Mental Health Psychotherapy Superbill Template Details

Medical professionals are always looking for ways to improve the quality and accuracy of patient care. One way to do this is by using a superbill template form. A superbill is a document that helps track services provided to a patient, as well as payments received from insurance companies. Superbill templates can help ensure that all required information is included on the bill, reducing the chances of errors and improving billing efficiency. There are many different types of superbill templates available online, so medical professionals can choose the one that best meets their needs.Creating a superbill template can be a great way to improve the accuracy and efficiency of your practice's billing process. There are many different templates available online, so you can find one that best suits your needs.

Before you decide to fill in superbill template, you will want to understand more in regards to the type of form you will work with.

QuestionAnswer
Form NameSuperbill Template
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessample superbill for mental health, mental health psychotherapy superbill template, superbill template mental health, printable psychotherapy superbill template

Form Preview Example

Family Practice Management Superbill Template

 

 

 

 

 

 

From the American Academy of Family Practice (AAFP) Family Practice Management Toolkit

 

 

(http://www.aafp.org/fpm/20060900/43inse.html)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of service:

 

 

 

 

 

Waiver? l฀

 

 

 

 

 

 

 

Patient name:

 

 

 

 

 

 

Insurance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subscriber name:

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

Group #:

 

 

Previous balance:

 

 

 

 

 

 

 

 

 

 

 

Copay:

 

 

Today’s charges:

 

 

Phone:

 

 

 

 

 

 

Account #:

 

 

Today’s payment: check#

 

 

DOB:

 

Age:

 

Sex:

 

Physician name:

 

 

Balance due:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RANK

Office visit

 

 

 

New

Est

RANK

Office procedures

 

 

 

RANK

Laboratory

 

 

 

Minimal

 

 

 

 

 

99211

 

Anoscopy

 

46600

 

 

Venipuncture

 

36415

 

Problem focused

 

 

 

99201

99212

 

Audiometry

 

92551

 

 

Blood glucose, monitoring device

 

82962

 

Expanded problem focused

 

 

99202

99213

 

Cerumen removal

 

69210

 

 

Blood glucose, visual dipstick

 

82948

 

Detailed

 

 

 

 

99203

99214

 

Colposcopy

 

57452

 

 

CBC, w/ auto differential

 

85025

 

Comprehensive

 

 

 

99204

99215

 

Colposcopy w/biopsy

 

57455

 

 

CBC, w/o auto differential

 

85027

 

Comprehensive (new patient)

 

 

99205

 

 

ECG, w/interpretation

 

93000

 

 

Cholesterol

 

82465

 

Significant, separate service

 

 

-25

-25

 

ECG, rhythm strip

 

93040

 

 

Hemoccult, guaiac

 

82270

 

Well visit

 

 

 

New

Est

 

Endometrial biopsy

 

58100

 

 

Hemoccult, immunoassay

 

82274

 

< 1 y

 

 

 

 

99381

99391

 

Flexible sigmoidoscopy

 

45330

 

 

Hemoglobin A1C

 

85018

 

1-4 y

 

 

 

 

99382

99392

 

Flexible sigmoidoscopy w/biopsy

45331

 

 

Lipid panel

 

80061

 

5-11 y

 

 

 

 

99383

99393

 

Fracture care, cast/splint

 

29_____

 

Liver panel

 

80076

 

12-17 y

 

 

 

 

99384

99394

 

Site: ____________________

 

 

 

 

KOH prep (skin, hair, nails)

 

87220

 

18-39 y

 

 

 

 

99385

99395

 

Nebulizer

 

94640

 

 

Metabolic panel, basic

 

80048

 

40-64 y

 

 

 

 

99386

99396

 

Nebulizer demo

 

94664

 

 

Metabolic panel, comprehensive

 

80053

 

65 y +

 

 

 

 

99387

99397

 

Spirometry

 

94010

 

 

Mononucleosis

 

86308

 

Medicare preventive services

 

 

 

 

Spirometry, pre and post

 

94060

 

 

Pregnancy, blood

 

84703

 

Pap

 

 

 

 

 

Q0091

 

Tympanometry

 

92567

 

 

Pregnancy, urine

 

81025

 

Pelvic & breast

 

 

 

 

G0101

 

Vasectomy

 

55250

 

 

Renal panel

 

80069

 

Prostate/PSA

 

 

 

 

G0103

 

Skin procedures

 

Units

 

Sedimentation rate

 

85651

 

Tobacco counseling/3-10 min

 

 

 

99406

 

Burn care, initial

16000

 

 

 

Strep, rapid

 

86403

 

Tobacco counseling/>10 min

 

 

 

99407

 

Foreign body, skin, simple

10120

 

 

 

Strep culture

 

87081

 

Welcome to Medicare exam

 

 

 

G0344

 

Foreign body, skin, complex

10121

 

 

 

Strep A

 

87880

 

ECG w/Welcome to Medicare exam

 

 

G0366

 

I&D, abscess

10060

 

 

 

TB

 

86580

 

Flexible sigmoidoscopy

 

 

 

G0104

 

I&D, hematoma/seroma

10140

 

 

 

UA, complete, non-automated

 

81000

 

Hemoccult, guaiac

 

 

 

 

G0107

 

Laceration repair, simple

120____

 

 

 

UA, w/o micro, non-automated

 

81002

 

Flu shot

 

 

 

 

 

G0008

 

Site: __________ Size: _____

 

 

 

 

UA, w/ micro, non-automated

 

81003

 

Pneumonia shot

 

 

 

 

G0009

 

Laceration repair, layered

120____

 

 

 

Urine colony count

 

87086

 

Consultation/preop clearance

 

 

 

 

Site: __________ Size: _____

 

 

 

 

Urine culture, presumptive

 

87088

 

Expanded problem focused

 

 

 

99242

 

Lesion, biopsy, one

11100

 

 

 

Wet mount/KOH

 

87210

 

Detailed

 

 

 

 

 

99243

 

Lesion, biopsy, each add’l

11101

 

 

 

Vaccines

 

 

 

Comprehensive/mod complexity

 

 

99244

 

Lesion, destruct., benign, 1-14

17110

 

 

 

DT, <7 y

 

90702

 

Comprehensive/high complexity

 

 

99245

 

Lesion, destruct., premal., single

17000

 

 

 

DTP

 

90701

 

Other services

 

 

 

 

 

 

Lesion, destruct., premal., ea. add’l

17003

 

 

 

DtaP, <7 y

 

90700

 

After posted hours

 

 

 

 

99050

 

Lesion, excision, benign

114____

 

 

 

Flu, 6-35 months

 

90657

 

Evening/weekend appointment

 

 

99051

 

Site: __________ Size: _____

 

 

 

 

Flu, 3 y +

 

90658

 

Home health certification

 

 

 

G0180

 

Lesion, excision, malignant

116____

 

 

 

Hep A, adult

 

90632

 

Home health recertification

 

 

 

G0179

 

Site: __________ Size: _____

 

 

 

 

Hep A, ped/adol, 2 dose

 

90633

 

Post-op follow-up

 

 

 

 

99024

 

Lesion, paring/cutting, one

11055

 

 

 

Hep B, adult

 

90746

 

Prolonged/30-74 min

 

 

 

99354

 

Lesion, paring/cutting, 2-4

11056

 

 

 

Hep B, ped/adol 3 dose

 

90744

 

Special reports/forms

 

 

 

99080

 

Lesion, shave

113____

 

 

 

Hep B-Hib

 

90748

 

Disability/Workers comp

 

 

 

99455

 

Site: __________ Size: _____

 

 

 

 

Hib, 4 dose

 

90645

 

Radiology

 

 

 

 

 

 

Nail removal, partial

11730

 

 

 

HPV

 

90649

 

 

 

 

 

 

 

 

 

 

Nail removal, w/matrix

11750

 

 

 

IPV

 

90713

 

 

 

 

 

 

 

 

 

 

Skin tag, 1-15

11200

 

 

 

MMR

 

90707

 

Diagnoses

 

 

 

 

 

 

Medications

 

Units

 

Pneumonia, >2 y

 

90732

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

Ampicillin, up to 500mg

J0290

 

 

 

Pneumonia conjugate, <5 y

 

90669

2

 

 

 

 

 

 

 

 

 

B-12, up to 1,000 mcg

J3420

 

 

 

Td, >7 y

 

90718

3

 

 

 

 

 

 

 

 

 

Epinephrine, up to 1ml

J0170

 

 

 

Varicella

 

90716

4

 

 

 

 

 

 

 

 

 

Kenalog, 10mg

J3301

 

 

 

Immunizations & Injections

 

Units

Next office visit

 

 

 

 

 

 

Lidocaine, 10mg

J2001

 

 

 

Allergen, one

95115

 

Recheck

 

Prev

PRN

_______ D W

M Y

 

Normal saline, 1000cc

J7030

 

 

 

Allergen, multiple

95117

 

Instructions:

 

 

 

 

 

 

 

Phenergan, up to 50mg

J2550

 

 

 

Imm admin, one

90471

 

 

 

 

 

 

 

 

 

 

 

Progesterone, 150mg

J1055

 

 

 

Imm admin, each add’l

90472

 

 

 

 

 

 

 

 

 

 

 

Rocephin, 250mg

J0696

 

 

 

Imm admin, intranasal, one

90473

 

 

 

 

 

 

 

 

 

 

 

Testosterone, 200mg

J1080

 

 

 

Imm admin, intranasal, each add’l

90474

 

Referral

 

 

 

 

 

 

 

Tigan, up to 200 mg

J3250

 

 

 

Injection, joint, small

20600

 

To:

 

 

 

 

 

 

 

Toradol, 15mg

J1885

 

 

 

Injection, joint, intermediate

20605

 

Instructions:

 

 

 

 

 

 

 

Miscellaneous services

 

 

 

 

Injection, joint, major

20610

 

 

 

 

 

 

 

 

 

 

 

 

 

Injection, ther/proph/diag

90772

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injection, trigger point

20552

 

Physician signature

 

 

 

 

 

 

 

 

 

 

 

Supplies

 

 

X ____________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Infectious & Parasitic Diseases

054.9Herpes simplex, any site

053.9Herpes zoster, NOS

075 Infectious mononucleosis

034.0Strep throat

079.99Viral infection, unspec.

078.10Warts, all sites

Neoplasms

Benign Neoplasms

239.2Skin, soft tissue neoplasm, unspec.

216.9Skin, unspec.

Endocrine, Nutritional & Metabolic Disorders

Endocrine

250.01Diabetes I, uncomplicated

250.91Diabetes, I, w/ unspec. complications

250.00Diabetes II, uncomplicated

250.90Diabetes II, w/ unspec. complications

242.90Hyperthyroidism, NOS

244.9Hypothyroidism, unspec.

Metabolic/Other

274.9Gout, unspec.

272.0Hypercholesterolemia, pure

272.2Hyperlipidemia, mixed

278.00Obesity, NOS

278.02Overweight

Blood Diseases

285.9Anemia, other, unspec.

Mental Disorders

300.00Anxiety state, unspec.

314.00Attention deficit, w/o hyperactivity

290.0Dementia, senile, uncomplicated

311

Depressive disorder, NOS

Nervous System & Sense Organ Disorders

Nervous System Diseases

354.0Carpal tunnel

345.90Epilepsy, unspec., not intractable

346.90Migraine, unspec., not intractable

Eye Diseases

372.30Conjunctivitis, unspec.

368.10Visual disturbance, unspec.

Ear Diseases

380.4Cerumen impaction

389.9Hearing loss, unspec.

380.10Otitis externa, unspec.

382.00Otitis media, acute

Circulatory System

Arrythmias

427.31Atrial fibrillation

Cardiac

413.9Angina pectoris, NOS

428.0Heart failure, congestive, unspec.

424.1Heart valve, aortic, not rheum.

414.9Ischemic heart disease, chronic, unspec.

Vascular

796.2Elevated BP w/o hypertension

401.1Hypertension, benign

458.0Hypotension, orthostatic

443.9Peripheral vascular disease, unspec.

451.9Thrombophlebitis, unspec.

459.81Venous insufficiency, unspec.

Respiratory System

Lower Respiratory Tract

493.90Asthma, unspec.

466.0Bronchitis, acute

496

COPD, NOS

486

Pneumonia, unspec.

Upper Respiratory Tract

462 Pharyngitis, acute

477.9Rhinitis, allergic, cause unspec.

461.9Sinusitis, acute, NOS

465.9Upper respiratory infection, acute, NOS

Digestive System

578.1Blood in stool

564.00Constipation, unspec.

562.10Diverticulosis of colon

562.11Diverticulitis of colon, NOS

535.50Gastritis, unspec., w/o hemorrhage

558.9Gastroenteritis, noninfectious, unspec.

530.81Gastroesophageal reflux, no esophagitis

455.6Hemorrhoids, NOS

564.1Irritable bowel syndrome

Genitourinary System

Urinary System Diseases

592.9Calculus, urinary, unspec.

595.0Cystitis, acute

599.70Hematuria, unspec.

593.9Renal insufficiency, acute

599.0Urinary tract infection, unspec. /pyuria

Male Genital Organ Dieases

607.84Impotence, organic

302.72Impotence, psychosexual dysfunction

601.9Prostatitis, NOS

Breast Diseases

611.72Breast lump

Female Genital Organ Diseases

V13.22 Cervical dysplasia, past history

616.0Cervicitis

622.10Dysplasia, cervix, unspec.

616.10Vaginitis/vulvitis, unspec.

Disorders of Menstruation

626.0Amenorrhea

627.9Menopausal disorders, unspec.

626.2Menstruation, excessive/frequent

625.3Menstruation, painful

626.6Metrorrhagia

Pregnancy, Childbirth

641.90Bleeding in preg., unspec.

V24.2 Postpartum follow-up, routine

V22.2 Pregnancy

V22.0 Prenatal care, normal, first pregnancy

V22.1 Prenatal care, normal, other pregnancy

Skin, Subcutaneous Tissue

706.1Acne, other

702.0Actinic keratosis

682.9Cellulitis/abscess, unspec.

692.9Contact dermatitis, NOS

691.8Eczema, atopic dermatitis

703.0Ingrown nail

110.1Onychomycosis

709.9Other skin disease, unspec.

696.1Psoriasis

695.3Rosacea

706.2Sebaceous cyst

702.19Seborrheic keratosis, NOS

707.9Ulcer, skin, chronic, unspec.

708.9Urticaria, unspec.

Musculoskeletal & Connective Tissue

General

716.90Arthropathy, unspec.

729.1Myalgia/myositis, unspec.

715.90Osteoarthrosis, unspec.

733.00Osteoporosis, unspec.

714.0Rheumatoid arthritis (not JRA)

727.00Synovitis/tenosynovitis, unspec.

Lower Extremity

729.5Pain in limb

Spine/Torso

724.4Back pain w/ radiation, unspec.

723.9Cervical disorder, NOS

Upper Extremity

726.10Shoulder syndrome, unspec.

Perinatal (Infant)

779.3Feeding problem, newborn

Signs & Symptoms

789.00Abdominal pain, unspec.

795.01Abnormal Pap, ASC-US

719.40Arthralgia, unspec.

569.3Bleeding, rectal

786.50Chest pain, unspec.

786.2Cough

787.91Diarrhea, NOS

780.4Dizziness/vertigo, NOS

787.20Dysphagia, unspec.

788.1Dysuria

782.3Edema, localized, NOS

783.3Feeding problem, infant/elderly

780.60Fever, unspec.

271.9Glucose intolerance

784.0Headache, unspec.

788.30Incontinence/enuresis, NOS

782.2Localized swelling/mass, superficial

785.6Lymph nodes, enlarged

780.79Malaise and fatigue, other

787.02Nausea, alone

787.01Nausea w/ vomiting

719.46Pain, knee

724.2Pain, low back

785.1Palpitations

788.42Polyuria

782.1Rash, nonvesicular, unspec.

782.0Sensory disturbance skin

786.05Shortness of breath

780.2Syncope

788.41Urinary frequency

787.03Vomiting, alone

783.21Weight loss

Injuries & Adverse Effects

Dislocations, Sprains & Strains

845.00Sprain/strain: ankle, unspec.

845.10Sprain/strain: foot, unspec.

842.10Sprain/strain: hand, unspec.

844.9Sprain/strain: knee/leg, unspec.

847.0Sprain/strain: neck, unspec.

840.9Sprain/strain: shoulder/upper arm, unspec.

842.00Sprain/strain: wrist, unspec.

Other Trauma, Adverse Effects

919.0Abrasion, unspec.

924.9Contusion, unspec.

919.4Insect bite

894.0Open wound, lower limb, unspec.

884.0Open wound, upper limb, unspec.

Supplemental Classification

V25.01

Contraception, oral

V25.02

Contraception, other (diaphragm, etc.)

V58.31

Dressing, surgical wound

V01.9

Exposure, infectious disease, unspec.

V72.31

Gynecological exam

V06.8

Immunization, combination, other

V06.1

Immunization, DTP

V04.81

Immunization, influenza

V25.2

Sterilization

V70.0

Well adult check

V20.2

Well child check

updated 9/08