Ear, Nose and Throat Superbill Template
Ear, Nose and Throat Superbill Template
Date of service: Patient name:
Insurance:
Address:
Phone: DOB:
Age: Sex:
Subscriber name: Group #: Copay: Account #: Physician name:
Previous balance: Today's charges: Today's payment: Balance due:
check#
MOD. Patient E/M
New
Est MOD. I&D, intraoral, tongue, floor of 41005 MOD. Flexible laryngoscopy with
mouth, sublingual, superficial
removal of lesion
31578
Level I
99201 99211
I&D, intraoral, tongue, floor of 41005 mouth, sublingual, superficial
Flexible laryngoscopy with stroboscopy
31579
Level II
99202 99212
I&D, extraoral, floor of mouth, 41015 sublingual
Incision of labial frenulum
40806
Level III
99203 99213
I&D, extraoral, floor of mouth, 41016 submental
Excision lingual frenulum
41115
Level IV
99204 99214
I&D, extraoral, submandibular 41017
Uvulectomy
42140
Level V
99205 99215
I&D, peritonsillar
42700
Destruction of lesion, palate or uvula (thermal, cryo)
42160
Consultations
I&D infected thyroglossal duct 60000 cyst
Palate Somnoplasty
4214552
Consultation Level I
99241
I&D external ear, simple
69000
Turbinate Somnoplasty
3014052
Consultation Level II
99242
I&D external ear, complicated 69005
Cautery ablation, any method, superficial
30801
Consultation Level III
99243
I&D, external auditory canal 69020
Cautery ablation, intramural
30802
Consultation Level IV
99244
Ear Procedures
Removal of foreign body, intranasal
30300
Consultation Level V
99245
Myringotomy
69420
Removal of foreign body, external 69200 auditory canal
Biopsy
Tympanostomy
69433
Vestibular Function Tests
Biopsy (Skin)
11100
Tympanostomy with general 69436 anesthesia
Spontaneous nystagmus
92531
each additional skin biopsy 11001
Impacted cerumen removal 69210
Caloric vestibular test
92532
Biopsy, nasal
30100
Control of Nasal Bleed
Optokinetic nystagmus test
92534
Biopsy, lip
40490
Simple nasal hemorrhage control
30901
Basic vestibular evaluation, with 92540 recording
Biopsy, vestibule of mouth 40808
Anterior, complete nasal
30903
Spontaneous nystagmus, with
92541
Biopsy, tongue (anterior 2/3) 41100
Biopsy, tongue (posterior 1/3)
Biopsy, floor of mouth
41105 41108
Biopsy, palate, uvula
42100
Biopsy, oropharynx
42800
Biopsy, hypopharynx
42802
Biopsy, nasopharynx, visible lesion
Biopsy, nasopharynx, unknown primary
Sialolithotomy
42804 42806
Sialolithotomy, uncomplicated, intraoral
42330
Sialolithotomy, submandibular, complicated, intraoral
42335
Sialolithotomy, parotid, extraoral or complicated intraoral
42340
Incision and Drainage
I&D abscess, simple, single 10060
I&D, complicated, multiple 10061
I&D hematoma, seroma, fluid 10140 collection
Puncture aspiration of abscess, cyst, hematoma
10160
I&D complex, postoperative wound infection
10180
I&D nasal abscess or hematoma
30000
I&D nasal septum abscess or 30020 hematoma
I&D vestibule of mouth, simple
40800
I&D vestibule of mouth, complicated
40801
I&D, intraoral, tongue, floor of 41000 mouth, lingual
hemorrhage control Posterior nasal hemorrhage control Nasal Endoscopy
30905
Diagnostic nasal endoscopy 31231
Maxillary sinusoscopy
31232
Sphenoid sinusoscopy
31235
Nasal endoscopic biopsy, polypectomy or debridement
31237
Nasal endoscopic hemorrhage 31238 control
Nasal endoscopy with dacryocystorhinostomy
31239
Nasal endoscopy with concha bullosa resection
31240
Endoscopic partial ethmoidectomy
31254
Endoscopic total ethmoidectomy
31255
Endoscopic maxillary antrostomy
31256
Endoscopic maxillary tissue removal
Frontal sinus endoscopy
Endoscopic sphenoidotomy
Endoscopic removal of sphenoid tissue
Endoscopic maxillary sinus dilation
Endoscopic frontal sinus dilation
Endoscopic sphenoid sinus dilation
Flexible Laryngoscopy
31267 31276 31287 31288 31295 31296 31297
Flexible diagnostic laryngoscopy
Flexible laryngoscopy with biopsy
Flexible laryngoscopy with foreign body removal
31575 31576 31577
recording
Positional nystagmus test, with recording
Caloric vestibular test, with recording
Optokinetic nystagmus test, with recording
Oscillating tracking test, with recording
Tympanometry and reflex threshold measurements
Pure tone screening
92542 92543 92544 92545 92550 92551
Pure tone audiometry; air only 92552
Pure tone audiometry: air and bone
Speech audiometry threshold
92553 92555
Speech audiometry threshold with 92556 speech recognition
Comprehensive audiometry
92557
Percutaneous allergy skin test
95004
Allergy testing for venoms
95017
Allergy testing for drugs, biological 95018
Intradermal allergy tests
95024
Single allergy injection (including 95120 extract)
Two or more allergy injections (including extract)
95125
Preparation and provision of antigens
95165
Inhalation bronchial challenge 95070
Nasopharyngoscopy
92511
Single allergy injection (without extract provision)
Venipuncture
95115 36415
Handling
99000
ICD-10 Codes
C00.9 C01 C02.3 C04.9 C05.0 C06.9 C07 C08.0 C10.9 C11.9 C13.9 C30.0 C32.0 C32.1 C32.9 C44.00 C44.01 C44.02 C44.09 C44.202 C44.209 C44.212 C44.219 C44.222 C44.229 C44.301 C44.309 C44.311 C44.319 C44.321 C44.329 C44.40 C44.41 C44.42 C44.49 C73 C77.0 D00.01 D00.02 D00.03 D00.04 D00.05 D00.06 D00.07 D00.08 D10.30 D10.39 D11.0 D11.7 D14.0 D14.1
Diagnosis
Malignant neoplasm of lip, unspecified Malignant neoplasm of base of tongue Malignant neoplasm of anterior two-thirds of tongue, part unspecified Malignant neoplasm of floor of mouth, unspecified Malignant neoplasm of hard palate Malignant neoplasm of mouth, unspecified Malignant neoplasm of parotid gland Malignant neoplasm of submandibular gland Malignant neoplasm of oropharynx, unspecified Malignant neoplasm of nasopharynx, unspecified Malignant neoplasm of hypopharynx, unspecified Malignant neoplasm of nasal cavity Malignant neoplasm of glottis Malignant neoplasm of supraglottis Malignant neoplasm of larynx, unspecified Unspecified malignant neoplasm of skin of lip Basal cell carcinoma of skin of lip Squamous cell carcinoma of skin of lip Other specified malignant neoplasm of skin of lip Unspecified malignant neoplasm of skin of right ear and external auricular canal Unspecified malignant neoplasm of skin of left ear and external auricular canal Basal cell carcinoma of skin of right ear and external auricular canal Basal cell carcinoma of skin of left ear and external auricular canal Squamous cell carcinoma of skin of right ear and external auricular canal Squamous cell carcinoma of skin of left ear and external auricular canal Unspecified malignant neoplasm of skin of nose Unspecified malignant neoplasm of other parts of face Basal cell carcinoma of skin of nose Basal cell carcinoma of skin of other parts of face Squamous cell carcinoma of skin of nose Squamous cell carcinoma of skin of other parts of face Unspecified malignant neoplasm of skin of scalp and neck Basal cell carcinoma of skin of scalp and neck Squamous cell carcinoma of skin of scalp and neck Other specified malignant neoplasm of skin of scalp and neck Malignant neoplasm of thyroid gland Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck Carcinoma in situ of labial mucosa and vermilion border Carcinoma in situ of buccal mucosa Carcinoma in situ of gingiva and edentulous alveolar ridge Carcinoma in situ of soft palate Carcinoma in situ of hard palate Carcinoma in situ of floor of mouth Carcinoma in situ of tongue Carcinoma in situ of pharynx Benign neoplasm of unspecified part of mouth Benign neoplasm of other parts of mouth Benign neoplasm of parotid gland Benign neoplasm of other major salivary gland Benign neoplasm of middle ear, nasal cavity and accessory sinuses Benign neoplasm of larynx
D22.11 D22.12 D23.11 D23.12 D33.3 D35.2 D37.01 D37.02 D37.030 D37.031 D37.032 D37.04 D37.05 D37.09 D38.0 D48.5 D49.0 D49.1 D49.2 D49.7 E04.1 E04.2 E05.90 E06.9 E21.0 E21.1 E21.2 E84.9 F45.8 F80.4 G47.09 G47.19 G47.30 G47.33 G50.1 G51.0 H6.301 H60.331 H60.332 H60.333 H60.391 H60.392 H60.393 H60.511 H60.512 H60.513 H60.521 H60.522 H60.523 H60.531 H60.532 H60.533 H60.541
Melanocytic nevi of right eyelid, including canthus Melanocytic nevi of left eyelid, including canthus Other benign neoplasm of skin of right eyelid, including canthus Other benign neoplasm of skin of left eyelid, including canthus Benign neoplasm of cranial nerves Benign neoplasm of pituitary gland Neoplasm of uncertain behavior of lip Neoplasm of uncertain behavior of tongue Neoplasm of uncertain behavior of the parotid salivary glands Neoplasm of uncertain behavior of the sublingual salivary glands Neoplasm of uncertain behavior of the submandibular salivary glands Neoplasm of uncertain behavior of the minor salivary glands Neoplasm of uncertain behavior of pharynx Neoplasm of uncertain behavior of other specified sites of the oral cavity Neoplasm of uncertain behavior of larynx Neoplasm of uncertain behavior of skin Neoplasm of unspecified behavior of digestive system Neoplasm of uncertain behavior of respiratory system Neoplasm of uncertain behavior of bone, soft tissue, and skin Neoplasm of uncertain behavior of endocrine glands and other parts of nervous system Nontoxic single thyroid nodule Nontoxic multinodular goiter Thyrotoxicosis, unspecified without thyrotoxic crisis or storm Thyroiditis, unspecified Primary hyperparathyroidism Secondary hyperparathyroidism, not elsewhere classified Other hyperparathyroidism Cystic fibrosis Other somatoform disorders Speech and language development delay due to hearing loss Other insomnia Other hypersomnia Sleep apnea, unspecified Obstructive sleep apnea (adult) (pediatric) Atypical facial pain Bell's palsy Acquired stenosis of right external ear canal, unspecified Swimmer's ear, right ear Swimmer's ear, left ear Swimmer's ear, bilateral Other infective otitis externa, right ear Other infective otitis externa, left ear Other infective otitis externa, bilateral Acute actinic otitis externa, right ear Acute actinic otitis externa, left ear Acute actinic otitis externa, bilateral Acute chemical otitis externa, right ear Acute chemical otitis externa, left ear Acute chemical otitis externa, bilateral Acute contact otitis externa, right ear Acute contact otitis externa, left ear Acute contact otitis externa, bilateral Acute eczematoid otitis externa, right ear
H60.542 H60.543 H60.551 H60.552 H60.553 H60.591 H60.592 H60.593 H60.61 H60.62 H60.63 H61.011 H61.012 H61.013 H61.021 H61.022 H61.023 H61.121 H61.122 H61.123 H61.21 H61.22 H61.23 H61.302 H61.303 H61.391 H61.392 H61.393 H61.811 H61.812 H61.813 H65.01 H65.02 H65.03 H65.04 H65.05 H65.06 H65.91 H65.92 H65.93 H66.001 H66.002 H66.003 H66.004 H66.005 H66.006 H66.011 H66.012 H66.013 H66.014 H66.015 H66.016 H66.11
Acute eczematoid otitis externa, left ear Acute eczematoid otitis externa, bilateral Acute reactive otitis externa, right ear Acute reactive otitis externa, left ear Acute reactive otitis externa, bilateral Other noninfective acute otitis externa, right ear Other noninfective acute otitis externa, left ear Other noninfective acute otitis externa, bilateral Unspecified chronic otitis externa, right ear Unspecified chronic otitis externa, left ear Unspecified chronic otitis externa, bilateral Acute perichondritis of right external ear Acute perichondritis of left external ear Acute perichondritis of external ear, bilateral Chronic perichondritis of right external ear Chronic perichondritis of left external ear Chronic perichondritis of external ear, bilateral Hematoma of pinna, right ear Hematoma of pinna, left ear Hematoma of pinna, bilateral Impacted cerumen, right ear Impacted cerumen, left ear Impacted cerumen, bilateral Acquired stenosis of left external ear canal, unspecified Acquired stenosis of external ear canal, unspecified, bilateral Other acquired stenosis of right external ear canal Other acquired stenosis of left external ear canal Other acquired stenosis of external ear canal, bilateral Exostosis of right external ear canal Exostosis of left external ear canal Exostosis of external ear canal, bilateral Acute serous otitis media, right ear Acute serous otitis media, left ear Acute serous otitis media, bilateral Acute serous otitis media, recurrent, right ear Acute serous otitis media, recurrent, left ear Acute serous otitis media, recurrent, bilateral Unspecified nonsuppurative otitis media, right ear Unspecified nonsuppurative otitis media, left ear Unspecified nonsuppurative otitis media, bilateral Acute suppurative otitis media without spontaneous rupture of ear drum, right ear Acute suppurative otitis media without spontaneous rupture of ear drum, left ear Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral Acute suppurative otitis media with spontaneous rupture of ear drum, right ear Acute suppurative otitis media with spontaneous rupture or ear drum, left ear Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral Chronic tubotympanic suppurative otitis media, right ear
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