6-7.5 cm

 

 

 

 

12002

 

 

12032

 

PAID ON ACCOUNT

 

 

 

 

 

 

 

 

 

81025 Pregnancy (Urine)

 

 

 

7.6-12.5 cm

 

 

 

12004

 

 

12034

 

VISA

 

 

M/C CHECK

CASH

 

 

 

 

87045

Stool Culture

 

 

 

0-2.5 cm

 

 

 

 

 

 

 

12041

 

 

 

 

 

TOTAL DUE

 

 

 

 

 

 

 

87186

Sensitivity

 

 

 

2.6-7.5 cm

 

 

 

 

 

 

 

12042

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

87210

Wet prep/Fecal WBC’s

 

 

7.8-12.5 cm

 

 

 

 

 

 

12044

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

87177 O&P x _______

 

 

 

 

Face, Ears, Eyes, Nose, Lips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

87328 Giardia-EIA

 

 

 

 

 

 

 

 

Simple

 

 

 

Intermediate

PHYSICIAN’S SIGNATURE

 

 

 

 

 

 

 

 

 

87230

C. difficile toxin

 

 

 

0-2.5 cm

 

 

 

 

12011

 

 

12051

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

86677

H. Pylori

 

 

 

2.6-5.0 cm

 

 

 

 

12013

 

 

12052

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

85610

PT / INR

85670 PTT

 

 

5.0-7.5 cm

 

 

 

 

12014

 

 

12053

 

RETURN VISIT ON:

 

 

 

 

 

 

 

 

Infectious & Parasitic Dis

098.0Gonorrhea, acute

042 HIV

075 Mono/Infectious mononucleosis

487.1Influenza w/ upper respiratory

795.5Positive PPD

079.9Viral Syndrome

Neoplasms

Malignant Neoplasms

174.9Breast, female, unsp

153.9Colon, unsp

162.9Lung, unsp

185 Prostate

173.9Skin, unsp

Benign Neoplasms

214.9Lipoma, any site

216.9Skin, unsp

218.9Uterus (leiomyoma, unsp.

Endo, Nutr & Meta. Dz

250.91Diab. mell., I, complicated

250.01Diab. mell, I, uncomplicated

250.90Diab.mell, II, complicated

250.00Diab.mell, II, uncomplicated

790.6Elevated sugars / Hyperglycemia/Iron

271.3Glucose intolerance

240.9Goiter, unspecified

274.9Gout, unspecified

272.4Hyperlipidimia

272.0Hypercholesterolemia

242.90Hyperthyroidism, NOS

276.8Hypokalemia

244.9Hypothyroidism, unsp

278.00Obesity/Overweight; Morbid 278.01

241.0Thyroid nodule

Blood Diseases

280.9Anemia, iron deficiency

281.0Anemia,Pernicious/ B12 Def.

285.9Anemia, unspecified

683 Lymphadenitis, acute

Mental Disorders

309.9Adjustment reaction unsp

305.00Alcohol abuse, unsp

303.90Alcoholism, unsp

331.0Alzheimers

307.1Anorexia nervosa

300.00Anxiety state, unsp

314.01ADD w/ hyperactivity

314.00ADD w/o hyperactivity

296.40Bipolar Disorder

307.51Bulimia

311 Depressive disorder, NOS

296.20Depression, Acute

305.90Drug abuse, unsp

304.90Drug dependence, unsp

780.52Insomia NOS

300.01Panic disorder

301.9Personality disorder unsp

290.0Senile dementia, NOS

302.70Sexual dysfunction,

780.50Sleep Disturbance

305.1Tobacco abuse

Nerve/Sense Disorders

354.0Carpal tunnel syndrome

432.9CVA/ Intracranial hemorrhage NOS

345.90Epilepsy, unsp w/o intractab

784.0Headache

307.81Headache, Tension

346.90Headache, Migraine, w/o intractable

357.9Neuropathy, unsp

310.2Postconcussion

333.99Restless legs

780.39Seizures, convulsions

333.1Tremor, essential

Eye Diseases

373.00Blepharitis, unsp

366.9Cataract, unsp

373.2Chalazion

372.00Conjunctivitis, Acute, Bact.

372.14Conjunctivitis, Allergic

077.99Conjunctivitis, Viral

918.1Corneal abrasion

930.9Eye foreign body, external

365.9Glaucoma, unsp.

373.11Hordeolum (stye)

368.10Visual disturbance, unsp

369.9Visual loss, unsp.

Ear Diseases

380.4Cerumen, Impacted

381.81Eustachian tube dysfunction

389.9Hearing loss, unsp

380.10 Otitis externa, unsp

382.00Otitis media, acute

381.10Otitis media, chronic

386.2Vertigo, central

386.10Vertigo, peripheral

Circulatory System

413.9Angina pectoris, stable

424.1Aortic Valve disorder

427.9Arrythmia

414.00ASHD

427.31Atrial Fibrillation

414.9CAD / Ischemic heart disease

426.9Conduction disorder unsp

428.0CHF

453.9DVT/Deep Venous Thrombosis

796.2Elevated BP w/o hypertension

401.1Hypertension, benign

401.0Hypertension, malignant

424.0Mitral Valve / MVP

412 Myocardial infarction, old

458.0Orthostatic hypotension

427.0Paroxysmal supraventricular

420.91Pericarditis, acute

443.9Peripheral vascular disease

427.60Premature beats unsp

427.69PVC/Premature Ventricular Contract.

415.19Pulmonary embolism

427.81Sick Sinus Syndrome

451.9Thrombophlebitis unsp

435.9TIA/Transient ischemic attack, unsp

454.9Varicose veins w/o ulcer/inflam

459.81Venous insufficienciency

427.1V-tach/Ventricular tachycardia

Respiratory System

493.90 Asthma, unsp.

466.11Bronchiolitis, acute, due to rsv

466.0Bronchitis, acute

491.9Bronchitis, chronic

496 COPD

464.4Croup

492.8Emphysema

799.0Hypoxia

464.0Laryngitis, acute

462 Pharyngitis, acute

472.1Pharyngitis, chronic

519.1R.A.D

486 Pneumonia, unsp

477.9Rhinitis, allergic

472.0Rhinitis, chronic

461.9Sinusitis, acute

473.9Sinusitis, chronic

034.0Strep throat

463 Tonsillitis, acute

465.9URI, acute

Digestive System

571.9Chronic liver disorder

571.5Cirrhosis, NOS

562.10Diverticulosis colon

536.8Dyspepsia

530.10Esophagitis, unsp

575.9Gallbladder disease

535.50Gastritis, w/o hemorrhage

009.1Gastroenteritis, infectious

558.9Gastroenteritis, noninfectious

530.11GERD

578.9GI Bleeding

007.1Giardiasis

455.6Hemorrhoids, NOS

070.30Hepatitis B

070.51Hepatitis C

Hernia: hiatal/553.3; inguinal/550.90

553.9Hernias, other, NOS

560.1Ileus

564.1Irritable bowel syndrome

792.1Occult Blood in stool

528.9Oral, soft tissue disease/Mouth Ulcer

529.9Oral, tongue disease

577.0Pancreatitis, acute

533.90Peptic ulcer disease

569.3Rectal bleeding

524.60Temporomandibular joint disorder

112.0Thrush, oral yeast

Genitourinary System

Renal Failure: Acute/584.9 Chronic/585

580.9Glomerulonephritis, acute

592.9Kidney Stone

791.0Proteinuria, nonpost ural

590.10Pyelonephritis, acute

599.0UTI (NOS)

Male Genital Organ Disease

302.72Erectal Dysfunction

604.90Orchitis/epididymitis

600.0BPH / Prostatic hypertrophy

601.9Prostatitis, acute

456.4Varicocele

Breast Diseases

611.72Breast lump / mass

610.1Fibrocystic disease

611.6Galactorrhea

Female Genital Organ Diseases

622.1Cervical dysplasia

622.7Cervical polyp, NOS

616.0Cervicitis

625.0Dyspareunia

617.9Endometriosis, unsp

626.4Irregular menses

614.9PID / Pelvic inflammatory disease

625.6Stress incontinence, .female

131.9Trichomoniasis, unsp

616.10Vaginitis/vulvitis

112.1Vaginitis, Yeast Disorders of Menstruation

626.0Amenorrhea

626.2Excessive/frequent menstruation

627.2Hot Flashes

627.9Menopausal disorder

625.3Painful menstruation

V07.4 Postmenopausal hormone replace

625.4Premenstrual tension syndrome

Fertility Problems

628.9Infertility, female

606.9Infertility, male

Pregnancy, Childbirth

634.90Abortion, spontaneous w/o comp

633.9Ectopic pregnancy,

V22.2 Pregnancy

640.00Threatened abortion, unsp

Skin, Subcutaneous

706.1Acne, other

702.0Actinic keratosis

682.9Cellulitis/abscess

707.9Chronic skin ulcer

692.9Contact dermatitis

691.0Diaper rash

691.8Eczema, atopic dermatitis

057.9Exanthem, Viral, NOS

054.9Herpes simplex

053.9Herpes zoster/shingles

684 Impetigo

703.0Ingrown nail

683 Lymphadenitis, acute

110.1Onychomycosis/Fungal Nail

709.9Other skin disease

698.9Pruritus, NOS

696.1Psoriasis

782.1Rash, nonvesicular

695.3Rosacea

706.2Sebaceous cyst

690.10Seborrheic dermatitis.

702.19Seborrheic keratosis

701.9Skin Tag

111.0Tinea versicolor

692.71Sunburn

078.19Warts

Musculoskeletal

716.90 Arthritis

723.9 Cervical disorder

722.2Disc syndrome, no myelopathy

727.43Ganglion, unsp

717.9Internal derangement, knee

726.32Lateral Epicondylitis/Tennis Elbow

724.2Low back pain

724.4Low back pain w/ radiation

728.85Muscle Spasm

729.1Myalgia/myositis

721.90Osteoarthritis/spine

715.90Osteoarthrosis, unsp

733.90Osteopenia

733.00Osteoporosis

729.5Pain in limb

714.0Rheumatoid arthritis

726.10Shoulder syndrome

726.2Shoulder Impingment Syndrome

Dislocations & Strains

836.2Knee meniscus injury

845.00Sprain/strain: ankle

845.10Sprain/strain: foot

844.9Sprain/strain: knee/leg

846.9Sprain/strain: low back

847.0Sprain/strain: neck

842.0Sprain/strain: wrist

842.10Sprain/strain: hand

Signs and Symptoms

789.00 Abdominal pain

790.2Abnormal glucose tolerance test

793.8Abnormal Mammogram

790.93Abnormal PSA

790.4Abnormal transaminase / LDH

795.0Abnormal PAP

793.1Abnormal Chest X-ray lung

783.0Anorexia

719.40Arthralgia, unsp

786.50Chest pain, unsp.

564.0Constipation

786.2Cough

276.5Dehydration

787.91Diarrhea, NOS

780.4Dizziness/vertigo

787.2Dysphagia

788.1Dysuria

782.3Edema localized

719.00Effusion/swelling of joint

784.7Epistaxis

783.41Failure to thrive

780.79Fatigue/Malaise

780.6Fever, nonperinatal

787.3Gas/bloating

787.1Heartburn

599.7Hematuria

789.1Hepatomegaly

784.49Hoarseness

788.30Incontinence/enuresis

785.6Lymph nodes, enlarged

785.2Murmur of heart, undiagnosed

787.02Nausea, alone

782.0Numbness

785.1Palpitations

786.05Shortness of breath

780.2Syncope

788.41Urinary frequency

787.03Vomiting, alone

783.1Weight gain

783.21Weight loss

786.07Wheezing

Other Trauma, Adverse Effects

919.0Abrasion, unsp

995.3Allergic Reaction

924.9Bruise contusion

949.0Burn, degree:________________

991.9Cold injury

850.0Concussion w/out LOC; LOC <60min

850.1Concussion w/ LOC <60min

Foreign body: ear/931 nose/932 skin/919.6

919.4Insect bite

870-897 Laceration: ___________________

995.2Medication reaction, adverse

Supplemental

V65.40 Advice/health instruction

V01.9 Contact/exposure, infec. Dis

V25.01 Contraception, oral

V25.02 Contraception, oth

V25.40 Contraception, surveillance

V61.10 Couns for marital & partner

V61.20 Counseling for parent/child

V70.3 DOT, I.N.S. PE, Sports PE

V72.81 EKG / Pre-Op Cardiovasc Exam

V72.84 Pre-Op Physical Exam

V61.0 Family disruption

V25.09 Family planning

V67.4 Follow-up exam

V72.3 Gynecological exam

V70.0 Health checkup

V58.61 High Risk Med: Coumadin

V58.69 High Risk Med: Other

V69.2 High Risk Sexual Behavior

V01.9 STD Contact/ Exposure

V06.9 Immunization

V03.2 Immunization: PPD

V03.5 Immunization: Td

V06.8 Immunization: DTaP

V06.4 Immunization: MMR

V05.3 Immunization: Hep B

V05.8 Immunization: Hib

V76.9 Screening, cancer

V58.3 Suture Removal/ Dressing Change

V20.2 Well child check

V65.5 Worried Well

Family History

V16.0 Colon CA

V16.1 Lung CA

V16.3 Breast CA

V16.42 Prostate CA

V17.1 Stroke/CVA

V17.4 ASHD/Atherosclerotic Heart Disease

V18.0 Diabetes