, 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 Biopsy, hypopharynx 42802 Nasal endoscopic biopsy, 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 Sialolithotomy Nasal endoscopy with concha 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 , 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 externa, right ear H60.392 Other infective otitis externa, left ear H60.393 Other infective otitis externa, bilateral H60.511 Acute actinic otitis externa, right ear H60.512 Acute actinic otitis externa, left ear H60.513 Acute actinic otitis externa, bilateral H60.521 Acute chemical otitis externa, right ear H60.522 Acute chemical otitis externa, left ear H60.523 Acute chemical otitis externa, bilateral H60.531 Acute contact otitis externa, right ear H60.532 Acute contact otitis externa, left ear H60.533 Acute contact otitis externa, bilateral H60.541 Acute eczematoid otitis externa, right ear H60.542 Acute eczematoid otitis externa, left ear H60.543 Acute eczematoid otitis externa, bilateral H60.551 Acute reactive otitis externa, right ear H60.552 Acute reactive otitis externa, left ear H60.553 Acute reactive otitis externa, bilateral H60.591 Other noninfective acute otitis externa, right ear H60.592 Other noninfective acute otitis externa, left ear H60.593 Other noninfective acute otitis externa, bilateral H60.61 Unspecified chronic otitis externa, right ear H60.62 Unspecified chronic otitis externa, left ear H60.63 Unspecified chronic otitis externa, bilateral H61.011 Acute perichondritis of right external ear H61.012 Acute perichondritis of left external ear H61.013 Acute perichondritis of external ear, bilateral H61.021 Chronic perichondritis of right external ear H61.022 Chronic perichondritis of left external ear H61.023 Chronic perichondritis of external ear, bilateral H61.121 Hematoma of pinna, right ear H61.122 Hematoma of pinna, left ear H61.123 Hematoma of pinna, bilateral H61.21 Impacted cerumen, right ear H61.22 Impacted cerumen, left ear H61.23 Impacted cerumen, bilateral H61.302 Acquired stenosis of left external ear canal, unspecified H61.303 Acquired stenosis of external ear canal, unspecified, bilateral H61.391 Other acquired stenosis of right external ear canal H61.392 Other acquired stenosis of left external ear canal H61.393 Other acquired stenosis of external ear canal, bilateral H61.811 Exostosis of right external ear canal H61.812 Exostosis of left external ear canal H61.813 Exostosis of external ear canal, bilateral H65.01 Acute serous , right ear H65.02 Acute serous otitis media, left ear H65.03 Acute serous otitis media, bilateral H65.04 Acute serous otitis media, recurrent, right ear H65.05 Acute serous otitis media, recurrent, left ear H65.06 Acute serous otitis media, recurrent, bilateral H65.91 Unspecified nonsuppurative otitis media, right ear H65.92 Unspecified nonsuppurative otitis media, left ear H65.93 Unspecified nonsuppurative otitis media, bilateral H66.001 Acute suppurative otitis media without spontaneous rupture of ear drum, right ear H66.002 Acute suppurative otitis media without spontaneous rupture of ear drum, left ear H66.003 Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral H66.004 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear H66.005 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear H66.006 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral H66.011 Acute suppurative otitis media with spontaneous rupture of ear drum, right ear H66.012 Acute suppurative otitis media with spontaneous rupture or ear drum, left ear H66.013 Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral H66.014 Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear H66.015 Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear H66.016 Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral H66.11 Chronic tubotympanic suppurative otitis media, right ear H66.12 Chronic tubotympanic suppurative otitis media, left ear H66.13 Chronic tubotympanic suppurative otitis media, bilateral H66.21 Chronic atticoantral suppurative otitis media, right ear H66.22 Chronic atticoantral suppurative otitis media, left ear H66.23 Chronic atticoantral suppurative otitis media, bilateral H66.3X1 Other chronic suppurative otitis media, right ear H66.3X2 Other chronic suppurative otitis media, left ear H66.3X3 Other chronic suppurative otitis media, bilateral H66.91 Otitis media, unspecified, right ear H66.92 Otitis media, unspecified, left ear H66.93 Otitis media, unspecified, bilateral H69.81 Other specified disorder of , right ear H69.82 Other specified disorder of Eustachian tube, left ear H69.83 Other specified disorder of Eustachian tube, bilateral H70.11 Chronic , right ear H70.12 Chronic mastoiditis, left ear H70.13 Chronic mastoiditis, bilateral H71.01 Cholesteatoma of attic, right ear H71.02 Cholesteatoma of attic, left ear H71.03 Cholesteatoma of attic, bilateral H71.11 Cholesteatoma of tympanum, right ear H71.12 Cholesteatoma of tympanum, left ear H71.13 Cholesteatoma of tympanum, bilateral H71.21 Cholesteatoma of mastoid, right ear H71.22 Cholesteatoma of mastoid, left ear H71.23 Cholesteatoma of mastoid, bilateral H71.91 Unspecified cholesteatoma, right ear H71.92 Unspecified cholesteatoma, left ear H71.93 Unspecified cholesteatoma, bilateral H72.01 Central perforation of tympanic membrane, right ear H72.01 Central perforation of tympanic membrane, right ear H72.02 Central perforation of tympanic membrane, left ear H72.02 Central perforation of tympanic membrane, left ear H72.03 Central perforation of tympanic membrane, bilateral H72.03 Central perforation of tympanic membrane, bilateral H72.11 Attic perforation of tympanic membrane, right ear H72.12 Attic perforation of tympanic membrane, left ear H72.13 Attic perforation of tympanic membrane, bilateral H72.2X1 Other marginal perforations of tympanic membrane, right ear H72.2X2 Other marginal perforations of tympanic membrane, left ear H72.2X3 Other marginal perorations of tympanic membrane, bilateral H72.811 Multiple perforations of tympanic membrane, right ear H72.812 Multiple perforations of tympanic membrane, left ear H72.813 Multiple perforations of tympanic membrane, bilateral H72.91 Unspecified perforation of tympanic membrane, right ear H72.92 Unspecified perforation of tympanic membrane, left ear H72.93 Unspecified perforation of tympanic membrane, bilateral H73.11 Chronic myringitis, right ear H73.12 Chronic myringitis, left ear H73.13 Chronic myringitis, bilateral H74.11 Adhesive right middle ear disease H74.12 Adhesive left middle ear disease H74.13 Adhesive middle ear disease, bilateral H80.91 Unspecified otosclerosis, right ear H80.92 Unspecified otosclerosis, left ear H80.93 Unspecified otosclerosis, bilateral H81.01 Meniere’s disease, right ear H81.02 Meniere’s disease, left ear H81.03 Meniere’s disease, bilateral H81.11 Benign paroxysmal , right ear H81.12 Benign paroxysmal vertigo, left ear H81.13 Benign paroxysmal vertigo, bilateral H81.41 Vertigo of central origin, right ear H81.42 Vertigo of central origin, left ear H81.43 Vertigo of central origin, bilateral H83.2X1 Labyrinthine dysfunction, right ear H83.2X2 Labyrinthine dysfunction, left ear H83.2X3 Labyrinthine dysfunction, bilateral H83.3X1 Noise effects on right inner ear H83.3X2 Noise effect on left inner ear H83.3X3 Noise effects on inner ear, bilateral H90.0 Conductive hearing loss, bilateral H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side H90.2 Conductive hearing loss, unspecified H90.3 Sensorineural hearing loss, bilateral H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side H90.5 Unspecified sensorineural hearing loss H90.6 Mixed conductive and sensorineural hearing loss, bilateral Mixed conductive and sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on H90.71 the contralateral side Mixed conductive and sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the H90.72 contralateral side H90.8 Mixed conductive and sensorineural hearing loss, unspecified H91.11 Presbycusis, right ear H91.12 Presbycusis, left ear H91.13 Presbycusis, bilateral H91.91 Unspecified hearing loss, right ear H91.92 Unspecified hearing loss, left ear H91.93 Unspecified hearing loss, bilateral H92.01 Otalgia, right ear H92.02 Otalgia, left ear H92.03 Otalgia, bilateral H93.11 , right ear H93.12 Tinnitus, left ear H93.13 Tinnitus, bilateral H93.291 Other abnormal auditory perceptions, right ear H93.292 Other abnormal auditory perceptions, left ear H93.293 Other abnormal auditory perceptions, bilateral J01.80 Other acute sinusitis J01.81 Other acute recurrent sinusitis J01.90 Acute sinusitis, unspecified J01.91 Acute recurrent sinusitis, unspecified J02.8 Acute pharyngitis due to other specified organism J02.9 Acute pharyngitis, unspecified J04.0 Acute laryngitis J30.0 Vasomotor rhinitis J30.1 Allergic rhinitis due to pollen J30.2 Other seasonal allergic rhinitis J30.89 Other allergic rhinitis J30.9 Allergic rhinitis, unspecified J31.0 Chronic rhinitis J31.2 Chronic pharyngitis J32.0 Chronic maxillary sinusitis J32.1 Chronic frontal sinusitis J32.2 Chronic ethmoidal sinusitis J32.3 Chronic sphenoidal sinusitis J32.4 Chronic pansinusitis J32.8 Other chronic sinusitis J33.0 Polyp of nasal cavity J33.1 Polypoid sinus degeneration J33.8 Other poly of sinus J34.2 Deviated nasal septum J34.3 Hypertrophy of nasal turbinates J34.81 Nasal mucositis (ulcerative) J34.89 Other specified disorder of nose and nasal sinuses J35.01 Chronic tonsillitis J35.02 Chronic adenoiditis J35.03 Chronic tonsillitis and adenoiditis J35.1 Hypertrophy of tonsils J35.2 Hypertrophy of adenoids J35.3 Hypertrophy of tonsils with hypertrophy of adenoids J36 Peritonsillar abscess J37.0 Chronic laryngitis J38.01 Paralysis of vocal cords and larynx, unilateral J38.02 Paralysis of vocal cords and larynx, bilateral J38.1 Polyp of vocal cord and larynx J38.2 Nodules of vocal cords J38.3 Other diseases of vocal cords J38.4 Edema of larynx J38.5 Laryngeal spasm J38.6 Stenosis of larynx J38.7 Other disease of larynx J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia J96.11 Chronic respiratory failure with hypoxia J96.12 Chronic respiratory failure with hypercapnia J96.21 Acute and chronic respiratory failure with hypoxia J96.22 Acute and chronic respiratory failure with hypercapnia K09.8 Other cysts of oral region, not elsewhere classified K09.9 Cyst of oral region, unspecified K11.21 Acute sialoadenitis K11.22 Acute recurrent sialoadenitis K11.23 Chronic sialoadenitis K11.5 Sialolithiasis K11.6 Mucocele of salivary gland K12.30 Oral mucositis (ulcerative), unspecified K13.0 Disease of lips K13.4 Granuloma and granuloma-like lesions of oral mucosa K13.6 Irritative hyperplasia of oral mucosa K13.70 Unspecified lesions of oral mucosa K13.79 Other lesions of oral mucosa K14.0 Glossitis K21.0 Gastro-esophageal reflux disease with esophagitis K21.9 Gastro-esophageal reflux disease without esophagitis K22.5 Diverticulum of esophagus, acquired L03.211 Cellulitis of face L03.221 Cellulitis of neck L72.0 Epidermal cyst L72.11 Pilar cyst L72.12 Trichodermal cyst L72.2 Steatocystoma multiplex L72.3 Sebaceous cyst L72.8 Other follicular cysts of the skin and subcutaneous tissue L91.0 Hypertrophic scar M26.60 Temporomandibular joint disorders, unspecified M26.69 Other specified disorders of temporomandibular joint M54.2 Cervicalgia M95.0 Acquired deformity of nose Q16.1 Congenital absence, atresia and stricture of auditory canal (external) Q18.0 Sinus, fistula and cyst of branchial cleft Q31.0 Web of larynx Q31.1 Congenital subglottic stenosis Q31.2 Laryngeal hypoplasia Q31.3 Laryngocele Q31.5 Congenital laryngomalacia Q31.8 Other congenital malformation of larynx Q32.0 Congenital tracheomalacia Q32.1 Other congenital malformations of trachea Q32.2 Congenital bronchomalacia Q32.3 Congenital stenosis of bronchus Q32.4 Other congenital malformations of bronchus Q38.1 Ankyloglossia Q89.2 Congenital malformations of other endocrine glands R04.0 Epistaxis R04.2 Hemoptysis R04.89 Hemorrhage from other sites in respiratory passages R04.9 Hemorrhage from respiratory passages, unspecified R05 Cough R06.00 Dyspnea, unspecified R06.09 Other forms of dyspnea R06.1 Stridor R06.89 Other abnormalities of breathing R13.10 Dysphagia, unspecified R22.0 Localized swelling, mass and lump, head R22.1 Localized swelling, mass and lump, neck R42 Dizziness and giddiness R43.0 Anosmia R43.1 Parosmia R43.2 Parageusia R43.8 Other disturbance of smell and taste R49.0 Dysphonia R51 Headache R59.0 Localized enlarged lymph nodes R59.1 Generalized enlarged lymph nodes R59.9 Enlarged lymph nodes, unspecified S02.10XA Unspecified fracture of base of skull, initial encounter for closed fracture S02.10XB Unspecified fracture of base of skull, initial encounter for open fracture S02.10XD Unspecified fracture of base of skull, subsequent encounter for fracture with routine healing S02.10XG Unspecified fracture of base of skull, subsequent encounter for fracture with delayed healing S02.10XK Unspecified fracture of base of skull, subsequent encounter for fracture with nonunion S02.10XS Unspecified fracture of base of skull, sequela S02.2XXA Fracture of nasal bones, initial encounter for closed fracture S02.2XXB Fracture of nasal bones, initial encounter for open fracture S02.2XXD Fracture of nasal bones, subsequent encounter for fracture with routine healing S02.2XXG Fracture of nasal bones, subsequent encounter for fracture with delayed healing S02.2XXK Fracture of nasal bones, subsequent encounter for fracture with nonunion S02.2XXS Fracture of nasal bones, sequela S02.3XXA Fracture of orbital floor, initial encounter for closed fracture S02.3XXB Fracture of orbital floor, initial encounter for open fracture S02.3XXD Fracture of orbital floor, subsequent encounter for fracture with routine healing S02.3XXG Fracture of orbital floor, subsequent encounter for fracture with delayed healing S02.3XXK Fracture of orbital floor, subsequent encounter for fracture with nonunion S02.3XXS Fracture of orbital floor, sequela S02.401A Maxillary fracture, unspecified, initial encounter for closed fracture S02.401B Maxillary fracture, unspecified, initial encounter for open fracture S02.401D Maxillary fracture, unspecified, subsequent encounter for fracture with routine healing S02.401G Maxillary fracture, unspecified, subsequent encounter for fracture with delayed healing S02.401K Maxillary fracture, unspecified, subsequent encounter for fracture with nonunion S02.401S Maxillary fracture, unspecified, sequela S02.402A Zygomatic fracture, unspecified, initial encounter for closed fracture S02.402B Zygomatic fracture, unspecified, initial encounter for open fracture S02.402D Zygomatic fracture, unspecified, subsequent encounter for fracture with routine healing S02.402G Zygomatic fracture, unspecified, subsequent encounter for fracture with delayed healing S02.402K Zygomatic fracture, unspecified, subsequent encounter for fracture with nonunion S02.402S Zygomatic fracture, unspecified, sequela S02.411A LeFort I fracture, initial encounter for closed fracture S02.411B LeFort I fracture, initial encounter for open fracture S02.411D LeFort I fracture, subsequent encounter for fracture with routine healing S02.411G LeFort I fracture, subsequent encounter for fracture with delayed healing S02.411K LeFort I fracture, subsequent encounter for fracture with nonunion S02.411S LeFort I fracture, sequela S02.413A LeFort III fracture, initial encounter for closed fracture S02.413B LeFort III fracture, initial encounter for open fracture S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing S02.413G LeFort III fracture, subsequent encounter for fracture with delayed healing S02.413K LeFort III fracture, subsequent encounter for fracture with nonunion S02.413S LeFort III fracture, sequela S02.42XA Fracture of alveolus maxilla, initial encounter for closed fracture S02.42XB Fracture of alveolus maxilla, initial encounter for open fracture S02.42XD Fracture of alveolus maxilla, subsequent encounter for fracture with routine healing S02.402G Zygomatic fracture, unspecified, subsequent encounter for fracture with delayed healing S02.402K Zygomatic fracture, unspecified, subsequent encounter for fracture with nonunion S02.402S Zygomatic fracture, unspecified, sequela S02.411A LeFort I fracture, initial encounter for closed fracture S02.411B LeFort I fracture, initial encounter for open fracture S02.411D LeFort I fracture, subsequent encounter for fracture with routine healing S02.411G LeFort I fracture, subsequent encounter for fracture with delayed healing S02.411K LeFort I fracture, subsequent encounter for fracture with nonunion S02.411S LeFort I fracture, sequela S02.413A LeFort III fracture, initial encounter for closed fracture S02.413B LeFort III fracture, initial encounter for open fracture S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing S02.413G LeFort III fracture, subsequent encounter for fracture with delayed healing S02.413K LeFort III fracture, subsequent encounter for fracture with nonunion S02.413S LeFort III fracture, sequela S02.42XA Fracture of alveolus maxilla, initial encounter for closed fracture S02.42XB Fracture of alveolus maxilla, initial encounter for open fracture S02.42XD Fracture of alveolus maxilla, subsequent encounter for fracture with routine healing S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing S02.413G LeFort III fracture, subsequent encounter for fracture with delayed healing S02.413K LeFort III fracture, subsequent encounter for fracture with nonunion S02.413S LeFort III fracture, sequela S02.42XA Fracture of alveolus maxilla, initial encounter for closed fracture S02.42XB Fracture of alveolus maxilla, initial encounter for open fracture S02.42XD Fracture of alveolus maxilla, subsequent encounter for fracture with routine healing S02.42XG Fracture of alveolus maxilla, subsequent encounter for fracture with delayed healing S02.42XK Fracture of alveolus maxilla, subsequent encounter for fracture with nonunion S02.42XS Fracture of alveolus maxilla, sequela S09.21XA Traumatic rupture of right ear drum, initial encounter S09.21XD Traumatic rupture of right ear drum, subsequent encounter S09.21XS Traumatic rupture of right ear drum, sequela S09.22XA Traumatic rupture of left ear drum, initial encounter S09.22XD Traumatic rupture of left ear drum, subsequent encounter S09.22XS Traumatic rupture of left ear drum, sequela S09.92XA Unspecified injury of nose, initial encounter S09.92XD Unspecified injury of nose, subsequent encounter S09.92XS Unspecified injury of nose, sequela S09.93XA Unspecified injury of face, initial encounter S09.93XD Unspecified injury of face, subsequent encounter S09.93XS Unspecified injury of face, sequela S16.8XXA Other specified injury of muscle, fascia and tendon at neck level, initial encounter S16.8XXD Other specified injury of muscle, fascia and tendon at neck level, subsequent encounter S16.8XXS Other specified injury of muscle, fascia and tendon at neck level, sequela S19.81XA Other specified injuries of larynx, initial encounter S19.81XD Other specified injuries of larynx, subsequent encounter S19.81XS Other specified injuries of larynx, sequela S19.82XA Other specified injuries of cervical trachea, initial encounter S19.82XD Other specified injuries of cervical trachea, subsequent encounter S19.82XS Other specified injuries of cervical trachea, sequela S19.83XA Other specified injuries of vocal cord, initial encounter S19.83XD Other specified injuries of vocal cord, subsequent encounter S19.83XS Other specified injuries of vocal cord, sequela S19.84XA Other specified injuries of thyroid gland, initial encounter S19.84XD Other specified injuries of thyroid gland, subsequent encounter S19.84XS Other specified injuries of thyroid gland, sequela S19.85XA Other specified injuries of pharynx and cervical esophagus, initial encounter S19.85XD Other specified injuries of pharynx and cervical esophagus, subsequent encounter S19.85XS Other specified injuries of pharynx and cervical esophagus, sequela S19.9XXA Unspecified injury of neck, initial encounter S19.9XXD Unspecified injury of neck, subsequent encounter S19.9XXS Unspecified injury of neck, sequela T16.1XXA Foreign body in right ear, initial encounter T16.1XXD Foreign body in right ear, subsequent encounter T16.1XXS Foreign body in right ear, sequela T16.2XXA Foreign body in left ear, initial encounter T16.2XXD Foreign body in left ear, subsequent encounter T16.2XXS Foreign body in left ear, sequela T17.0XXA Foreign body in nasal sinus, initial encounter T17.0XXD Foreign body in nasal sinus, subsequent encounter T17.0XXS Foreign body in nasal sinus, sequela T17.1XXA Foreign body in nostril, initial encounter T17.1XXD Foreign body in nostril, subsequent encounter T17.1XXS Foreign body in nostril, sequela Z01.10 Encounter for examination of and hearing without abnormal findings Z01.110 Encounter for hearing examination following failed hearing screening Z01.118 Encounter for examination of ears and hearing with other abnormal findings Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm Encounter for follow-up examination after completed treatment for condition other than malignant Z09 neoplasm Z43.0 Encounter for attention to tracheostomy Z44.8 Encounter for fitting and adjustment of other external prosthetic devices Z71.1 Person with feared health complaint in whom no diagnosis is made Z79.899 Other long term (current) drug therapy Encounter for follow-up examination after completed treatment for condition other than malignant Z09 neoplasm Z43.0 Encounter for attention to tracheostomy Z44.8 Encounter for fitting and adjustment of other external prosthetic devices Z71.1 Person with feared health complaint in whom no diagnosis is made Z79.899 Other long term (current) drug therapy Encounter for follow-up examination after completed treatment for condition other than malignant Z09 neoplasm Z43.0 Encounter for attention to tracheostomy Z44.8 Encounter for fitting and adjustment of other external prosthetic devices Z71.1 Person with feared health complaint in whom no diagnosis is made Z79.899 Other long term (current) drug therapy

Disclaimer: This sample ICD-10 superbill is designed to assist otolaryngology practices in quickly completing and submitting procedure(s) and diagnosis(s) codes from a patient visit for reimbursement. It is generally customized for an otolaryngology office and contains fields for patient information, the most common CPT (procedure) and ICD-10-CM (diagnostic) codes used by Otolaryngologists. Members should note that this superbill is designed solely as an exercise in demonstrating the process of transitioning to the new ICD-10-CM coding system, and does not represent an endorsement by the Academy of the use of superbills or this particular superbill format.

For more information on the transition to ICD-10 please contact the health policy team at: [email protected].