Free compliance & forms tool
Superbill Template and Generator
A superbill is an itemized statement of the services a patient received, with the provider's identifiers, diagnosis codes, procedure codes and charges. Patients send it to their insurance company to ask for out-of-network reimbursement. This generator builds one: enter the provider, patient, your own CPT or HCPCS and ICD-10 codes, and fees, then print it. It checks NPI numbers and code formats but never suggests codes.
Prepared by Prospyr · Reviewed October 3, 2026 · Free, no sign-up, runs in your browser
The form opens with example data. Replace it with yours, or . Codes are whatever you type: the tool checks their shape and never suggests a code. Patient details are not saved or sent anywhere.
Total charges $415.00 · 4 to fix (see the format check below the form)
Total charges
$415.00
Paid today$0.00
Balance$415.00
Format check
4 to fix, 0 to review. Shape checks only: they do not confirm a code exists or fits the service.
- Fix: Add the patient's name.
- Fix: Line 1: add the date of service.
- Fix: Line 2: add the date of service.
- Fix: Line 3: add the date of service.
A record of services and charges, not a claim form and not a promise of reimbursement. You choose the codes; CPT is a registered trademark of the American Medical Association.
Preview
Example Dermatology & Aesthetics
100 Example Way, Suite 200 Austin, TX 78701
(512) 555-0100
SUPERBILL
Statement of services and charges
Billing provider NPI: 1234567893
Tax ID: 12-3456789
Rendering provider: Alex Example, MD
Rendering NPI: 1003000126
Place of service: 11
Patient: —
Date of birth: —
Address: —
Phone: —
Date of service: —
Diagnoses (ICD-10-CM)
A. L57.0
| Date | Code | Mod | Description | Dx | Units | Fee | Charge |
|---|---|---|---|---|---|---|---|
| 99213 | Established patient office visit | A | 1 | $185.00 | $185.00 | ||
| 17000 | Destruction of premalignant lesion, first lesion | A | 1 | $140.00 | $140.00 | ||
| 17003 | Destruction of premalignant lesions, 2nd to 14th, each | A | 3 | $30.00 | $90.00 | ||
| Total charges | $415.00 | ||||||
| Payment received | $0.00 | ||||||
| Balance | $415.00 | ||||||
This superbill lists the services provided and the charges for them. It is not a claim and does not guarantee payment. Submit it to your insurance company according to its out-of-network or reimbursement instructions.
What a medical superbill contains
A medical superbill carries the same facts a payer reads on a claim, in a form a patient can hand over. The pieces, in the order the template prints them:
- Provider block: practice name and address, billing NPI, tax ID, rendering provider and NPI.
- Patient block: name, date of birth, address, and insurance details if you have them.
- Diagnoses: ICD-10-CM codes, lettered A, B, C and so on.
- Service lines: date, CPT or HCPCS code, modifier, diagnosis pointer, units and fee.
- Totals: charges, payment received and balance, plus a signature line.
The layout follows the logic of the CMS-1500 claim form, which the National Uniform Claim Committee (NUCC) maintains, so the data transfers cleanly if your biller or the patient's plan asks for a claim form.
Worked example: an office visit with a lesion treatment
The tool opens on this example. The practice codes, diagnosis and fees are placeholders to show the arithmetic, not guidance on what to bill.
| Code | Dx | Units | Fee | Charge |
|---|---|---|---|---|
| 99213 | A | 1 | $185.00 | $185.00 |
| 17000 | A | 1 | $140.00 | $140.00 |
| 17003 | A | 3 | $30.00 | $90.00 |
| Total charges | $415.00 | |||
If the patient pays $100 today, the balance prints as $315.00. Each line is units times fee, and the total is the sum of the lines.
Superbill template checks: NPI, code shape and diagnosis pointers
The format check beside the form catches the mistakes that get a superbill bounced:
- An NPI that does not pass the CMS check-digit calculation, usually a typo.
- A procedure code that is not shaped like CPT (5 digits, or 4 digits plus F or T) or HCPCS (a letter plus 4 digits).
- A diagnosis that is not shaped like an ICD-10-CM code.
- A diagnosis pointer that points to a letter with no diagnosis entered.
- Missing dates, units or fees.
These are shape checks. Only the provider and coder can say whether a code is the right one for the service documented in the chart. The charting that supports a superbill lives in the visit record; Prospyr's charting and aesthetic EMR keep the note, the products used and the charges together.
Superbill generator for cash-pay practices
Many aesthetic and wellness practices are cash-pay. Patients with out-of-network benefits sometimes ask for a superbill so they can submit it themselves. Having a clean template ready keeps the front desk from rebuilding one in a word processor each time. Set the expectation up front: the practice provides the record, the plan decides what it pays, and many plans do not cover cosmetic care.
For patients who pay with a card on file or a membership, the same visit data feeds the receipt. See memberships for how Prospyr tracks those.
Frequently asked questions
What is a superbill?
A superbill is a one-page itemized record of a visit: who treated the patient, who the patient is, the date, the diagnosis and procedure codes, and the charge for each service. It is not a claim form. Practices that do not bill insurance directly give it to the patient so the patient can submit it to their plan.
What information goes on a superbill?
Practice name, address and phone, the billing provider's NPI and tax ID, the rendering provider, the patient's name, date of birth and insurance details, the date and place of service, diagnosis codes, procedure codes with modifiers and units, a diagnosis pointer for each line, the charges, payments and a balance. A provider signature line is common. This template includes all of those.
What is a diagnosis pointer?
A diagnosis pointer is a letter that links a service line to a diagnosis. If diagnosis A is the first ICD-10 code you list, a pointer of A on a line tells the payer that diagnosis supports that service. The CMS-1500 claim form uses letters A through L, and so does this tool.
Does this tool pick CPT or ICD-10 codes?
No. You type the codes and the tool only checks their shape, for example five digits for a CPT code or a letter plus four digits for HCPCS. Choosing the right code for a service is a coding decision for the provider and your coder, and the tool cannot confirm that a code exists or fits.
What is an NPI and how does the tool check it?
An NPI is a 10-digit National Provider Identifier with a check digit in the last position (45 CFR 162.406). The tool runs the CMS check-digit calculation (the Luhn formula with the 80840 prefix) and flags numbers that fail. A pass means the number is well formed, not that it is registered to your practice; look it up in the NPPES registry for that.
Does a superbill guarantee the patient will be reimbursed?
No. Reimbursement depends on the patient's plan, its out-of-network benefits, and whether the service is covered. A superbill is the document the patient submits, and the insurer decides. Cosmetic services are commonly excluded, so set that expectation with patients.
Is my patient's information stored?
No. Patient fields stay in the open page and disappear when you close it, and they are never put in the web address. Only your practice and provider details are saved, in your own browser's storage, so you do not retype them. You can clear them with the Forget saved details button.
Sources and scope
- NUCC: 1500 Health Insurance Claim Form instructions
The claim form whose data elements (diagnosis codes A through L, procedure codes, modifiers, pointers, NPI, tax ID, charges) the superbill layout mirrors.
- CMS: Requirements for NPI and NPI check digit (PDF, January 23, 2004)
The Luhn mod-10 check-digit method with the 80840 prefix, used to validate NPI numbers in the tool.
- 45 CFR 162.406: Standard unique health identifier for health care providers (eCFR)
Defines the NPI as a 10-position numeric identifier with a check digit in the 10th position.
- CMS: ICD-10 codes
Where the ICD-10-CM code set is published. Look codes up here; this tool only checks their shape.
- CMS: HCPCS general information
HCPCS Level II codes (a letter followed by four digits).
- American Medical Association: CPT (Current Procedural Terminology)
CPT is copyrighted by the AMA. The tool does not include code descriptions; you enter your own.
A record-keeping template, not billing or coding advice. It does not choose, suggest or verify CPT, HCPCS or ICD-10 codes, and a superbill does not guarantee reimbursement. Your provider and coder decide what is billed.