IUJ1J

SUPERBILLTo access complete view ofAHIMA’s superbill, visit http://www.ahima.org/icd10PLEASE RETURN THIS FORM TORECEPTIONISTPt Name:__________Date:_______Bill #:________ [ ] Care [ ] Priv.[ ] MC [ ] Medicaid [ ] CashTime In:______ Time Out:______SYMPTOMS/ DIAGNOSISR10.9 Abdom. PainR63.4 Abn. Weight LossT78.4 Allergic ReactionG30.9 AlzheimersD64.9 AnemiaD51.0 Anemia, PerniciousI20.9 AnginaF41.9 AnxietyR06.81 ApneaI49.9 Arrhythmia, CardiacI70.0 Atherosclerosis - AortaJ45.909 AsthmaI48.0 Atrial Fib.I48.1 Atrial FlutterI47.1 Atrial Tach.E53.8 B-12 Defic.M54.9 Back PainK92.1 Blood - StoolN40.0_ BPHR00.1 BradycardiaI49.5 Brady/Sick SinusJ42 Bronchitis, ChronicJ20._ Bronchitis, AcuteThis sample superbill was converted to ICD-10-CM by the American Health Information Management Association (AHIMA) solely as an exercise in demonstrating the process oftransitioning to a new coding system. It does not represent an endorsement by AHIMA of the use of superbills or this particular superbill format.Sue Bowman, AHIMA65