How to Create a Superbill: Complete Guide

Creating a superbill correctly is one of the most important billing skills a private practice therapist can have. This step-by-step guide covers exactly what you need to gather, how to structure each section, and how to hand it off to your client so they can get reimbursed without hassle.

Before You Start: Understand What a Superbill Is

A superbill is a specialized receipt that includes the diagnostic and procedural codes insurers need to process out-of-network claims. It is not an invoice and it is not a SOAP note — it is its own document type with its own requirements. If you are new to this, start with our overview of what a superbill is and how it works.

Step 1: Gather Your Provider Information

You will need to have the following ready before you can create a superbill:

• Your full legal name as it appears with your licensing board
• Your license type (LCSW, LPC, LMFT, PhD, PsyD, etc.) and license number
• Your 10-digit NPI (National Provider Identifier) — look this up at nppes.cms.hhs.gov if you have lost it
• Your EIN or SSN (for tax identification on the document)
• Your taxonomy code — the specialty code that identifies your provider type
• Your practice address and phone number

Set all of this up once in a template or billing tool. You should not be hunting for your NPI every time you generate a superbill.

Step 2: Collect Client and Insurance Details

At intake, collect a copy of your client's insurance card (front and back) or ask them to complete an intake form that captures:

• Client's full legal name and date of birth
• Insurance company name and plan name
• Member ID number
• Group number
• Primary policy holder name and relationship (if the client is a dependent)

If the client's insurance information changes — which happens with job changes — make sure you update your records before generating the next superbill.

Step 3: Select the Correct CPT Code

The CPT code tells the insurer what type of session you provided. For individual outpatient psychotherapy, choose based on session length:

• 90832 — 30-minute psychotherapy
• 90834 — 45-minute psychotherapy
• 90837 — 60-minute psychotherapy (the most common code)
• 90791 — Initial psychiatric diagnostic evaluation
• 90847 — Family therapy with patient present

Use the code that matches the actual face-to-face time, not the scheduled session length. If a 60-minute session runs to 45 minutes, bill 90834.

Step 4: Choose the ICD-10 Diagnosis Code

Every superbill must include at least one ICD-10 diagnosis code. This must reflect a legitimate clinical diagnosis — do not use a code simply because it is easier to get reimbursed. Common mental health ICD-10 codes include:

• F41.1 — Generalized Anxiety Disorder
• F32.1 — Major Depressive Disorder, single episode, moderate
• F43.10 — PTSD, unspecified
• F90.0 — ADHD, predominantly inattentive type

Be as specific as possible. Insurers have an easier time processing specific codes than catch-all codes like F41.9 (unspecified anxiety) or F99 (unspecified mental disorder).

Step 5: Add the Place of Service Code

Place of Service (POS) codes tell the insurer where the session occurred:

• 11 — Office (in-person session at your practice address)
• 02 — Telehealth, patient not at home
• 10 — Telehealth, patient at home (the most common telehealth code post-2020)

Step 6: Record Dates, Fees, and Payment

List each session on its own line. Include the date of service, the fee charged, and the amount paid by the client. If the client has a balance or paid a different amount than your standard rate, document that clearly. Never leave the "amount paid" field blank — insurers use it to calculate reimbursement.

Step 7: Sign and Deliver

Sign the superbill (wet signature or electronic). Then deliver it to your client — most therapists send a PDF by secure email or through a HIPAA-compliant portal. Your client will then submit it to their insurer directly, either through the member portal or by mail.

Step 8: Keep Records

Retain a copy of every superbill you generate for at least seven years. In the event of an audit or a dispute with your client's insurer, you will need to be able to produce it. Cloud storage with encryption is fine; unsecured email is not.

How Often Should You Generate Superbills?

Most therapists generate superbills monthly. Some clients prefer to submit after each session, especially if they are close to meeting their deductible. Build the cadence into your practice workflow and communicate it clearly during intake.

How Superbilled Helps

Superbilled automates every step in this guide. Enter your provider information once, add your client's details at intake, and generate a compliant superbill PDF in under a minute. There are no templates to maintain, no codes to look up manually, and nothing to forget.