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Ear, Nose and Throat Superbill Template Date of Service: Insurance: Patient Name

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Ear, Nose and Throat Superbill Template Date of Service: Insurance: Patient Name Ear, Nose and Throat Superbill Template Date of service: Insurance: Patient name: Subscriber name: Address: Group #: Previous balance: Copay: Today’s charges: Phone: Account #: Today’s payment: check# DOB: Age: Sex: Physician name: Balance due: MOD. Patient E/M New Est MOD. I&D, intraoral, tongue, floor of 41005 MOD. Flexible laryngoscopy with 31578 mouth, sublingual, superficial removal of lesion Level I 99201 99211 I&D, intraoral, tongue, floor of 41005 Flexible laryngoscopy with 31579 mouth, sublingual, superficial stroboscopy Level II 99202 99212 I&D, extraoral, floor of mouth, 41015 Incision of labial frenulum 40806 sublingual Level III 99203 99213 I&D, extraoral, floor of mouth, 41016 Excision lingual frenulum 41115 submental Level IV 99204 99214 I&D, extraoral, submandibular 41017 Uvulectomy 42140 Level V 99205 99215 I&D, peritonsillar 42700 Destruction of lesion, palate or 42160 uvula (thermal, cryo) Consultations I&D infected thyroglossal duct 60000 Palate Somnoplasty 42145- cyst 52 Consultation Level I 99241 I&D external ear, simple 69000 Turbinate Somnoplasty 30140- 52 Consultation Level II 99242 I&D external ear, complicated 69005 Cautery ablation, any method, 30801 superficial Consultation Level III 99243 I&D, external auditory canal 69020 Cautery ablation, intramural 30802 Consultation Level IV 99244 Ear Procedures Removal of foreign body, 30300 intranasal Consultation Level V 99245 Myringotomy 69420 Removal of foreign body, external 69200 auditory canal Biopsy Tympanostomy 69433 Vestibular Function Tests Biopsy (Skin) 11100 Tympanostomy with general 69436 Spontaneous nystagmus 92531 anesthesia each additional skin biopsy 11001 Impacted cerumen removal 69210 Caloric vestibular test 92532 Biopsy, nasal 30100 Control of Nasal Bleed Optokinetic nystagmus test 92534 Biopsy, lip 40490 Simple nasal hemorrhage 30901 Basic vestibular evaluation, with 92540 control recording Biopsy, vestibule of mouth 40808 Anterior, complete nasal 30903 Spontaneous nystagmus, with 92541 hemorrhage control recording Biopsy, tongue (anterior 2/3) 41100 Posterior nasal hemorrhage 30905 Positional nystagmus test, with 92542 control recording Biopsy, tongue (posterior 41105 Nasal Endoscopy Caloric vestibular test, with 92543 1/3) recording Biopsy, floor of mouth 41108 Diagnostic nasal endoscopy 31231 Optokinetic nystagmus test, with 92544 recording Biopsy, palate, uvula 42100 Maxillary sinusoscopy 31232 Oscillating tracking test, with 92545 recording Biopsy, oropharynx 42800 Sphenoid sinusoscopy 31235 Tympanometry and reflex 92550 threshold measurements Nasal endoscopic biopsy, Biopsy, hypopharynx 42802 31237 Pure tone screening 92551 polypectomy or debridement Biopsy, nasopharynx, visible 42804 Nasal endoscopic hemorrhage 31238 Pure tone audiometry; air only 92552 lesion control Biopsy, nasopharynx, 42806 Nasal endoscopy with 31239 Pure tone audiometry: air and 92553 unknown primary dacryocystorhinostomy bone Nasal endoscopy with concha Sialolithotomy 31240 Speech audiometry threshold 92555 bullosa resection Sialolithotomy, 42330 Endoscopic partial 31254 Speech audiometry threshold with 92556 uncomplicated, intraoral ethmoidectomy speech recognition Sialolithotomy, 42335 Endoscopic total 31255 Comprehensive audiometry 92557 submandibular, complicated, ethmoidectomy intraoral Sialolithotomy, parotid, 42340 Endoscopic maxillary 31256 Percutaneous allergy skin test 95004 extraoral or complicated antrostomy intraoral Incision and Drainage Endoscopic maxillary tissue 31267 Allergy testing for venoms 95017 removal I&D abscess, simple, single 10060 Frontal sinus endoscopy 31276 Allergy testing for drugs, biological 95018 I&D, complicated, multiple 10061 Endoscopic sphenoidotomy 31287 Intradermal allergy tests 95024 I&D hematoma, seroma, fluid 10140 Endoscopic removal of 31288 Single allergy injection (including 95120 collection sphenoid tissue extract) Puncture aspiration of 10160 Endoscopic maxillary sinus 31295 Two or more allergy injections 95125 abscess, cyst, hematoma dilation (including extract) I&D complex, postoperative 10180 Endoscopic frontal sinus 31296 Preparation and provision of 95165 wound infection dilation antigens I&D nasal abscess or 30000 Endoscopic sphenoid sinus 31297 Inhalation bronchial challenge 95070 hematoma dilation I&D nasal septum abscess or 30020 Flexible Laryngoscopy Nasopharyngoscopy 92511 hematoma I&D vestibule of mouth, 40800 Flexible diagnostic 31575 Single allergy injection (without 95115 simple laryngoscopy extract provision) I&D vestibule of mouth, 40801 Flexible laryngoscopy with 31576 Venipuncture 36415 complicated biopsy I&D, intraoral, tongue, floor of 41000 Flexible laryngoscopy with 31577 Handling 99000 mouth, lingual foreign body removal ICD-10 Codes Diagnosis C00.9 Malignant neoplasm of lip, unspecified C01 Malignant neoplasm of base of tongue C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified C04.9 Malignant neoplasm of floor of mouth, unspecified C05.0 Malignant neoplasm of hard palate C06.9 Malignant neoplasm of mouth, unspecified C07 Malignant neoplasm of parotid gland C08.0 Malignant neoplasm of submandibular gland C10.9 Malignant neoplasm of oropharynx, unspecified C11.9 Malignant neoplasm of nasopharynx, unspecified C13.9 Malignant neoplasm of hypopharynx, unspecified C30.0 Malignant neoplasm of nasal cavity C32.0 Malignant neoplasm of glottis C32.1 Malignant neoplasm of supraglottis C32.9 Malignant neoplasm of larynx, unspecified C44.00 Unspecified malignant neoplasm of skin of lip C44.01 Basal cell carcinoma of skin of lip C44.02 Squamous cell carcinoma of skin of lip C44.09 Other specified malignant neoplasm of skin of lip C44.202 Unspecified malignant neoplasm of skin of right ear and external auricular canal C44.209 Unspecified malignant neoplasm of skin of left ear and external auricular canal C44.212 Basal cell carcinoma of skin of right ear and external auricular canal C44.219 Basal cell carcinoma of skin of left ear and external auricular canal C44.222 Squamous cell carcinoma of skin of right ear and external auricular canal C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal C44.301 Unspecified malignant neoplasm of skin of nose C44.309 Unspecified malignant neoplasm of other parts of face C44.311 Basal cell carcinoma of skin of nose C44.319 Basal cell carcinoma of skin of other parts of face C44.321 Squamous cell carcinoma of skin of nose C44.329 Squamous cell carcinoma of skin of other parts of face C44.40 Unspecified malignant neoplasm of skin of scalp and neck C44.41 Basal cell carcinoma of skin of scalp and neck C44.42 Squamous cell carcinoma of skin of scalp and neck C44.49 Other specified malignant neoplasm of skin of scalp and neck C73 Malignant neoplasm of thyroid gland C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck D00.01 Carcinoma in situ of labial mucosa and vermilion border D00.02 Carcinoma in situ of buccal mucosa D00.03 Carcinoma in situ of gingiva and edentulous alveolar ridge D00.04 Carcinoma in situ of soft palate D00.05 Carcinoma in situ of hard palate D00.06 Carcinoma in situ of floor of mouth D00.07 Carcinoma in situ of tongue D00.08 Carcinoma in situ of pharynx D10.30 Benign neoplasm of unspecified part of mouth D10.39 Benign neoplasm of other parts of mouth D11.0 Benign neoplasm of parotid gland D11.7 Benign neoplasm of other major salivary gland D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses D14.1 Benign neoplasm of larynx D22.11 Melanocytic nevi of right eyelid, including canthus D22.12 Melanocytic nevi of left eyelid, including canthus D23.11 Other benign neoplasm of skin of right eyelid, including canthus D23.12 Other benign neoplasm of skin of left eyelid, including canthus D33.3 Benign neoplasm of cranial nerves D35.2 Benign neoplasm of pituitary gland D37.01 Neoplasm of uncertain behavior of lip D37.02 Neoplasm of uncertain behavior of tongue D37.030 Neoplasm of uncertain behavior of the parotid salivary glands D37.031 Neoplasm of uncertain behavior of the sublingual salivary glands D37.032 Neoplasm of uncertain behavior of the submandibular salivary glands D37.04 Neoplasm of uncertain behavior of the minor salivary glands D37.05 Neoplasm of uncertain behavior of pharynx D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity D38.0 Neoplasm of uncertain behavior of larynx D48.5 Neoplasm of uncertain behavior of skin D49.0 Neoplasm of unspecified behavior of digestive system D49.1 Neoplasm of uncertain behavior of respiratory system D49.2 Neoplasm of uncertain behavior of bone, soft tissue, and skin D49.7 Neoplasm of uncertain behavior of endocrine glands and other parts of nervous system E04.1 Nontoxic single thyroid nodule E04.2 Nontoxic multinodular goiter E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm E06.9 Thyroiditis, unspecified E21.0 Primary hyperparathyroidism E21.1 Secondary hyperparathyroidism, not elsewhere classified E21.2 Other hyperparathyroidism E84.9 Cystic fibrosis F45.8 Other somatoform disorders F80.4 Speech and language development delay due to hearing loss G47.09 Other insomnia G47.19 Other hypersomnia G47.30 Sleep apnea, unspecified G47.33 Obstructive sleep apnea (adult) (pediatric) G50.1 Atypical facial pain G51.0 Bell’s palsy H6.301 Acquired stenosis of right external ear canal, unspecified H60.331 Swimmer’s ear, right ear H60.332 Swimmer’s ear, left ear H60.333 Swimmer’s ear, bilateral H60.391 Other infective otitis externa, right ear H60.392 Other infective
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