Fill Out Your Family Practice Superbill Form
The Family Practice Superbill form is an essential tool for healthcare providers in managing patient billing and insurance claims efficiently. It serves as a comprehensive record that streamlines the process of capturing key information regarding patient visits, services rendered, and associated diagnoses. The form typically includes sections to note the date of service, patient details such as name, age, and sex, as well as insurance details, including subscriber name and group number. Additionally, it outlines various procedure codes and diagnosis codes, allowing physicians to document office visits, laboratory tests, and procedural interventions accurately. Providers rank services based on the complexity of office visits—listing categories like minimal, problem-focused, and comprehensive exams. With the inclusion of payment details like copay amounts and payment methods, this form aids in transparent financial transactions. Overall, the Superbill simplifies the billing process, ensuring both healthcare providers and patients are on the same page regarding services and payments while also enabling efficient claims submission to insurance companies.
Family Practice Superbill 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)
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Date of service: |
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Waiver? l |
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Patient name: |
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Insurance: |
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Subscriber name: |
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Address: |
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Group #: |
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Previous balance: |
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Copay: |
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Today’s charges: |
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Phone: |
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Account #: |
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Today’s payment: check# |
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DOB: |
Age: Sex: |
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Physician name: |
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Balance due: |
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RANK |
Office visit |
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New |
Est |
RANK |
Office procedures |
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RANK |
Laboratory |
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Minimal |
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99211 |
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Anoscopy |
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46600 |
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Venipuncture |
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36415 |
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Problem focused |
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99201 |
99212 |
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Audiometry |
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92551 |
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Blood glucose, monitoring device |
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82962 |
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Expanded problem focused |
99202 |
99213 |
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Cerumen removal |
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69210 |
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Blood glucose, visual dipstick |
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82948 |
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Detailed |
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99203 |
99214 |
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Colposcopy |
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57452 |
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CBC, w/ auto differential |
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85025 |
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Comprehensive |
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99204 |
99215 |
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Colposcopy w/biopsy |
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57455 |
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CBC, w/o auto differential |
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85027 |
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Comprehensive (new patient) |
99205 |
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ECG, w/interpretation |
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93000 |
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Cholesterol |
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82465 |
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Significant, separate service |
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ECG, rhythm strip |
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93040 |
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Hemoccult, guaiac |
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82270 |
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Well visit |
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New |
Est |
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Endometrial biopsy |
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58100 |
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Hemoccult, immunoassay |
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82274 |
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< 1 y |
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99381 |
99391 |
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Flexible sigmoidoscopy |
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45330 |
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Hemoglobin A1C |
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85018 |
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99382 |
99392 |
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Flexible sigmoidoscopy w/biopsy |
45331 |
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Lipid panel |
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80061 |
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99383 |
99393 |
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Fracture care, cast/splint |
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29_____ |
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Liver panel |
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80076 |
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99384 |
99394 |
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Site: ____________________ |
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KOH prep (skin, hair, nails) |
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87220 |
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99385 |
99395 |
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Nebulizer |
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94640 |
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Metabolic panel, basic |
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80048 |
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99386 |
99396 |
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Nebulizer demo |
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94664 |
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Metabolic panel, comprehensive |
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80053 |
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65 y + |
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99387 |
99397 |
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Spirometry |
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94010 |
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Mononucleosis |
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86308 |
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Medicare preventive services |
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Spirometry, pre and post |
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94060 |
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Pregnancy, blood |
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84703 |
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Pap |
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Q0091 |
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Tympanometry |
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92567 |
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Pregnancy, urine |
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81025 |
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Pelvic & breast |
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G0101 |
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Vasectomy |
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55250 |
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Renal panel |
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80069 |
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Prostate/PSA |
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G0103 |
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Skin procedures |
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Units |
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Sedimentation rate |
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85651 |
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Tobacco |
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99406 |
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Burn care, initial |
16000 |
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Strep, rapid |
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86403 |
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Tobacco counseling/>10 min |
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99407 |
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Foreign body, skin, simple |
10120 |
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Strep culture |
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87081 |
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Welcome to Medicare exam |
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G0344 |
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Foreign body, skin, complex |
10121 |
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Strep A |
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87880 |
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ECG w/Welcome to Medicare exam |
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G0366 |
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I&D, abscess |
10060 |
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TB |
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86580 |
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Flexible sigmoidoscopy |
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G0104 |
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I&D, hematoma/seroma |
10140 |
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UA, complete, |
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81000 |
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Hemoccult, guaiac |
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G0107 |
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Laceration repair, simple |
120____ |
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UA, w/o micro, |
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81002 |
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Flu shot |
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G0008 |
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Site: __________ Size: _____ |
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UA, w/ micro, |
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81003 |
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Pneumonia shot |
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G0009 |
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Laceration repair, layered |
120____ |
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Urine colony count |
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87086 |
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Consultation/preop clearance |
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Site: __________ Size: _____ |
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Urine culture, presumptive |
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87088 |
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Expanded problem focused |
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99242 |
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Lesion, biopsy, one |
11100 |
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Wet mount/KOH |
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87210 |
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Detailed |
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99243 |
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Lesion, biopsy, each add’l |
11101 |
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Vaccines |
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Comprehensive/mod complexity |
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99244 |
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Lesion, destruct., benign, |
17110 |
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DT, <7 y |
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90702 |
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Comprehensive/high complexity |
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99245 |
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Lesion, destruct., premal., single |
17000 |
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DTP |
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90701 |
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Other services |
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Lesion, destruct., premal., ea. add’l |
17003 |
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DtaP, <7 y |
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90700 |
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After posted hours |
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99050 |
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Lesion, excision, benign |
114____ |
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Flu, |
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90657 |
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Evening/weekend appointment |
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99051 |
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Site: __________ Size: _____ |
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Flu, 3 y + |
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90658 |
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Home health certification |
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G0180 |
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Lesion, excision, malignant |
116____ |
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Hep A, adult |
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90632 |
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Home health recertification |
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G0179 |
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Site: __________ Size: _____ |
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Hep A, ped/adol, 2 dose |
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90633 |
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99024 |
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Lesion, paring/cutting, one |
11055 |
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Hep B, adult |
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90746 |
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99354 |
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Lesion, paring/cutting, |
11056 |
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Hep B, ped/adol 3 dose |
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90744 |
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Special reports/forms |
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99080 |
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Lesion, shave |
113____ |
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Hep |
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90748 |
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Disability/Workers comp |
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99455 |
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Site: __________ Size: _____ |
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Hib, 4 dose |
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90645 |
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Radiology |
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Nail removal, partial |
11730 |
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HPV |
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90649 |
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Nail removal, w/matrix |
11750 |
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IPV |
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90713 |
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Skin tag, |
11200 |
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MMR |
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90707 |
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Diagnoses |
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Medications |
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Units |
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Pneumonia, >2 y |
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90732 |
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1 |
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Ampicillin, up to 500mg |
J0290 |
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Pneumonia conjugate, <5 y |
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90669 |
2 |
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J3420 |
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Td, >7 y |
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90718 |
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3 |
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Epinephrine, up to 1ml |
J0170 |
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Varicella |
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90716 |
4 |
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Kenalog, 10mg |
J3301 |
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Immunizations & Injections |
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Units |
Next office visit |
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Lidocaine, 10mg |
J2001 |
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Allergen, one |
95115 |
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Recheck |
Prev |
PRN |
_______ |
D W |
M Y |
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Normal saline, 1000cc |
J7030 |
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Allergen, multiple |
95117 |
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Instructions: |
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Phenergan, up to 50mg |
J2550 |
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Imm admin, one |
90471 |
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Progesterone, 150mg |
J1055 |
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Imm admin, each add’l |
90472 |
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Rocephin, 250mg |
J0696 |
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Imm admin, intranasal, one |
90473 |
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Testosterone, 200mg |
J1080 |
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Imm admin, intranasal, each add’l |
90474 |
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Referral |
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Tigan, up to 200 mg |
J3250 |
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Injection, joint, small |
20600 |
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To: |
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Toradol, 15mg |
J1885 |
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Injection, joint, intermediate |
20605 |
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Instructions: |
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Miscellaneous services |
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Injection, joint, major |
20610 |
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Injection, ther/proph/diag |
90772 |
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Injection, trigger point |
20552 |
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Physician signature |
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Supplies |
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X ____________________________________________________ |
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Infectious & Parasitic Diseases
B00.9 Herpesviral infection, unspecified
A60.9 Anogenital herpesviral infection
B02.9 Zoster without complications
B27.00 Gammaherpesviral mononucleosis without complication
B27.01 Gammaherpesviral mononucleosis with polyneuropathy
B27.02 Gammaherpesviral mononucleosis with meningitis
B27.09 Gammaherpesviral mononucleosis with other complications
B27.10 Cytomegaloviral mononucleosis without complications
B27.11 Cytomegaloviral mononucleosis with polyneuropathy
B27.12 Cytomegaloviral mononucleosis with meningitis
B27.19 Cytomegaloviral mononucleosis with other complication
B27.80 Other infectious mononucleosis without complication
B27.81 Other infectious mononucleosis with polyneuropathy
B27.82 Other infectious mononucleosis with meningitis
B27.89 Other infectious mononucleosis with other complication
B27.90 Infectious mononucleosis, unspecified without complication
B27.91 Infectious mononucleosis, unspecified with polyneuropathy
B27.92 Infectious mononucleosis, unspecified with meningitis
B27.99 Infectious mononucleosis, unspecified with other complication
J02.0 Streptococcal pharyngitis
J03.00 Acute streptococcal tonsillitis, unspecified
J03.01 Acute recurrent streptococcal tonsillitis
J02.0 Streptococcal sore throat
B97.8 Other viral agents as the cause of diseases classified elsewhere
B07 Viral warts
Neoplasms Benign Neoplasms
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
D23.9 Other benign neoplasm of skin, unspecified
Endocrine, Nutritional & Metabolic Disorders
Endocrine
E10.8 Type 1 diabetes mellitus with unspecified complications
E10.9 Type 1 diabetes mellitus without complications
E11.8 Type 2 diabetes mellitus with unspecified complications
E11.9 Type 2 diabetes mellitus without complications
E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
E03.9 Hypothyroidism, unspecified
Metabolic/Other
M10.9 |
Gout, unspecified |
E78.0 |
Pure hypercholesterolemia |
E78.2 |
Mixed hyperlipidemia |
E66.1 |
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E66.9 |
Obesity, unspecified |
E66.3 |
Overweight |
E66.09 |
Other obesity due to excess calories |
Blood Diseases |
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D64.9 |
Anemia, unspecified |
Mental Disorders
F41.9 Anxiety disorder, unspecified
F90.0
F90.9
F03 Unspecified dementia
F33.9 Major depressive disorder, recurrent, unspecified
Nervous System & Sense Organ Disorders
Nervous System Diseases
G56.00 Carpal tunnel syndrome, unspecified side
G56.01 Carpal tunnel syndrome, right side
G56.02 Carpal tunnel syndrome, left side
G40.90 Epilepsy, unspecified, not intractable
G40.901 Epilepsy, unspecified, not intractable, with status epilepticus
G40.909 Epilepsy, unspecified, not intractable, without status epilepticus
G43.90 Migraine, unspecified, not intractable
G44.039 Episodic paroxysmal hemicrania, not intractable Episodic paroxysmal hemicrania NOS
G44.049 Chronic paroxysmal hemicrania, not intractable Chronic paroxysmal hemicrania NOS
Eye Diseases
H10.9 Unspecified conjunctivitis
H53.10 Unspecified subjective visual disturbances
H53.11 Day blindness
Ear Diseases
H61.20 Impacted cerumen, unspecified ear
H61.21 Impacted cerumen, right ear
H61.22 Impacted cerumen, left ear
H61.23 Impacted cerumen, bilateral
H60.00 Abscess of external ear, unspecified ear
H60.01 Abscess of right external ear
H60.02 Abscess of left external ear
H60.03 Abscess of external ear, bilateral
H60.10 Cellulitis of external ear, unspecified ear
H60.11 Cellulitis of right external ear
H60.12 Cellulitis of left external ear
H60.13 Cellulitis of external ear, bilateral
H60.311 Diffuse otitis externa, right ear
H60.312 Diffuse otitis externa, left ear
H60.313 Diffuse otitis externa, bilateral
H60.319 Diffuse otitis externa, unspecified ear
H60.32 Hemorrhagic otitis externa
H60.321 Hemorrhagic otitis externa, right ear
H60.322 Hemorrhagic otitis externa, left ear
H60.323 Hemorrhagic otitis externa, bilateral
H60.329 Hemorrhagic otitis externa, unspecified ear
H60.391 Other infective otitis externa, right ear
H60.392 Other infective otitis externa, left ear
H60.393 Other infective otitis externa, bilateral
H60.399 Other infective otitis externa, unspecified ear
H66.001 Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
H66.002 Acute suppurative otitis media without spontaneous rupture of ear drum, left ear
H66.003 Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral
H66.004 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
H66.005 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear
H66.006 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral
H66.007 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear
H66.009 Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
Circulatory System
Arrythmias
I48.0 Atrial fibrillation
Cardiac
I20.8 Other forms of angina pectoris
I20.9 Angina pectoris, unspecified
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris
I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris
I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris
I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm
I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris
I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm
2
I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris
I50.9 Heart failure, unspecified
I35.0 Nonrheumatic aortic (valve) stenosis
I35.1 Nonrheumatic aortic (valve) insufficiency
I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency
I35.8 Other nonrheumatic aortic valve disorders
I35.9 Nonrheumatic aortic valve disorder, unspecified
I39 Endocarditis and heart valve disorders in diseases classified elsewhere
I25.9 Chronic ischemic heart disease, unspecified
Vascular
R03.0 Elevated
I10 Essential (primary) hypertension
I95.1 Orthostatic hypotension
I73.9 Peripheral vascular disease, unspecified
I80.9 Phlebitis and thrombophlebitis of unspecified site
I87.2 Venous insufficiency (chronic) (peripheral)
I87.9 Disorder of vein, unspecified
Respiratory System
Lower Respiratory Tract
J45.909 |
Unspecified asthma, uncomplicated |
J45.998 |
Other asthma |
J20.0 |
Acute bronchitis due to Mycoplasma |
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pneumoniae |
J20.1 |
Acute bronchitis due to Hemophilus |
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influenzae |
J20.2 |
Acute bronchitis due to streptococcus |
J20.3 |
Acute bronchitis due to coxsackievirus |
J20.4 |
Acute bronchitis due to parainfluenza |
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virus |
J20.5 |
Acute bronchitis due to respiratory |
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syncytial virus |
J20.6 |
Acute bronchitis due to rhinovirus |
J20.7 |
Acute bronchitis due to echovirus |
J20.8 |
Acute bronchitis due to other specified |
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organisms |
J20.9 |
Acute bronchitis, unspecified |
J44.9 |
Chronic obstructive pulmonary disease, |
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unspecified |
J18.8 |
Other pneumonia, unspecified |
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organism |
J18.9 |
Pneumonia, unspecified organism |
Upper Respiratory Tract
J02.8 Acute pharyngitis due to other specified organisms
J02.9 Acute pharyngitis, unspecified
J30.0 Vasomotor rhinitis
J30.9 Allergic rhinitis, unspecified
J01.90 Acute sinusitis, unspecified
J01.91 Acute recurrent sinusitis, unspecified
J01.80 Other acute sinusitis
J01.81 Other acute recurrent sinusitis
J06.9 Acute upper respiratory infection, unspecified
Digestive System
K92.1 |
Melena |
K59.00 |
Constipation, unspecified |
K57.30 |
Diverticulosis of large intestine without |
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perforation or abscess without bleeding |
K57.50 |
Diverticulosis of both small and large |
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intestine without perforation or abscess |
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without bleeding |
K57.90 |
Diverticulosis of intestine, part |
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unspecified, without perforation or |
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abscess without bleeding |
K57.20 |
Diverticulitis of large intestine with |
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perforation and abscess without |
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bleeding |
K57.40 |
Diverticulitis of both small and large |
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intestine with perforation and abscess |
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without bleeding |
K57.52 |
Diverticulitis of both small and large |
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intestine without perforation or abscess |
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without bleeding |
K57.80 |
Diverticulitis of intestine, part |
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unspecified, with perforation and |
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abscess without bleeding |
K57.92 |
Diverticulitis of intestine, part |
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unspecified, without perforation or |
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abscess without bleeding |
K29.70 |
Gastritis, unspecified, without bleeding |
K29.90 |
Gastroduodenitis, unspecified, without |
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bleeding |
K52.8 |
Other specified noninfective |
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gastroenteritis and colitis |
K52.9 |
Noninfective gastroenteritis and colitis, |
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unspecified |
K21.9 |
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without esophagitis |
I84.20 |
Unspecified hemorrhoids without |
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complication |
K58.0 |
Irritable bowel syndrome with diarrhea |
K58.9 |
Irritable bowel syndrome without |
|
diarrhea |
Genitourinary System Urinary System Diseases
N20.2 Calculus of kidney with calculus of ureter
N20.9 Urinary calculus, unspecified
N30.00 Acute cystitis without hematuria
N30.01 Acute cystitis with hematuria
R31.0 Gross hematuria
R31.1 Benign essential microscopic hematuria
R31.2 Other microscopic hematuria
R31.9 Hematuria, unspecified
N28.9 Disorder of kidney and ureter, unspecified
N29 Other disorders of kidney and ureter in diseases classified elsewhere
N39.0 Urinary tract infection, site not specified
Male Genital Organ Diseases
N52.01 Erectile dysfunction due to arterial insufficiency
N52.02
N52.03 Combined arterial insufficiency and
N52.1 Erectile dysfunction due to diseases classified elsewhere
N52.2
N52.31 Erectile dysfunction following radical prostatectomy
N52.32 Erectile dysfunction following radical cystectomy
N52.33 Erectile dysfunction following urethral surgery
N52.34 Erectile dysfunction following simple prostatectomy
N52.39 Other
N53.8 Other male sexual dysfunction
N53.9 Unspecified male sexual dysfunction
F52.21 Male erectile disorder
N41.9 Inflammatory disease of prostate, unspecified
Breast Diseases
N63 Unspecified lump in breast
Female Genital Organ Diseases
Z87.44 Personal history of cervical dysplasia
N72 Inflammatory disease of cervix uteri
N87.9 Dysplasia of cervix uteri, unspecified
N76.0 Acute vaginitis
N76.1 Subacute and chronic vaginitis
N76.2 Acute vulvitis
N76.3 Subacute and chronic vulvitis
N76.4 Abscess of vulva
Disorders of Menstruation
N91.0 Primary amenorrhea
N91.1 Secondary amenorrhea
N91.2 Amenorrhea, unspecified
N95.9 Unspecified menopausal and perimenopausal disorder
N92.0 Excessive and frequent menstruation with regular cycle
N92.1 Excessive and frequent menstruation with irregular cycle
N94.4 Primary dysmenorrhea
N94.5 Secondary dysmenorrhea
N94.6 Dysmenorrhea, unspecified
N92.1 Excessive and frequent menstruation with irregular cycle
Pregnancy, Childbirth
O46.90 Antepartum hemorrhage, unspecified, unspecified trimester
Z39.2 Encounter for routine postpartum
Z33.1 Pregnant state, incidental
Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester
Z34.01 Encounter for supervision of normal first pregnancy, unspecified trimester
Z34.02 Encounter for supervision of normal first pregnancy, second trimester
Z34.03 Encounter for supervision of normal first pregnancy, third trimester
V22.1 Prenatal care, normal, other pregnancy
Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester
Z34.81 Encounter for supervision of other normal pregnancy, first trimester
Z34.82 Encounter for supervision of other normal pregnancy, second trimester
Z34.83 Encounter for supervision of other normal pregnancy, third trimester
Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester
Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester
Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester
Skin, Subcutaneous Tissue
L70.0 Acne vulgaris
L70.1 Acne conglobata
L70.3 Acne tropica
L70.4 Infantile acne
L70.5 Acné excoriée des jeunes filles
L70.8 Other acne
L70.9 Acne, unspecified
L73.0 Acne keloid
L57.0 Actinic keratosis
L03.90 Cellulitis, unspecified
L03.91 Acute lymphangitis, unspecified
3
L03.129 Acute lymphangitis of unspecified part of limb
L03.119 Cellulitis of unspecified part of limb
L98.3 Eosinophilic cellulitis [Wells]
L23.9 Allergic contact dermatitis, unspecified cause
L24.9 Irritant contact dermatitis, unspecified cause
L25.9 Unspecified contact dermatitis, unspecified cause
L30.0 Nummular dermatitis
L30.2 Cutaneous autosensitization
L30.8 Other specified dermatitis
L30.9 Dermatitis, unspecified
L20.8 Other atopic dermatitis
L20.81 Atopic neurodermatitis
L20.82 Flexural eczema
L20.83 Infantile (acute) (chronic) eczema
L20.84 Intrinsic (allergic) eczema
L20.89 Other atopic dermatitis
L20.9 Atopic dermatitis, unspecified
L21.8 Other seborrheic dermatitis
L60.0 Ingrowing nail
B35.1 Tinea unguium
L44.9 Papulosquamous disorder, unspecified
L45 Papulosquamous disorders in diseases classified elsewhere
L98.9 Disorder of the skin and subcutaneous tissue, unspecified
L40.0 Psoriasis vulgaris
L40.1 Generalized pustular psoriasis
L40.2 Acrodermatitis continua
L40.3 Pustulosis palmaris et plantaris
L40.4 Guttate psoriasis
L40.8 Other psoriasis
L40.9 Psoriasis, unspecified
L71.0 Perioral dermatitis
L71.1 Rhinophyma
L71.8 Other rosacea
L71.9 Rosacea, unspecified
L72.0 Epidermal cyst
L72.1 Trichodermal cyst
L72.2 Steatocystoma multiplex
L72.8 Other follicular cysts of the skin and subcutaneous tissue
L72.9 Follicular cyst of the skin and subcutaneous tissue, unspecified
L82.0 Inflamed seborrheic keratosis
L82.1 Other seborrheic keratosis
L98.491
L98.492
L98.493
L98.494
L98.499
L50.9 Urticaria, unspecified
Musculoskeletal & Connective Tissue
General
M12.9 Arthropathy, unspecified
M60.80 Other myositis, unspecified site
M60.811 Other myositis, right shoulder
M60.812 Other myositis, left shoulder
M60.819 Other myositis, unspecified shoulder
M60.821 Other myositis, right upper arm
M60.822 Other myositis, left upper arm
M60.829 Other myositis, unspecified upper arm
M60.831 Other myositis, right forearm
M60.832 Other myositis, left forearm
M60.839 Other myositis, unspecified forearm
M60.841 Other myositis, right hand
M60.842 Other myositis, left hand
M60.849 Other myositis, unspecified hand
M60.851 Other myositis, right thigh
M60.852 Other myositis, left thigh
M60.859 |
Other myositis, unspecified thigh |
M60.861 |
Other myositis, right lower leg |
M60.862 |
Other myositis, left lower leg |
M60.869 |
Other myositis, unspecified lower leg |
M60.871 |
Other myositis, right ankle and foot |
M60.872 |
Other myositis, left ankle and foot |
M60.879 |
Other myositis, unspecified ankle and |
|
foot |
M60.88 |
Other myositis, Other site |
M60.89 |
Other myositis, multiple sites |
M60.9 |
Myositis, unspecified |
M79.1 |
Myalgia |
M79.7 |
Fibromyalgia |
M15.9 |
Polyosteoarthritis, unspecified |
M19.90 |
Unspecified osteoarthritis, unspecified |
|
site |
M81.8 |
Other osteoporosis without current |
|
pathological fracture |
M05.70 |
Rheumatoid arthritis with rheumatoid |
|
factor of unspecified site without organ |
|
or systems involvement |
M05.71 |
Rheumatoid arthritis with rheumatoid |
|
factor of shoulder without organ or |
|
systems involvement |
M05.711 |
Rheumatoid arthritis with rheumatoid |
|
factor of right shoulder without organ or |
|
systems involvement |
M05.712 |
Rheumatoid arthritis with rheumatoid |
|
factor of left shoulder without organ or |
|
systems involvement |
M05.719 |
Rheumatoid arthritis with rheumatoid |
|
factor of unspecified shoulder without |
|
organ or systems involvement |
M05.721 |
Rheumatoid arthritis with rheumatoid |
|
factor of right elbow without organ or |
|
systems involvement |
M05.722 |
Rheumatoid arthritis with rheumatoid |
|
factor of left elbow without organ or |
|
systems involvement |
M05.729 |
Rheumatoid arthritis with rheumatoid |
|
factor of unspecified elbow without |
|
organ or systems involvement |
M05.73 |
Rheumatoid arthritis with rheumatoid |
|
factor of wrist without organ or systems |
|
involvement |
M05.731 |
Rheumatoid arthritis with rheumatoid |
|
factor of right wrist without organ or |
|
systems involvement |
M05.732 |
Rheumatoid arthritis with rheumatoid |
|
factor of left wrist without organ or |
|
systems involvement |
M05.739 |
Rheumatoid arthritis with rheumatoid |
|
factor of unspecified wrist without organ |
|
or systems involvement |
M05.74 |
Rheumatoid arthritis with rheumatoid |
|
factor of hand without organ or systems |
|
involvement |
M05.741 |
Rheumatoid arthritis with rheumatoid |
|
factor of right hand without organ or |
|
systems involvement |
M05.742 |
Rheumatoid arthritis with rheumatoid |
|
factor of left hand without organ or |
|
systems involvement |
M05.749 |
Rheumatoid arthritis with rheumatoid |
|
factor of unspecified hand without |
|
organ or systems involvement |
M05.75 |
Rheumatoid arthritis with rheumatoid |
|
factor of hip without organ or systems |
|
involvement |
M05.751 |
Rheumatoid arthritis with rheumatoid |
|
factor of right hip without organ or |
|
systems involvement |
M05.752 |
Rheumatoid arthritis with rheumatoid |
|
factor of left hip without organ or |
|
systems involvement |
M05.759 |
Rheumatoid arthritis with rheumatoid |
|
factor of unspecified hip without organ |
|
or systems involvement |
M05.76 Rheumatoid arthritis with rheumatoid factor of knee without organ or systems involvement
M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement
M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
M05.769 Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement
M05.77 Rheumatoid arthritis with rheumatoid factor of ankle and foot without organ or systems involvement
M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement
M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.779 Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement
M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M05.80 Other rheumatoid arthritis with rheumatoid factor of unspecified site
M05.811 Other rheumatoid arthritis with rheumatoid factor of right shoulder
M05.812 Other rheumatoid arthritis with rheumatoid factor of left shoulder
M05.819 Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder
M05.82 Other rheumatoid arthritis with rheumatoid factor of elbow
M05.821 Other rheumatoid arthritis with rheumatoid factor of right elbow
M05.822 Other rheumatoid arthritis with rheumatoid factor of left elbow
M05.829 Other rheumatoid arthritis with rheumatoid factor of unspecified elbow
M05.83 Other rheumatoid arthritis with rheumatoid factor of wrist
M05.831 Other rheumatoid arthritis with rheumatoid factor of right wrist
M05.832 Other rheumatoid arthritis with rheumatoid factor of left wrist
M05.839 Other rheumatoid arthritis with rheumatoid factor of unspecified wrist
M05.84 Other rheumatoid arthritis with rheumatoid factor of hand
M05.841 Other rheumatoid arthritis with rheumatoid factor of right hand
M05.842 Other rheumatoid arthritis with rheumatoid factor of left hand
M05.849 Other rheumatoid arthritis with rheumatoid factor of unspecified hand
M05.85 Other rheumatoid arthritis with rheumatoid factor of hip
M05.851 Other rheumatoid arthritis with rheumatoid factor of right hip
M05.852 Other rheumatoid arthritis with rheumatoid factor of left hip
M05.859 Other rheumatoid arthritis with rheumatoid factor of unspecified hip
M05.86 Other rheumatoid arthritis with rheumatoid factor of knee
M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee
M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee
M05.869 Other rheumatoid arthritis with rheumatoid factor of unspecified knee
M05.87 Other rheumatoid arthritis with rheumatoid factor of ankle and foot
4
M05.871 |
Other rheumatoid arthritis with |
M06.219 |
Rheumatoid bursitis, unspecified |
M06.83 |
Other specified rheumatoid arthritis, |
|
rheumatoid factor of right ankle and |
|
shoulder |
|
wrist |
|
foot |
M06.22 |
Rheumatoid bursitis, elbow |
M06.831 |
Other specified rheumatoid arthritis, |
M05.872 |
Other rheumatoid arthritis with |
M06.221 |
Rheumatoid bursitis, right elbow |
|
right wrist |
|
rheumatoid factor of left ankle and foot |
M06.222 |
Rheumatoid bursitis, left elbow |
M06.832 |
Other specified rheumatoid arthritis, left |
M05.879 |
Other rheumatoid arthritis with |
M06.229 |
Rheumatoid bursitis, unspecified elbow |
|
wrist |
|
rheumatoid factor of unspecified ankle |
M06.23 |
Rheumatoid bursitis, wrist |
M06.839 |
Other specified rheumatoid arthritis, |
|
and foot |
M06.231 |
Rheumatoid bursitis, right wrist |
|
unspecified wrist |
M05.89 |
Other rheumatoid arthritis with |
M06.232 |
Rheumatoid bursitis, left wrist |
M06.84 |
Other specified rheumatoid arthritis, |
|
rheumatoid factor of multiple sites |
M06.239 |
Rheumatoid bursitis, unspecified wrist |
|
hand |
M05.9 |
Rheumatoid arthritis with rheumatoid |
M06.24 |
Rheumatoid bursitis, hand |
M06.841 |
Other specified rheumatoid arthritis, |
|
factor, unspecified |
M06.241 |
Rheumatoid bursitis, right hand |
|
right hand |
M06.00 |
Rheumatoid arthritis without |
M06.242 |
Rheumatoid bursitis, left hand |
M06.842 |
Other specified rheumatoid arthritis, left |
|
rheumatoid factor, unspecified site |
M06.249 |
Rheumatoid bursitis, unspecified hand |
|
hand |
M06.01 |
Rheumatoid arthritis without |
M06.25 |
Rheumatoid bursitis, hip |
M06.849 |
Other specified rheumatoid arthritis, |
|
rheumatoid factor, shoulder |
M06.251 |
Rheumatoid bursitis, right hip |
|
unspecified hand |
M06.011 |
Rheumatoid arthritis without |
M06.252 |
Rheumatoid bursitis, left hip |
M06.85 |
Other specified rheumatoid arthritis, hip |
|
rheumatoid factor, right shoulder |
M06.259 |
Rheumatoid bursitis, unspecified hip |
M06.851 |
Other specified rheumatoid arthritis, |
M06.012 |
Rheumatoid arthritis without |
M06.26 |
Rheumatoid bursitis, knee |
|
right hip |
|
rheumatoid factor, left shoulder |
M06.261 |
Rheumatoid bursitis, right knee |
M06.852 |
Other specified rheumatoid arthritis, left |
M06.019 |
Rheumatoid arthritis without |
M06.262 |
Rheumatoid bursitis, left knee |
|
hip |
|
rheumatoid factor, unspecified shoulder |
M06.269 |
Rheumatoid bursitis, unspecified knee |
M06.859 |
Other specified rheumatoid arthritis, |
M06.021 |
Rheumatoid arthritis without |
M06.27 |
Rheumatoid bursitis, ankle and foot |
|
unspecified hip |
|
rheumatoid factor, right elbow |
M06.271 |
Rheumatoid bursitis, right ankle and |
M06.86 |
Other specified rheumatoid arthritis, |
M06.022 |
Rheumatoid arthritis without |
|
foot |
|
knee |
|
rheumatoid factor, left elbow |
M06.272 |
Rheumatoid bursitis, left ankle and foot |
M06.861 |
Other specified rheumatoid arthritis, |
M06.029 |
Rheumatoid arthritis without |
M06.279 |
Rheumatoid bursitis, unspecified ankle |
|
right knee |
|
rheumatoid factor, unspecified elbow |
|
and foot |
M06.862 |
Other specified rheumatoid arthritis, left |
M06.03 |
Rheumatoid arthritis without |
M06.28 |
Rheumatoid bursitis, vertebrae |
|
knee |
|
rheumatoid factor, wrist |
M06.29 |
Rheumatoid bursitis, multiple sites |
M06.869 |
Other specified rheumatoid arthritis, |
M06.031 |
Rheumatoid arthritis without |
M06.30 |
Rheumatoid nodule, unspecified site |
|
unspecified knee |
|
rheumatoid factor, right wrist |
M06.31 |
Rheumatoid nodule, shoulder |
M06.87 |
Other specified rheumatoid arthritis, |
M06.032 |
Rheumatoid arthritis without |
M06.311 |
Rheumatoid nodule, right shoulder |
|
ankle and foot |
|
rheumatoid factor, left wrist |
M06.312 |
Rheumatoid nodule, left shoulder |
M06.871 |
Other specified rheumatoid arthritis, |
M06.039 |
Rheumatoid arthritis without |
M06.319 |
Rheumatoid nodule, unspecified |
|
right ankle and foot |
|
rheumatoid factor, unspecified wrist |
|
shoulder |
M06.872 |
Other specified rheumatoid arthritis, |
M06.04 |
Rheumatoid arthritis without |
M06.32 |
Rheumatoid nodule, elbow |
|
left ankle and foot |
|
rheumatoid factor, hand |
M06.321 |
Rheumatoid nodule, right elbow |
M06.879 |
Other specified rheumatoid arthritis, |
M06.041 |
Rheumatoid arthritis without |
M06.322 |
Rheumatoid nodule, left elbow |
|
unspecified ankle and foot |
|
rheumatoid factor, right hand |
M06.329 |
Rheumatoid nodule, unspecified elbow |
M06.88 |
Other specified rheumatoid arthritis, |
M06.042 |
Rheumatoid arthritis without |
M06.33 |
Rheumatoid nodule, wrist |
M06.89 |
Other specified rheumatoid arthritis, |
|
rheumatoid factor, left hand |
M06.331 |
Rheumatoid nodule, right wrist |
|
multiple sites |
M06.049 |
Rheumatoid arthritis without |
M06.332 |
Rheumatoid nodule, left wrist |
M06.9 |
Rheumatoid arthritis, unspecified |
|
rheumatoid factor, unspecified hand |
M06.339 |
Rheumatoid nodule, unspecified wrist |
M65.9 |
Synovitis and tenosynovitis, |
M06.05 |
Rheumatoid arthritis without |
M06.34 |
Rheumatoid nodule, hand |
|
unspecified |
|
rheumatoid factor, hip |
M06.341 |
Rheumatoid nodule, right hand |
|
|
M06.051 |
Rheumatoid arthritis without |
M06.342 |
Rheumatoid nodule, left hand |
Lower Extremity |
|
|
rheumatoid factor, right hip |
M06.349 |
Rheumatoid nodule, unspecified hand |
M79.601 |
Pain in right arm |
M06.052 |
Rheumatoid arthritis without |
M06.352 |
Rheumatoid nodule, left hip |
M79.602 |
Pain in left arm |
|
rheumatoid factor, left hip |
M06.359 |
Rheumatoid nodule, unspecified hip |
M79.603 |
Pain in arm, unspecified |
M06.059 |
Rheumatoid arthritis without |
M06.36 |
Rheumatoid nodule, knee |
M79.604 |
Pain in right leg |
|
rheumatoid factor, unspecified hip |
M06.361 |
Rheumatoid nodule, right knee |
M79.605 |
Pain in left leg |
M06.06 |
Rheumatoid arthritis without |
M06.362 |
Rheumatoid nodule, left knee |
M79.606 |
Pain in leg, unspecified |
|
rheumatoid factor, knee |
M06.369 |
Rheumatoid nodule, unspecified knee |
M79.609 |
Pain in unspecified limb |
M06.061 |
Rheumatoid arthritis without |
M06.37 |
Rheumatoid nodule, ankle and foot |
M79.621 |
Pain in right upper arm |
|
rheumatoid factor, right knee |
M06.371 |
Rheumatoid nodule, right ankle and |
M79.622 |
Pain in left upper arm |
M06.062 |
Rheumatoid arthritis without |
|
foot |
M79.629 |
Pain in unspecified upper arm |
|
rheumatoid factor, left knee |
M06.372 |
Rheumatoid nodule, left ankle and foot |
M79.631 |
Pain in right forearm |
M06.069 |
Rheumatoid arthritis without |
M06.379 |
Rheumatoid nodule, unspecified ankle |
M79.632 |
Pain in left forearm |
|
rheumatoid factor, unspecified knee |
|
and foot |
M79.639 |
Pain in unspecified forearm |
M06.07 |
Rheumatoid arthritis without |
M06.38 |
Rheumatoid nodule, vertebrae |
M79.641 |
Pain in right hand |
|
rheumatoid factor, ankle and foot |
M06.39 |
Rheumatoid nodule, multiple sites |
M79.642 |
Pain in left hand |
M06.071 |
Rheumatoid arthritis without |
M06.80 |
Other specified rheumatoid arthritis, |
M79.643 |
Pain in unspecified hand |
|
rheumatoid factor, right ankle and foot |
|
unspecified site |
M79.644 |
Pain in right finger(s) |
M06.072 |
Rheumatoid arthritis without |
M06.81 |
Other specified rheumatoid arthritis, |
M79.645 |
Pain in left finger(s) |
|
rheumatoid factor, left ankle and foot |
|
shoulder |
M79.646 |
Pain in unspecified (s) |
M06.079 |
Rheumatoid arthritis without |
M06.811 |
Other specified rheumatoid arthritis, |
M79.651 |
Pain in right thigh |
|
rheumatoid factor, unspecified ankle |
|
right shoulder |
M79.652 |
Pain in left thigh |
|
and foot |
M06.812 |
Other specified rheumatoid arthritis, left |
M79.659 |
Pain in unspecified thigh |
M06.08 |
Rheumatoid arthritis without |
|
shoulder |
M79.661 |
Pain in right lower leg |
|
rheumatoid factor, vertebrae |
M06.819 |
Other specified rheumatoid arthritis, |
M79.662 |
Pain in left lower leg |
M06.09 |
Rheumatoid arthritis without |
|
unspecified shoulder |
M79.669 |
Pain in unspecified lower leg |
|
rheumatoid factor, multiple sites |
M06.82 |
Other specified rheumatoid arthritis, |
M79.671 |
Pain in right foot |
M06.1 |
|
elbow |
M79.672 |
Pain in left foot |
|
M06.2 |
Rheumatoid bursitis |
M06.821 |
Other specified rheumatoid arthritis, |
M79.673 |
Pain in unspecified foot |
M06.20 |
Rheumatoid bursitis, unspecified site |
|
right elbow |
M79.674 |
Pain in right toe(s) |
M06.21 |
Rheumatoid bursitis, shoulder |
M06.822 |
Other specified rheumatoid arthritis, left |
M79.675 |
Pain in left toe(s) |
M06.211 |
Rheumatoid bursitis, right shoulder |
|
elbow |
M79.676 |
Pain in unspecified toe(s) |
M06.212 |
Rheumatoid bursitis, left shoulder |
M06.829 |
Other specified rheumatoid arthritis, |
|
|
|
|
|
unspecified elbow |
|
|
5
Spine/Torso |
G44.321 |
Chronic |
S93.409A Sprain of unspecified ligament of |
||
M54.14 |
Radiculopathy, thoracic region |
|
intractable |
|
unspecified ankle; initial encounter |
M54.15 |
Radiculopathy, thoracolumbar region |
G44.329 |
Chronic |
S93.409D Sprain of unspecified ligament of |
|
M54.16 |
Radiculopathy, lumbar region |
|
intractable |
|
unspecified ankle; subsequent |
M54.17 |
Radiculopathy, lumbosacral region |
G44.40 |
|
encounter |
|
M51.14 |
Intervertebral disc disorders with |
|
elsewhere classified, not intractable |
S96.919A Strain of unspecified muscle and |
|
|
radiculopathy, thoracic region |
G44.41 |
|
tendon at ankle and foot level, |
|
M51.15 |
Intervertebral disc disorders with |
|
elsewhere classified, intractable |
|
unspecified side; initial encounter |
|
radiculopathy, thoracolumbar region |
G44.51 |
Hemicrania continua |
S96.919D Strain of unspecified muscle and |
|
M51.16 |
Intervertebral disc disorders with |
G44.52 |
New daily persistent headache |
|
tendon at ankle and foot level, |
|
radiculopathy, lumbar region |
|
(NDPH) |
|
unspecified side; subsequent |
M51.17 |
Intervertebral disc disorders with |
G44.53 |
Primary thunderclap headache |
|
encounter |
|
radiculopathy, lumbosacral region |
G44.59 |
Other complicated headache |
S93.609A |
Unspecified sprain of unspecified foot; |
M53.9 |
Dorsopathy, unspecified |
|
syndrome |
|
initial encounter |
|
|
G44.81 |
Hypnic headache |
S93.609D Unspecified sprain of unspecified foot; |
|
Upper Extremity |
G44.82 |
Headache associated with sexual |
|
subsequent encounter |
|
M75.10 |
Rotator cuff syndrome, unspecified |
|
activity |
S63.90A |
Initial encounter; Sprain of |
|
shoulder |
G44.83 |
Primary cough headache |
|
unspecified part of unspecified wrist |
M75.11 |
Rotator cuff syndrome, right shoulder |
G44.84 |
Primary exertional headache |
|
and hand |
M75.12 |
Rotator cuff syndrome, left shoulder |
G44.85 |
Primary stabbing headache |
S63.90D |
Subsequent encounter; Sprain of |
|
|
G44.89 |
Other headache syndrome |
|
unspecified part of unspecified wrist |
Perinatal (Infant) |
R32 |
Unspecified urinary incontinence |
|
and hand |
|
P92.0 |
Vomiting of newborn |
R22.0 |
Localized swelling, mass and lump, |
S63.509A |
Initial encounter; Unspecified sprain |
P92.1 |
Regurgitation and rumination of |
|
head |
|
of unspecified wrist |
|
newborn |
R22.1 |
Localized swelling, mass and lump, |
S63.509D Subsequent encounter; Unspecified |
|
P92.2 |
Slow feeding of newborn |
|
neck |
|
sprain of unspecified wrist |
P92.3 |
Underfeeding of newborn |
R22.2 |
Localized swelling, mass and lump, |
S66.919A Strain of unspecified muscle, fascia |
|
P92.4 |
Overfeeding of newborn |
|
trunk |
|
and tendon at wrist and hand level of |
P92.5 |
Neonatal difficulty in feeding at breast |
R22.30 |
Localized swelling, mass and lump, |
|
unspecified side; Initial encounter |
P92.8 |
Other feeding problems of newborn |
|
upper limb, unspecified side |
S66.919D Strain of unspecified muscle, fascia |
|
P92.9 |
Feeding problem of newborn, |
R22.31 |
Localized swelling, mass and lump, |
|
and tendon at wrist and hand level of |
|
unspecified |
|
right upper limb |
|
unspecified side; Subsequent |
|
|
R22.32 |
Localized swelling, mass and lump, |
|
encounter |
Signs & Symptoms |
|
left upper limb |
S83.90A |
Initial encounter; Sprain of |
|
R10.0 |
Acute abdomen |
R22.33 |
Localized swelling, mass and lump, |
|
unspecified site of knee, unspecified |
R10.83 |
Colic |
|
upper limb, bilateral |
|
side |
R10.9 |
Unspecified abdominal pain |
R22.40 |
Localized swelling, mass and lump, |
S83.90D |
Subsequent encounter; Sprain of |
R87.619 |
Unspecified abnormal cytological |
|
lower limb, unspecified side |
|
unspecified site of knee, unspecified |
|
findings in specimens from cervix |
R22.41 |
Localized swelling, mass and lump, |
S86.919A |
Initial encounter; Strain of |
|
uteri |
|
right lower limb |
|
unspecified muscle(s) and tendon(s) |
M25.50 |
Pain in unspecified joint |
R22.42 |
Localized swelling, mass and lump, |
|
at lower leg level, unspecified leg |
K62.5 |
Hemorrhage of anus and rectum |
|
left lower limb |
S86.919D Subsequent encounter; Strain of |
|
R07.81 |
Pleurodynia |
R22.43 |
Localized swelling, mass and lump, |
|
unspecified muscle(s) and tendon(s) |
R07.82 |
Intercostal pain |
|
lower limb, bilateral |
|
at lower leg level, unspecified leg |
R07.89 |
Other chest pain |
R22.9 |
Localized swelling, mass and lump, |
S16.1A |
Initial encounter; Strain of muscle, |
R07.9 |
Chest pain, unspecified |
|
unspecified |
|
fascia and tendon at neck level |
R05 |
Cough |
R59.0 |
Localized enlarged lymph nodes |
S16.1D |
Subsequent encounter; Strain of |
R19.7 |
Diarrhea, unspecified |
R59.1 |
Generalized enlarged lymph nodes |
|
muscle, fascia and tendon at neck |
R42 |
Dizziness and giddiness |
R59.9 |
Enlarged lymph nodes, unspecified |
|
level |
R13.10 |
Dysphagia, unspecified |
R53.0 |
Neoplastic (malignant) related fatigue |
S13.4A |
Initial encounter; Sprain of ligaments |
R13.11 |
Dysphagia, oral phase |
R53.1 |
Weakness |
|
of cervical spine |
R13.12 |
Dysphagia, oropharyngeal phase |
R53.2 |
Functional quadriplegia |
S13.4D |
Subsequent encounter; Sprain of |
R13.13 |
Dysphagia, pharyngeal phase |
R53.81 |
Other malaise |
|
ligaments of cervical spine |
R13.14 |
Dysphagia, pharyngoesophageal |
R53.83 |
Other fatigue |
S13.8A |
Initial encounter; Sprain of joints and |
|
phase |
G93.3 |
Postviral fatigue syndrome |
|
ligaments of other parts of neck |
R13.19 |
Other dysphagia |
R11.1 |
Nausea alone |
S13.8D |
Subsequent encounter; Sprain of |
R30.0 |
Dysuria |
R11.0 |
Nausea with vomiting |
|
joints and ligaments of other parts of |
R30.9 |
Painful micturition, unspecified |
M25.561 |
Pain in right knee |
|
neck |
R60.0 |
Localized edema |
M25.562 |
Pain in left knee |
S43.409A |
Initial encounter; Unspecified sprain |
R60.1 |
Generalized edema |
M25.569 |
Pain in unspecified knee |
|
of unspecified shoulder joint |
R60.9 |
Edema, unspecified |
M54.5 |
Low back pain |
S43.409D Subsequent encounter; Unspecified |
|
R63.3 |
Feeding difficulties |
R00.2 |
Palpitations |
|
sprain of unspecified shoulder joint |
R50.2 |
Drug induced fever |
R35.8 |
Other polyuria |
S43.90A |
Initial encounter; Sprain of |
R50.8 |
Other specified fever |
R21 |
Rash and other nonspecific skin |
|
unspecified parts of shoulder girdle, |
R50.9 |
Fever, unspecified |
|
eruption |
|
unspecified side |
E74.9 |
Disorder of carbohydrate metabolism, |
R20.1 |
Hypoesthesia of skin |
S43.90D |
Subsequent encounter; Sprain of |
|
unspecified |
R20.2 |
Paresthesia of skin |
|
unspecified parts of shoulder girdle, |
G44.10 |
Vascular headache, not elsewhere |
R20.3 |
Hyperesthesia |
|
unspecified side |
|
classified, not intractable |
R20.8 |
Other disturbances of skin sensation |
S46.919A |
Strain of unspecified muscle, fascia |
G44.11 |
Vascular headache, not elsewhere |
R20.9 |
Unspecified disturbances of skin |
|
and tendon at shoulder and upper |
|
classified, intractable |
|
sensation |
|
arm level, unspecified arm; Initial |
G44.301 |
R06.02 |
Shortness of breath |
|
encounter |
|
|
unspecified, intractable |
R55 |
Syncope and collapse |
S46.919D Strain of unspecified muscle, fascia |
|
G44.309 |
R35.0 |
Frequency of micturition |
|
and tendon at shoulder and upper |
|
|
unspecified, not intractable |
R11.2 |
Projectile vomiting |
|
arm level, unspecified arm; |
G44.311 |
Acute |
R11.3 |
Other vomiting without nausea |
|
Subsequent encounter |
|
intractable |
R63.4 |
Abnormal weight loss |
|
|
G44.319 |
Acute |
|
|
Other Trauma, Adverse Effects |
|
|
Intractable |
Injuries & Adverse Effects |
S00.01A |
Abrasion of scalp; Initial encounter |
|
|
|
Dislocations, Sprains & Strains |
|
|
|
6
S00.01D |
Abrasion of scalp; Subsequent |
S30.817D Abrasion of anus; Subsequent |
S00.531D Contusion of lip; Subsequent |
||
|
encounter |
|
encounter |
|
encounter |
S00.219A |
Abrasion of unspecified eyelid and |
S40.219A |
Abrasion of unspecified shoulder; |
S00.532A |
Contusion of oral cavity; Initial |
|
periocular area; Initial encounter |
|
Initial encounter |
|
encounter |
S00.219D Abrasion of unspecified eyelid and |
S40.219D Abrasion of unspecified shoulder; |
S00.532D Contusion of oral cavity; Subsequent |
|||
|
periocular area; Subsequent |
|
Subsequent encounter |
|
encounter |
|
encounter |
S40.819A |
Abrasion of unspecified upper arm; |
S10.0A |
Contusion of throat; Initial encounter |
S00.31A |
Abrasion of nose; Initial encounter |
|
Initial encounter |
S10.0D |
Contusion of throat; Subsequent |
S00.31D |
Abrasion of nose; Subsequent |
S40.819D Abrasion of unspecified upper arm; |
|
encounter |
|
|
encounter |
|
Subsequent encounter |
S10.83A |
Contusion of other part of neck; Initial |
S00.419A |
Abrasion of unspecified ear; Initial |
S50.319A |
Abrasion of unspecified elbow; Initial |
|
encounter |
|
encounter |
|
encounter |
S10.83D |
Contusion of other part of necks; |
S00.419D Abrasion of unspecified ear; |
S50.319D Abrasion of unspecified elbow; |
|
Subsequent encounter |
||
|
Subsequent encounter |
|
Subsequent encounter |
S10.93A |
Contusion of unspecified part of neck; |
S00.511A |
Abrasion of lip; Initial encounter |
S50.819A |
Abrasion of unspecified forearm; |
|
Initial encounter |
S00.511D Abrasion of lip; Subsequent |
|
Initial encounter |
S10.93D |
Contusion of unspecified part of neck; |
|
|
encounter |
S50.819D Abrasion of unspecified forearm; |
|
Subsequent encounter |
|
S00.512A |
Abrasion of oral cavity; Initial |
|
Subsequent encounter |
S20.00A |
Contusion of breast, unspecified |
|
encounter |
S60.319A |
Abrasion of unspecified thumb; Initial |
|
breast; Initial encounter |
S00.512D Abrasion of oral cavity; Subsequent |
|
encounter |
S20.00D |
Contusion of breast, unspecified |
|
|
encounter |
S60.319D Abrasion of unspecified thumb; |
|
breast; Subsequent encounter |
|
S10.11A |
Abrasion of throat; Initial encounter |
|
Subsequent encounter |
S20.219A |
Contusion of unspecified front wall of |
S10.11D |
Abrasion of throat; Subsequent |
S60.419A |
Abrasion of unspecified finger; Initial |
|
thorax; Initial encounter |
|
encounter |
|
encounter |
S20.219D Contusion of unspecified front wall of |
|
S10.81A |
Abrasion of other part of neck; Initial |
S60.419D Abrasion of unspecified finger; |
|
thorax; Subsequent encounter |
|
|
encounter |
|
Subsequent encounter |
S20.229A Contusion of unspecified back wall of |
|
S10.81S |
Abrasion of other part of necks |
S60.519A |
Abrasion of unspecified hand; Initial |
|
thorax; Initial encounter |
|
subsequent encounter |
|
encounter |
S20.229D Contusion of unspecified back wall of |
|
S10.91A |
Abrasion of unspecified part of neck; |
S60.519D Abrasion of unspecified hand; |
|
thorax; Subsequent encounter |
|
|
Initial encounter |
|
Subsequent encounter |
S30.00A |
Contusion of lower back and pelvis; |
S10.91D |
Abrasion of unspecified part of neck; |
S60.819A |
Abrasion of unspecified wrist; Initial |
|
Initial encounter |
|
Subsequent encounter |
|
encounter |
S30.00D |
Contusion of lower back and pelvis; |
S20.119A Abrasion of breast, unspecified |
S60.819D Abrasion of unspecified wrist; |
|
Subsequent encounter |
||
|
breast; Initial encounter |
|
Subsequent encounter |
S30.1A |
Contusion of abdominal wall; Initial |
S20.119D Abrasion of breast, unspecified |
S70.219A |
Abrasion, unspecified hip; Initial |
|
encounter |
|
|
breast; Subsequent encounter |
|
encounter |
S30.1D |
Contusion of abdominal wall; |
S20.319A Abrasion of unspecified front wall of |
S70.219D Abrasion, unspecified hip; |
|
Subsequent encounter |
||
|
thorax; Initial encounter |
|
Subsequent encounter |
S30.21A |
Contusion of penis; Initial encounter |
S20.319D Abrasion of unspecified front wall of |
S70.319A |
Abrasion, unspecified thigh; Initial |
S30.21D |
Contusion of penis; Subsequent |
|
|
thorax; Subsequent encounter |
|
encounter |
|
encounter |
S20.419A Abrasion of unspecified back wall of |
S70.319D Abrasion, unspecified thigh; |
S30.22A |
Contusion of scrotum and testes; |
||
|
thorax; Initial encounter |
|
Subsequent encounter |
|
Initial encounter |
S20.419D Abrasion of unspecified back wall of |
S80.219A |
Abrasion, unspecified knee; Initial |
S30.22D |
Contusion of scrotum and testes; |
|
|
thorax; Subsequent encounter |
|
encounter |
|
Subsequent encounter |
S20.91A |
Abrasion of unspecified parts of |
S80.219D Abrasion, unspecified knee; |
S30.23A |
Contusion of vagina and vulva; Initial |
|
|
thorax; Initial encounter |
|
Subsequent encounter |
|
encounter |
S20.91D |
Abrasion of unspecified parts of |
S90.413A |
Abrasion, unspecified great toe; Initial |
S30.23D |
Contusion of vagina and vulva; |
|
thorax; Subsequent encounter |
|
encounter |
|
Subsequent encounter |
S30.810A Abrasion of lower back and pelvis; |
S90.413D Abrasion, unspecified great toe; |
S30.201A Contusion of unspecified external |
|||
|
Initial encounter |
|
Subsequent encounter |
|
genital organs, male; Initial encounter |
S30.810D Abrasion of lower back and pelvis; |
S90.416A |
Abrasion, unspecified lesser toe(s); |
S30.201D Contusion of unspecified external |
||
|
Subsequent encounter |
|
Initial encounter |
|
genital organs, male; Subsequent |
S30.811A |
Abrasion of abdominal wall; Initial |
S90.416D Abrasion, unspecified lesser toe(s); |
|
encounter |
|
|
encounter |
|
Subsequent encounter |
S30.202A Contusion of unspecified external |
|
S30.811D Abrasion of abdominal wall; |
S90.519A |
Abrasion, unspecified ankle; Initial |
|
genital organs, female; Initial |
|
|
Subsequent encounter |
|
encounter |
|
encounter |
S30.812A |
Abrasion of penis; Initial encounter |
S90.519D Abrasion, unspecified ankle; |
S30.202D Contusion of unspecified external |
||
S30.812D Abrasion of penis; Subsequent |
|
Subsequent encounter |
|
genital organs, female; Subsequent |
|
|
encounter |
S90.819A |
Abrasion, unspecified foot; Initial |
|
encounter |
S30.813A |
Abrasion of scrotum and testes; Initial |
|
encounter |
S30.3A |
Contusion of anus; Initial encounter |
|
encounter |
S90.819D Abrasion, unspecified foot; |
S30.3D |
Contusion of anus; Subsequent |
|
S30.813D Abrasion of scrotum and testes; |
|
Subsequent encounter |
|
encounter |
|
|
Subsequent encounter |
S00.03A |
Contusion of scalp; Initial encounter |
S40.019A |
Contusion of unspecified shoulder; |
S30.814A |
Abrasion of vagina and vulva; Initial |
S00.03D |
Contusion of scalp; Subsequent |
|
Initial encounter |
|
encounter |
|
encounter |
S40.019D Contusion of unspecified shoulder; |
|
S30.814D Abrasion of vagina and vulva; |
S00.19A |
Contusion of unspecified eyelid and |
|
Subsequent encounter |
|
|
Subsequent encounter |
|
periocular area; Initial encounter |
S40.029A |
Contusion of unspecified upper arm; |
S30.815A |
Abrasion of unspecified external |
S00.19D |
Contusion of unspecified eyelid and |
|
Initial encounter |
|
genital organs, male; Initial encounter |
|
periocular area; Subsequent |
S40.029D Contusion of unspecified upper arm; |
|
S30.815D Abrasion of unspecified external |
|
encounter |
|
Subsequent encounter |
|
|
genital organs, male; Subsequent |
S00.33A |
Contusion of nose; Initial encounter |
S50.00A |
Contusion of unspecified elbow; Initial |
|
encounter |
S00.33D |
Contusion of nose; Subsequent |
|
encounter |
S30.816A Abrasion of unspecified external |
|
encounter |
S50.00D |
Contusion of unspecified elbow; |
|
|
genital organs, female; Initial |
S00.439A |
Contusion of unspecified ear; Initial |
|
Subsequent encounter |
|
encounter |
|
encounter |
S50.10A |
Contusion of unspecified forearm; |
S30.816D Abrasion of unspecified external |
S00.439D Contusion of unspecified ear; |
|
Initial encounter |
||
|
genital organs, female; Subsequent |
|
Subsequent encounter |
S50.10D |
Contusion of unspecified forearm; |
|
encounter |
S00.531A |
Contusion of lip; Initial encounter |
|
Subsequent encounter |
S30.817A |
Abrasion of anus; Initial encounter |
|
|
S60.019 |
Contusion of unspecified thumb; Initial |
|
|
|
|
|
encounter |
7
S60.019 |
Contusion of unspecified thumb; |
S10.96D |
Insect bite of unspecified part of neck; |
S40.269D Insect bite of unspecified shoulder; |
|
|
Subsequent encounter |
|
Subsequent encounter |
|
Subsequent encounter |
S60.00A |
Contusion of unspecified finger |
S20.161A |
Insect bite of breast, right breast; |
S40.869A |
Insect bite of unspecified upper arm; |
|
without damage to nail; Initial |
|
Initial encounter |
|
Initial encounter |
|
encounter |
S20.161D Insect bite of breast, right breast; |
S40.869D Insect bite of unspecified upper arm; |
||
S60.00D |
Contusion of unspecified finger |
|
Subsequent encounter |
|
Subsequent encounter |
|
without damage to nail; Subsequent |
S20.162A |
Insect bite of breast, left breast; Initial |
S50.369A |
Insect bite of unspecified elbow; Initial |
|
encounter |
|
encounter |
|
encounter |
S60.229A |
Contusion of unspecified hand; Initial |
S20.162D Insect bite of breast, left breast; |
S50.369D Insect bite of unspecified elbow; |
||
|
encounter |
|
Subsequent encounter |
|
Subsequent encounter |
S60.229D Contusion of unspecified hand; |
S20.169A |
Insect bite of breast, unspecified |
S50.869A |
Insect bite of unspecified forearm; |
|
|
Subsequent encounter |
|
breast; Initial encounter |
|
Initial encounter |
S60.211A |
Contusion of right wrist; Initial |
S20.169D Insect bite of breast, unspecified |
S50.869D Insect bite of unspecified forearm; |
||
|
encounter |
|
breast; Subsequent encounter |
|
Subsequent encounter |
S60.211D Contusion of right wrist; Subsequent |
S20.361A |
Insect bite of right front wall of thorax; |
S60.369A |
Insect bite of unspecified thumb; |
|
|
encounter |
|
Initial encounter |
|
Initial encounter |
S60.212A |
Contusion of left wrist; Initial |
S20.361D Insect bite of right front wall of thorax; |
S60.369D Insect bite of unspecified thumb; |
||
|
encounter |
|
Subsequent encounter |
|
Subsequent encounter |
S60.212D Contusion of left wrist; Subsequent |
S20.361S |
Insect bite of right front wall of thorax; |
S60.468A |
Insect bite of other finger; Initial |
|
|
encounter |
|
Subsequent encounter |
|
encounter |
S60.219A |
Contusion of unspecified wrist; Initial |
S20.362A |
Insect bite of left front wall of thorax; |
S60.468D Insect bite of other finger; Subsequent |
|
|
encounter |
|
Initial encounter |
|
encounter |
S60.219D Contusion of unspecified wrist; |
S20.362D Insect bite of left front wall of thorax; |
S60.469A |
Insect bite of unspecified finger; Initial |
||
|
Subsequent encounter |
|
Subsequent encounter |
|
encounter |
S70.00A |
Contusion, unspecified hip; Initial |
S20.369A |
Insect bite of unspecified front wall of |
S60.469D Insect bite of unspecified finger; |
|
|
encounter |
|
thorax; Initial encounter |
|
Subsequent encounter |
S70.00D |
Contusion, unspecified hip; |
S20.369D Insect bite of unspecified front wall of |
S60.569A |
Insect bite of unspecified hand; Initial |
|
|
Subsequent encounter |
|
thorax; Subsequent encounter |
|
encounter |
S70.10A |
Contusion, unspecified thigh; Initial |
S20.461A |
Insect bite of right back wall of thorax; |
S60.569D Insect bite of unspecified hand; |
|
|
encounter |
|
Initial encounter |
|
Subsequent encounter |
S70.10D |
Contusion, unspecified thigh; |
S20.461D Insect bite of right back wall of thorax; |
S60.869A |
Insect bite of unspecified wrist; Initial |
|
|
Subsequent encounter |
|
Subsequent encounter |
|
encounter |
S80.00A |
Contusion, unspecified knee; Initial |
S20.462A |
Insect bite of left back wall of thorax; |
S60.869D Insect bite of unspecified wrist; |
|
|
encounter |
|
Initial encounter |
|
Subsequent encounter |
S80.00D |
Contusion, unspecified knee; |
S20.462D Insect bite of left back wall of thorax; |
S70.269A |
Insect bite, unspecified hip; Initial |
|
|
Subsequent encounter |
|
Subsequent encounter |
|
encounter |
S90.11A |
Contusion, unspecified great toe; |
S20.469A |
Insect bite of unspecified back wall of |
S70.269D Insect bite, unspecified hip; |
|
|
Initial encounter |
|
thorax; Initial encounter |
|
Subsequent encounter |
S90.11D |
Contusion, unspecified great toe; |
S20.469D Insect bite of unspecified back wall of |
S70.369A |
Insect bite, unspecified thigh; Initial |
|
|
Subsequent encounter |
|
thorax; Subsequent encounter |
|
encounter |
S90.129A |
Contusion, unspecified lesser toe(s); |
S20.96A |
Insect bite of unspecified parts of |
S70.369D Insect bite, unspecified thigh; |
|
|
Initial encounter |
|
thorax; Initial encounter |
|
Subsequent encounter |
S90.129D Contusion, unspecified lesser toe(s); |
S20.96D |
Insect bite of unspecified parts of |
S80.269A |
Insect bite, unspecified knee; Initial |
|
|
Subsequent encounter |
|
thorax; Subsequent encounter |
|
encounter |
S90.00A |
Contusion, unspecified ankle; Initial |
S30.860A |
Insect bite of lower back and pelvis; |
S80.269D Insect bite, unspecified knee; |
|
|
encounter |
|
Initial encounter |
|
Subsequent encounter |
S90.00D |
Contusion, unspecified ankle; |
S30.860D Insect bite of lower back and pelvis; |
S90.463A |
Insect bite, unspecified great toe; |
|
|
Subsequent encounter |
|
Subsequent encounter |
|
Initial encounter |
S00.06A |
Insect bite of scalp; Initial encounter |
S30.861A |
Insect bite of abdominal wall; Initial |
S90.463D Insect bite, unspecified great toe; |
|
S00.06D |
Insect bite of scalp; Subsequent |
|
encounter |
|
Subsequent encounter |
|
encounter |
S30.861D Insect bite of abdominal wall; |
S90.466A |
Insect bite, unspecified lesser toe(s); |
|
S00.269A |
Insect bite of unspecified eyelid and |
|
Subsequent encounter |
|
Initial encounter |
|
periocular area; Initial encounter |
S30.862A |
Insect bite of penis; Initial encounter |
S90.466D Insect bite, unspecified lesser toe(s); |
|
S00.269D Insect bite of unspecified eyelid and |
S30.862D Insect bite of penis; Subsequent |
|
Subsequent encounter |
||
|
periocular area; Subsequent |
|
encounter |
S90.569A |
Insect bite, unspecified ankle; Initial |
|
encounter |
S30.863A Insect bite of scrotum and testes; |
|
encounter |
|
S00.36A |
Insect bite of nose; Initial encounter |
|
Initial encounter |
S90.569D Insect bite, unspecified ankle; |
|
S00.36D |
Insect bite of nose; Subsequent |
S30.863D Insect bite of scrotum and testes; |
|
Subsequent encounter |
|
|
encounter |
|
Subsequent encounter |
S90.869A |
Insect bite, unspecified foot; Initial |
S00.469A |
Insect bite of unspecified ear; Initial |
S30.864A |
Insect bite of vagina and vulva; Initial |
|
encounter |
|
encounter |
|
encounter |
S90.869D Insect bite, unspecified foot; |
|
S00.469D Insect bite of unspecified ear; |
S30.864D Insect bite of vagina and vulva; |
|
Subsequent encounter |
||
|
Subsequent encounter |
|
Subsequent encounter |
S71.009A Unspecified open wound, unspecified |
|
S00.561A |
Insect bite of lip; Initial encounter |
S30.865A |
Insect bite of unspecified external |
|
hip; Initial encounter |
S00.561D Insect bite of lip; Subsequent |
|
genital organs, male; Initial encounter |
S71.009D Unspecified open wound, unspecified |
||
|
encounter |
S30.865D Insect bite of unspecified external |
|
hip; Subsequent encounter |
|
S00.562A |
Insect bite of oral cavity; Initial |
|
genital organs, male; Subsequent |
S71.109A |
Unspecified open wound, unspecified |
|
encounter |
|
encounter |
|
thigh; Initial encounter |
S00.562D Insect bite of oral cavity; Subsequent |
S30.866A |
Insect bite of unspecified external |
S71.109D Unspecified open wound, unspecified |
||
|
encounter |
|
genital organs, female; Initial |
|
thigh; Subsequent encounter |
S10.16A |
Insect bite of throat; Initial encounter |
|
encounter |
S41.009A |
Unspecified open wound of |
S10.16D |
Insect bite of throat; Subsequent |
S30.866D Insect bite of unspecified external |
|
unspecified shoulder; Initial encounter |
|
|
encounter |
|
genital organs, female; Subsequent |
S41.009D Unspecified open wound of |
|
S10.86A |
Insect bite of other part of neck; Initial |
|
encounter |
|
unspecified shoulder; Subsequent |
|
encounter |
S30.867A |
Insect bite of anus; Initial encounter |
|
encounter |
S10.86S |
Insect bite of other part of necks; |
S30.867D Insect bite of anus; Subsequent |
S41.109A Unspecified open wound of |
||
|
subsequent encounter |
|
encounter |
|
unspecified upper arm; Initial |
S10.96A |
Insect bite of unspecified part of neck; |
S40.269A |
Insect bite of unspecified shoulder; |
|
encounter |
|
Initial encounter |
|
Initial encounter |
|
|
8
S41.109D Unspecified open wound of unspecified upper arm; Subsequent encounter
S51.009A Unspecified open wound of unspecified elbow; Initial encounter
S51.009D Unspecified open wound of unspecified elbow; Subsequent encounter
S51.809A Unspecified open wound of unspecified forearm; Initial encounter
S51.809D Unspecified open wound of unspecified forearm; Subsequent encounter
Supplemental Classification
Z30.011 Encounter for initial prescription of contraceptive pills
Z30.013 Encounter for initial prescription of
injectable contraceptive
Z30.018 Encounter for initial prescription of other contraceptives
Z30.019 Encounter for initial prescription of contraceptives, unspecified
Z48.01 Encounter for change or removal of
surgical wound dressing
Z20.9 Contact with and exposure to unspecified communicable disease
Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
Z01.42 Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear
Z23 Encounter for immunization
Z30.2 Encounter for sterilization
Z00.00 Encounter for general adult medical examination without abnormal findings
Z00.01 Encounter for general adult medical examination with abnormal findings
Z00.10 Encounter for routine child health examination without abnormal findings
Z00.11 Encounter for routine child health examination with abnormal findings
9
Form Characteristics
| Fact Name | Description |
|---|---|
| Purpose of Superbill | The Family Practice Superbill is used to document services provided to patients during their healthcare visits. |
| Importance for Billing | This form serves as a basis for billing insurance companies for services rendered, making accurate completion crucial for reimbursement. |
| Content Components | The Superbill includes patient information, insurance details, services provided, diagnosis codes, and payment information. |
| Governing Body | The template is provided by the American Academy of Family Physicians (AAFP) and aligns with industry standards. |
| Usage in States | While the template is widely used, individual states may have specific requirements for their versions of the Superbill. |
| Legal Compliance | Healthcare providers must ensure the Superbill complies with HIPAA regulations to protect patient confidentiality. |
| Common Elements | Elements such as CPT codes for procedures and ICD codes for diagnoses are standard parts of the Superbill. |
| Frequency of Updates | The Superbill may be updated annually to reflect changes in coding practices and healthcare regulations. |
| Integration with EHRs | Many practices integrate the Superbill with Electronic Health Records (EHR) to streamline billing processes. |
Guidelines on Utilizing Family Practice Superbill
Filling out the Family Practice Superbill form is an important step in documenting a patient's visit and ensuring accurate billing for services rendered. Completing this form requires attention to detail and accurate patient and service information. Below are detailed steps to guide you through the process.
- Begin by entering the date of service at the top of the form.
- Indicate if a waiver applies by marking the appropriate box.
- Enter the patient's name and date of birth (DOB).
- Fill in the patient's age and sex.
- Provide the patient's address and phone number.
- Include the account number if applicable.
- Capture the insurance information by entering the insurance company name and subscriber name.
- Fill out the group number for the insurance policy and note any previous balance.
- Document the co-pay amount and the total charges for today.
- Record the payment received today, including the check number if payment was made by check.
- Incorporate the applicable services provided during the visit. This includes selecting the office visit rank and documenting any relevant procedures or laboratory tests performed.
- Provide the physician's name at the bottom of the form.
- Finally, calculate the balance due and ensure all sections are filled accurately.
With the form filled out, it's ready for submission. Ensure that all information is legible and double-check for any errors. Proper completion of the Superbill will facilitate prompt processing for insurance claims and patient billing.
What You Should Know About This Form
What is the Family Practice Superbill form?
The Family Practice Superbill is a detailed document used in medical practices to facilitate billing for services rendered to patients. Created by the American Academy of Family Practice, it serves as a complete record of encounter details, including patient information, diagnoses, procedures performed, and charges incurred. This form streamlines the billing process and ensures that practices can submit accurate claims to insurance companies efficiently.
Who needs to use the Family Practice Superbill form?
This form is essential for healthcare providers, specifically family practitioners, utilizing it to bill insurance companies for services provided to patients during office visits or procedures. Additionally, billing staff or medical coders within the practice may use the Superbill to prepare and submit claims, ensuring all necessary codes are included for reimbursement.
What information is required on the Family Practice Superbill form?
The Superbill requires a variety of patient and service-related data. Essential details include the patient's name, date of service, insurance information, subscriber name, and contact information. It also captures specifics about the services rendered, such as office visit types, procedures, laboratory tests, medications, and injections, along with their associated charges and applicable diagnosis codes.
How does the Family Practice Superbill aid in billing accuracy?
This form enhances billing accuracy by consolidating all relevant information in one place. Using the Superbill helps medical coders ensure that all services rendered are correctly documented. By matching the pertinent diagnosis codes with the services billed, it minimizes billing errors that could lead to claim denials or delays in payment.
Are there any specific codes associated with services in the Superbill?
Yes, the Family Practice Superbill includes various codes associated with medical services, such as CPT codes for procedures and ICD codes for diagnoses. These codes are vital for accurately describing the services performed and ensuring that the billing reflects the complexity and nature of the care provided.
What is the importance of the waiver section on the Superbill?
The waiver section is crucial as it gives practices the ability to declare that certain services may not be covered by insurance, providing transparency to the patient. By indicating a waiver, the practice can inform the patient about their financial responsibilities prior to the service, allowing for better financial planning and avoiding unexpected charges later.
Can the Family Practice Superbill be customized?
Yes, the Superbill can be tailored to meet specific needs of a medical practice. While the standard format provided by the American Academy of Family Practice covers essential elements, practices may add or modify sections to include specific services or codes unique to their offerings, thereby streamlining their billing workflow.
How can one ensure compliance with insurance requirements using the Superbill?
To ensure compliance, practices should regularly review the billing codes and procedures listed in the Superbill against the latest requirements from insurance companies. Updating the Superbill with any new or revised codes will help maintain alignment with billing regulations, reducing the risk of disputes or rejections from payers.
What steps should be taken after the Superbill is completed?
Once the Superbill is completed, it should be thoroughly checked for accuracy before submission to the insurance company. The next steps involve processing the claims, following up on submitted claims to ensure prompt payment, and maintaining detailed records for any future audits or inquiries from insurance providers. Remember to discuss any out-of-pocket expenses with the patient to avoid confusion later.
Common mistakes
Filling out the Family Practice Superbill form can be a challenging task for patients. However, several common mistakes can hinder the process. One major error is failing to accurately complete the patient identification information. For example, omitting the date of service or incorrectly entering the patient name can lead to significant delays in processing the form. It is essential to ensure that all personal details match the documentation on file to avoid any confusion.
Another frequent mistake involves misunderstanding the insurance information section. Patients often either provide incomplete details or enter incorrect numerical data, such as the group number or subscriber name. This can lead to denials when the claims are submitted. Taking the time to verify these details with your insurance card before submission can save substantial time and stress.
Additionally, failing to document charges and copay accurately is a common oversight. Patients sometimes leave the fields for today’s charges and today’s payment blank or incorrectly filled out, leading to confusion regarding payment responsibilities. A thorough review of billing statements prior to completing the Superbill can help to mitigate this issue.
Another error often seen is neglecting the physician’s information. If the physician's name is left blank or incorrectly documented, it could result in complications when submitting for reimbursements. Always verify that the correct name is added.
Finally, patients frequently skip including the diagnosis codes or list them incorrectly. Accurate coding is crucial as it directly correlates with the services billed. Failing to provide precise diagnosis information can delay processing and result in unpaid claims. It is advisable to consult with the medical staff to confirm that all relevant diagnoses are accurately captured on the form.
Documents used along the form
The Family Practice Superbill is a key document used in medical billing and insurance claims in family medical practices. However, it is not the only form used in the process of healthcare documentation and reimbursement. There are several other forms and documents that often accompany the Superbill, each serving a specific purpose to ensure accurate coding, billing, and communication in patient care. Below is an overview of important supplementary documents commonly utilized alongside the Family Practice Superbill.
- Patient Registration Form: This form collects essential information about the patient, including personal details, insurance coverage, and medical history. It is typically filled out during the patient's first visit and helps streamline the administrative process.
- Patient Consent Form: Patients must sign this document to give consent for treatment. It may also outline the risks involved in certain procedures and the use of their personal health information.
- Insurance Claim Form (CMS-1500): Often used by healthcare providers to submit claims to insurance companies. This form details the services provided and is critical for securing payment from insurers.
- Health History Form: This form gathers comprehensive information about a patient’s medical history, medications, allergies, and family health background. It is vital for informed patient care.
- Progress Notes: These are clinical documentation entries made by healthcare providers during patient visits. They capture details of the examination, diagnosis, treatment plans, and progress over time.
- Referral Form: When a patient needs to see a specialist, a referral form is issued. It contains information about the patient's condition and reasons for referral, facilitating continuity of care.
- Authorization for Release of Information: This form allows providers to share a patient's health information with third parties, such as specialists or insurance companies, following patient consent.
- Encounter Form: Similar to a Superbill but may include different information. It summarizes the services provided during a patient visit and can be used for billing and statistical purposes.
- Audit Trail Document: This record tracks changes or corrections made to electronic health records. It ensures transparency and accountability in patient documentation efforts.
- Chronic Care Management Plan: For patients with chronic conditions, this document outlines the care management strategies and goals, ensuring a structured approach to treatment.
Each of these documents plays a vital role in the overall patient care process and healthcare administration. Utilizing them alongside the Family Practice Superbill enhances the accuracy of medical billing, improves patient outcomes, and ensures compliance with healthcare regulations.
Similar forms
Billing Statement: Similar to a Family Practice Superbill, a billing statement provides a summary of services rendered, patient information, and the associated charges. It is often sent to patients or insurance companies and outlines what was billed, what’s covered, and what balance is due.
Encounter Form: The encounter form is used in a medical office to document the patient visit details. Like a superbill, it captures information about diagnoses, procedures performed, and the billable items, making it easier to process payments.
Insurance Claim Form (CMS-1500): The CMS-1500 form serves as a key document for billing Medicare and many private payers. Much like a superbill, it details the services provided and allows healthcare providers to submit claims for reimbursement.
Patient Invoice: This document is issued to a patient after services have been provided. It lists the services performed, costs, payments received, and any amount still owed, similar in purpose to a superbill in communicating financial information.
Dos and Don'ts
Things to Do When Filling Out the Family Practice Superbill Form:
- Provide accurate patient information, including name, date of birth, and insurance details.
- Complete all required sections to ensure the form is valid and comprehensive.
- Double-check for any misentered information before submission.
- Use the appropriate coding for diagnoses and procedures based on the most current guidelines.
- Sign the form where required, indicating it was completed by the appropriate personnel.
Things Not to Do When Filling Out the Family Practice Superbill Form:
- Do not leave any mandatory fields blank, as this can delay processing.
- Avoid using outdated codes that may not be applicable to the services provided.
- Do not alter or overwriting information. If changes are needed, start a new form.
- Refrain from providing personal opinions or comments in the form; stick to factual information only.
- Do not forget to verify that all calculations for charges and payments are accurate.
Misconceptions
Misconceptions About the Family Practice Superbill Form
- It's Just for Billing Purposes: Many people believe that the Family Practice Superbill is solely a billing tool. In reality, it serves multiple purposes, including tracking a patient's visit details, documenting the services provided, and providing a comprehensive overview of a patient's care during an appointment.
- Only Doctors Use It: Another common myth is that only physicians interact with the Superbill. In fact, various staff members, including nurses and administrative personnel, utilize the form. They rely on it for accurate record-keeping and ensuring that all patient interactions are properly documented.
- All Superbills Are the Same: Some assume that all Superbill forms are standardized. However, each practice may customize their Superbill to reflect specific services and procedures they offer. This customization is important for accurately capturing the unique aspects of patient care provided by that practice.
- It’s Not Necessary for Routine Visits: Many individuals think a Superbill is only needed for specialized appointments. This is misleading. Even routine visits require the completion of a Superbill to ensure proper documentation, billing, and continuity of care.
Key takeaways
The Family Practice Superbill form serves as a crucial tool for healthcare providers in managing patient billing and coding efficiently. Here are some key takeaways regarding its effective use:
- Accurate Information: Ensure all patient details, such as name, date of service, and insurance information, are correctly filled out to avoid billing disputes.
- Appropriate Coding: Selecting the correct procedure and diagnosis codes is vital for accurate billing and reimbursement from insurance providers.
- Prioritize Services: Rank the provided services based on their relevance to the patient's visit to enhance clarity for billing departments.
- Co-pay and Payment: Clearly indicate any copayment amount and today's payment to maintain transparency with patients regarding their financial responsibilities.
- Documentation: Keep a copy of the Superbill for your records, as it can be essential for future reference or in case of audits.
- Monitor Balances: Regularly review previous balances and the balance due to manage accounts effectively and avoid collection issues.
- Utilize the Template: Leverage the standardized format of the Superbill for consistent usage across all patient interactions to streamline administrative processes.
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