CONCEPT #31 OF 100 · Medical, Dental & Clinical Practices · LAYOUT: clinical_box_grid
Out-of-Network Medical & Physical Therapy Superbill (CPT / ICD-10 / NPI)
Standard / Reference: CMS-1500 Data Element Alignment · NPI Registry Type 1/2 · HSA/FSA IRC § 213(d) Receipt
Why professionals use this template: Cash-pay and concierge clinics needing clean, insurer-accepted superbills with NPI Type 1/2, Tax ID, Place of Service (POS 11/02), ICD-10-CM pointers, and CPT modifiers.
144-DPI VECTOR PREVIEW · PAGE 1 OF 1
ACROFORM READY
Included Financial Metrics & Line-Item Schedule
Target Roles: Concierge Physicians, Physical Therapists, Psychologists & Out-of-Network Clinics · Search Keywords: medical superbill template pdf with cpt and icd 10 codes, out of network insurance reimbursement superbill, physical therapy superbill receipt, hsa fsa qualified medical receipt
RENDERING NPI / TAX ID
NPI 1487902145 · 84-3910422
PRIMARY ICD-10 DIAGNOSIS
M54.50 · M25.511
TOTAL CHARGES PAID
$265.00 (PAID IN FULL)
PATIENT REIMBURSEMENT DUE
$265.00 DIRECT TO INSURED
| CODE | DESCRIPTION & TECHNICAL SPECIFICATION | BASIS / QTY | AMOUNT / DELTA |
|---|---|---|---|
| CPT-97162 | Physical Therapy Evaluation: Moderate Complexity (45 Min One-on-One Clinical Eval) | 1 Unit · Dx: A,B | $145.00 |
| CPT-97110 | Therapeutic Exercise to Develop Strength, Endurance & Range of Motion (GP Modifier) | 2 Units (30m) · Dx: A | $80.00 |
| CPT-97140 | Manual Therapy Techniques (Joint Mobilization & Myofascial Release — 59/GP Mod) | 1 Unit (15m) · Dx: A | $40.00 |
| PAY-HSA | Patient Out-of-Pocket Payment Settled via HSA Visa Card #4812 (Assign Benefits to Patient) | Paid at Visit | -$265.00 |
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