Definition
Professional billing covers the work of individual practitioners such as physicians, nurse practitioners, and therapists. Claims use the CMS-1500 paper form or the 837P electronic transaction. Each claim lists procedure codes, place of service codes, and the rendering provider’s National Provider Identifier (NPI).
Why it matters
When a physician works in a hospital, the professional claim and the facility claim are separate. Each needs the right form, place of service, and modifiers such as 26 for the professional component. A professional service sent on an institutional claim will be rejected.
Example
A cardiologist reads an echocardiogram performed at the hospital. The group bills the interpretation on an 837P with modifier 26, and the hospital bills the technical part on an 837I.