Step 5 — Billing codes

Turn the session into a billable record. Feeds the Superbill and CMS-1500 in Step 6.

CPT codes

For each code:

• Units
• Unit charge
• Modifiers (optional)
• Internal clinical note (won't appear on patient-facing documents)

Multiple CPT lines per session are normal.

ICD-10 codes

• Mark one as primary
• Add secondary diagnoses as needed
• Internal clinical note per code

Diagnosis pointers

Each CPT line is linked to one or more ICD-10 codes that justify it. This is what payers look for.

See Billing & documentation for Superbill and CMS-1500 specifics.

Common pediatric nutrition code combinations and modifier guidance coming soon.