Blank Family Practice Superbill PDF Template
The Family Practice Superbill form, provided by the American Academy of Family Practice (AAFP), is a comprehensive tool designed to streamline billing processes for family practices. This template is a key element in the Family Practice Management Toolkit, facilitating easy tracking and billing of various medical services ranging from office visits to laboratory tests, procedures, and even vaccinations. It includes details such as patient information, date of service, insurance details, and a breakdown of services rendered categorized by office visits, laboratory services, and other procedures. Physicians are able to indicate the specific services provided, such as detailed office visits, blood tests, ECGs, and vaccinations, using standardized medical billing codes. Additionally, it incorporates sections for diagnoses, medications, next office visit recommendations, referral instructions, and special services like after-hours consultations—essentially covering every aspect of patient care and practice management. This organized approach not only aids in accurate and efficient billing but also ensures compliance with healthcare reporting standards, thus optimizing the operational aspects of family practices.
Preview - Family Practice Superbill Form
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 |
|
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, |
|
unspecified |
J18.8 |
Other pneumonia, unspecified |
|
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 Data
| Fact Name | Description |
|---|---|
| Origin | The Family Practice Superbill form is provided by the American Academy of Family Practice (AAFP) as part of their Family Practice Management Toolkit. |
| Content Overview | Includes sections for patient information, insurance details, various medical services with codes (office visits, procedures, laboratory services), medications, diagnoses, and preventive services. |
| Purpose | Designed to streamline the billing process in family practice settings by including commonly used codes and services to ensure accurate and efficient billing. |
| Accessibility | Accessible to healthcare providers through the AAFP website, ensuring that practitioners can easily incorporate the form into their administrative tasks. |
Instructions on Utilizing Family Practice Superbill
Filling out the Family Practice Superbill form is a straightforward process designed to ensure that all necessary information is accurately captured for billing and insurance purposes. As we move forward, it's essential to pay close attention to detail and ensure all data is correct to prevent any delays in processing. Here's a step-by-step guide to assist you in completing the form efficiently.
- Start by entering the Date of service at the top of the form.
- Check the box next to Waiver? if applicable for the patient's situation.
- Fill in the Patient name, DOB (Date of Birth), Age, and Sex.
- Provide the Physician name who conducted the visit.
- Under the insurance section, input the Insurance company name, Subscriber name, Address, Group #, and the patient's Phone number.
- For billing information, include any Previous balance, Copay, Today’s charges, Account #, Today’s payment, and check # if a payment was made.
- In the services section, rank the office visit, office procedures, and laboratory services provided during the visit using the provided codes. Mark any applicable well visit codes as well.
- If any Medicare preventive services were performed, ensure to mark them clearly.
- Under Diagnoses, list all conditions diagnosed during the visit, alongside their respective codes.
- In the Medications section, specify any medications administered, including the units and the medication codes.
- Fill out the Immunizations & Injections section with any vaccines given during the visit, marking the units for each.
- For the Next office visit, indicate when the patient is expected back, along with any instructions given.
- If a Referral is made, include the details of the referral, to whom it was made, and any special instructions.
- Ensure the Physician signature is added to validate the Superbill.
Once the form is filled out, double-check for accuracy to ensure all the information provided is correct and complete. Accuracy is crucial to ensuring prompt and proper billing, potentially reducing the likelihood of claim rejections or delays in payment. If you have any questions or need further clarification while filling out the form, don't hesitate to ask for assistance.
Obtain Answers on Family Practice Superbill
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What is a Family Practice Superbill?
A Family Practice Superbill is a comprehensive form used by healthcare providers, particularly in family practice, to collect and organize charges for services rendered to a patient. It includes details such as patient information, date of service, physician name, procedures, office visits, laboratory tests, diagnoses codes, and medications administered. It serves as a crucial document for billing and insurance purposes.
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How do I obtain a Family Practice Superbill?
Family Practice Superbills are typically provided by the healthcare facility where you received your services. You can request a copy directly from your family practice office, usually from the billing department. It's also possible to download templates from professional organizations such as the American Academy of Family Practice (AAFP).
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Why is my insurance information included on the Superbill?
Insurance information is essential on a Superbill because it enables the healthcare provider to submit a claim to your insurance company for reimbursement of services provided. The Superbill contains detailed information about the visit, including insurance specifics, which is needed to process the claim efficiently.
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What does 'DOB' stand for on the Superbill?
'DOB' on the Superbill stands for Date of Birth. It's a critical piece of patient information that helps in accurately identifying the patient and ensuring that their medical records, billing, and insurance claims are correctly processed.
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Can a Superbill be used for reimbursement from my insurance company?
Yes, a Superbill can be used for reimbursement purposes. Patients who pay for their medical services out of pocket can submit the Superbill to their insurance company for direct reimbursement. The Superbill contains all the necessary information, such as codes for procedures and services rendered, to facilitate the reimbursement process.
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What if there are errors on my Superbill?
If you spot errors on your Superbill, it's important to contact your healthcare provider's office as soon as possible to have them corrected. Errors could include incorrect patient information, wrong or missing service codes, or inaccurate dates of service. Prompt correction ensures accurate billing and insurance claims processing.
Common mistakes
Filling out a Family Practice Superbill form accurately is crucial for ensuring that medical services are billed correctly. However, several common mistakes can occur during this process:
- Incorrect Patient Information: Entering incomplete or inaccurate patient details, such as name, date of birth, or insurance details, can lead to claim rejections or delays.
- Failing to Update Insurance Information: Not updating insurance information or subscriber details can result in claim denials, as coverage may have changed.
- Incorrect Service Dates: Not specifying the correct date of service for each procedure or visit can cause billing discrepancies and payment delays.
- Leaving the Physician Name Blank: Every superbill must include the attending physician's name to ensure the bill is processed correctly.
- Overlooking Copay and Payment Details: Not documenting the copay collected or the method of today’s payment may result in inaccurate patient account balances.
- Misidentifying Procedures or Services: Using incorrect codes or failing to adequately describe the service provided can lead to underpayment or denial of claims.
- Not Specifying Consultation Type: Whether the patient is new or established should be clearly marked to bill the visit accurately.
- Omitting Modifiers: Failing to add necessary modifiers to procedure codes can lead to rejected claims for not meeting specific billing criteria.
- Incomplete Vaccination Information: Not adequately documenting vaccinations given, including the specific vaccine and the administration site, can affect reimbursement.
In conclusion, careful attention to detail is essential when completing the Family Practice Superbill form. Avoiding these common mistakes can streamline the billing process, ensuring timely and correct payments for services rendered.
Documents used along the form
The Family Practice Superbill form is an essential document used in healthcare settings, particularly within family practice offices. This form serves as a billing tool, summarizing the services provided to a patient during a visit, including diagnostic codes, treatment codes, procedures performed, and other relevant billing information. To streamline the documentation and billing process further, several other forms and documents are commonly used alongside the Family Practice Superbill form. Each plays a crucial role in ensuring accurate and comprehensive patient care and billing management.
- Patient Registration Form: Captures essential details about the patient, including contact information, insurance details, and medical history. This form is typically completed during the patient's first visit and updated as necessary.
- Insurance Verification Form: Used by office staff to confirm a patient's insurance coverage before services are rendered. This ensures that the procedures and visits billed are covered under the patient’s current insurance plan.
- Consent for Treatment Form: A legal document that patients sign to give their consent for medical treatment. This form is vital for compliance and to inform patients about the procedures and treatments they will receive.
- Health History Questionnaire: Provides comprehensive information about the patient’s medical history, allergies, current medications, and any chronic conditions. This document is critical for informing treatment plans and for updating the patient's medical records.
- Medication List: A detailed list of medications that a patient is currently taking, including dosages and frequency. This document helps prevent prescription errors and informs drug management plans.
- Referral Forms: If a patient needs to see a specialist or requires services outside the family practice, referral forms are used to document and authorize these referrals, ensuring continuity of care.
- Privacy Notice and Acknowledgement Form: Informs patients about their privacy rights under the Health Insurance Portability and Accountability Act (HIPAA) and records their acknowledgment of receipt of this information. This form is crucial for compliance with federal privacy regulations.
In conclusion, while the Family Practice Superbill form plays a central role in the billing process, it is just one part of a suite of documents that support the administrative and clinical aspects of patient care. Each document serves a specific purpose, from capturing patient details and medical history to ensuring compliance with legal requirements. Together, these forms enable healthcare providers to deliver care efficiently, ensure accurate billing, and maintain comprehensive patient records.
Similar forms
Medical Encounter Form: Like the Family Practice Superbill, this document outlines services provided during a patient visit, including procedures and diagnoses. It serves as a communication tool between healthcare providers and billing or administrative professionals.
Procedure Coding Sheet: Similar to the Superbill, it lists procedures performed, but focuses more on coding for billing purposes. It translates medical services into codes necessary for insurance claims and reimbursement, akin to the CPT and ICD codes on the Superbill.
Insurance Claim Form: This document is closely related to the Superbill as it is used to file claims with insurance companies. It contains patient information, insurance details, and services rendered, similar to the Superbill's content but formatted for insurers.
Health Maintenance Organization (HMO) Referral Form: Although more specific, it shares similarities with the Superbill in providing patient and visit details. It is used within HMOs for authorizing referred services, showing patient information and the necessity for additional care.
Electronic Health Records (EHR) Summary: This comprehensive document records a patient's visit, including details found in a Superbill such as diagnoses and procedures. It’s part of the larger digital record system, showcasing the patient’s medical history and the services they’ve received.
Visit Discharge Summary: While it contains comprehensive details about the patient’s condition and the care they received during an inpatient stay, it parallels the Superbill by detailing diagnoses and procedures, facilitating continuity of care and accurate billing.
Prescription Pad: This document lists medications prescribed during a visit, which can be detailed on a Superbill under medications provided or prescribed, contributing to the overall understanding of the patient's treatment plan and medical billing.
Laboratory Requisition Form: Similar to parts of the Superbill, these forms detail tests ordered during a visit. They provide clear instructions to the laboratory on what tests are needed, reflecting the diagnosis and care plan found on the Superbill.
Medication Administration Record (MAR): This tracks medications administered, corresponding with the Superbill’s documentation of drugs given during office visits. It ensures accuracy in patient care and billing for medications.
Advance Beneficiary Notice (ABN): While this form is specific to Medicare, it informs patients of services Medicare might not cover, similar to how the Superbill may include notes on waivers or patient responsibilities. It’s a crucial tool for managing expectations and financial responsibilities.
Dos and Don'ts
When filling out the Family Practice Superbill form, there are several best practices and pitfalls to avoid ensuring accuracy and compliance. Below are lists of what you should and shouldn't do:
Things You Should Do:
- Verify patient information for accuracy, including name, date of birth, insurance details, and account numbers, to prevent billing and processing delays.
- Ensure that the date of service and the physician's name are correctly entered, as these are key components for insurance claims and patient records.
- Select the correct codes for office visits, procedures, and laboratory services provided. This includes checking for the appropriate office visit level, procedure codes, and ensuring any performed laboratory tests are accurately documented.
- Review the completed form for any errors or omissions before submission. This includes double-checking the accuracy of all entered information, and ensuring that any applicable waivers are properly noted.
Things You Shouldn't Do:
- Leave sections incomplete. Every required field should be filled out to ensure the claims process can proceed without unnecessary interruptions.
- Guess or approximate codes. Always use the precise code that best describes the service, procedure, or diagnosis. Incorrect coding can lead to claim rejections or denials.
- Forget to update the patient's insurance information. Always confirm that the insurance details are current to avoid delays or denials in coverage.
- Overlook the need for patient or provider signatures, if required. The absence of necessary signatures can invalidate a claim or delay its processing.
Misconceptions
When discussing the Family Practice Superbill form, several misconceptions commonly arise, potentially leading to confusion about its purpose, use, and implications. Let's address some of these misunderstandings:
- It's only for insurance companies: While it's true that the Superbill is an essential document for insurance billing, its utility extends beyond that. It serves as a comprehensive record of the services provided during a patient’s visit, which can be useful for the patient's personal records and future healthcare providers.
- It’s the same as an invoice: This is a common misunderstanding. Although the Superbill does list services provided along with their associated costs, it includes detailed medical information, diagnosis codes, and service codes, making it more detailed than a standard invoice aimed at requesting payment.
- It determines the final cost a patient pays: The information on a Superbill allows insurance companies to determine coverage, but it doesn’t directly determine the patient's out-of-pocket costs. These costs are affected by the individual's insurance plan, deductibles, copays, and whether the provider is in-network.
- It's only for family practices: Despite the name, the form is not exclusive to family practices. Many types of healthcare providers use a version of the Superbill tailored to their specialties to document and bill for services rendered.
- All medical procedures can be listed on the Superbill: While the Superbill covers a wide range of services and diagnoses, there are limitations. Some specific procedures or lesser-known diagnoses may not have pre-assigned codes and might require additional documentation.
- Patients cannot understand the Superbill: It's a misconception that the medical codes and jargon on a Superbill are beyond a layperson's comprehension. With a bit of guidance, patients can learn to understand the basics of the information presented, such as service dates, provider details, and the types of services rendered.
- Superbills guarantee insurance coverage: Submitting a Superbill to an insurance company does not guarantee coverage or payment. Coverage is subject to the terms of the patient's insurance policy, including exclusions, prior authorizations, and network participation of the providers.
Understanding these aspects of the Family Practice Superbill can help both healthcare providers and patients navigate the complexities of medical billing more effectively, ensuring clearer communication and reducing potential billing errors.
Key takeaways
Filling out and using the Family Practice Superbill form correctly is vital for efficient billing and reimbursement. Here are key takeaways to consider:
- The Superbill form originates from the American Academy of Family Practice (AAFP) and is designed to streamline the billing process in family practice settings.
- Essential patient information such as name, date of birth, sex, and insurance details must be accurately filled to ensure there are no delays in claim processing.
- The form includes sections for various services such as office visits, office procedures, laboratory tests, immunizations & injections, and diagnoses, among others. Each section has predefined codes to select from for ease of use.
- It’s crucial to review and double-check all codes entered, as incorrect or missing codes can lead to claim rejections or denials, causing delays in payment.
- Well visits, consultations, and preventive services have their designated areas in the Superbill, which helps in identifying these services quickly for billing purposes.
- Medications administered during the office visit can and should be billed using the form, with specific codes for each medication provided.
- Any referral information, including specialist visits or tests ordered outside the family practice, should be documented properly for continuity of care and billing.
- The physician’s or healthcare provider's signature is mandatory at the end of the Superbill to validate the services rendered during the office visit.
- For accurate reimbursement, the form should be completed the same day as the patient's visit to ensure all services are billed correctly and timely.
- Keeping a copy of the completed Superbill in the patient's record is essential for future reference, auditing purposes, and to resolve any discrepancies with insurance claims.
Attention to detail and a thorough understanding of the Superbill’s components can significantly impact the billing cycle’s efficiency and the practice’s overall financial health.
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