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Top 5 tips for ProFee Physician Discrepancies

Top 5 tips for ProFee Physician Discrepancies


We often receive questions on the differences between Professional Fee “ProFee” coding and facility outpatient coding, particularly for how to better communicate with providers on coding discrepancies. With the ongoing trend of physician group acquisition, facility-side managers are increasingly assigned the role of also managing the coding policies of newly-acquired physician groups with very little experience in the ProFee arena. Accuracy is imperative, particularly when one is integrating new acquisitions to current processes and systems, and creating a new ProFee department under a facility’s umbrella.

So, what makes ProFee coding and billing so different from the facility culture? Many facilities/medical groups rely on a system of paying their providers based on a point system that CMS publishes on a quarterly basis called Work Relative Value Units (wRVUs). The Physician Fee Schedule with wRVU information can be found here (  Each CPT code that is assigned for each case equals a certain amount of wRVUs per CMS. Many physician groups, in turn, establish a system that calculates the total number of wRVUs per month into a payment for the physician at the end of the month/quarter.

The importance of correct CPT code assignment on physician payment creates the need for a strong ProFee coding department within the physician group. This lends itself to the common practice of ProFee coders focusing on a certain specialty or specialties, so that the providers can depend on an expert in their specialty to accurately describe their level of work for each case. Alternatively, this also lends itself to an increased level of provider communication, questions, and even discrepancies.

So, how do you best handle these communications with providers regarding discrepancies in their ProFee coding?

5 Tips for Physician Discussions:


1. Stay one step ahead: Stay current on upcoming coding changes and communicate these ahead of time.

One of the major complaints we have heard over the years is: “Why wasn’t I told that?” Make a habit of browsing your latest AHA Coding Clinic, AMA CPT Assistant, Physician Fee Schedule, NCD/LCD, and NCCI edit/manual updates each time they are released and provide updates on any pertinent changes to your providers. If there is a major change for your providers in the upcoming NCCI manual, for example, your providers will appreciate a “heads up” email about how this will affect their wRVUs and when to expect the change.

ProFee one step aheadWe recommend submitting an official email with the upcoming change, a snippet or attachment of the official resource that will explain the change, and when this change will take effect. This will dramatically decrease the amount of discrepancies that will occur during an abrupt coding change.

2. Keep it “official”: Only utilize and cite official resources.

We recommend utilizing only official resources such as the AMA CPT Assistant publications, AHA Coding Clinic for ICD-10-CM/PCS, the Medicare Claims Processing Manual, the NCCI manual, etc. Blogs and articles can be good resources and starting points for research; however, providers will appreciate the use of official resources during discussions, particularly with discrepancies involving a difference in wRVUs.

One important point is to take your time and research during these discussions. You never want to be caught stating something is correct or incorrect due to “I’ve always coded it this way” and be unable to support your decision down the road with official resources.

Occasionally, official resources and specific specialty society advice can be in disagreement or unclear. We recommend escalating to coding management when official resources and specific specialty society advice are in disagreement.

Remember that it should not be observed or perceived as an “us against them” or “coding department is fighting with the providers” scenario. Therefore, utilizing only official resources is key to open and accurate communication.

3. Use your resources: Consulting firm, colleagues, AMA, CPT assistant, etc.

ProFee coding and billing will stretch the depth of your knowledge and the intricacies and details of CPT, in particular. There are many options, however, to reach out to multiple resources for a second opinion. Do you have a question on an unclear answer from the AMA CPT Assistant? Reach out to the AMA for a follow-up question. Do you have a tough case that needs additional research? Reach out to a seasoned colleague or have coders bring their tough cases to the next coding meeting for discussion and education.

Resources ProFeeDo you need a second opinion? YES is proud to offer a ProFee “question queue” service, where your coders and/or management can place tough cases for review prior to dropping or posting the codes/charges. We have found that this significantly increases both quality and productivity for your coders, while also assisting in trending issues that need attention from management. All of these steps will decrease the amount of provider complaints.

4. Escalate when needed.

We recommend not including coders directly in any tense discussions and to designate a department or team for physician relations/education.In our experience, any tense coding/reimbursement discussions can create an environment that is not conducive to quality coding and productivity. We suggest escalating these types of discussions to management or a physician liaison department, so that the coders can focus on quality coding in a timely manner. Your coders will be much happier!

YES can also assist in provider education and communication. Let us know your needs and we would be happy to assist!

5. Communicate: Communication is key!

Communicate, communicate, communicate! Did we mention communicate?

Communication key ProFeeAs mentioned previously, the major complaint we have heard over the years from providers is the lack of communication between the providers and coders. This can be one of the biggest obstacles in a newly managed physician group. However, the more the coding department is open to communication, the more the department can better serve their providers and give them the appropriate reimbursement for their work. Building a level of open communication and trust takes time, particularly in a physician practice that may have been managed differently in the past prior to a merger, but it will make a world of difference to the success of your physician group practice. 

Have further questions? Feel free to contact us for more information on how our team of experts can assist in creating a strong ProFee coding department.

Vanessa Youmans

Vanessa Youmans, MA, CCS, CPC – Director OP/Profee Coding & Auditing
ProFee Top 5 tips

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YES HIM Consulting, Inc. Largo, Fl.
Office: (727) 531-3839       Fax: (727) 240-4592