A Superbill is a specific list of all services a patient received from the healthcare provider during their visit. It includes things like provider information, various medical codes like CPT codes, HCPCS and REV Codes and ICD-10 codes, referral information, and other important items. 

The following is required information:

• Provider Name
• Patient First Name and Last Name
• Patient date of birth (DOB)
• Date of visit / Date of Service
• Procedure Codes and Description (CPT / HCPC / REV)** 
• Diagnosis Codes and Description (ICD-10)***
• Fees Charged

Optional but helpful information includes: 

• Insurance ID
• Patient address
• Patient phone number
• Modifiers****
• Units or Minutes

** CPT (Current Procedural Terminology) Codes are used to describe the medical procedures that a provider performed on a patient. The American Medical Association (AMA) is the entity that issues and maintains CPT codes. 

*** “ICD-10 is the 10th revision of the World Health Organization’s International Classification of Diseases (ICD) coding system. The ICD-10-CM (Clinical Modification) codes are used to capture diagnoses in all healthcare settings, while ICD-10-PCS (Procedure Coding System) codes are used to capture procedures only in inpatient settings.”

****  According to M-Scribe “A modifier is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code.”