German Practice Management FHIR Profiles (R4) - Local Development build (v0.49.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

International Interoperability

International Interoperability

This page documents how de.cognovis.fhir.praxis concepts map to international FHIR standards. German ambulatory practice management has many domain-specific regulatory structures with no direct international equivalent. Where possible, this IG reuses standard R4 resources and patterns, making international alignment explicit.

Mapping Overview

Domain	fhir-praxis-de Approach	International Basis	Notes
Queue Management	Encounter extensions	R5 Encounter.subjectStatus backport	Partial mapping; queue position has no standard
RLV Budget	Contract resource	Loosely inspired by Da Vinci VBPR	Fundamentally different concept
Honorarbescheid	PaymentReconciliation + ClaimResponse	X12 835 remittance advice concept	German-specific: quarterly, KV corrections
GOÄ Private Billing	Claim.item.factor + ChargeItemDefinition	Native FHIR pricing	Factor range 1.0–3.5 is DE-specific
PVS / Fremdabrechnung	Coverage.billing-assignment + Claim.payee	Native Claim.payee third-party biller pattern	German-specific factoring semantics and coverage-scoped consent
AI Provenance	Provenance with Device agent	FHIR Provenance (R4)	Extends with EU AI Act Art. 50 specifics
Zeitbudget	ChargeItemDefinition extension	No international equivalent	German KBV regulatory concept
KV Benchmark	Basic resource extensions	No international equivalent	German KV regulatory concept
Accounts Receivable	Account extensions	FHIR Account (R4)	Dunning levels (Mahnstufe) are DE-specific
Condition Extensions	Condition extensions	FHIR Condition (R4)	Dauerdiagnose has no direct equivalent

Detailed Mapping

Queue Management (Warteraum)

International basis: FHIR R5 introduces Encounter.subjectStatus with values like arrived, triaged, and receiving-care to track patient flow. This IG backports that concept to R4 via extensions.

What we add:

• ArrivalTimeExt — Precise arrival timestamp (R5 has the status but not a discrete timestamp)
• EncounterCalledExt — Timestamp when the patient is called into the treatment room

No international standard exists for queue position or waiting room management beyond the R5 subject status concept. Our extensions fill this gap for German practice workflows.

RLV Budget (Regelleistungsvolumen)

International basis: The Da Vinci Value-Based Performance Reporting (VBPR) IG uses similar contract-based patterns for value-based care agreements. However, the German RLV is fundamentally different: it represents a capitation cap (Mengensteuerung) imposed by the KV on individual physicians, not a quality-based reporting framework.

What we model:

• Contract resource for the budget allocation (RLV-Zuweisung)
• Extensions for Fallwert, zugewiesenes Budget, Entbudgetierung
• Separate QZV (qualifikationsgebundene Zusatzvolumina) tracking

No international equivalent exists for physician-level capitation budgets imposed by regional payer associations. This is a unique feature of the German KV system.

Honorarbescheid (Remittance)

International basis: The concept maps to the US X12 835 remittance advice — a payer's explanation of payment for submitted claims. FHIR models this with PaymentReconciliation (normative in R4) and ClaimResponse.

German specifics:

• Quarterly batch processing — Unlike US real-time adjudication, German KV payments are reconciled per quarter
• KV correction codes (CorrectionRuleCS) — Richtigstellungen with codes like UV (Volumenüberschreitung), PL (Plausibilitätsprüfung), WP (Wirtschaftlichkeitsprüfung) that have no international equivalent
• BSNR-level aggregation — Payments are tied to the Betriebsstättennummer, not individual claims

GOÄ Private Billing (Gebührenordnung für Ärzte)

International basis: FHIR natively supports fee-schedule billing through:

• Claim.item.factor for multipliers
• ChargeItemDefinition.priceComponent for base pricing
• Claim.item.unitPrice for calculated amounts

German specifics:

• Factor range 1.0–3.5 — The GOÄ Steigerungsfaktor system is unique to Germany
• Schwellenwert 2.3 — Factors above 2.3x require written justification (Begründungspflicht)
• Höchstsatz 3.5 — Maximum factor, exceeding requires patient consent
• Our MultiplierMin/Default/MaxExt extensions on ChargeItemDefinition encode these regulatory boundaries

The multiplier pattern itself maps well to Claim.item.factor in international FHIR — only the specific regulatory rules around the factor values are DE-specific.

PVS / Fremdabrechnung (External Billing Service)

International basis: FHIR R4 already models a third-party biller through Claim.payee. The interoperable pattern is:

• Claim.payee.type = other
• Claim.payee.party -> Organization

This is sufficient for the generic "someone else receives payment" case and aligns well with US revenue-cycle-management and billing-service workflows.

What we add for Germany:

• Coverage.billing-assignment extension — The routing decision lives on the selected Coverage, not on Patient or Encounter
• PvsOrganizationTypeCS#pvs — Additional coding on Organization.type to mark the referenced organization as a PVS / billing service
• Coverage-scoped consent pattern — Consent.provision.purpose = HPAYMT, Consent.provision.data.reference -> Coverage, Consent.provision.actor.reference -> Organization(PVS)

Why the extension is Coverage-scoped: A single patient can have multiple payer relationships at the same time (e.g. GKV, PKV Zusatzversicherung, Selbstzahler). Routing to a PVS is a property of the concrete coverage relationship, not a patient-wide default.

Runtime mapping: During claim generation, an adapter can inspect the selected Coverage. If billing-assignment is present, the referenced organization is mapped to Claim.payee.party and Claim.payee.type is set to other. If the extension is absent, the claim stays in the direct-pay/default flow.

AI Provenance (EU AI Act)

International basis: FHIR Provenance with a Device agent representing the AI system is the natural model. The W3C PROV-O ontology underlies FHIR Provenance, making it internationally compatible.

What we add for EU AI Act Art. 50:

• AiGeneratedExt — Classifies content as AI-generated vs. AI-assisted (AiProvenanceCS)
• AiModelExt — Model version identifier
• AiPurposeExt — Purpose of AI usage
• HumanReviewedExt / HumanReviewerExt / HumanReviewTimestampExt — Human-in-the-loop review tracking

No international FHIR IG currently standardizes AI provenance tracking. As EU AI Act enforcement begins, we expect international alignment efforts. Our approach is designed to be forward-compatible with emerging standards.

Zeitbudget (KBV Prüfzeit)

No international equivalent. The KBV Prüfzeit is a German regulatory concept where each EBM billing code has an assigned time in minutes. The sum of Prüfzeiten per physician per quarter must not exceed a plausibility threshold.

Our ZeitbudgetMaxMinutenExt and ZeitbudgetAbrechnungskreiseExt model this on ChargeItemDefinition. There is no international FHIR concept for regulatory time budgets tied to billing codes.

KV Benchmark (Fachgruppen-Durchschnittswerte)

No international equivalent. KV benchmark data provides average billing volumes, case counts, and reimbursement rates by medical specialty group (Fachgruppe) and KV region. This data is published quarterly by each KV and used for internal practice controlling.

We model this on the Basic resource since there is no natural FHIR resource for statistical benchmark data. The closest international concept would be quality measure reporting (e.g., US HEDIS), but the German KV benchmark is purely financial/volume-based, not quality-based.

Accounts Receivable (Offene Posten)

International basis: The FHIR Account resource is internationally defined and covers patient accounts, billing accounts, and financial tracking.

German specifics:

• Mahnstufe (dunning level 0–3) — Structured escalation process for overdue invoices
• Mahnsperre — Ability to block dunning for specific accounts
• Mahngebühr — Dunning fees per level

The dunning workflow is not unique to Germany but the specific Mahnstufen structure and associated fees follow German commercial law (BGB/HGB) conventions.

Condition Extensions (Diagnosen)

Dauerdiagnose (permanent diagnosis): A German concept marking a diagnosis as permanently relevant across quarters. FHIR Condition.clinicalStatus = active is similar but not identical — a Dauerdiagnose is specifically an administrative marker that ensures the diagnosis appears on every Abrechnungsschein without re-entry. The clinical status may change independently.

DiagnoseSeite (laterality): The custom DiagnoseSeiteExt was removed in v0.31.0 in favour of http://fhir.de/StructureDefinition/seitenlokalisation from de.basisprofil.r4. The DiagnoseSeiteCS / DiagnoseSeiteVS vocabulary assets are retained for mapping purposes and remain mappable to SNOMED CT laterality qualifiers (7771000 left, 24028007 right, 51440002 bilateral).