Model Superbill for Audiology Services

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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.
P a g e |1
MODEL AUDIOLOGY SUPERBILL
PATIENT:
INSURED:
REFERRING PHYSICIAN:
ADDRESS:
FILE:
INSURANCE PLAN:
DATE:
INSURANCE PLAN #:
DATE INITIAL SYMPTOM:
DATE FIRST CONSULTATION:
PLACE OF SERVICE:
 HOME
 OFFICE
 OTHER:
DIAGNOSIS:
PRIMARY (Audiology):
ICD-10 CODE:
SECONDARY (Medical):
ICD-10 CODE:
HEARING AID/EARMOLD DEFECT:
SERVICES:
 PROCEDURE
Audiological Assessment Procedures
CPT

Tympanometry and reflex threshold
measurements
92550



Screening test, pure tone, air only
92551
Pure tone audiometry (threshold);air only
Pure tone audiometry (threshold); air and
bone
92552


Speech audiometry threshold
Speech audiometry threshold; w/speech
recognition
Comprehensive audiometry threshold
evaluation and speech recognition
92555




Audiometric testing of groups
92559
Bekesy audiometry; screening
92560
Bekesy audiometry; diagnostic
Loudness balance test, alternate binaural or
monaural
92561






Tone decay test
92563
Short increment sensitivity index (SISI)
92564
Stenger test, pure tone
92565
Tympanometry (impedance testing)
92567
Acoustic reflex testing, threshold
Acoustic immittance testing, includes
tympanometry (impedance testing), acoustic
reflex threshold testing, and acoustic reflex
decay testing
92568
Filtered speech test
92571
Staggered spondaic word test
92572
Sensorineural acuity level test
92575
Synthetic sentence identification test
92576
Stenger test, speech
92577
Visual reinforcement audiometry (VRA)
92579
Conditioning play audiometry
92582
Select picture audiometry
92583
Electrocochleography
92584










92553
92556
CHARGE
 PROCEDURE





92557
92562
92570



CPT
Auditory evoked potentials, comprehensive
92585
Auditory evoked potentials, limited
Evoked otoacoustic emissions, screening
(qualitative measurement of distortion product
or transient evoked otoacoustic emissions),
automated analysis
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
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
Evaluation of central auditory function, with
report; initial 60 minutes
92586
each additional 15 minutes
Assessment of tinnitus (includes pitch,
loudness matching, and masking)
92621
CHARGE
92558
92587
92588
92620
92625
Hearing Aid Assessment and Fitting Procedures







Hearing aid exam and selection; monaural
92590
Hearing aid exam and selection; binaural
92591
Hearing aid check; monaural
92592
Hearing aid check; binaural
Electroacoustic evaluation for hearing aid;
monoaural
92593
binaural
Ear protector attenuation measurements
92594
92595
92596
Vestibular and Balance System Assessment Procedures




Spontaneous nystagmus, including gaze
92531
Positional nystagmus test
Caloric vestibular test, each irrigation
(binaural, bithermal stimulation constitutes 4
tests)
92532
Optokinetic nystagmus test
92534
92533
Model Audiology Superbill
 PROCEDURE
P a g e |2
CPT

Caloric vestibular test with recording,
bilateral; bithermal


monothermal
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
Spontaneous nystagmus test, incl. gaze and
fixation nystagmus, with recording
Positional nystagmus test, minimum of four
positions
Optokinetic nystagmus test, bi-directional,
foveal or peripheral stimulation, w/ recording
92538



Oscillating tracking test, with recording
92545
Sinusoidal vertical axis rotational testing
Use of vertical electrodes in any or all of the
above tests
92546

Computerized dynamic posturography
92548



CHARGE
92537
92540
92541
92542
92544
92547
Vestibular and Balance Rehabilitation Services

Canalith repositioning procedure(s) (eg, Epley
maneuver, Semont maneuver) per day.
95992
Cerumen Management Services


Removal impacted cerumen using
irrigation/lavage, unilateral
Removal impacted cerumen requiring
instrumentation, unilateral
69209
69210
Cochlear implant follow-up exam <7 years of
age


Reprogram cochlear implant <7 years of age
Cochlear implant follow-up exam >7 years of
age


92601

92602

92603

Reprogram cochlear implant > 7 years of age 92604
Diagnostic analysis with programming of
auditory brainstem implant, per hour
92640

Habilitative and Rehabilitative Services

























Auditory Implant Services

 PROCEDURE
Treatment of speech, language, voice,
communication, and/or auditory processing
disorder; individual
92507






group, two or more individuals
Evaluation of auditory rehabilitation status,
1st hour
92508


each additional 15 minutes
Auditory rehabilitation; pre-lingual hearing
loss
Auditory rehabilitation; post-lingual hearing
loss
92627

92630










92626
92633
Hearing Aids/FM Systems (HCPCS Level II Codes)





Assessment for Hearing Aid
V5010
Fitting/Orientation/Checking of Hearing Aid
V5011
Repair/Modification of a Hearing Aid
V5014
Conformity Evaluation
Hearing aid, Monaural, body worn,
air conduction
V5020
V5030

CPT
bone conduction
Hearing Aid, Monaural, in the ear (ITE)
V5040
Hearing Aid, Monaural, behind the ear (BTE)
Glasses, air conduction
V5060
V5070
Glasses, bone conduction
V5080
Dispensing fee, Unspecified Hearing Aid
V5090
Hearing Aid, bilateral, body worn
V5100
Dispensing fee, bilateral
V5110
Binaural, body
V5120
Binaural, ITE
V5130
Binaural, BTE
V5140
Binaural, glasses
V5150
Dispensing fee, binaural
V5160
Hearing Aid, CROS, ITE
V5170
Hearing Aid, CROS, BTE
V5180
Hearing Aid, CROS, glasses
V5190
Dispensing fee, CROS
V5200
Hearing Aid, BICROS, ITE
V5210
Hearing Aid, BICROS, BTE
V5220
Hearing Aid, BICROS, glasses
V5230
Dispensing Fee, BICROS
V5240
Dispensing Fee, Monaural Hearing Aid
Hearing Aid, Analog, monaural, completely in
the ear canal (CIC)
Hearing aid, analog, monaural, in the canal
(ITC)
Hearing aid, digitally programmable analog,
monaural, CIC
Hearing aid, digitally programmable analog,
monaural, ITC
Hearing aid, digitally programmable analog,
monaural, ITE
Hearing aid, digitally programmable analog,
monaural, BTE
V5241
Hearing aid, analog, binaural, CIC
V5248
Hearing aid, analog, binaural, ITC
Hearing aid, digitally programmable analog,
binaural, CIC
Hearing aid, digitally programmable analog,
binaural, ITC
Hearing aid, digitally programmable, binaural,
ITE
Hearing aid, digitally programmable, binaural,
BTE
V5249
Hearing aid, digital, monaural, CIC
V5254
Hearing aid, digital, monaural, ITC
V5255
Hearing aid, digital, monaural, ITE
V5256
Hearing aid, digital, monaural, BTE
V5257
Hearing aid, digital, binaural, CIC
V5258
Hearing aid, digital, binaural, ITC
V5259
Hearing aid, digital, binaural, ITE
V5260
Hearing aid, digital, binaural, BTE
V5261
Hearing aid, disposable, any type, monaural
V5262
V5050
V5242
V5243
V5244
V5245
V5246
V5247
V5250
V5251
V5252
V5253
CHARGE
Model Audiology Superbill
 PROCEDURE
























P a g e |3
CPT
CHARGE
 PROCEDURE
Hearing aid, disposable, any type, binaural
V5263

Earmold/insert, not disposable, any type
V5264
Earmold/insert, disposable, any type
V5265

Battery for use in hearing device
V5266
Hearing aid or assistive listening
device/supplies/accessories, not otherwise
specified
V5267
Assistive listening device, telephone amplifier,
any type
V5268
Assistive listening device, alerting, any type
V5269
Assistive listening device, television amplifier,
any type
V5270
Assistive listening device, television caption
decoder
V5271


Assistive listening device, TDD
Assistive listening device, for use with
cochlear implant
Assistive learning device not otherwise
specified
V5272
Other Procedures
V5273


Ear impression, each
Personal FM/DM system, monaural (one
receiver, transmitter and microphone)
Personal FM/DM system, binaural (two
receivers, transmitter and microphone)
Personal FM/DM neck, loop induction
receiver
V5275
Personal FM/DM, ear level receiver
V5284
Personal FM/DM, direct audio input receiver
V5285
Personal blue tooth FM/DM receiver
Personal FM/DM receiver, not otherwise
specified
Personal FM/DM transmitter assistive
listening device
Personal FM/DM adapter/boot coupling
device for receiver, any type
V5286
Transmitter microphone, any type
V5290
Hearing Service, Miscellaneous
V5299
V5274
V5281
V5282
V5283
V5287



V5288
V5289

Electrophysiology Procedures











Nerve conduction studies; 1-2 studies
95907
3-4 studies
95908
5-6 studies
95909
7-8 studies
95910
9-10 studies
95911
11-12 studies
95912

CPT
Visual evoked potential (VEP) testing central
nervous system, checkerboard or flash
Neuromuscular junction testing (repetitive
stimulation, paired stimuli), each nerve, any 1
method
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)
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)
95930
95937
95940
95941
Otorhinolaryngological service or procedure
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
92700
11-20 minutes of medical discussion
98967
21-30 minutes of medical discussion
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.
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
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
98968
98966
98969
99366
99368
13 or more studies
95913
Short-latency somatosensory evoked
potential study, stimulation of any/all
peripheral nerves or skin sites, recording from
the central nervous system; in upper limbs
95925
in lower limbs
95926
in upper & lower limbs
95938
in the trunk or head
95927
Total Charges: $
CHARGE
Model Audiology Superbill
P a g e |4
BILLING INFORMATION
PREVIOUS BALANCE:
$
TODAY’S CHARGES:
$
TOTAL DUE:
$
PAID TODAY:
$
PAID BY:
 CASH
BALANCE:
 CREDIT
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.
 VISA  MC  OTHER
$
 CHECK
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
NPI # 1234567890  TAX ID # 22-22222  MARYLAND LICENSE # 3333

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