Even the most seasoned healthcare provider in Arizona can still take a second to consider whether to use CPT or HCPCS codes. While they may look like normal administrative details, these codes are a core part of how care is documented, billed, and reimbursed, especially when working with Arizona’s Medicaid Program—Arizona Health Care Cost Containment System (AHCCCS)—and other private insurers across the state.
Knowing the difference between the two doesn’t have to be complicated. In this guide to AHCCCS billing codes, we’ll break down exactly what each code set covers, when to use them, and how mastering both can help you bill smarter and get paid faster.
With constant updates, payer-specific requirements, and overlapping services, it can be challenging to stay ahead. 5 Star Billing is here to help with our Arizona medical billing services so you remain accurate, compliant, and stress-free.
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What Are CPT Codes?
Current Procedural Terminology (CPT) codes were created by the American Medical Association (AMA). These codes are the go-to language for describing the services and procedures performed by healthcare providers, and are required for Medicare and Medicaid billing compliance.
They capture the breadth of healthcare services, including:
- Office visits
- Blood draw
- Diagnostic services
- Minor surgeries
- Routine check-ups
If it’s part of a provider’s responsibility, there’s likely a CPT code for it.
Who Uses CPT Codes?
Everyone in the billing world uses CPT codes.
- Commercial insurers rely on CPT codes to determine what was done and how much to reimburse.
- Medicaid programs, including AHCCCS in Arizona, also use CPT codes to process provider claims.
| Example |
| Let’s say a primary care provider sees an established patient with a moderate-level concern. The correct CPT code might be 99213 (office or other outpatient visit). This physician procedure code in Arizona tells exactly what happened during the visit, allowing them to be reimbursed accordingly. |
Tip: CPT codes are always five-digit numeric codes, like 99213 or 93000 (for an electrocardiogram).
What Are HCPCS Codes?
HCPCS stands for Healthcare Common Procedure Coding System. It was developed by the Centers for Medicare & Medicaid Services (CMS) to fill the gaps CPT doesn’t cover.
Where CPT focuses on procedures, Arizona HCPCS codes cover everything else, like medical supplies, equipment, and non-physician services. To keep things organized, HCPCS is split into two levels:
| Level | What It Covers | Example |
| Level I | CPT Codes | 99213 |
| Level II | Items/services not included in CPT | E1130 (Standard wheelchair) |
If you’re billing for a syringe, crutches, an ambulance ride, or even certain injectable drugs, you’ll likely use HCPCS Level II codes in Arizona.
Who Requires HCPCS Codes?
- Medicare
- Medicaid (including AHCCCS)
- Some private insurers
| Example |
| Let’s say a patient covered under AHCCCS receives a standard wheelchair. You’d use the non-physician service codes in Arizona, such as E1130. This code tells the payer that the service or item was non-physician in nature, but still medically necessary. |
Tip: HCPCS Level II codes are alphanumeric. They start with a letter (A-V) followed by four numbers (e.g., A4556, J1050, E1130).
Billing Considerations in Arizona
CPT and HCPCS codes each serve a purpose, but in Arizona, using them correctly takes more than knowing what they mean. There are things you need to consider when billing in the Grand Canyon State:
- AHCCCS Requires the Right Code Type
Arizona’s Medicaid program (AHCCCS) expects providers to use CPT codes for services and HCPCS codes for items or non-physician services.
For example: Use CPT 90471 for vaccine administration and HCPCS J1050 for the medication itself.
- MCOs Have Their Own Rules
When you’re working with Medicaid Managed Care Organizations (MCOs) like Mercy Care, Banner University Family Care, or Care1st Health Plan Arizona, consider if they have plan-specific requirements, such as:
- Modifier use (e.g., KX, LT, RT)
- Prior authorization rules
- Limits on frequency or billing combinations
Check each plan’s provider manual or work with 5 Star Billing, which tracks those details for you.
- Wrong Code, Wrong Result
Submitting Arizona CPT codes when HCPCS codes are required is one of the most common billing errors. Using one without the other will only get you paid in half (or not at all).
- Medicare’s Local Coverage Rules May Apply
If you’re billing Medicare patients or dual-eligible patients (Medicare + AHCCCS), don’t forget about Local Coverage Determinations (LCDs) from Noridian, Arizona’s Medicare Administrative Contractor (MAC).
These LCDs often spell out:
- What codes are payable
- Which modifiers are required
- Documentation or diagnosis requirements for coverage
Common Pitfalls and How to Avoid Them
Even the most seasoned billers can slip up when you’re under Arizona’s Medicaid and insurance requirements. These are some of the most common coding mistakes we see (and how to steer clear of them):
- Mistaking HCPCS for CPT (and Vice Versa)
Using a CPT code when a HCPCS code is required. For example, billing 90471 for a vaccine injection without also including the HCPCS code for the vaccine itself (J1050).
What to do: Take the time to understand the purpose of each code set (service vs. item) and use both codes when the situation calls for it.
- Skipping Required Modifiers
Modifiers help clarify what happened during a visit. Missing them could cause your claim to be rejected or underpaid.
If a provider sees a patient for a scheduled routine check-up (CPT 99213) but also ends up performing an ear irrigation (CPT 69210), you must add Modifier -25 to the office visit code (99213). In this case, Modifier -25 signals that the office visit was separately identifiable and medically necessary in addition to the procedure.
What to do: Stay updated on payer-specific modifier rules and flag services that commonly require modifiers during billing reviews.
- Billing Only One Code When a Combo Is Required
Some services require both CPT and an HCPCS code to describe what was provided fully. For example, if you administer vitamin B12 (HCPCS J3420) for a therapeutic injection (CPT 96372), both codes are needed to reflect the full encounter.
What to do: Use coding cheat sheets or EHR billing prompts to catch combo requirements.
- Using Outdated Code Books or Payer Guidelines
CPT and HCPCS codes update annually, and payer requirements can change even more frequently.
What to do: Update your cheat sheet annually. Use current AMA, CMS, or AHCCCS resources.
Let 5 Star Billing Help You Stay Compliant
The difference between struggling with coding complexities and thriving financially comes down to one decision: continuing at it alone or partnering with experts who’ve already mastered it.
If you need a helping hand, let our expertise in medical billing codes in Arizona give you the certainty and confidence to navigate the state’s challenging payer landscape. With 5 Star Billing as your billing partner, you get:
✔ Expert CPT & HCPCS Coding Aligned with Arizona Payers
✔ Certified Coders Trained in AHCCCS + Commercial Rules
✔ Denial Prevention and Modifier Precision
✔ Always Up to Date with CMS + AMA Changes
Let us make it easier for you. Contact us today and find out how our Arizona-focused expertise can stop the revenue leaks and transform your practice’s financial health.
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Frequently Asked Questions
What’s the best way to keep up with CPT and HCPCS code changes?
Subscribe to CMS and AMA update bulletins, attend coding webinars, and use a billing partner like 5 Star Billing that tracks changes in real time and updates workflows accordingly.
Are CPT and HCPCS codes the same nationwide, or do they vary by state?
AHCCCS and Arizona MCOs often have different requirements than commercial payers. It’s important to review plan-specific guidelines or work with billing experts familiar with Arizona’s Medicaid landscape to ensure accuracy.
How do I know which code to use for AHCCCS vs. a commercial plan?
AHCCCS and Arizona MCOs often have different requirements than commercial payers. It’s important to review plan-specific guidelines or work with billing experts familiar with Arizona’s Medicaid landscape to ensure accuracy.
Is it enough to just follow the CPT and HCPCS books?
Not quite. Code books are a great baseline, but payers often issue updates, policies, and coding edits that override general guidance. Staying compliant means keeping up with CMS changes, LCDs, and local plan policies.