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

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download