Superbill Notes are used to record an Episode of Care that occurred over a short period of time. Before a Superbill Note can be created, there is an initial setup that must be completed.
Jump to Section:
Superbill Setup - Create Procedure and Diagnosis Sets
Go to Setup > SuperBill Setup.
Create a Procedure Set
- Select the Procedure Sets tab.
- Click New Procedure Set.
- Enter a Name for the Procedure Set.
- In the Procedure box, select the Procedure(s) to be included in this set.
- Check the box under Require Duration to make a duration required.
- Click Save. The new Procedure Set is now on the list.
- Repeat these steps for each Procedure Set you wish to create.
Create a Diagnosis Set
- Select the Diagnosis Sets tab.
- Click New Diagnosis Set.
- Enter a Name for the Diagnosis Set.
- In the Diagnosis box, select the Diagnosis(es) to be included in this set.
- Click Save. The new Diagnosis Set is now on the list.
- Repeat these steps for each Diagnosis Set you wish to create.
Once the sets are created, the Superbill Note can be created in FormLabTM. There are 3 Common Designs:
- Superbill Note - Evaluation Visit (Superbill Diagnoses with Visit Type).
- Superbill Note - Service Visit (Superbill Diagnoses with Superbill Procedures).
- Superbill Note - Proc Mapping (Superbill Diagnoses with Superbill Procedure Mapping).
To begin the form creation, follow the same steps as you would to start a Billable Progress Note:
- Go to Administration > FormLabTM.
- Click Start New Form.
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Click the tabs below for steps on how to create each of the common Superbill Note designs.
Superbill Note - Evaluation Visit
The first example of a common Superbill Note is the Evaluation Visit. In this Superbill Note, we will use a Visit Type from the system, a Treatment Diagnosis (Primary Diagnosis) which is any diagnosis from the system, and a Secondary Diagnosis which is assigned as a specific Diagnosis Set.
- Follow steps 1 - 6 in Create a Billable Progress Note.
- This will load in the minimum controls required to make the form billable.
- Add the Superbill Diagnoses Control €“ Treatment Diagnosis following these steps:
- Right-click on [Section] Superbill.
- Select Add Billing Control.
- Select Superbill Diagnoses.
- Enter Treatment Diagnosis for the Superbill Diagnoses Label. This is a required field.
- Click OK and the control will appear under the associated section.
- Move the Control so it is between the Duration and Billing Note Control.
- Add the Superbill Diagnoses Control - Secondary Diagnosis following these steps:
- Right-click on [Section] Superbill.
- Select Add Billing Control.
- Select Superbill Diagnoses.
- Enter Secondary Diagnosis for the Superbill Diagnoses Label. This is a required field.
- Under Superbill Diagnosis Type, select Multiple Diagnosis Selector.
- Choose a created Diagnosis Set from the drop-down list.
- Click OK and the control will appear under the associated section.
- Move the Control so it is between the Superbill (Treatment) Diagnoses and Billing Note Control.
- Click Save Form Design.
- Click Preview to see what the published form will look like.
- Click the Publish button once you are satisfied with the form.
- The form has now been added to the Form List so it can be added to a Program’s Chart Structure.
Superbill Note - Service Visit
The second example of a common Superbill Note is the Service Visit. In this Superbill Note, we will use a Treatment Diagnosis (Primary Diagnosis) which is any diagnosis from the system, a Secondary Diagnosis which is assigned as a specific Diagnosis Set, and Superbill Procedures.
- Follow steps 1 - 6 in Create a Billable Progress Note.
- This will load in the minimum controls required to make the form billable.
- Delete the Visit Type Control by following these steps.
- Right-click on [Visit Type] Visit Type.
- Select Delete.
- You will see a warning, click OK.
- Add the Superbill Diagnoses Control - Treatment Diagnosis following these steps:
- Right-click on [Section] Superbill.
- Select Add Billing Control.
- Select Superbill Diagnoses.
- Enter Treatment Diagnosis for the Superbill Diagnoses Label. This is a required field.
- Click OK and the control will appear under the associated section.
- Move the Control so it is between the Duration and Billing Note Control.
- Add the Superbill Diagnoses Control - Secondary Diagnosis following these steps:
- Right-click on [Section] Superbill.
- Select Add Billing Control.
- Select Superbill Diagnoses.
- Enter Secondary Diagnosis for the Superbill Diagnoses Label. This is a required field.
- Under Superbill Diagnosis Type, select Multiple Diagnosis Selector.
- Choose a created Diagnosis Set from the drop-down list.
- Click OK and the control will appear under the associated section.
- Move the Control so it is between the Superbill (Treatment) Diagnoses and Billing Note Control.
- Add the Superbill Procedures by following these steps:
- Right-click on [Section] Superbill.
- Select Add Billing Control.
- Select Superbill Procedures.
- Enter Procedures for the Superbill Procedures Label.
- Choose a created Procedure Set from the drop-down list.
- Click OK and the control will appear under the associated section.
- Move the Control so it is between the Superbill Secondary Diagnoses and Billing Note Control.
- Click Save Form Design.
- Click Preview to see what the published form will look like.
- Click the Publish button once you are satisfied with the form.
- The form has now been added to the Form List so it can be added to a Program’s Chart Structure.
Superbill Note - Proc Mapping
The third example of a common Superbill Note is the Proc Mapping. In this Superbill Note, we will use a Treatment Diagnosis (Primary Diagnosis) which is any diagnosis from the system, a Secondary Diagnosis which is assigned as a specific Diagnosis Set, and Superbill Procedures with Procedure Mapping.
- Follow steps 1 - 6 in Create a Billable Progress Note.
- This will load in the minimum controls required to make the form billable.
- Delete the Visit Type Control following these steps:
- Right-click on [Visit Type] Visit Type.
- Select Delete.
- You will see a warning, click OK.
- Add the Superbill Diagnoses Control - Treatment Diagnosis following these steps:
- Right-click on [Section] Superbill.
- Select Add Billing Control.
- Select Superbill Diagnoses.
- Enter Treatment Diagnosis for the Superbill Diagnoses Label. This is a required field.
- Click OK and the control will appear under the associated section.
- Move the Control so it is between the Duration and Billing Note Control.
- Add the Superbill Diagnoses Control €“ Secondary Diagnosis following these steps:
- Right-click on [Section] Superbill.
- Select Add Billing Control.
- Select Superbill Diagnoses.
- Enter Secondary Diagnosis for the Superbill Diagnoses Label. This is a required field.
- Under Superbill Diagnosis Type, select Multiple Diagnosis Selector.
- Choose a created Diagnosis Set from the drop-down list.
- Click OK and the control will appear under the associated section.
- Move the Control so it is between the Superbill (Treatment) Diagnoses and Billing Note Control.
- Add the Superbill Procedures by following these steps:
- Right-click on [Section] Superbill.
- Select Add Billing Control.
- Select Superbill Procedures.
- Enter Procedures for the Superbill Procedures Label.
- Check the box for Enable Superbill Diagnoses Mapping.
- Choose a created Procedure Set from the drop-down list.
- Click OK and the control will appear under the associated section.
- Move the Control so it is between the Superbill Secondary Diagnoses and Billing Note Control.
- Click Save Form Design.
- Click Preview to see what the published form will look like.
- Click the Publish button once you are satisfied with the form.
- The form has now been added to the Form List so it can be added to a Program’s Chart Structure.