How do I create a superbill?

With Practice Fusion, you can submit superbills to an integrated billing partner or create bills without integration to print or export.

Creating a superbill

Any user may create a superbill for a patient that has a patient record number entered in their chart by following the instructions listed below:

1. Within a patient encounter, click Actions in the top right corner.

2. Select Add superbill.

3. The superbill will open in a new tab.

Once you have opened the superbill, you will have the ability to add CPT codes, diagnosis codes, and modifiers. For each procedure added, a corresponding diagnosis code must also be selected. You can also add additional notes and edit provider/facility details.

Adding a procedure

To add a CPT code to the superbill, click Add procedure. Search for a procedure or select one from your list of frequently used and custom  CPT codes. You may search by code or procedure description.

If you are unable to locate a particular code,  you can create a custom code by clicking the blue Add custom code link at the end of the list of search results. Input the custom code and description, and click Save.

To add an existing custom CPT code to your bill, click into the Procedure field and begin typing the procedure code. All custom codes will also be listed under the Custom Code sub-list.

You can add multiple CPT codes to a superbill simultaneously by continuing to search for and select additional codes. Once you have selected the procedures, click Add. Alternatively, you can add each procedure separately using the Add procedure link each time.

Adding a diagnosis

You may associate up to 4 diagnoses per CPT code in the Practice Fusion superbill. While the official CMS 1500 claim form that your biller creates allows for 12 diagnoses to be documented *per claim*, only 4 diagnosis pointers can be associated *per CPT code*. To simplify and standardize the superbill process in Practice Fusion, we are limiting each CPT line to 4 diagnosis codes. Please note that the Practice Fusion superbill is not used as an electronic claim and can be adjusted to include diagnosis pointers and additional diagnoses after it has been submitted to your billing system for review.

To select a diagnosis, click
Add a diagnosis below the selected procedure.

You can quickly select diagnoses from the patient’s encounter and diagnosis history by utilizing the Chart tab in the fly-out pane. From within the fly-out pane, you can also select a diagnosis from your customized My Dx list. Using our diagnosis search, you may also search for new diagnoses by either:

  • ICD-9

  • ICD-10

  • Diagnosis description

Click Search for a diagnosis to select a new diagnosis. As you begin typing in the Add diagnosis box, Practice Fusion will offer a list of potential diagnoses, presenting the ICD-9 code with the corresponding ICD-10 code.  Select the appropriate diagnosis from the drop-down menu. Note: Any diagnosis that maps to multiple ICD-10 codes and requires further refinement will display an orange alert

If you select a diagnosis that maps to only one ICD-10 code, the ICD-10 code will automatically be added to the superbill. In some instances, an ICD-9 code may correspond to multiple ICD-10 codes and you will be prompted to select the specific ICD-10 code. Use the Filter to narrow the list of potential ICD-10 codes. For more detailed instructions, see How do I add ICD-10 diagnoses when creating a superbill?

After adding up to four diagnoses for the procedure, click Done. Once you’ve saved your diagnoses, you can re-order them within your superbill by clicking the 4 horizontal lines to the left of the diagnosis and dragging up or down. Diagnoses can also be deleted. 

Editing patient, provider, and facility details and entering additional notes

The patient’s demographic information will auto-populate in the superbill. If you have edited any patient demographic information after creating your superbill, click the Refresh button to pull in the updated information.

Within the Other details portion of the superbill, you may review  provider/facility information and enter any additional notes. Click Edit to update any fields.

For Kareo user integrated before November 2, 2014:

Please be sure that you’re selecting the provider’s name from under the “Billing System Providers” section within the “Rendering Provider” drop down menu. Likewise, please also be sure to select from the “Billing System Facilities” menu from within the “Seen at Facility” drop down menu. Both the “Billing System Provider and Facilities” list is directly imported from your Kareo account. If you do need to add a provider or facility to appear on those lists, please do so within your Kareo account. For more information, please see: How do I create a superbill when I am bound with Kareo?

Completing your superbill

Once you have completed your superbill, you can save it by selecting a status from the drop-down menu in the top-right corner. When ready, you can print or download the superbill. Alternatively, if you are connected with one of our integrated billing partners, selecting Ready for biller will electronically submit the superbill to your billing software.

Reviewing superbills

You can view all your superbills in the Reports section under Billing Report. Use the drop-down at the top to filter results by Draft, Ready for biller, Archive, or Error. To make it easy to find a bill, you can search for a specific bill, or sort by any of the columns by clicking the header once to sort ascending and again for descending order.


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