Superbill

To access superbill, click on the appointment in appointment calendar then click superbill or click patient encounters then click on superbill or click Billing > Superbill. Search the patient then search the encounter.

Adding a Diagnosis

To add a diagnosis, type the ICD9 number or part of the diagnosis description.  The filter is by number or character by character to display the list of diagnoses that best match the characters you have typed. The diagnosis is then added as the primary diagnosis. Continue to select another diagnosis.

Click delete to remove the diagnosis from the list.

Click the Add a CPT Codes to the Superbill, type a description or CPT code and select it from the list. A modifier can be typed or selected. A list price is pulled in for the list price assigned to this payer and facility. A contract price is pulled in from the payer contract price list, if configured. Units can be entered. Unit charge pulls in if a price has been set for the insurer assigned to this patient encounter. If no price is found, one can be entered. A sales tax rate can also be entered for a CPT.  CPTII modifiers are used for Quality Measures. NDC and CLIA can be pulled in with a CPT or manually added on this screen.

To finalize a Superbill and release it to Billing, select Finalize in the status pull down field. If this Superbill is not billable, then select Non Billable. Non Billable will also cause the encounter to not show on Find patient nor will this patient encounter be counted in Meaningful Use data.

Favorites: The Favorites tab in the Superbill section allows providers to save and quickly access frequently used diagnosis and billing codes. This feature helps reduce repetitive code searches during patient encounters by maintaining a personalized list of commonly used ICD9, ICD10, CPT, or service codes. Providers can select saved favorite codes and add them directly to the current encounter using the Add To Encounter button. The tab also provides options to save commonly used codes to the favorites list and remove codes that are no longer needed.

Search: Allows providers to search diagnosis codes using different search methods.

• Codes Search: Allows providers to search by codes.
• Indexed Search: Allows providers to browse diagnosis codes through an alphabetical indexed list for easier selection.

History: The History tab in the Superbill section displays previously used diagnosis, procedure, and billing codes associated with the patient’s past encounters. This allows providers to quickly review and reuse historical billing information when documenting or creating claims for the current encounter.

Order Sets: The Order Sets tab allows providers to create, manage, and apply predefined groups of orders such as superbill sets, lab orders, prescription sets, and chief complaint sets to streamline clinical and billing workflows.

Superbill Sets: The Superbill Sets tab allows providers to create and manage predefined groups of diagnoses, services, and billing codes that can be quickly applied to patient encounters for faster documentation and claim preparation.

Appointment: The Appointment tab displays the patient’s appointment history and scheduled appointments, along with details such as appointment date, provider, facility, room, status, and visit information.

AI Claimmaker: The AI Claimmaker screen allows providers to generate and review AI-assisted coding and claim recommendations for the current patient encounter. Providers can enter encounter details or notes in the input area and use the Recommend and Verify button to generate suggested ICD and CPT codes. The Auto Save ICD and CPT Codes when recommended option automatically adds recommended codes to the encounter, while the Include Encounter Note option includes encounter documentation in the AI analysis. The generated responses, along with query details, user information, and timestamps, are displayed in the response section for review and verification before claim submission.

Open Claim: Opens the billing claim associated with the current encounter for review or editing.

Send Claim: Sends the prepared claim for submission to the payer.

Next Appointment: Opens details of the patient’s next scheduled appointment.

Print: Opens the Superbill Report screen, allowing providers to preview, print, or export the patient’s superbill report containing encounter details, diagnoses, services, charges, insurance information, and billing data.

Alert: Opens the Patient Alert window, which displays important patient-related alerts and clinical information such as surgical dates, surgery expiration details, and other configured patient alerts for provider review.

Patient Comments: Opens the patient comments section to view or add notes related to the patient.

Close: Closes the current screen or encounter window.

Pull From Prior: This pulls in the diagnosis and CPTs from this patient’s last visit.

Print Note: Prints the Note.