Physicians and mid-level providers, both employed and self-employed, are still dealing with financial and compliance issues. Financial and compliance risks may increase consequently. Quality measurements and costs will drive reimbursement as the industry transitions to a value-based payment paradigm. To top it off, the Government and private payers are also preparing for a tighter examination of claims. There has never been a more explicit demand for highly trained professional developers.

Coding and billing for the physician’s portion of a patient’s contact are referred to as ProFee coding or professional fee. All of the work done by the provider and all of the payments they will receive for their medical services are covered by the ProFee code.

A Few Illustrations Of Pro Fee Coding

ProFee coders provide codes to patients based on the time and work spent on them and the procedures they undergo, using the CPT and HCPCS code sets (CMS, 2019). Using the Medicare Physician Fee Schedule (CMS, 2020), the providers will earn a specific number of points, called Work Relative Value Units (WRUs), for finding the correct CPT code.

Payroll is based on total RVUs per month for some medical groups. The RVUs are calculated at the conclusion of each month, and a dollar sum is equal to the total RVU points. Based on that sum, the provider receives a reimbursement check. To summarize, the pay a provider receives is directly influenced by ProFee coding.

ProFee vs. Facility Billing Differences

The billing and reimbursement variances between ProFee and the facility must be understood before we can talk about the coding differences.

It is the personal nature of coding that sets professional fee services apart from other industries. Code-for-code, chart-for-chart - ProFee directly affects a person’s salary. Here are some examples of fee coding for professionals:

APCs vs. RVUs

It is common for APCs to be activated by the procedure code with the highest priority. A facility’s APC accuracy may be above 95%, but the actual code-for-code CPT accuracy may be below the aim of 95%. It’s possible to arrive at the same APC by selecting a procedure code that’s “in the ballpark” or by overlooking an additional process code like debridement.

As a result, the facility’s reimbursement could be directly affected if the CPT is not 100% accurate. RVU reimbursement structures are based on specific procedure codes for ProFee, though. Your providers could lose significant RVUs if a procedure code for debridement is missing or a procedure code match is incorrect.


The reimbursement of professional fees is not the same as OPPS (Outpatient Prospective Payment System), as you may have guessed by now. As a result, APC payment package rates do not apply to ProFee services.

Outpatient Code Editor

Professional fee guidelines do not make use of the Outpatient Code Editor in the same way as they do OPPS. A provider may have performed a procedure in many settings, including an inpatient environment. Hence a ProFee side coder would not receive an Inpatient Only Procedure change.

NCCI Edits vs. NCCI Manual

In many cases, coding employees are informed of NCCI revisions for CPT codes that cannot be billed together by their encoder. However, it’s essential to read the NCCI manual to learn about the rest of its content. The NCCI manual is sometimes compared to tax law documents since it contains thick information that must be memorized by coders. So professional fee coders prefer to specialize, whereas facility coders tend to focus on what’s next on their list when coding.

Medically Unlikely Edits (MUEs)

From the facility’s perspective, Medically Unlikely Edits (MUEs) are a comparable idea. According to the CMS, an HCPCS/CPT code’s MUE is the maximum number of units of service a provider is required to record for a single beneficiary on a single date of service. Aside from the facility and professional fee sides of invoicing, Medically Unlikely Edits differ.

Global Surgery Edits

The concept of Global Surgery Edits is distinct from that of the hospital. All of a surgeon’s usual services are included in the “global surgical package” or “global surgery,” as defined by the CMS. The preoperative, intraoperative, and postoperative services routinely performed by the surgeon or by members of the same group with the same specialization” are included in the Medicare payment for a surgical treatment. That is to say, surgical CPT codes may have a worldwide term during which all necessary treatments may not be reimbursed individually. If the surgical code includes a 90-day worldwide surgery term, for example, a standard postoperative visit may be included in the package. An important point to keep in mind is that each CPT code has its own global surgical period based on the Medicare Physician Fee Schedule.

Status Indicators

OPPS uses status indications, so you may already be familiar with some of the status indicators. To put it another way, in the case of status T per OPPS, the code is reimbursable individually, with a separate APC payment. This code is only paid when no additional services receivable under the physician fee schedule are invoiced on the same date by the same provider, as shown by Professional Fee Status Indicator T. Services payable under the physician fee schedule provided on the same date are bundled with physician services for which payment is given if they are billed by the same provider.


In spite of the fact that numerous modifiers can be used for both professional fee and facility CPT procedure coding, certain modifiers are only utilized for professional fee coding, while others are only utilized for facility CPT process coding. For example, the facility side uses modifiers 73 and 74, while ProFee would use modifications 52 or 53. Additionally, E/M-specific modifiers, such as modifier 24, might be used in this context.

Consequences of improper code assignments 

Reimbursement for ProFee coding is a 1-for-1 code match, but reimbursement for facility coding is done through APC groups. When it comes to coding and billing, there are a few parallels and variances between how facilities and providers do it.

Because of the 1-for-1 match in ProFee code, there is virtually no opportunity for error. Consequently, healthcare providers bear the expense of any errors or discrepancies in coding.