Chiropractic Invoice Template: A Cash-Patient Invoice and a Superbill With CPT and ICD-10 Codes

Invoice, receipt or superbill?

For a cash patient who pays at the visit, a receipt is enough for their records. An invoice is needed when there is a balance, such as a care plan paid in installments or a corporate wellness arrangement. A superbill is a detailed statement for a patient who wants to claim out-of-network benefits from their own insurer: it has the codes an insurer needs, but you do not submit it. Many cash practices hand out superbills on request, and the template below covers both.

Under the No Surprises Act, self-pay and uninsured patients are entitled to a good faith estimate before scheduled care. The invoice should match it; see our good faith estimate template for chiropractors.

Template 1: cash-patient invoice

1. Practice name, address, phone, invoice number and date.
2. Patient name, date of birth and date of service.
3. Services. One line per service, with the fee from your fee schedule.
4. Care plan or package applied. For example, visit 4 of a 12-visit plan, and how much of the plan is paid.
5. Amount paid today, payment method, balance due.
6. Next appointment and your cancellation policy in one sentence.

Template 2: superbill for out-of-network reimbursement

1. Provider details. Practice name and address, rendering chiropractor, individual NPI, group NPI if you have one, tax ID.
2. Patient details. Name, date of birth, address, and insurance member ID if the patient gives it.
3. Date of service and place of service code. 11 is an office.
4. Diagnosis codes (ICD-10). The codes you documented, for example M54.50, low back pain, unspecified, or M99.03, segmental dysfunction of the lumbar region.
5. Procedure codes (CPT) with units and fees. Each linked to the diagnosis it treats.
6. Amount paid by the patient. Insurers reimburse the patient against what was paid.
7. Provider signature and date.

Worked example on our assumptions: the fees are illustrative, not market rates, and the codes must match your own documentation.

Diagnosis codes on this example: M99.01, M99.02 and M99.03 (segmental dysfunction of the cervical, thoracic and lumbar regions, the three regions adjusted) and M54.50 (low back pain, unspecified). Place of service 11. On most follow-up visits the evaluation line drops off and the superbill is the manipulation code plus any therapy units.

A note on spinal manipulation codes: 98940 covers 1 to 2 regions, 98941 covers 3 to 4 and 98942 covers 5 regions. The regions treated must be documented in the visit note; the superbill should never claim more than the note supports.

Care plans and packages on the invoice

Many cash practices sell care plans, for example 12 visits paid in three monthly installments. Show the plan on every invoice: the plan total, what has been paid, the visits used and the visits left. Patients who see "visit 4 of 12, $360 of $900 paid" stop asking at the front desk. If a patient on a plan asks for a superbill, list each visit at your regular fee schedule and show the plan payments as the amount paid, so the reimbursement request matches what they actually paid; check this approach with your own compliance adviser.

Keep the copies

Keep every invoice and superbill with the visit note it came from. When a patient's insurer questions a reimbursement, or the patient asks for a year of statements for a health savings account, you need to produce the same document with the same codes and fees. Number invoices in sequence and never edit one after it is sent; issue a corrected invoice with a new number and a note that it replaces the old one. State rules on how long to keep patient financial records vary, so follow your state board's retention period.

When to send it

Hand the receipt or superbill at checkout, or email it the same day; patients claiming reimbursement often want a monthly superbill instead, covering every visit that month. Set that up once per patient. For balances, send the invoice the day of the visit and a reminder before the next appointment rather than after it.

Common mistakes

• No NPI or tax ID on a superbill, so the insurer rejects the patient's claim.
• Codes that do not match the note, which is a compliance problem, not a paperwork one.
• Package visits shown at $0, which gives the patient nothing to claim.
• Superbills sent weeks late, after the patient has stopped trusting they will come.

Where Unmanually fits

Massage practices run the same care-plan and rebooking clock (massage membership and rebooking guide). Price visits and care plans with the free chiropractic fee calculator. Then let the office run itself: Unmanually is a 24/7 AI Office Manager for chiropractors that you run by voice. It answers calls between adjustments, books and reschedules patients, sends reminders, emails receipts and monthly superbills you approve, and follows up on care-plan balances. Clinical and coding decisions stay with you. See Unmanually for chiropractors, or read how to start a chiropractic cash practice.