Superbill
A superbill is a pre-coded encounter form a provider uses to record the services furnished during a visit, used to generate a claim.
Updated
A superbill (also called a super-bill, encounter form, or charge ticket) is a pre-coded form a provider uses to record the services, diagnoses, and modifiers furnished during a patient encounter. It lists the procedure and diagnosis codes a practice commonly bills, allowing the provider to mark what was done during the visit and hand the form to the billing function.
The superbill is the bridge between the clinical encounter and the claim: it captures the encounter's services in a coded form that billing can translate into a billable claim. It is a working document for the practice's own charge-capture process, not a document the patient or the payer sees.
In practice
A superbill is only as accurate as the provider's selection on it, and an error on the form propagates into the claim. Practices that still use paper or template superbills rely on the form being kept current with the practice's services and the current year's codes, and on the provider documenting accurately at the point of care rather than reconstructing the encounter later.
Commonly confused with
- Claim: A superbill is the practice's internal encounter form; a claim is the bill submitted to the payer. The superbill feeds the claim; it is not itself a claim and is not sent to the payer.
- Charge capture: Charge capture is the process of recording billable services; the superbill is one common tool that process uses. A practice can capture charges through an EHR instead of a paper superbill, in which case the superbill concept is built into the system.