Ear, Nose and Throat Superbill Template Date of service: Insurance: Patient name: Subscriber name: Address: Group #: Previous balance: Copay: Today’s charges: Phone: Account #: Today’s payment: check# DOB: Age: Sex: Physician name: Balance due: MOD. Patient E/M New Est MOD. I&D, intraoral, tongue, floor of mouth, sublingual, superficial 41005 MOD. Flexible laryngoscopy with removal of lesion 31578 Level I 99201 99211 I&D, intraoral, tongue, floor of mouth, sublingual, superficial 41005 Flexible laryngoscopy with stroboscopy 31579 Level II 99202 99212 I&D, extraoral, floor of mouth, sublingual 41015 Incision of labial frenulum 40806 Level III 99203 99213 I&D, extraoral, floor of mouth, submental 41016 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 cyst 60000 Palate Somnoplasty 42145- 52 Consultation Level I 99241 I&D external ear, simple 69000 Turbinate Somnoplasty 30140- 52 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 auditory canal 69200 Biopsy Tympanostomy 69433 Vestibular Function Tests 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
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Ear, Nose and Throat Superbill Template · Ear, Nose and Throat Superbill Template Date of service: ... 41105 Nasal Endoscopy Caloric vestibular test, ... D48.5 Neoplasm of uncertain
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Ear, Nose and Throat Superbill Template Date of service: Insurance:
Patient name:
Subscriber name:
Address: Group #: Previous balance:
Copay: Today’s charges:
Phone: Account #: Today’s payment: check#
DOB: Age: Sex: Physician name: Balance due:
MOD. Patient E/M New Est MOD. I&D, intraoral, tongue, floor of
mouth, sublingual, superficial
41005 MOD. Flexible laryngoscopy with
removal of lesion 31578
Level I 99201 99211 I&D, intraoral, tongue, floor of
mouth, sublingual, superficial
41005 Flexible laryngoscopy with
stroboscopy 31579
Level II 99202 99212 I&D, extraoral, floor of mouth,
sublingual 41015 Incision of labial frenulum 40806
Level III 99203 99213 I&D, extraoral, floor of mouth,
submental 41016 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
M26.69 Other specified disorders of temporomandibular joint
M54.2 Cervicalgia
M95.0 Acquired deformity of nose
Q16.1 Congenital absence, atresia and stricture of auditory canal (external)
Q18.0 Sinus, fistula and cyst of branchial cleft
Q31.0 Web of larynx
Q31.1 Congenital subglottic stenosis
Q31.2 Laryngeal hypoplasia
Q31.3 Laryngocele
Q31.5 Congenital laryngomalacia
Q31.8 Other congenital malformation of larynx
Q32.0 Congenital tracheomalacia
Q32.1 Other congenital malformations of trachea
Q32.2 Congenital bronchomalacia
Q32.3 Congenital stenosis of bronchus
Q32.4 Other congenital malformations of bronchus
Q38.1 Ankyloglossia
Q89.2 Congenital malformations of other endocrine glands
R04.0 Epistaxis
R04.2 Hemoptysis
R04.89 Hemorrhage from other sites in respiratory passages
R04.9 Hemorrhage from respiratory passages, unspecified
R05 Cough
R06.00 Dyspnea, unspecified
R06.09 Other forms of dyspnea
R06.1 Stridor
R06.89 Other abnormalities of breathing
R13.10 Dysphagia, unspecified
R22.0 Localized swelling, mass and lump, head
R22.1 Localized swelling, mass and lump, neck
R42 Dizziness and giddiness
R43.0 Anosmia
R43.1 Parosmia
R43.2 Parageusia
R43.8 Other disturbance of smell and taste
R49.0 Dysphonia
R51 Headache
R59.0 Localized enlarged lymph nodes
R59.1 Generalized enlarged lymph nodes
R59.9 Enlarged lymph nodes, unspecified
S02.10XA Unspecified fracture of base of skull, initial encounter for closed fracture
S02.10XB Unspecified fracture of base of skull, initial encounter for open fracture
S02.10XD Unspecified fracture of base of skull, subsequent encounter for fracture with routine healing
S02.10XG Unspecified fracture of base of skull, subsequent encounter for fracture with delayed healing
S02.10XK Unspecified fracture of base of skull, subsequent encounter for fracture with nonunion
S02.10XS Unspecified fracture of base of skull, sequela
S02.2XXA Fracture of nasal bones, initial encounter for closed fracture
S02.2XXB Fracture of nasal bones, initial encounter for open fracture
S02.2XXD Fracture of nasal bones, subsequent encounter for fracture with routine healing
S02.2XXG Fracture of nasal bones, subsequent encounter for fracture with delayed healing
S02.2XXK Fracture of nasal bones, subsequent encounter for fracture with nonunion
S02.2XXS Fracture of nasal bones, sequela
S02.3XXA Fracture of orbital floor, initial encounter for closed fracture
S02.3XXB Fracture of orbital floor, initial encounter for open fracture
S02.3XXD Fracture of orbital floor, subsequent encounter for fracture with routine healing
S02.3XXG Fracture of orbital floor, subsequent encounter for fracture with delayed healing
S02.3XXK Fracture of orbital floor, subsequent encounter for fracture with nonunion
S02.3XXS Fracture of orbital floor, sequela
S02.401A Maxillary fracture, unspecified, initial encounter for closed fracture
S02.401B Maxillary fracture, unspecified, initial encounter for open fracture
S02.401D Maxillary fracture, unspecified, subsequent encounter for fracture with routine healing
S02.401G Maxillary fracture, unspecified, subsequent encounter for fracture with delayed healing
S02.401K Maxillary fracture, unspecified, subsequent encounter for fracture with nonunion
S02.401S Maxillary fracture, unspecified, sequela
S02.402A Zygomatic fracture, unspecified, initial encounter for closed fracture
S02.402B Zygomatic fracture, unspecified, initial encounter for open fracture
S02.402D Zygomatic fracture, unspecified, subsequent encounter for fracture with routine healing
S02.402G Zygomatic fracture, unspecified, subsequent encounter for fracture with delayed healing
S02.402K Zygomatic fracture, unspecified, subsequent encounter for fracture with nonunion
S02.402S Zygomatic fracture, unspecified, sequela
S02.411A LeFort I fracture, initial encounter for closed fracture
S02.411B LeFort I fracture, initial encounter for open fracture
S02.411D LeFort I fracture, subsequent encounter for fracture with routine healing
S02.411G LeFort I fracture, subsequent encounter for fracture with delayed healing
S02.411K LeFort I fracture, subsequent encounter for fracture with nonunion
S02.411S LeFort I fracture, sequela
S02.413A LeFort III fracture, initial encounter for closed fracture
S02.413B LeFort III fracture, initial encounter for open fracture
S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing
S02.413G LeFort III fracture, subsequent encounter for fracture with delayed healing
S02.413K LeFort III fracture, subsequent encounter for fracture with nonunion
S02.413S LeFort III fracture, sequela
S02.42XA Fracture of alveolus maxilla, initial encounter for closed fracture
S02.42XB Fracture of alveolus maxilla, initial encounter for open fracture
S02.42XD Fracture of alveolus maxilla, subsequent encounter for fracture with routine healing
S02.402G Zygomatic fracture, unspecified, subsequent encounter for fracture with delayed healing
S02.402K Zygomatic fracture, unspecified, subsequent encounter for fracture with nonunion
S02.402S Zygomatic fracture, unspecified, sequela
S02.411A LeFort I fracture, initial encounter for closed fracture
S02.411B LeFort I fracture, initial encounter for open fracture
S02.411D LeFort I fracture, subsequent encounter for fracture with routine healing
S02.411G LeFort I fracture, subsequent encounter for fracture with delayed healing
S02.411K LeFort I fracture, subsequent encounter for fracture with nonunion
S02.411S LeFort I fracture, sequela
S02.413A LeFort III fracture, initial encounter for closed fracture
S02.413B LeFort III fracture, initial encounter for open fracture
S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing
S02.413G LeFort III fracture, subsequent encounter for fracture with delayed healing
S02.413K LeFort III fracture, subsequent encounter for fracture with nonunion
S02.413S LeFort III fracture, sequela
S02.42XA Fracture of alveolus maxilla, initial encounter for closed fracture
S02.42XB Fracture of alveolus maxilla, initial encounter for open fracture
S02.42XD Fracture of alveolus maxilla, subsequent encounter for fracture with routine healing
S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing
S02.413G LeFort III fracture, subsequent encounter for fracture with delayed healing
S02.413K LeFort III fracture, subsequent encounter for fracture with nonunion
S02.413S LeFort III fracture, sequela
S02.42XA Fracture of alveolus maxilla, initial encounter for closed fracture
S02.42XB Fracture of alveolus maxilla, initial encounter for open fracture
S02.42XD Fracture of alveolus maxilla, subsequent encounter for fracture with routine healing
S02.42XG Fracture of alveolus maxilla, subsequent encounter for fracture with delayed healing
S02.42XK Fracture of alveolus maxilla, subsequent encounter for fracture with nonunion
S02.42XS Fracture of alveolus maxilla, sequela
S09.21XA Traumatic rupture of right ear drum, initial encounter
S09.21XD Traumatic rupture of right ear drum, subsequent encounter
S09.21XS Traumatic rupture of right ear drum, sequela
S09.22XA Traumatic rupture of left ear drum, initial encounter
S09.22XD Traumatic rupture of left ear drum, subsequent encounter
S09.22XS Traumatic rupture of left ear drum, sequela
S09.92XA Unspecified injury of nose, initial encounter
S09.92XD Unspecified injury of nose, subsequent encounter
S09.92XS Unspecified injury of nose, sequela
S09.93XA Unspecified injury of face, initial encounter
S09.93XD Unspecified injury of face, subsequent encounter
S09.93XS Unspecified injury of face, sequela
S16.8XXA Other specified injury of muscle, fascia and tendon at neck level, initial encounter
S16.8XXD Other specified injury of muscle, fascia and tendon at neck level, subsequent encounter
S16.8XXS Other specified injury of muscle, fascia and tendon at neck level, sequela
S19.81XA Other specified injuries of larynx, initial encounter
S19.81XD Other specified injuries of larynx, subsequent encounter
S19.81XS Other specified injuries of larynx, sequela
S19.82XA Other specified injuries of cervical trachea, initial encounter
S19.82XD Other specified injuries of cervical trachea, subsequent encounter
S19.82XS Other specified injuries of cervical trachea, sequela
S19.83XA Other specified injuries of vocal cord, initial encounter
S19.83XD Other specified injuries of vocal cord, subsequent encounter
S19.83XS Other specified injuries of vocal cord, sequela
S19.84XA Other specified injuries of thyroid gland, initial encounter
S19.84XD Other specified injuries of thyroid gland, subsequent encounter
S19.84XS Other specified injuries of thyroid gland, sequela
S19.85XA Other specified injuries of pharynx and cervical esophagus, initial encounter
S19.85XD Other specified injuries of pharynx and cervical esophagus, subsequent encounter
S19.85XS Other specified injuries of pharynx and cervical esophagus, sequela
S19.9XXA Unspecified injury of neck, initial encounter
S19.9XXD Unspecified injury of neck, subsequent encounter
S19.9XXS Unspecified injury of neck, sequela
T16.1XXA Foreign body in right ear, initial encounter
T16.1XXD Foreign body in right ear, subsequent encounter
T16.1XXS Foreign body in right ear, sequela
T16.2XXA Foreign body in left ear, initial encounter
T16.2XXD Foreign body in left ear, subsequent encounter
T16.2XXS Foreign body in left ear, sequela
T17.0XXA Foreign body in nasal sinus, initial encounter
T17.0XXD Foreign body in nasal sinus, subsequent encounter
T17.0XXS Foreign body in nasal sinus, sequela
T17.1XXA Foreign body in nostril, initial encounter
T17.1XXD Foreign body in nostril, subsequent encounter
T17.1XXS Foreign body in nostril, sequela
Z01.10 Encounter for examination of ears and hearing without abnormal findings
Z01.110 Encounter for hearing examination following failed hearing screening
Z01.118 Encounter for examination of ears and hearing with other abnormal findings
Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
Z09 Encounter for follow-up examination after completed treatment for condition other than malignant neoplasm
Z43.0 Encounter for attention to tracheostomy
Z44.8 Encounter for fitting and adjustment of other external prosthetic devices
Z71.1 Person with feared health complaint in whom no diagnosis is made
Z79.899 Other long term (current) drug therapy
Z09 Encounter for follow-up examination after completed treatment for condition other than malignant neoplasm
Z43.0 Encounter for attention to tracheostomy
Z44.8 Encounter for fitting and adjustment of other external prosthetic devices
Z71.1 Person with feared health complaint in whom no diagnosis is made
Z79.899 Other long term (current) drug therapy
Z09 Encounter for follow-up examination after completed treatment for condition other than malignant neoplasm
Z43.0 Encounter for attention to tracheostomy
Z44.8 Encounter for fitting and adjustment of other external prosthetic devices
Z71.1 Person with feared health complaint in whom no diagnosis is made
Z79.899 Other long term (current) drug therapy
Disclaimer: This sample ICD-10 superbill is designed to assist otolaryngology practices in quickly completing and submitting procedure(s) and diagnosis(s) codes from a patient visit for reimbursement. It is generally customized for an otolaryngology office and contains fields for patient information, the most common CPT (procedure) and ICD-10-CM (diagnostic) codes used by Otolaryngologists. Members should note that this superbill is designed solely as an exercise in demonstrating the process of transitioning to the new ICD-10-CM coding system, and does not represent an endorsement by the Academy of the use of superbills or this particular superbill format. For more information on the transition to ICD-10 please contact the health policy team at: [email protected].