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SUPERBILL Name Appt Date Time Ticket # Today's Charge Primary Insurance Acct. # Today's Payment Pt. Balance Co-pay Today's Balance Office Visits Procedure Diagnosis (Continued) New Patients 99201 Problem Focused 45300 Proctosigmoidoscopy R15.1 Fecal Smearing 99202 Expanded Problem 46600 Diagnostic Anoscopy K62.5 Hemorrhage Anus/Rectum 99203 Detailed 46221 Hemorrhoid Ligation K64.8 Internal Hemorrhoids (w/o mention of 99204 Moderate 46220 Removal, Anal Tag degree) 99205 Comprehensive 46230 Removal, 2+ Anal Tags K64.9 Internal Hemorrhoids - Bleeding (w/o 46083 Incision Ext. Hemorrhoid mention of degree) Consultations 46320 Excision Ext. Hemorrhoid K64.0 1st Degree Hemorrhoids (Grade I) - 99241 Problem Focused 45005 I&D Abscess w/o Proplapse Outside Anal Canal 99242 Expanded Problem 46910 Viral Wart, Condyloma, K64.1 2nd Degree Hemorrhoids (Grade II) – Papilloma destruction by That Prolapse with Straining but 99243 Detailed electrodesiccation (any Retract Spontaneously number) K64.2 3rd Degree Hemorrhoids (Grade III) – 99244 Moderate That Prolapse with Straining and 99245 Comprehensive 46924 Viral Wart, Condyloma, Require Manual Replacement Papilloma destruction by Established Patients laser, cryosurgery, K64.3 4th Degree Hemorrhoids (Grade IV) – 99211 Problem Focused electrosurgery (any number) with Prolapsed Tissue That Cannot be 99212 Expanded Problem J3490 Nitroglycerin Ointment Manually Replaced 99213 Detailed A4550 Surgical Trays O22.4 Hemorrhoids Complicating Pregnancy 99214 Moderate Diagnosis O87.2 Hemorrhoids Complicating Puerperium 99215 Comprehensive K61.0 Anal Abscess K64.4 External Hemorrhoids K60.0 Anal Fissure - Acute K64.5 External Hemorrhoids w/ Thrombosis Other K60.1 Anal Fissure - Chronic K62.89 Hypertrophic Anal Papillae 99024 Problem Focused K60.2 Anal Fissure - Unspecified R15.0 Incomplete Defecation K60.3 Anal Fistula K58.0 Irritable bowel syndrome, w/ Diarrhea K59.4 Anal Spasm K58.9 Irritable Bowel Syndrome, w/o Diarrhea Note: Any service listed above K92.1 Melena when billed with a procedure should be billed with modifer -25 K19.5 Other Fecal Abnormalities D37.5 Neoplasm, Rectum K52.9 Colitis, Unspecified K62.89 Other Specified Disease Anus/Rectum Other Service or Diagnosis K52.89 Colitis, Specified (Pain) K59.00 Constipation, Unspecified L29.0 Pruritus Ani K59.01 Constipation, Slow Transit K62.3 Rectal Prolapse K59.09 Consitpation, Other R21 Rash + Other N/S Skin Eruption K50.011- K64.4 Skin Tags Crohn's Disease K50.919 K62.4 Stenosis of Rectum and Anus R19.7 Diarrhea, Unspecified A63.0 Anogential (venereal) warts Physician Signature Date Return in _________days/weeks/years Follow-up Instructions.

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