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Superbill template builder

Build an acupuncture superbill template once, keep it, and print a complete one every time.

Fill in your billing details, choose the codes you actually use, add your fees, and print a clean template. It is saved in your browser, so next time you only change what changed.

Build your superbill template.

Work through the three steps. The page on the right updates as you type, and your details are saved on this device as you go.

Practice and provider details are kept on this device, so you only type them once.

Practice
Plans often ask for it. Leave it blank if you would rather not print it.
Provider
For example L.Ac. or Dipl. Ac.
10 digits. A missing NPI or license number is a common reason a plan sends a superbill back.

Your template saves in this browser as you type. Nothing is sent to us.

Practice name
SuperbillPatient reimbursement statement
Patient name
Date of birth
Patient address
Date(s) of service
Rendering providerProvider name
NPI
Place of service11 — Office
State license
Diagnosis (ICD-10)
A. B. C. D.
CPTMod.DescriptionUnitsFee
Acupuncture
☐97810Acupuncture, without electrical stimulation, initial 15 minutes of personal one-on-one contact
☐97811Acupuncture, without electrical stimulation, each additional 15 minutes of personal one-on-one contact, with re-insertion of needle(s)
Total charged
Amount paid
Payment method
Provider signature

Provided to the patient for their own reimbursement request.

Prints on 1 page (US Letter).

How to use and keep it.

A template saves time only if it stays current. Set it up once, then touch it when something changes.

  1. Print or save it as a PDF

    Use Print or save as PDF, then choose “Save as PDF” as the destination in your print dialog. Keep a blank copy on file, or print a few for the front desk.

  2. Fill in the rest for each patient

    Add the patient’s name, date of birth and address, the date of service, the ICD-10 diagnosis codes, the units for each code you performed and the amount paid. Then sign it. Need the diagnosis codes handy? Print our acupuncture ICD-10 list.

  3. Back it up

    The template lives in this browser only. Clearing site data, or opening the page on another computer, starts you from a blank one. Download backup saves a small file you can restore later.

  4. Review it when your details change

    A new address, a renewed license, a new NPI or a fee change all belong on the template the same day. Check it at least once a year.

Notes on the codes in the template.

Why some codes are always on the sheet and others are opt-in.

Acupuncture codes 97810 to 97814
97810 and 97813 are the first 15 minutes, without and with electrical stimulation. 97811 and 97814 are each additional 15 minutes and are defined “with re-insertion of needle(s)”, which in practice means a new needle set. Only add units for them when that applies and your payers accept it. The CPT codes cheat sheet walks through units and common denials.
Modifier 25 on consultations
A consultation (99202 to 99214) billed on the same day as needling usually needs modifier 25, or it can be denied as bundled into the acupuncture. Some payers do not cover a same-day consultation at all, and a full one is not meant for every visit.
Modifier GP
Medicare and VA payers ask for GP on physical-medicine codes such as 97026, 97124 and 97140. It is off by default because it is a payer question, not an acupuncture rule.
Cupping and moxibustion
There is no CPT code specific to either, so they are not on the sheet. Practices commonly charge for them as a cash-pay add-on instead of using an unlisted-procedure code.
Herbs and preventive visits
Insurers generally do not pay for either. When you add them, they print marked “patient responsibility” so the patient is not surprised.

The same settings, inside Goji.

This builder mirrors the superbill settings in Goji: the same code catalog, the same starting points and the same modifier rules. In the app, each visit’s superbill is filled in for you from the chart and the invoice. Goji never submits a claim; the document goes to the patient. See billing and the invoicing docs.

Frequently asked

Superbill template questions, answered.

Is my information sent anywhere?

No. The template is built and saved in your own browser, and the print preview is made on your device. We never receive your practice details, NPI or fees. Download a backup file if you want to keep the template somewhere safer than one browser.

Do I need a different template for each patient?

No. This template holds what stays the same: your practice and provider details, the codes you bill and your fees. You fill in the patient, the date, the diagnosis codes, the units and the amount paid on each copy.

Which CPT codes should I put on it?

The four acupuncture codes (97810, 97811, 97813 and 97814) cover needling. Add consultation, herb or other codes only if you bill them and your payers accept them. Which codes a plan pays for is the plan’s decision, so check with the payers your patients use.

Does a superbill get me paid by insurance?

A superbill is the document your patient submits to their own plan or HSA or FSA administrator. It does not guarantee reimbursement, and you are not filing a claim. See the patient-facing guide for what patients are told to check.

Can I have Goji fill this in for each visit?

Yes. In Goji the same settings sit under Settings, Billing. A visit’s superbill then picks up the provider IDs, suggested codes, charges from the invoice and the signature line without retyping.

Rather not fill in a template by hand?

Goji builds the superbill from the visit: your provider IDs, suggested codes, the charges from the invoice and a signature line. Start free and see one.

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