MODEL SUPERBILL for AUDIOLOGY

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1 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 More information on coding for audiology services can also be found on ASHA s billing and reimbursement website.

2 Page 1 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): SECONDARY (Medical): HEARING AID/EARMOLD DEFECT: ICD-10/9 CODE: ICD-10/9 CODE: SERVICES: Audiological Assessment Procedures o Tympanometry and reflex threshold measurements o Screening test, pure tone, air only o Pure tone audiometry (threshold);air only o Pure tone audiometry (threshold); air and bone o Speech audiometry threshold o Speech audiometry threshold; w/speech recognition o Comprehensive audiometry threshold evaluation and speech recognition o Audiometric testing of groups o Bekesy audiometry; screening o Bekesy audiometry; diagnostic o Loudness balance test, alternate binaural or monaural o Tone decay test o Short increment sensitivity index (SISI) o Stenger test, pure tone o Tympanometry (impedance testing) o Acoustic reflex testing, threshold o Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing o Filtered speech test o Staggered spondaic word test o Sensorineural acuity level test o Synthetic sentence identification test o Stenger test, speech o Visual reinforcement audiometry (VRA) o Conditioning play audiometry o Select picture audiometry o Electrocochleography o Auditory evoked potentials, comprehensive o Auditory evoked potentials, limited o Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis 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 o Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report o Evaluation of central auditory function, with report; initial 60 minutes o each additional 15 minutes o Assessment of tinnitus (includes pitch, loudness matching, and masking) Hearing Aid Assessment and Fitting Procedures o Hearing aid exam and selection; monaural o Hearing aid exam and selection; binaural o Hearing aid check; monaural o Hearing aid check; binaural o Electroacoustic evaluation for hearing aid; monoaural o binaural o Ear protector attenuation measurements Vestibular and Balance System Assessment Procedures o Spontaneous nystagmus, including gaze o Positional nystagmus test o Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests) o Optokinetic nystagmus test 92534

3 Model Audiology Superbill Page 2 o Caloric vestibular test with recording, bilateral; bithermal o monothermal o 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 o Spontaneous nystagmus test, incl. gaze and fixation nystagmus, with recording o Positional nystagmus test, minimum of four positions o Optokinetic nystagmus test, bi-directional, foveal or peripheral stimulation, w/ recording o Oscillating tracking test, with recording o Sinusoidal vertical axis rotational testing o Use of vertical electrodes in any or all of the above tests o Computerized dynamic posturography Vestibular and Balance Rehabilitation Services o Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver) per day Cerumen Management Services o Removal of impacted cerumen, one or both ears Auditory Implant Services o Cochlear implant follow-up exam <7 years of age o Reprogram cochlear implant <7 years of age o Cochlear implant follow-up exam >7 years of age o Reprogram cochlear implant > 7 years of age o Diagnostic analysis with programming of auditory brainstem implant, per hour Habilitative and Rehabilitative Services o Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual o group, two or more individuals o Evaluation of auditory rehabilitation status, 1st hour o each additional 15 minutes o Auditory rehabilitation; pre-lingual hearing loss o Auditory rehabilitation; post-lingual hearing loss Hearing Aids/FM Systems (HCPCS Level II Codes) o Assessment for Hearing Aid V5010 o Fitting/Orientation/Checking of Hearing Aid V5011 o Repair/Modification of a Hearing Aid V5014 o Conformity Evaluation V5020 o Hearing aid, Monaural, body worn, air conduction V5030 o bone conduction V5040 o Hearing Aid, Monaural, in the ear (ITE) V5050 o Hearing Aid, Monaural, behind the ear (BTE) V5060 o Glasses, air conduction V5070 o Glasses, bone conduction V5080 o Dispensing fee, Un Hearing Aid V5090 o Hearing Aid, bilateral, body worn V5100 o Dispensing fee, bilateral V5110 o Binaural, body V5120 o Binaural, ITE V5130 o Binaural, BTE V5140 o Binaural, glasses V5150 o Dispensing fee, binaural V5160 o Hearing Aid, CROS, ITE V5170 o Hearing Aid, CROS, BTE V5180 o Hearing Aid, CROS, glasses V5190 o Dispensing fee, CROS V5200 o Hearing Aid, BICROS, ITE V5210 o Hearing Aid, BICROS, BTE V5220 o Hearing Aid, BICROS, glasses V5230 o Dispensing Fee, BICROS V5240 o Dispensing Fee, Monaural Hearing Aid V5241 o Hearing Aid, Analog, monaural, completely in the ear canal (CIC) V5242 o Hearing aid, analog, monaural, in the canal (ITC) monaural, CIC monaural, ITC monaural, ITE monaural, BTE o Hearing aid, analog, binaural, CIC o Hearing aid, analog, binaural, ITC binaural, CIC binaural, ITC o Hearing aid, digitally programmable, binaural, ITE o Hearing aid, digitally programmable, binaural, BTE o Hearing aid, digital, monaural, CIC o Hearing aid, digital, monaural, ITC o Hearing aid, digital, monaural, ITE o Hearing aid, digital, monaural, BTE o Hearing aid, digital, binaural, CIC o Hearing aid, digital, binaural, ITC o Hearing aid, digital, binaural, ITE o Hearing aid, digital, binaural, BTE o Hearing aid, disposable, any type, monaural o Hearing aid, disposable, any type, binaural V5243 V5244 V5245 V5246 V5247 V5248 V5249 V5250 V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5262 V5263

4 Model Audiology Superbill Page 3 o Earmold/insert, not disposable, any type V5264 o Earmold/insert, disposable, any type V5265 o Battery for use in hearing device V5266 o Hearing aid or assistive listening device/supplies/accessories, not otherwise V5267 o Assistive listening device, telephone amplifier, any type V5268 o Assistive listening device, alerting, any type o Assistive listening device, television amplifier, any type o Assistive listening device, television caption decoder o Assistive listening device, TDD o Assistive listening device, for use with cochlear implant o Assistive learning device not otherwise o Ear impression, each o Personal FM/DM system, monaural (one receiver, transmitter and microphone) o Personal FM/DM system, binaural (two receivers, transmitter and microphone) o Personal FM/DM neck, loop induction receiver o Personal FM/DM, ear level receiver o Personal FM/DM, direct audio input receiver o Personal blue tooth FM/DM receiver o Personal FM/DM receiver, not otherwise o Personal FM/DM transmitter assistive listening device o Personal FM/DM adapter/boot coupling device for receiver, any type o Transmitter microphone, any type o Hearing Service, Miscellaneous V5269 V5270 V5271 V5272 V5273 V5274 V5275 V5281 V5282 V5283 V5284 V5285 V5286 V5287 V5288 V5289 V5290 V5299 Electrophysiology Procedures o Nerve conduction studies; 1-2 studies o 3-4 studies o 5-6 studies o 7-8 studies o 9-10 studies o studies o 13 or more studies o Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs o in lower limbs o in upper & lower limbs o in the trunk or head o Visual evoked potential (VEP) testing central nervous system, checkerboard or flash o Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 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) o 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 primary procedure) Other Procedures o Otorhinolaryngological service or procedure o 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 medical discussion o minutes of medical discussion o minutes of medical discussion o 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 o 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 care professional 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 care professional Total Charges: $

5 Model Audiology Superbill Page 4 BILLING INFORMATION PREVIOUS BALANCE: $ TODAY S CHARGES: $ TOTAL DUE: $ PAID TODAY: $ PAID BY: o CASH o CREDIT VISA MC OTHER BALANCE: $ o CHECK 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 (999) PHONE (888) FAX NPI # s TAX ID # s MARYLAND LICENSE # 3333

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