Superbill is the name of the itemized form utilized by healthcare providers in the United States for reflecting rendered services. Superbill is the main data source for creation of healthcare claim, which will be submitted to payers (insurances, funds, programs) for reimbursement. Although the superbill form is not unified, and it is created/modified depending on healthcare provider specialty, type of rendered services, additional requirements, as well as ease of handling, there is a set of obligatory attributes, relevant to all superbill types.

Superbill form consists of 4 main parts, containing mandatory fields to be completed for accurate claim creation:

Ordering/referring/attending physician

• Last/First name and Degree
• NPI (National Provider Identifier
  National Provider Identifier
  A National Provider Identifier or NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services ....
  
  )

Patient Information

• Patient’s first and last name
• Patient DOB
  DOB
  DOB or Dob may refer to:*Dob, Domžale, village in Slovenia*Mounir Dob , Algerian football referee*Date of birth or birthday *2,5-dimethoxy-4-bromoamphetamine, Bromo-DMA, a psychedelic drug**Meta-DOB, related substance...
  
  
• Insurance information (Insurance name/and ID)
• Date of first symptom (upon necessity)
• Last date seen (upon necessity)

Visit information

• Date of service
• Procedure codes
  Procedure codes
  Procedure codes are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals.-International:...
  
   (CPT) – list of commonly used codes by medical provider according to the provider specialty
• Diagnosis codes
  Diagnosis codes
  In healthcare, diagnostic codes are used to group and identify diseases, disorders, symptoms, human response patterns, and medical signs, and are used to measure morbidity and mortality...
  
   (ICD-9) – list of commonly used codes by medical provider according to the provider specialty
• Modifiers (Location and conditions modifiers)
• Time (for timed codes)
• Units
• Quantity for drugs
• Authorization information (if applicable)

Superbill utilization rules

1. Each superbill must be signed by rendering provider of service. Superbill without a signature cannot be processed by medical biller. By signing the document the healthcare provider is acknowledging the services rendered and confirming that information on superbill is permitted to be sent to insurance company by medical biller.
2. All required fields should be completed (with the exception of those that are considered optional)
3. Provided information should be readable
4. CPT and ICD-9 (ICD-10
   ICD-10
   The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
   
    -Starting October 2013) codes should be marked clearly
5. In case if required CPT or ICD-9 code could not be found in the given list, Provider should give legible handwritten description of service/diagnosis, along with additional information (units, time, type, etc)
6. Only generally accepted medical terminology and abbreviations are allowed

Further reading

• The Superbill-Guide to a Uniform Billing and-Or Claims System(IsBN 0685033295)by Medical Group Management Association Staff, Costello, William E.

External links

• http://www.ambanet.net/, American Medical Billing Association
• http://www.wchsb.com/, WCH Billing Bureau
• http://www.aapc.com/, American Academy of Professional Coders
• http://www.ahima.org/, American Health Information Management Association