Sample Super Bill

E&M/Office Visit Level:

 Office/Other Outpatient Visit

New Pt

Established Pt

Level 1: Problem Focused

99201 (retiring in 2021)

99211

Level 2: Expanded problem focused

99202

99212

Level 3: Detailed

99203

99213

Level 4: Comprehensive, moderate

99204

99214

Level 5: Comprehensive, high

99205

99215

Blood pressure:

Systolic:

Diastolic:

3074F:   <130

3078F:  <80

3075F:  130-139

3079F:  80-89

3077F:  >140

3080F:  >90

BMI (3008F):

Z68.1: 19.9 or less

Z68.24: 24.0-24.9

Z68.29: 29.0-29.9

Z68.34: 34.0-34.9

Z68.39: 39.0-39.9

Z68.45: 70 or greater

Z68.20: 20.0-20.9

Z68.25: 25.0-25.9

Z68.30: 30.0-30.9

Z68.35: 35.0-35.9

Z68.41: 40.0-44.9

Z68.21: 21.0-21.9

Z68.26: 26.0-26.9

Z68.31: 31.0-31.9

Z68.36: 36.0-36.9

Z68.42: 45.0-49.9

Z68.22: 22.0-22.9

Z68.27: 27.0-27.9

Z68.32: 32.0-32.9

Z68.37: 37.0-37.9

Z68.43: 50.0-59.9

Z68.23: 23.0-23.9

Z68.28: 28.0-28.9

Z68.33: 33.0-33.9

Z68.38: 38.0-38.9

Z68.44: 60.0-69.9

Diabetic Care:

HbA1c:

3044F: <7.0%

3051F:

 >7.0%-<8.0%

3052F:

>8.0%-<9.0%

3046F: >9.0%

Nephropathy:

3060F: positive microalbumin test result (30-300)

3062F: positive microalbumin test result documented/reviewed (>30)

3061F: negative microalbumin tests documented/reviewed

3066F: receiving dialysis, ESRD treatment, CRF, ARF, renal insufficiency

4010F: ACE inhibitor/ARB therapy

Preventive Screenings/Exclusions:

Colorectal Cancer:

Breast Cancer:

Osteoporosis:

Z85.038: Cancer, personal history, other malignant neoplasm of large intestine

Z90.13: History of bilateral mastectomy

G0130: Bone mineral density test

Z90.12: Absence of left breast

Z85.048: Cancer, personal history, other malignant neoplasm of rectum, rectosigmoid junction, anus

Z90.11: Absence of right breast

Vaccinations:

G8482: Flu vaccine ordered & administered

4040F: Pneumonia vaccine administered or previously given

G8483: Flu vaccine not given for documented reason

4040F-1P: Pneumonia vaccine not administered for medical reasons

Medication Reconciliation Post-Discharge:

1111F: Discharge medications reconciled w/ current medication in the outpatient record

99495: Transition of care

99496: Transition of care

Annual Wellness/Initial Preventive Physical Exam:

G0438: Initial annual wellness

G0439: Subsequent annual wellness

G0402: Initial Preventive Physical Exam – IPPE (Welcome); once in a patient’s lifetime; billed in first 12 months of joining Medicare

*If you’re a federally-qualified health center (FQHC) you must bill G0468 along with one of the 3 codes listed above (G0438, G0439, G0402)

Fall Risks:

1100F: screening, 2 or more falls in past year or any fall with injury in the past year

1101F: screening, no falls in the past year or only 1 fall without injury in the past year

1100F-1P: patient not screened, medical reasons

1101F-1P: patient not screened, medical reasons

Advanced Directive:

1157F: Advance care planning or similar legal document in record

1158F: Advance care planning discussion notated in record

S0257: Counseling/discussion regarding advanced directive/end of life care with patient and/or surrogate

Medication List & Review (need to bill both):

1159F: Medication list documented in record

1160F: Review of all medications by provider & documented in record

Functional Status:

Pain Assessment:

1170F: Functional status assessed

1125F: Pain severity quantified, present

1126F: Pain severity quantified, no pain present

Tobacco Cessation:

1034F: Current tobacco smoker

1035F: Current smokeless tobacco user

1036F: Current non-smoker

Depression Screening: G0444 (annual depression screening)

G8431: Screening for depression documented as positive and follow up plan is documented

96160: Pre-natal/Post-partum health risk assessment with scoring and documentation

G850: Screening for depression documented as negative, follow up plan is not required

96127: Brief emotional/behavioral assessment (ADD/ADHD) with scoring and documentation

Improving Bladder Control:

1090F: Presence or absence of urinary incontinence

0509F: Urinary incontinence plan of care documented

Monitoring Physical Activity:

Z71.82: Exercise counseling

1003F: Level of activity assessed

Frequent LAB Studies

CBC

Lipid

Microalbumin (protein)

BMP

HbA1c

UA C/S

CMP

TSH

Urinalysis

PT/INR

PSA

eGFR

36415:  Venipuncture

Hepatic/LFTs

UACR (urine-creatinine ration)

Frequently Ordered Tests

Mammogram

Other:

Colonoscopy

Other: