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Superbill Template: 20+ Templates for Various Health Care Services

A superbill is an in-depth receipt which signifies the various services catered by healthcare providers. These bills contain all the necessary information that is typically absent from your traditional bill. Superbills are generated for clients who function with a practitioner, residing in the outer networks of the healthcare industry. These providers could refer to a various line of professions such as psychiatrists, therapists, chiropractors etc.

Superbills are used as the elementary source of information by insurance corporations for creating healthcare claims. Clients who submit these claims to insurance companies are eligible to receive reimbursement for the services opted for by them. There are a lot of practitioners who submit these claims on behalf of the clients.

Any form of reimbursement which is provided by the insurance companies is directly routed back to the client. Due to this, it is highly essential that, as a practitioner, you provide your clients with a superbill allowing them to participate in the reimbursement.

Components of A Superbill

A generalized superbill consists of three major sections information. These sections are further categorized to allow for additional amounts of information. The major sections prevalent in the superbill are:

  1. Provider Information – The provider information refers to the details of the superbill provider or the healthcare service provider. This section is written in an easy-going, simple and straightforward manner. It consists of all the important information which are required for submitting an insurance claim. The details which are further incorporated into the healthcare provider information section include the provider’s:
  2. First and Last Name
  3. Office Address and Phone Number
  4. Phone Number and Email Address
  5. Signature
  6. Employee Identification Number – The Employer Identification Number is used as the identification standard. The number is supplied by the IRS for tax purposes. Also known as the Federal Tax Identification Number, the Employee Identification Number is often referred to as the social security number for businesses.
  7. National Provider Identifier – The National Provider Identifier is a 10-digit identification number that is used as a basis for recognition among healthcare providers. It is provided to the various individual healthcare providers such as therapists, doctors who function beyond the borders of typical healthcare providers. Issued by the Centers for Medicare and Medicaid Services, the number is employed by complete hospitals as well. Doing so allows the hospitals to function in accordance with the NPI which allows them to operate freely within the insurance system.
  8. Patient Information – The Patient Information section retains all data in regards to the patient. This information is required by the healthcare providers as well as their clients for the purposes of applying to the insurance claim, which furnishes them with reimbursement opportunities. The details of the patient which are provided beneath this information are:
  9. First name and last name
  10. Current Residential Address
  11. Contact Number
  12. Date of Birth
  13. Insurance Information
  14. Visit Information – The Visit Information is in-charge of retaining all the information regarding a particular visit or multiple visits made by the patient to the healthcare provider. Unlike a typical bill, a superbill displays detailed information regarding each and every individual appointment made by the patient to the provider.

If the patient makes singular appointments or visits to the healthcare provider, the superbill contains information only regarding that particular event. However, for multiple appointments, the superbill is required to provide an individual date for each individual appointment that is registered.

The information which is provided below the visit information is:

  1. Date of Visit
  2. Procedures Codes and their Description – The Procedure Codes refer to CPT or the Current Procedural Terminology. CPT is a medical coding system which was created to provide easy recognition to medical, surgical and diagnostic procedures.
  3. Diagnosis Codes and their Description – The diagnosis codes classify any symptoms, diseases, diagnoses and other such data to supply the consumer with the specifics, regarding the reason for them receiving the care.

There is a lot of diagnoses which requires multiple diagnostic codes. This is performed when a patient is diagnosed and treated with multiple medical issues. Typically, providers use a coding schema for this process. This schema gets updated as and when required. The current coding schema is referred to by the acronym ICD10.

The previous coding schema was referred to by the acronym ICD09 which has currently been deemed ineffective. If you are receiving treatment from a provider who still uses the old coding schema of ICD09, your insurance claim will automatically get rejected by the insurance company.

  1. Modifiers
  2. The Duration of the Session usually noted in minutes.
  3. Fees Charged

Superbill Format

There are numerous healthcare providers who function beyond the traditional norms of Medicare and healthcare. Due to this, there are a plethora of superbill formats that are available on the Internet as well as in medical circles. All of these formats are designed, keeping in mind their varied individual uses including superbill for medical, acupuncture, podiatry, chiropractic, speech therapy etc. uses.

However, there are a few norms according to which all templates are designed. Due to this, every superbill has a few common factors which are in accordance with each the next superbill.

Given below is the step-by-step format using which the superbill format is created.

  1. A superbill starts off with the name of the healthcare provider, be it the name of an organization or an individual provider. Beneath it, the name of the medical organization, such as the American Academy of Family Practice or AAFP, is provided. It is under this medical organization that the healthcare provider is recognized.
  2. Next, the superbill registers the Parent Information. This section includes the patient name, date of service, address, phone number, date of birth, age, sex etc.
  3. After this, the superbill mentions the various details of the provider. The Provider Information includes the physician’s name, account no., waiver details, insurance details, previous balance, today’s charges, today’s payment (if any), the balance due and so on.
  4. Beneath this, the superbill provides details regarding the services provided by the healthcare provider along with the rank and the code. These services are categorized under a particular heading beneath which all the distinct services are named. Apart from this, a few superbills can also include a section for medications, immunization & injections and other such miscellaneous services.
  5. Next, the superbill contains a Referral section at the bottom. This section is used when the specialist refers the patient to another specialist where they can receive better treatment. The referral section contains two sections, namely – the name of the referred specialist and instructions which are provided to the referred specialist.
  6. Finally, there is a section for the physician’s signature at the bottom of the page.

How To Fill A Superbill Template

In order to make an insurance claim and be eligible for reimbursement, there are seven typical elements which you must correctly fill and keep in mind.

These elements include:

  1. The name, credentials, business alias, contact information, TIN or Tax Identification Number and the NPI number of the healthcare provider should be mandatorily provided.
  2. The patient should have at least one primary ICD-10 diagnosis.
  3. There should be at least one CPT code selected.
  4. The fee and the amount paid by the patient to the healthcare provider should be thoroughly mentioned.
  5. The signature of the healthcare provider and the date should be present on the form.
  6. The client must have a copy of the superbill.

Apart from this, the client must also sign as well as date the release box which is present in the form.

Types of Superbill Template

ICD-10 Superbill Template

ICD-10 or ICD-10-CM stands for Internation Classification of Diseases, Tenth Revision, Clinical Modification. This is a coding system that is used by physicians to code the various diagnoses, symptoms and the procedures to be used for the treatment. The coding system allows provides the healthcare services with a better level of detail of specificity and classification in the United States.

Medical Superbill Template

Superbills are completed and submitted by the providers for the sole purposes of reimbursement. These superbills are typically based on the procedures and diagnosis which the patient has to go through during their treatment process. Superbills also allow for the display of the patient’s diagnoses and procedures which are specific to their appointment.

Given below is an example of a sample medical superbill template which could be used by healthcare providers to provide data regarding the patient’s treatment.

 

Patient Name: ______________________  Date: ___________  Time In: _____________

Bill No. ________________                                                         Time Out:____________

 

Symptoms/ Diagnosis

 

Code                                                                          Name of the Symptom/Diagnosis

 #1                                                                                           Diagnosis No. 1

 #2                                                                                           Diagnosis No. 2

 #3                                                                                           Diagnosis No. 3

 #4                                                                                           Diagnosis No. 4

 #5                                                                                           Diagnosis No. 5

 

 

Consults

Name of Consult                                                                                         Consult Code

Consult 1                                                                                                           xxxxx

Consult 2                                                                                                           xxxxx

Consult 3                                                                                                           xxxxx

Consult 4                                                                                                           xxxxx

Consult 5                                                                                                           xxxxx

 

                                                                                                _______________________

                                                                                                    Signature of Provider

 

 

 

Acupuncture Superbill Template

There is a varied range of acupuncture services provided. Due to this, it often becomes hard to recall the details of all the acupuncture services provided to the client. Due to this, we have provided an acupuncture superbill template which will assist providers in billing for the acupuncture services.

Given below is a sample acupuncture superbill template:

Name of The Organization or Individual                                                          NPI No.:

Address                                                                                                         EIN No.:

Contact Number                                                                                         

 

Date of Service:

 

Patient Information:

Name:

Address:

Phone No:

Date of Birth:

Age:

Sex:

 

Insurance Information:

Subscriber Name:

Insurance Company:

Subscriber ID:

 

Provider’s Statement

Insert the provider’s statement here

 

Office Visit Details

 

Consultation Details:

 

Other Services:

 

Diagnosis:

 

Accupuncture Procedures Details:

 

Therapeutic Procedure Details:

 

Physical Modalities Details:

 

Details of Miscellaneous Procedures:

 

Other Procedures:

 

Supplies Details:

 

Billing Information:

Previous Balance: _________________

Charges Subtotal: _________________

Discounts (if any):__________________

 

Today’s Charges:___________________

 

Today’s Payments:__________________

 

Payment via:

Cash:              __________________________

Check:                       __________________________

Credit Card: __________________________

 

Balance Due:            ___________________________

 

Referral:

 

To: ____________________________

Instructions (if any):

 

____________________________________

Provider’s Signature

Podiatry Superbill Template

A podiatry superbill helps the podiatrists to keep acquainted with the superbill which are to be used frequently. Apart from this, the CPT codes which are included in the template are done according to the choice of the podiatrists for their convenience. With the coming of the new ICD-10 convention, we have designed a superbill template which allows podiatrists to make an easy selection of the diagnostics available.

Given below is an example of an ICD-10 Podiatry Superbill Template:

 

Appointment Date:

Appointment Time:

Last Seen Date:

 

Patient Details

Patient’s Name:

Gender:

Date of Birth:

Address:

 

Reason:

 

Contact Number:

Cellphone Number:

E-Mail Address:

 

Case Details:

Case Name:

Case No.:

Case Number:

Case Type:

 

Insurance Details

PR Insurance:

Member ID:

Co-Pay Amount:

Deductible:

 

Provider Details:

Rendering Provider:

PCP:

Referring Provider:

 

CPT Codes

 

CPT                                        Description               CPT                            Description

Code                                                                         Code                         

 

 

ICD Codes

 

ICD-10                                               Description               ICD-10                                   Description

Code                                                                          Code                           

 

 

Payment Details:

Charges:

 

Mode of Payment:

Cash:

Check:

MC:

VISA:

AMX:

Debt:

Credit Card No.:

 

Balance:

 

 

                                                                                    _____________________________

                                                                                                Doctor’s Signature

 

 

Chiropractic Superbill Template

 

Patient Details:

Name of Patient:

Address:

Contact Number:

E-Mail Address:

Gender:

 

Date of Service:

 

Code              Description               Fee      Code              Description               Fee

 

Office Visit Details (for new patients)                             Passive Modalities

 

Office Visit Details(for recurring patients)                                 Active Modalities

 

CMT Procedures

 

Miscellaneous Details

 

X-Ray Details

 

 

Payment Details:

Previous Balance: _________________

Charges Subtotal: _________________

Discounts (if any):__________________

 

Today’s Charges:___________________

 

Today’s Payments:__________________

 

Payment via:

Cash:              __________________________

Check:                       __________________________

Credit Card: __________________________

 

Balance Due:            ___________________________

 

 

Referral Details:

To:

Instructions:

 

                                                                                    ____________________________

                                                                                                Doctor’s Signature

 

 

Dietitian Superbill Template

Dietitian superbill templates are provided for the purpose of Registered Dietitian Nutritionists or RDNs. Such specialists provide MNT services to a client. With the help of a dietitian superbill template, clients can also file for health plan payment.

Given below is a sample dietitian superbill template:

Name of The HealthCare Providers

Address:

Contact Number:

Email Address:

Website:

Tax ID:

 

Patient Information:

Name of the Patient:

Patient Account Number:

Address:

Telephone Number:

Date of Birth:

Gender:

 

Insurance Details:

Insurance Carrier:

Policy No.:

Group No:

 

Dates of Service:

Diagnosis:

 

Procedure Codes

            Details                                   Rank                                      Details                                   Rank

 

Evalulative Procedures                                          Special Services and Reports

 

Therapeutic Procedures                                         Other Psychiatric Therapy

 

Team Conferences                                                  Telephone Calls

 

Payment Details:

 

Total Sessions                                                                                              Charge Per Session

Total Charges

Adjustments

Payments

Prior Balance

Balance Due

 

                                                                                                ___________________________

                                                                                                            Provider’s Signature

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