In medical billing, one of the most important compliance questions is who is eligible to bill insurance directly under their own name. Not every licensed provider has the same billing rights, and misunderstanding these rules often leads to claim denials, compliance risks, or revenue loss.
At Solubillix, we help healthcare practices stay compliant while maximizing reimbursement. Below, we outline which providers can bill independently, what restrictions apply, and how CPT code usage is affected.
Physicians (MDs and DOs)
- Eligibility: Fully authorized to bill directly with their own NPI.
- Restrictions: Must hold active licensure in the practicing state. Documentation and coding must demonstrate medical necessity.
- CPT Billing: Eligible for all E/M codes, procedures, and specialty services.
Nurse Practitioners (NPs) and Advanced Practice Nurses (APNs)
- Eligibility: Recognized by most payers for independent billing. Medicare reimburses at 85% of physician rates.
- Restrictions: State laws may require a collaborative or supervisory agreement.
- CPT Billing: May bill preventive, E/M, and certain procedures aligned with state-defined scope.
Physician Assistants (PAs)
- Eligibility: Can bill under their own NPI with many payers, though some require billing under a supervising physician.
- Restrictions: Dependent practitioners; rules vary by payer and state.
- CPT Billing: E/M and procedures within their clinical authority.
Optometrists (ODs)
- Eligibility: May bill directly for eye care and vision services.
- Restrictions: Limited to services defined in state optometry scope.
- CPT Billing: Eye exams, vision therapy, and optometric procedures.
Licensed Clinical Social Workers (LCSWs)
- Eligibility: Accepted by Medicare, Medicaid, and most commercial insurers.
- Restrictions: Services must be behavioral health related only.
- CPT Billing: Psychotherapy and assessment codes.
Licensed Professional Counselors (LPCs)
- Eligibility: Varies by payer. Some commercial insurers allow independent billing; Medicare does not currently reimburse LPCs directly.
- Restrictions: Limited to behavioral health therapy.
- CPT Billing: Therapy codes where permitted by the payer.
Psychologists (PhD, PsyD)
- Eligibility: Widely recognized for independent billing.
- Restrictions: Prescriptive authority is limited by state law.
- CPT Billing: Psychological testing, psychotherapy, and behavioral assessments.
Registered Nurses (RNs)
- Eligibility: Cannot bill independently for professional services.
- Restrictions: Services are billed under a physician, NP, or facility.
- CPT Billing: Not applicable for direct billing.
Chiropractors (DCs)
- Eligibility: Recognized by Medicare, but only for spinal manipulation.
- Restrictions: Cannot bill Medicare for exams, physical therapy, or diagnostics.
- CPT Billing: 98940–98942 (chiropractic manipulation codes).
Compliance Takeaways
- Billing rights depend on provider type, payer policy, and state scope of practice.
- Medicare and commercial insurance rules are not always the same.
- Using the correct CPT codes and modifiers is critical for reimbursement.
Why This Matters for Your Practice?
Improper billing leads to:
❌ Denied claims and reduced cash flow
❌ Payer audits and penalties
❌ Delays in revenue cycles
✅ At Solubillix, our team ensures your practice bills under the correct provider, applies the right CPT codes, and stays compliant with payer regulations. We help providers capture every dollar they’ve earned—without the compliance risk.
👉 Ready to eliminate billing errors and increase reimbursement?
Contact Solubillix today and let us handle your billing with precision and compliance at the core.
