Who is responsible for the accurate and correct use of CPT codes?

The accurate and correct use of CPT codes is primarily the responsibility of physicians. This is because CPT codes, which stand for Current Procedural Terminology codes, are used to describe medical, surgical, and diagnostic services and are essential for proper billing and reimbursement for healthcare services. Physicians have the requisite knowledge and clinical experience necessary to determine the correct codes that most accurately reflect the procedures and services rendered during patient visits.

Physicians utilize these codes during the documentation of patient encounters to ensure that they capture all relevant services performed, supporting both accurate billing and compliance with regulations. While office administrators and billing specialists play roles in managing and submitting claims, it is ultimately the physician who must ensure that the coding aligns with the services provided based on their clinical judgment and interpretation of the patient's needs. Nurses may assist in documentation and provide relevant information, but they are not ultimately responsible for coding decisions.