Ear, Nose and Throat Superbill Template

Ear, Nose and Throat Superbill Template

Date of service:

Insurance:

Patient name:

Subscriber name:

Address:

Phone:

DOB:

MOD.

Patient E/M

Age:

New

Est

Sex:

MOD.

Group #:

Previous balance:

Copay:

Today¡¯s charges:

Account #:

Today¡¯s payment:

Physician name:

Balance due:

I&D, intraoral, tongue, floor of 41005

mouth, sublingual, superficial

MOD.

check#

Flexible laryngoscopy with

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

Destruction of lesion, palate or

uvula (thermal, cryo)

42160

I&D infected thyroglossal duct 60000

cyst

Palate Somnoplasty

4214552

Turbinate Somnoplasty

3014052

Consultations

42700

Consultation Level I

99241

I&D external ear, simple

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

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

auditory canal

69200

Tympanostomy

69433

Vestibular Function Tests

Biopsy

69000

69020

Biopsy (Skin)

11100

Tympanostomy with general

anesthesia

69436

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

recording

92540

Biopsy, vestibule of mouth

40808

Anterior, complete nasal

30903

Spontaneous nystagmus, with

92541

hemorrhage control

Biopsy, tongue (anterior 2/3)

41100

Posterior nasal hemorrhage

control

Biopsy, tongue (posterior

1/3)

41105

Nasal Endoscopy

Biopsy, floor of mouth

41108

Diagnostic nasal endoscopy

Biopsy, palate, uvula

42100

Biopsy, oropharynx

recording

Positional nystagmus test, with

recording

92542

Caloric vestibular test, with

recording

92543

31231

Optokinetic nystagmus test, with

recording

92544

Maxillary sinusoscopy

31232

Oscillating tracking test, with

recording

92545

42800

Sphenoid sinusoscopy

31235

Tympanometry and reflex

threshold measurements

92550

Biopsy, hypopharynx

42802

Nasal endoscopic biopsy,

polypectomy or debridement

31237

Pure tone screening

92551

Biopsy, nasopharynx, visible

lesion

42804

Nasal endoscopic hemorrhage 31238

control

Pure tone audiometry; air only

92552

Biopsy, nasopharynx,

unknown primary

42806

Nasal endoscopy with

dacryocystorhinostomy

31239

Pure tone audiometry: air and

bone

92553

Nasal endoscopy with concha

bullosa resection

31240

Speech audiometry threshold

92555

Sialolithotomy

30905

Sialolithotomy,

uncomplicated, intraoral

42330

Endoscopic partial

ethmoidectomy

31254

Speech audiometry threshold with

speech recognition

92556

Sialolithotomy,

submandibular, complicated,

intraoral

42335

Endoscopic total

ethmoidectomy

31255

Comprehensive audiometry

92557

Sialolithotomy, parotid,

extraoral or complicated

intraoral

42340

Endoscopic maxillary

antrostomy

31256

Percutaneous allergy skin test

95004

Endoscopic maxillary tissue

removal

31267

Allergy testing for venoms

95017

Incision and Drainage

I&D abscess, simple, single

10060

Frontal sinus endoscopy

31276

Allergy testing for drugs, biological 95018

I&D, complicated, multiple

10061

Endoscopic sphenoidotomy

31287

Intradermal allergy tests

95024

I&D hematoma, seroma, fluid

collection

10140

Endoscopic removal of

sphenoid tissue

31288

Single allergy injection (including

extract)

95120

Puncture aspiration of

abscess, cyst, hematoma

10160

Endoscopic maxillary sinus

dilation

31295

Two or more allergy injections

(including extract)

95125

I&D complex, postoperative

wound infection

10180

Endoscopic frontal sinus

dilation

31296

Preparation and provision of

antigens

95165

I&D nasal abscess or

hematoma

30000

Endoscopic sphenoid sinus

dilation

31297

Inhalation bronchial challenge

95070

I&D nasal septum abscess or

hematoma

30020

Flexible Laryngoscopy

Nasopharyngoscopy

92511

I&D vestibule of mouth,

simple

40800

Flexible diagnostic

laryngoscopy

31575

Single allergy injection (without

extract provision)

95115

I&D vestibule of mouth,

complicated

40801

Flexible laryngoscopy with

biopsy

31576

Venipuncture

36415

I&D, intraoral, tongue, floor of

mouth, lingual

41000

Flexible laryngoscopy with

foreign body removal

31577

Handling

99000

ICD-10 Codes

Diagnosis

C00.9

Malignant neoplasm of lip, unspecified

C01

Malignant neoplasm of base of tongue

C02.3

Malignant neoplasm of anterior two-thirds of tongue, part unspecified

C04.9

Malignant neoplasm of floor of mouth, unspecified

C05.0

Malignant neoplasm of hard palate

C06.9

Malignant neoplasm of mouth, unspecified

C07

Malignant neoplasm of parotid gland

C08.0

Malignant neoplasm of submandibular gland

C10.9

Malignant neoplasm of oropharynx, unspecified

C11.9

Malignant neoplasm of nasopharynx, unspecified

C13.9

Malignant neoplasm of hypopharynx, unspecified

C30.0

Malignant neoplasm of nasal cavity

C32.0

Malignant neoplasm of glottis

C32.1

Malignant neoplasm of supraglottis

C32.9

Malignant neoplasm of larynx, unspecified

C44.00

Unspecified malignant neoplasm of skin of lip

C44.01

Basal cell carcinoma of skin of lip

C44.02

Squamous cell carcinoma of skin of lip

C44.09

Other specified malignant neoplasm of skin of lip

C44.202

Unspecified malignant neoplasm of skin of right ear and external auricular canal

C44.209

Unspecified malignant neoplasm of skin of left ear and external auricular canal

C44.212

Basal cell carcinoma of skin of right ear and external auricular canal

C44.219

Basal cell carcinoma of skin of left ear and external auricular canal

C44.222

Squamous cell carcinoma of skin of right ear and external auricular canal

C44.229

Squamous cell carcinoma of skin of left ear and external auricular canal

C44.301

Unspecified malignant neoplasm of skin of nose

C44.309

Unspecified malignant neoplasm of other parts of face

C44.311

Basal cell carcinoma of skin of nose

C44.319

Basal cell carcinoma of skin of other parts of face

C44.321

Squamous cell carcinoma of skin of nose

C44.329

Squamous cell carcinoma of skin of other parts of face

C44.40

Unspecified malignant neoplasm of skin of scalp and neck

C44.41

Basal cell carcinoma of skin of scalp and neck

C44.42

Squamous cell carcinoma of skin of scalp and neck

C44.49

Other specified malignant neoplasm of skin of scalp and neck

C73

Malignant neoplasm of thyroid gland

C77.0

Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck

D00.01

Carcinoma in situ of labial mucosa and vermilion border

D00.02

Carcinoma in situ of buccal mucosa

D00.03

Carcinoma in situ of gingiva and edentulous alveolar ridge

D00.04

Carcinoma in situ of soft palate

D00.05

Carcinoma in situ of hard palate

D00.06

Carcinoma in situ of floor of mouth

D00.07

Carcinoma in situ of tongue

D00.08

Carcinoma in situ of pharynx

D10.30

Benign neoplasm of unspecified part of mouth

D10.39

Benign neoplasm of other parts of mouth

D11.0

Benign neoplasm of parotid gland

D11.7

Benign neoplasm of other major salivary gland

D14.0

Benign neoplasm of middle ear, nasal cavity and accessory sinuses

D14.1

Benign neoplasm of larynx

D22.11

Melanocytic nevi of right eyelid, including canthus

D22.12

Melanocytic nevi of left eyelid, including canthus

D23.11

Other benign neoplasm of skin of right eyelid, including canthus

D23.12

Other benign neoplasm of skin of left eyelid, including canthus

D33.3

Benign neoplasm of cranial nerves

D35.2

Benign neoplasm of pituitary gland

D37.01

Neoplasm of uncertain behavior of lip

D37.02

Neoplasm of uncertain behavior of tongue

D37.030

Neoplasm of uncertain behavior of the parotid salivary glands

D37.031

Neoplasm of uncertain behavior of the sublingual salivary glands

D37.032

Neoplasm of uncertain behavior of the submandibular salivary glands

D37.04

Neoplasm of uncertain behavior of the minor salivary glands

D37.05

Neoplasm of uncertain behavior of pharynx

D37.09

Neoplasm of uncertain behavior of other specified sites of the oral cavity

D38.0

Neoplasm of uncertain behavior of larynx

D48.5

Neoplasm of uncertain behavior of skin

D49.0

Neoplasm of unspecified behavior of digestive system

D49.1

Neoplasm of uncertain behavior of respiratory system

D49.2

Neoplasm of uncertain behavior of bone, soft tissue, and skin

D49.7

Neoplasm of uncertain behavior of endocrine glands and other parts of nervous system

E04.1

Nontoxic single thyroid nodule

E04.2

Nontoxic multinodular goiter

E05.90

Thyrotoxicosis, unspecified without thyrotoxic crisis or storm

E06.9

Thyroiditis, unspecified

E21.0

Primary hyperparathyroidism

E21.1

Secondary hyperparathyroidism, not elsewhere classified

E21.2

Other hyperparathyroidism

E84.9

Cystic fibrosis

F45.8

Other somatoform disorders

F80.4

Speech and language development delay due to hearing loss

G47.09

Other insomnia

G47.19

Other hypersomnia

G47.30

Sleep apnea, unspecified

G47.33

Obstructive sleep apnea (adult) (pediatric)

G50.1

Atypical facial pain

G51.0

Bell¡¯s palsy

H6.301

Acquired stenosis of right external ear canal, unspecified

H60.331

Swimmer¡¯s ear, right ear

H60.332

Swimmer¡¯s ear, left ear

H60.333

Swimmer¡¯s ear, bilateral

H60.391

Other infective otitis externa, right ear

H60.392

Other infective otitis externa, left ear

H60.393

Other infective otitis externa, bilateral

H60.511

Acute actinic otitis externa, right ear

H60.512

Acute actinic otitis externa, left ear

H60.513

Acute actinic otitis externa, bilateral

H60.521

Acute chemical otitis externa, right ear

H60.522

Acute chemical otitis externa, left ear

H60.523

Acute chemical otitis externa, bilateral

H60.531

Acute contact otitis externa, right ear

H60.532

Acute contact otitis externa, left ear

H60.533

Acute contact otitis externa, bilateral

H60.541

Acute eczematoid otitis externa, right ear

H60.542

Acute eczematoid otitis externa, left ear

H60.543

Acute eczematoid otitis externa, bilateral

H60.551

Acute reactive otitis externa, right ear

H60.552

Acute reactive otitis externa, left ear

H60.553

Acute reactive otitis externa, bilateral

H60.591

Other noninfective acute otitis externa, right ear

H60.592

Other noninfective acute otitis externa, left ear

H60.593

Other noninfective acute otitis externa, bilateral

H60.61

Unspecified chronic otitis externa, right ear

H60.62

Unspecified chronic otitis externa, left ear

H60.63

Unspecified chronic otitis externa, bilateral

H61.011

Acute perichondritis of right external ear

H61.012

Acute perichondritis of left external ear

H61.013

Acute perichondritis of external ear, bilateral

H61.021

Chronic perichondritis of right external ear

H61.022

Chronic perichondritis of left external ear

H61.023

Chronic perichondritis of external ear, bilateral

H61.121

Hematoma of pinna, right ear

H61.122

Hematoma of pinna, left ear

H61.123

Hematoma of pinna, bilateral

H61.21

Impacted cerumen, right ear

H61.22

Impacted cerumen, left ear

H61.23

Impacted cerumen, bilateral

H61.302

Acquired stenosis of left external ear canal, unspecified

H61.303

Acquired stenosis of external ear canal, unspecified, bilateral

H61.391

Other acquired stenosis of right external ear canal

H61.392

Other acquired stenosis of left external ear canal

H61.393

Other acquired stenosis of external ear canal, bilateral

H61.811

Exostosis of right external ear canal

H61.812

Exostosis of left external ear canal

H61.813

Exostosis of external ear canal, bilateral

H65.01

Acute serous otitis media, right ear

H65.02

Acute serous otitis media, left ear

H65.03

Acute serous otitis media, bilateral

H65.04

Acute serous otitis media, recurrent, right ear

H65.05

Acute serous otitis media, recurrent, left ear

H65.06

Acute serous otitis media, recurrent, bilateral

H65.91

Unspecified nonsuppurative otitis media, right ear

H65.92

Unspecified nonsuppurative otitis media, left ear

H65.93

Unspecified nonsuppurative otitis media, bilateral

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

H66.011

Acute suppurative otitis media with spontaneous rupture of ear drum, right ear

H66.012

Acute suppurative otitis media with spontaneous rupture or ear drum, left ear

H66.013

Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral

H66.014

Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear

H66.015

Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear

H66.016

Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral

H66.11

Chronic tubotympanic suppurative otitis media, right ear

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