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Physiotherapy bill format for Management

okay so let's go over what's your reimbursement form or some people call it a super bill let's go over exactly what your universal form should entail to get your patient the best opportunity to be able to get reimbursed for your cash based services so a lot of standard clients will use a 15 to 90 form so I just kind of modified that a lot of standard insurance clearance once the 1,590 form done it's just an annoying piece of paperwork so what I did is just modeled it and organized it and added some stuff to fit for my cash based practice and this is an example of what I use at my clinic persuit physical therapy so I just call it a patient reimbursement form I state that it's a modified 1,590 form and I have my opening statement which is this this is the verify that patient has received and paid for the services provided and their plan of care wat or suit physical therapy this patient has paid in full out-of-pocket for the services provided at persuit physical therapy this form provides all the necessary information for the patient to submit a claim to their insurance company for reimbursement or application to their deductible this form along with receipt should be provided to the patient's insurance company please provide any payment or reimbursement directly to the patient so that's what I say or that's my statement there because I don't want them sending it to me I want to send the reimbursement form to the patient so that's my first statement so to just kind of organize this kind of I have the patient's fill out the patient info okay they can fill out this stuff at home and then I have them fill out their health insurance info okay and they are responsible for actually doing that as they submit their claim to their health insurance next is going to be the provider info okay this is the stuff that you have to do you have to have your facility name you have your address your facility type and there's a code for that outpatient physical therapy code is code 11 the actual provider and then the providers license number which I took my information off of here you should have your tax ID or your EIN number and then your national provider number also okay so this goes under the tab for the provider info okay so that's my first page right there and again I have this stuff fell down already and then I have the patient and fill out the first two two boxes there so next is the services provided so I have three spaces here for icd-10 codes and I'll fill this in depending on what the patient has whether it's one two or three diagnoses okay so next is going to be the data service the CPT code units cost per unit and the charges they do want to see the cost per per unit and the units it's super annoying that's why I keep this standardized and simple as possible so remember that there are new eval codes versus easy medium and complex eval so make sure that your CPT code for the for the evaluation is it and we're just going to use the example here as as a hundred fifty a visit so the data service the eval code it's it's one unit and the charges whatever you charge for the actual for the actual eval for this example we're saying $150 so then they do want you to break it down into different codes and how many units per code and the cost per code and the total charge so on I only do two things I do manual therapy in ther acts I you know keep it simple stupid so on the 17th was was the first visit I did manual therapy two units I just say I charge 115 $150 a visit so I did two units a manual two units at their expand 150 and then the next visit was on the 27th I did the same thing I do the same thing every time it's just manual therapy enteric so I keep it simple and then I did it again so that they were here for three three visits plans to discharge the home home exercise program the total charge is 400 $50 and then I have a electronic signature here and this is what my patients get plain and simple this is what they get with after they completed their plan of care and this is my outline form of what I use at my clinic for a reimbursement form so just let me know if you have any questions or concerns about this just put them in the comment box below and thank you for tuning in