Super Bills

A Super Bill is an itemized bill that gathers the charges from a visit, along with billing codes, diagnoses, provider details, and the patient’s insurance, into one document the patient can submit to their insurer for out-of-network reimbursement.

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Build a Super Bill from a Visit

Open the patient’s chart and go to the Billing tab. In the Super Bills section, click Construct Super Bill.

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Build a Super Bill from a Note

If the visit already has a clinical note, you can do the billing without leaving the note.

• In the note’s actions menu, click Link Superbill. In the window that opens, pick a Super Bill the patient already has and click Link, or click Create new to start one from this visit’s charges.
• Once the note has a Super Bill, that same action reads Replace Superbill. The window names the bill the note is on, and that bill is greyed out in the list as Already linked to this note — so pick a different one to move the note, and it never ends up on two.
• The note’s Super Bill opens on its own Superbill tab, where you can add codes and details in place. Everything you type there saves on its own, and the tab strip tells you when it has.
• Print in the note’s actions menu follows the tab you’re on: on the Superbill tab it prints the Super Bill, and on any other tab it prints the note. The printed Super Bill is the same document the full editor prints.
• To email the bill to the patient, or to see what it adds up to, open it in the full editor from the Super Bills list on the patient’s Billing tab. The note’s tab is for the codes and claim details, not the whole bill.
• Duplicating a note copies its Super Bill too, and links the copy to the new note. The copy carries the codes, claim details and insurance you had filled in, but none of the original’s charges — so nothing already paid for follows it, and editing the copy never changes the bill you copied from. Add the copy’s charges yourself, or leave it as a claim to re-bill.
• All of this works the same on an AI Scribe note and on a saved manual note.

This entry point needs both Billing Read (to look up the bill and candidate charges) and Billing Invoices Write (to create or move one). A note that isn’t linked to an appointment can still have a Super Bill — there are just no charges to seed it with, so the new bill starts empty and you add the lines yourself.

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Edit the Super Bill

A Diagnosis & Procedures summary at the top of the editor (and on the printed bill) groups the CPT/HCPCS and ICD-10 codes drawn from the linked note and the per-line entries — useful for a quick scan before you send it. The editor lets you review and complete everything an insurer needs. For each billed item, edit the fields directly on its row:

• CPT/HCPCS billing code — type to search the CPT/HCPCS catalog, then pick a result.
• Modifier(s) — search and add the standard CMS modifiers; multiple modifiers are stored as separate chips. The picker also offers the ABN insurance modifiers GA, GX, GY, and GZ for any code — use these when the payer, not the procedure, determines coverage (for example, GY on 99213 to bypass Medicaid).
• ICD-10 Diagnoses — search by code, description, or common lay/workflow terms (e.g. “dexa” surfaces Z13.820, “sore throat” surfaces pharyngitis codes). Add as many as apply.
• Place of Service — pick the CMS place-of-service code (e.g. 11 — Office, 02 — Telehealth).
• Rendering Provider, Facility, Billing Provider, and TIN (the billing provider’s Tax Identification Number).

Rendering Provider and Facility are search-and-pick fields. Picking a provider autofills the Rendering NPI from that provider’s saved NPI; picking a facility autofills the TIN from that location’s saved Tax Identification Number. If you need a free-typed name that isn’t a provider or a saved location (for example a care-team label), start typing and click the Use ”…” row that appears at the top of the list. If a service, product, or medication has default billing codes set in Settings, its CPT, modifiers, ICD-10, and place-of-service fields are pre-filled — you only adjust what’s different. The Start and End dates on the bill and on each line come from the appointment. When the bill has no appointment behind it, Decoda uses the date the note was written, then the date the bill was created, so the dates are never blank. Change them if the service happened on a different day.

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Add, Copy, and Remove Lines

Click + Add line item at the bottom of the list to start a blank line you fill in yourself. To bill the same service more than once on one bill — a repeat visit, a second body site, or units split across separate lines — click Duplicate on the line you want another copy of. The copy appears directly below it, carrying over the billing code, modifiers, diagnoses, NDC, place of service, dates, count, and amount. Change whatever differs, such as the date or the number of units. Both lines count toward the bill’s total, and a code that now appears twice is still listed once in the Diagnosis & Procedures summary. A copy isn’t tied to the original charge, so it shows a Remove link instead of the Include checkbox that charges from the visit have. Use Remove to delete a line you added or copied; you’ll be asked to confirm, since the codes typed on that line go with it. Lines that came from the visit’s charges can’t be removed — clear the Include checkbox to leave one off the bill instead. The editor also shows the Primary Payer, Plan Name, Coverage Type, and Claims Address, pulled from the patient’s insurance on file. Add Notes for the patient or payer if needed.

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Send or Print

When the Super Bill is ready:

• Click Print / Save PDF to print it or save a copy.
• Click Email to send it to the patient. The bill goes to the patient’s email address on file.