MODEL SUPERBILL
for AUDIOLOGY
The following is a model of a superbill which could be used by an audiology practice
when billing private health plans. This sample is not meant to dictate which services
should or should not be listed on the bill. Most billable codes are from the American
Medical Association (AMA) Current Procedural Terminology (CPT) ®. Prosthetic and
durable medical equipment codes, such as hearing aid codes, are published by the
Centers for Medicare and Medicaid Services (CMS) as the Healthcare Common
Procedure Code System (HCPCS).
The superbill is a standard form which health plans use to process claims. For the
professional rendering services, it provides a time efficient means to document services,
fees, codes, and other information required by insurance companies, (i.e., certification
and licensure). The patient uses this form to file for health plan payment.
NOTE: This is only a model, therefore some procedures, codes, or other pertinent
information may not be found on the following model. A complete list of audiology
related codes is available in Coding & Billing for Audiology and Speech-Language
Pathology, which is updated annually. You can purchase this product through ASHA’s
Online Store
or by calling ASHA’s Product Sales at 1-888-498-6699.
More information on coding for audiology services can also be found on ASHA’s
billing
and reimbursement website
.
MODEL AUDIOLOGY SUPERBILL
PATIENT: INSURED:
REFERRING PHYSICIAN: ADDRESS:
FILE: INSURANCE PLAN:
DATE: INSURANCE PLAN #:
DATE INITIAL SYMPTOM: DATE FIRST CONSULTATION: PLACE OF SERVICE: o HOME o OFFICE o OTHER:
DIAGNOSIS:
PRIMARY (Audiology): ICD-10/9 CODE:
SECONDARY (Medical): ICD-10/9 CODE:
HEARING AID/EARMOLD DEFECT:
SERVICES:
þ
PROCEDURE CPT CHARGEAudiological Assessment Procedures
o
Tympanometry and reflex thresholdmeasurements 92550
o
Screening test, pure tone, air only 92551o
Pure tone audiometry (threshold);air only 92552o
Pure tone audiometry (threshold); air andbone 92553
o
Speech audiometry threshold 92555o
Speech audiometry threshold; w/speechrecognition 92556
o
Comprehensive audiometry thresholdevaluation and speech recognition 92557
o
Audiometric testing of groups 92559o
Bekesy audiometry; screening 92560o
Bekesy audiometry; diagnostic 92561o
Loudness balance test, alternate binaural ormonaural 92562
o
Tone decay test 92563o
Short increment sensitivity index (SISI) 92564o
Stenger test, pure tone 92565o
Tympanometry (impedance testing) 92567o
Acoustic reflex testing, threshold 92568o
Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflexdecay testing 92570
o
Filtered speech test 92571o
Staggered spondaic word test 92572o
Sensorineural acuity level test 92575o
Synthetic sentence identification test 92576o
Stenger test, speech 92577o
Visual reinforcement audiometry (VRA) 92579o
Conditioning play audiometry 92582o
Select picture audiometry 92583o
Electrocochleography 92584þ
PROCEDURE CPT CHARGEo
Auditory evoked potentials, comprehensive 92585o
Auditory evoked potentials, limited 92586o
Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions),automated analysis 92558
o
Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report 92587o
Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation andreport 92588
o
Evaluation of central auditory function, withreport; initial 60 minutes 92620
o
each additional 15 minutes 92621o
Assessment of tinnitus (includes pitch,loudness matching, and masking) 92625
Hearing Aid Assessment and Fitting Procedures
o
Hearing aid exam and selection; monaural 92590o
Hearing aid exam and selection; binaural 92591o
Hearing aid check; monaural 92592o
Hearing aid check; binaural 92593o
Electroacoustic evaluation for hearing aid;monoaural 92594
o
binaural 92595o
Ear protector attenuation measurements 92596Vestibular and Balance System Assessment Procedures
o
Spontaneous nystagmus, including gaze 92531o
Positional nystagmus test 92532o
Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4tests) 92533
M o d e l A u d i o l o g y S u p e r b i l l P a g e | 2
þ
PROCEDURE CPT CHARGEo
Caloric vestibular test with recording,bilateral; bithermal 92537
o
monothermal 92538o
Basic vestibular evaluation, incl. spontaneous nystagmus test w/eccentric gaze fixation nystagmus, w/recording, positional nystagmus test, min. of 4 positions, w/recording, optokinetic nystagmus test, bidirectional foveal & peripheral stimulation, w/recording, & oscillating tracking test,w/recording 92540
o
Spontaneous nystagmus test, incl. gaze and fixation nystagmus, with recording 92541o
Positional nystagmus test, minimum of fourpositions 92542
o
Optokinetic nystagmus test, bi-directional,foveal or peripheral stimulation, w/ recording 92544
o
Oscillating tracking test, with recording 92545o
Sinusoidal vertical axis rotational testing 92546o
Use of vertical electrodes in any or all of the above tests 92547o
Computerized dynamic posturography 92548Vestibular and Balance Rehabilitation Services
o
Canalith repositioning procedure(s) (eg, Epleymaneuver, Semont maneuver) per day. 95992
Cerumen Management Services
o
Removal of impacted cerumen, one or bothears 69210
Auditory Implant Services
o
Cochlear implant follow-up exam <7 years ofage 92601
o
Reprogram cochlear implant <7 years of age 92602o
Cochlear implant follow-up exam >7 years ofage 92603
o
Reprogram cochlear implant > 7 years of age 92604o
Diagnostic analysis with programming ofauditory brainstem implant, per hour 92640
Habilitative and Rehabilitative Services
o
Treatment of speech, language, voice,communication, and/or auditory processing
disorder; individual 92507
o
group, two or more individuals 92508o
Evaluation of auditory rehabilitation status,1st hour 92626
o
each additional 15 minutes 92627o
Auditory rehabilitation; pre-lingual hearingloss 92630
o
Auditory rehabilitation; post-lingual hearingloss 92633
Hearing Aids/FM Systems (HCPCS Level II Codes)
o
Assessment for Hearing Aid V5010o
Fitting/Orientation/Checking of Hearing Aid V5011o
Repair/Modification of a Hearing Aid V5014o
Conformity Evaluation V5020o
Hearing aid, Monaural, body worn,air conduction V5030
o
bone conduction V5040þ
PROCEDURE CPT CHARGEo
Hearing Aid, Monaural, in the ear (ITE) V5050o
Hearing Aid, Monaural, behind the ear (BTE) V5060o
Glasses, air conduction V5070o
Glasses, bone conduction V5080o
Dispensing fee, Unspecified Hearing Aid V5090o
Hearing Aid, bilateral, body worn V5100o
Dispensing fee, bilateral V5110o
Binaural, body V5120o
Binaural, ITE V5130o
Binaural, BTE V5140o
Binaural, glasses V5150o
Dispensing fee, binaural V5160o
Hearing Aid, CROS, ITE V5170o
Hearing Aid, CROS, BTE V5180o
Hearing Aid, CROS, glasses V5190o
Dispensing fee, CROS V5200o
Hearing Aid, BICROS, ITE V5210o
Hearing Aid, BICROS, BTE V5220o
Hearing Aid, BICROS, glasses V5230o
Dispensing Fee, BICROS V5240o
Dispensing Fee, Monaural Hearing Aid V5241o
Hearing Aid, Analog, monaural, completely in the ear canal (CIC) V5242o
Hearing aid, analog, monaural, in the canal(ITC) V5243
o
Hearing aid, digitally programmable analog,monaural, CIC V5244
o
Hearing aid, digitally programmable analog,monaural, ITC V5245
o
Hearing aid, digitally programmable analog,monaural, ITE V5246
o
Hearing aid, digitally programmable analog,monaural, BTE V5247
o
Hearing aid, analog, binaural, CIC V5248o
Hearing aid, analog, binaural, ITC V5249o
Hearing aid, digitally programmable analog,binaural, CIC V5250
o
Hearing aid, digitally programmable analog,binaural, ITC V5251
o
Hearing aid, digitally programmable, binaural,ITE V5252
o
Hearing aid, digitally programmable, binaural,BTE V5253
o
Hearing aid, digital, monaural, CIC V5254o
Hearing aid, digital, monaural, ITC V5255o
Hearing aid, digital, monaural, ITE V5256o
Hearing aid, digital, monaural, BTE V5257o
Hearing aid, digital, binaural, CIC V5258o
Hearing aid, digital, binaural, ITC V5259o
Hearing aid, digital, binaural, ITE V5260o
Hearing aid, digital, binaural, BTE V5261o
Hearing aid, disposable, any type, monaural V5262þ
PROCEDURE CPT CHARGEo
Earmold/insert, not disposable, any type V5264o
Earmold/insert, disposable, any type V5265o
Battery for use in hearing device V5266o
Hearing aid or assistive listening device/supplies/accessories, not otherwisespecified V5267
o
Assistive listening device, telephone amplifier,any type V5268
o
Assistive listening device, alerting, any type V5269o
Assistive listening device, television amplifier,any type V5270
o
Assistive listening device, television captiondecoder V5271
o
Assistive listening device, TDD V5272o
Assistive listening device, for use withcochlear implant V5273
o
Assistive learning device not otherwisespecified V5274
o
Ear impression, each V5275o
Personal FM/DM system, monaural (onereceiver, transmitter and microphone) V5281
o
Personal FM/DM system, binaural (tworeceivers, transmitter and microphone) V5282
o
Personal FM/DM neck, loop inductionreceiver V5283
o
Personal FM/DM, ear level receiver V5284o
Personal FM/DM, direct audio input receiver V5285o
Personal blue tooth FM/DM receiver V5286o
Personal FM/DM receiver, not otherwisespecified V5287
o
Personal FM/DM transmitter assistivelistening device V5288
o
Personal FM/DM adapter/boot couplingdevice for receiver, any type V5289
o
Transmitter microphone, any type V5290o
Hearing Service, Miscellaneous V5299Electrophysiology Procedures
o
Nerve conduction studies; 1-2 studies 95907o
3-4 studies 95908o
5-6 studies 95909o
7-8 studies 95910o
9-10 studies 95911o
11-12 studies 95912o
13 or more studies 95913o
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs 95925o
in lower limbs 95926o
in upper & lower limbs 95938o
in the trunk or head 95927þ
PROCEDURE CPT CHARGEo
Visual evoked potential (VEP) testing central nervous system, checkerboard or flash 95930o
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1method 95937
o
Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) 95940o
Continuous neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primaryprocedure) 95941
Other Procedures
o
Otorhinolaryngological service or procedure 92700o
Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure with the next 24 hours or soonest available appointment; 5-10 minutes of medicaldiscussion 98966
o
11-20 minutes of medical discussion 98967o
21-30 minutes of medical discussion 98968o
Online assessment & management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment & management service provided within the previous 7 days, using the Internet or similar electronic communications network. 98969o
Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more; participation by nonphysician qualified health careprofessional 99366
o
Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health careprofessional 99368
M o d e l A u d i o l o g y S u p e r b i l l P a g e | 4
BILLING INFORMATION
PREVIOUS BALANCE: $ TODAY’S CHARGES: $ TOTAL DUE: $ PAID TODAY: $ PAID BY: o CASH o CREDIT¡ VISA ¡ MC ¡ OTHER
o CHECK
BALANCE: $
AUTHORIZATIONS
I hereby authorize direct payment of benefits to Audiology & Hearing Center, Inc.
SIGNATURE: DATE:
I hereby authorize John Smith, PhD, CCC-A to release any information acquired in the course of treatment.
SIGNATURE: DATE:
John Smith, PhD, CCC-A
Audiology & Hearing Center, Inc. 999 Anywhere Street Rockville, MD 00000 (999) 999-9999 PHONE
(888) 888-8888 FAX