Sample Medical Center

4312 Sample Rd., Suite 23
Sampleville, ST  12345
Tel (555) 555-0142  Fax (555) 555-0149
Tax ID: 12-3456789  NPI: 1234567890
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Sample Superbill Report - All content is sample
Appointment
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*Last payment(CPCHECK) made 9/12/2017 for 25.00  Resp Balance: 35.00
Referring Provider
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Primary Insurance
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  Group:
Diagnosis:
Actinic keratosisL57.0
Seborrheic keratosis, inflamedL82.1
Seborrheic keratosis, irritatedL82.0
Neoplasm uncertain behavior, skinD48.5
Melanocytic nevi, unspecifiedD22.9
Basal cell carcinoma, unsp siteC44.91
Squamous cell ca of skin, unspC44.92
Acne vulgarisL70.0
Psoriasis vulgarisL40.0
Atopic dermatitis, unspecifiedL20.9
Rosacea, unspecifiedL71.9
Dermatitis, unspecifiedL30.9
Verruca vulgarisB07.9
Acrochordon (skin tag)L91.8
Sebaceous cystL72.3
DescriptionCode
New Patient - Office Visits
Level 1, Brief99201
Level 2, Limited99202
Level 3, Expanded99203
Level 4, Comprehensive99204
Level 5, Comprehensive/Complex99205
Established Patient - Office Visits
Level 1, Minimal99211
Level 2, Limited99212
Level 3, Expanded99213
Level 4, Comprehensive99214
Level 5, Comprehensive/Complex99215
DescriptionCode
Destruction
Premalig lesion, 1st17000
Add'l lesion ea (2-14)17003
15 or more lesions17004
Benign, up to 1417110
Biopsy / Excision
Tangential, 1st lesion11102
Tangential, ea add'l11103
Punch, 1st lesion11104
Exc benign trunk 0.6-1.0cm11401
Exc malig trunk 0.6-1.0cm11601
DescriptionCode
Pathology
Path, level IV (skin)88305
Path, level V88307
Special stain, group I88312
IHC, initial single88342
Cultures / Materials
Aerobic culture87070
Fungus, dermatophyte87106
KOH prep87220
Triamcinolone acet, 10mgJ3301
Surgical trayA4550
Notes
Provider Signature / Date
Patient Signature / Date
Billing Reviewed By / Date