Weighing the Differences and Similarities of ProFee Coding and Facility Coding

Weighing the Differences and Similarities of Pro Fee Coding and Facility Coding


What are the differences and similarities between ProFee Coding and Facility Coding? Physician group acquisition by major health systems remains a common trend in the industry. One survey of over 8,700 physicians indicates that only 31% of physicians surveyed identify as an independent practice owner or partner as of 2018. This is down from 48.5% in 2012, a whopping 35% decrease in independently owned practices in only 6 years (Merritt Hawkins, 2018). Do you have concerns on how to increase pro fee coding accuracy? Review our case study on the implementations of a coding quality improvement plan, which resulted in a 17% increase in CPT accuracy and 18% in DX accuracy, over 33 months. If your organization is considering outsourcing your coding and auditing needs, review our previous article that debunks the common myths of outsourcing and describes the benefits that working with consultants can bring.

In these acquisitions, the question remains: Who will manage the physician group? Which department will the physician group report to or merge with on the facility side? Does the management on the facility side have the resources and professional fee coding (Pro Fee coding) knowledge base to be able to navigate this acquisition?

ProFee CodingIf the answer to any of these questions is the facility side coding/HIM department, the facility management might be in for a significant surprise. As a consultant, I have received this question many times when an abrupt acquisition takes place: “We just acquired a large physician group. ProFee coding and billing aren’t THAT different, right?”

Review our article, “Eliminate These Professional Fee Coding Risks to Save Your Bottom Line,” for strategies on how to overcome your ProFee coding challenges.

Billing Differences:

Before discussing the coding differences, it is also imperative to understand the billing and reimbursement differences between ProFee and the facility.
The major difference in ProFee culture is the personal aspect of coding to properly reimburse providers for work performed. In other words, ProFee directly impacts someone’s paycheck, code-for-code, chart-for-chart. Here are some pro fee coding examples:

• APCs vs. RVUs
APCs are usually driven by the most major procedure code. It could be possible for a facility’s APC accuracy to be over 95%, while the actual code-for-code CPT accuracy could be below the goal of 95%. One could possibly choose a procedure code “in the right ballpark” or forget an additional procedure code like debridement and still arrive at the same APC. In other words, reimbursement for the facility may or may not be directly affected if the CPT accuracy is not 100%. However, on the ProFee side, RVU reimbursement structures are driven on an individual procedure code basis. One missed procedure code for debridement or a non-exact procedure code match could cost your providers valuable RVUs.

As you may have already guessed, professional fee reimbursement is not the same as OPPS (Outpatient Prospective Payment System). Therefore, ProFee services are not reimbursed utilizing the APC payment package rates (CMS, 2019).

• Outpatient Code Editor
Similar to OPPS, the Outpatient Code Editor is also not utilized in the professional fee guidelines. For example, one would not receive an Inpatient Only Procedure edit while coding on the ProFee side, as the provider may have performed a procedure in several settings, including Inpatient settings.

• NCCI Edits vs. NCCI Manual
Many facilities rely on their encoder to notify their coding staff of NCCI edits for CPT codes that cannot be billed together. However, it is imperative to know the further discussions within the NCCI manual. We often get the question from clients: “Doesn’t my encoder notify me of all NCCI edits within the NCCI manual?” The answer: not necessarily. We often compare the NCCI manual to the documents required for tax law; it is dense material that requires coders to know each section by heart. This is often why professional fee coders tend to specialize, while facility coders tend to code the next encounter in the queue.

• Medically Unlikely Edits (MUEs)
Medically Unlikely Edits (MUEs) are a similar concept from the facility side. Per the CMS, “An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service” (CMS, 2019). However, it is important to note that Medically Unlikely Edits differ between the facility and professional fee sides of billing.

• Global Surgery Edits
Global Surgery Edits are a different and separate concept from the facility side. Per the CMS, “The global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the preoperative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty” (Medicare Learning Network, 2018). In other words, surgical CPT codes may have a global period for which all necessary services may not be separately reimbursable. For example, a routine post-operative visit may be included within the package if the surgical code has a 90-day global surgery period per the CMS. An important note is that each CPT code has its own global surgery period per the Medicare Physician Fee Schedule, so this can be CPT code specific.

ProFee Coding• E/M Levels
How E/M levels are coded are different from the professional and facility sides of the bill. E/M levels were initially developed for professional fee coding based on three key components – medical decision making being of the utmost importance with the development of new standards in 2021. On the other hand, “[T]he Centers for Medicare & Medicaid Services (CMS) has allowed each facility to develop unique internal guidelines to report clinic and emergency department services provided by hospitals by mapping them to the levels of effort represented by the existing CPT ® codes. As a result, today, each hospital has its own E/ M methodology, although hospitals within the same health system may have the same or similar methodologies” (AHIMA, 2003). Most facilities drive E/M levels off of resource intensity for the entire visit, while professional E/M leveling requires a per visit review of the three key components per provider.

• Status Indicators
If you are used to status indicators per OPPS, you may have some of the status indicators memorized. For example, status indicator T per OPPS means that the code will be separately reimbursable, with a separate APC payment. However, professional fee status indicator T implies the opposite: “These codes are paid only if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made” (CMS, 2017).

• Modifiers
Although many modifiers can be utilized for both pro fee coding and facility CPT procedure coding, some modifiers are only utilized for professional fee coding, while some can only be used for facility coding. For example, modifiers 73 and 74 are only utilized on the facility side, while profee would utilize modifiers 52 or 53 instead. Another example would be E/M specific modifiers, such as modifier 24.

Billing Similarities:

With so many differences between facility coding vs. professional coding as discussed above, this leaves very few similarities:
• ICD-10-CM diagnosis coding is utilized
• CPT procedure coding is utilized
• National Coverage Determinations/Local Coverage Determinations for medical necessity are a similar concept between both facility and professional fee coding. However, some NCD/LCDs are Part A or Part B specific.

Major Coding Differences:

• Manual Processes
In our experience, the professional fee arena of billing and coding often requires more manual processes than one might be used to on the facility side. We have seen some professional fee systems that are anywhere from completely paper-based to integrated into the facility system entirely. This can lend itself to additional and different coding differences for professional fee coding departments. Some examples include: Productivity standards are usually lower due to manual processes; typo errors are possible in a paper-based or non-encoder-based posting system; processes for holds are manual and can increase coding time; processes for encounter reconciliation are manual and can increase administration time and the likelihood of errors, etc. Another example can be that the encoder is not connected to the billing system itself, often requiring the coder to perform an additional step that is not needed on the facility side.

• Medicare Physician Fee Schedule
In a similar manner, the Medicare Physician Fee Schedule (MPFS) adds another manual process to the professional fee coding process. Often, the MPFS excel spreadsheet is the only place one can identify items for each CPT code, including assistant surgeon eligibility, co-surgeon eligibility, multiple procedure reductions and appending modifier 51 appropriately, global period packages, to name a few. Many encoders and systems do not have this information built-in, thus requiring the coder to add another manual step into their process.

• NCCI Manual
Although the NCCI manual has been discussed above, it warrants another discussion in terms of profee coding and manual processes. Currently, many encoders do not include all edits that are in the NCCI manual that are not included in the CCI tables. This requires the coding staff to memorize the nuances of the NCCI manual without the prompting of an encoder, often contributing to why many professional fee coding departments choose to have their coders specialize.

• Provider Discussions/Questions
We are often asked if provider discussions/questions are common in the professional fee side of coding, and the simple answer is “absolutely!” One important difference between facility and professional fee culture is the personal aspect of the effects on coding accuracy. Since many facilities utilize a system of points per each CPT code to accurately reimburse their providers for work performed, coding accuracy is of the utmost importance. Thus, creating a need for an efficient and productive pipeline for provider and coder communications, discussions, and questions. For more tips on provider discussions in professional fee coding, please see our article on the “Top 5 tips for ProFee Physician Discrepancies.”

• Personal
Whenever speaking about professional fee culture vs. facility coding, emphasizing the word “personal” is imperative. ProFee is personal. If there is a coding error, the error will affect someone’s personal paycheck, for hospital systems that utilize a wRVU system for calculating paychecks. Thus, if that is the situation at your hospital system, how one defines processes and communications must be formulated with that in mind.

Do you need assistance with a physician group acquisition? We offer individual professional fee services, as well as a comprehensive physician group acquisition package for facilities. Contact us at info@yes-himconsulting.com for more information.

Vanessa Youmans

Vanessa Youmans, MA, CCS, CPC – Director OP/Profee Coding & Auditing
ProFee Coding

Subscribe to our Newsletter


  • By clicking Submit, you agree to YES HIM Consulting's Privacy Policy.