In an era of increased demands on physicians, an often-overlooked part of the revenue cycle process is the capture of information –the type of service rendered, their appropriate codes, insurance details and any physician notes—for use in a medical claim document, known as charge capture.
Improper coding and missed charges are consequences of not having a reliable charge-capture process, which can cost a practice a good deal of revenue, or lead to errors that could have been avoided.
Christopher Maiona, MD, a senior fellow in hospital medicine and chief medical officer for PatientKeeper, which provides software applications for physicians, offers suggestions for how to improve the charge capture process.
Maiona finds that physicians and their billing staff often don't have enough education about how charge capture works, or how their particular platform works, since billing isn’t exactly taught in medical school.
“First and foremost I would advise that you understand the platform you are using for your charge capture. Speak to the folks in your clinical documentation or billing department. Understand how those funds are contributing to the care you’re providing your patients,” he says.
This might include performing billing audits on a regular basis. Maiona encourages physicians to be actively involved, or to put someone in charge of overseeing how their charge capture system works so that they are not leaving it entirely up to administrative staff.
“You want a simple, intuitive user interface. It’s there to help you,” Maiona says. If a charge capture software is clunky or complicated, it’s going to defeat the point of having it in the first place. Physicians lose enough time to the demands of their EHRs; they don’t need complications when submitting professional fees.
“In an era of physician burnout, we should do everything we can do for our physicians to make sure they have an effective or simple tool for revenue cycle management. It should not be a burden.”
Charge-capture software should submit charges at the point of service, Maiona says. If a physician or a billing person is inputting charges later in batches, such as at the end of a work day, “that might not be the best timing to effect accurate charges,” he says.
Not to mention that having administrative staff manually input clinical documentation is often “a waste of hours,” he says.
Integrate with an EHR
Perhaps most important, Maiona says, a charge capture platform “should integrate with your EHR, into the notes, pull from a physical exam and diagnoses, and take all those factors into account to determine if your billing is legitimate or if you’re leaving money on the table.”
A good charge capture system will help providers find the correct codes for charge entry at the point of service, and differentiate between patients, which increases the likelihood of getting paid correctly and in a timely manner.
“The platform should help so the physician can spend more time taking care of patients and less time worrying about the financial and administrative sides.”
Additionally, a charge-capture platform that integrates with an EHR should have the ability to pull information from patient notes, connecting the charge with the services performed, which provides backup in case of a financial audit.
Maiona says he’s also seen physicians’ improve their bottom line by ten percent simply by adding in a charge capture platform. “That’s a lot of money that you didn’t know you were missing.”