How do I know what CPT codes I am able to bill?

Nov 19

Understanding which CPT (Current Procedural Terminology) codes you can bill depends on several factors related to your practice, specialty, and services provided. Here's how to determine this:

1. Scope of Practice

Check your state’s regulations and the scope of practice for your profession. Some procedures or services may only be billable if they are within your professional licensure.
For advanced practice providers (e.g., nurse practitioners, physician assistants), verify whether specific codes require physician supervision.

2. Specialty Guidelines

Review guidelines from your medical specialty board or professional association. These organizations often provide resources or training specific to the services you provide.

3. Insurance Contracts

Review contracts with payers (e.g., Medicare, Medicaid, private insurers). These contracts specify which services are covered and any restrictions on billing.
Check payer-specific billing guidelines, as they may not cover every CPT code or may require prior authorization.

4. Credentialing and Enrollment

Ensure you are credentialed and enrolled with the payer for the codes you intend to bill. For instance, some payers might not allow a provider to bill for specific codes based on their provider type.

5. CMS and Payer Policies

For Medicare and Medicaid, consult the CMS guidelines, including the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
Review the Correct Coding Initiative (CCI) edits to avoid billing incompatible codes together.

6. Code Descriptions and Documentation Requirements

Familiarize yourself with the AMA CPT Codebook, which includes code descriptions, definitions, and usage guidelines.
Ensure your documentation supports the codes being billed, as payers may request records during audits.

7. Revenue Cycle Management

Collaborate with your billing department or a certified medical coder to ensure you are selecting appropriate codes and modifiers.

8. Continuing Education

Attend workshops, webinars, or training sessions on coding updates. CPT codes are updated annually, so staying informed is crucial.

This Q&A does not constitute legal, accounting, or tax advice and

does not address state or local law.

April Salsbury

April Salsbury, MBA is a strategist, an analyst, an operational guru, a recognized leader and C-suite global healthcare executive with drive and focus for competitive markets. Co-host of The Business Forum Show and regular contributor to various business journals, she possess multi-functional and multi-national competencies with more than 20 years experience in business and healthcare. Her expertise is in invigorating revenue growth and infusing value of lean practices in growing companies through improvements to cash flow and operations management.