Resources to help your practice succeed
- Our step-by-step guides and video tutorials will help you through the transition.
Please take a moment to tour our ICD-10 superbill workflow in the video tutorial below:
Creating a superbill using ICD-10
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, modifiers, and diagnosis codes. 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.
You can add multiple CPT codes simultaneously by continuing to search for and select additional codes. Once you have selected the procedures, click Add.
Searching and adding diagnoses (ICD-9 and ICD-10)
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.
Encounter, Historical, and My Dx list Diagnoses
You can quickly select diagnoses from the patient’s encounter and diagnosis history by utilizing the Chart tab in the fly-out pane. Alternatively, you can select a diagnosis from your My Dx list.
In order for a diagnosis to display under the Encounter section, you must either:
Add the diagnosis via the Assessment section of the encounter
Add the diagnosis via the Diagnosis section of the encounter and check the ‘attach diagnosis to this encounter’ box
Select the diagnosis from the flyout pane to add it to the procedure. If you select a diagnosis that maps to only one ICD-10 code, the ICD-10 code will automatically be added to the superbill. If the diagnosis selected maps to multiple ICD-10 codes, you will be prompted to further refine and select the appropriate ICD-10 code. Note: Any diagnosis that maps to multiple ICD-10 codes and requires further refinement will display an orange alert.
If the diagnosis selected maps to multiple ICD-10 codes, use the Filter to narrow the list of potential results to the number listed in parenthesis. Each filter is related to the diagnosis (i.e. encounter type, fracture type, laterality).
Searching for a new diagnosis
Using our new diagnosis search, you may also search for diagnoses by either:
Click Search for a diagnosis and begin typing into 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. If the selected diagnosis maps to multiple ICD-10 codes, you will be prompted to further select the appropriate ICD-10 code. Use the Filter to help narrow the list of potential diagnosis codes. Once you have located the correct diagnosis code, click on the diagnosis to add it to the procedure.
You can add multiple diagnoses to the procedure by continuing to search for and selecting additional codes. Once you have selected all of the diagnoses that are associated with that procedure, click Done.
You can re-ordering the diagnoses within your superbill by clicking the 4 horizontal lines to the left of the diagnosis and dragging up or down.
Once you have added all of the procedures and diagnoses pertaining to the encounter, you may complete the rest of the superbill. The next steps include editing patient/provider/facility information and saving and submitting your superbill to your billing partner.
For additional instructions on completing your superbill, see How do I create a superbill?
Additional ICD-10 Resources
To learn more about implementing ICD-10 in your practice, please click here.