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Healthcare today requires organizations to be very efficient in the delivery of services. The unfortunate reality is that hospitals and organizations are experiencing decreases in reimbursements, and many of these providers are faced with financial challenges that inevitably will require them to do more with less in order to stay afloat.

As a result, organizations must have sound patient care and financial and administrative processes in place. Considering the era of audit activity and historical audit findings, organizations also must relook at charge capture processes to ensure that they are sound and that services are being reported accurately in order to eliminate any potential financial risk. 

The services billed by an organization must reflect actual services provided to beneficiaries as documented in patient records. Effective charge capture practices must be in place within any organization, and they must be based on the documentation found within each patient’s medical record. It goes without saying that accurate and complete documentation practices are critical and that organizations continuously should evaluate and strive to improve documentation. Remember the saying, “if it’s not documented, it didn’t happen.”

In response to staffing cutbacks, clinicians often are required to wear multiple hats. While their primary focus always remains on providing quality clinical care to their patients, clinicians often must take on various administrative and financial responsibilities as well. This may include scheduling, registration, as well as charge capture, depending on the department. Furthermore, clinical department managers likewise not only are involved in traditional management functions (such as HR activities, department staffing, measurement of staff quality, budget preparation and maintaining the financial viability of their departments), but they often also are called upon to provide front-line patient care and get involved in some of the same administrative and financial functions their staffs are executing. 

Depending on the organization, coders are not always utilized in the assignment of the codes that ultimately are reflected on outpatient claims for services provided. This can be particularly true for hospital ancillary departments such as laboratory, radiology, cardiac catheterization, electrophysiology, pharmacy, etc. In these arenas, the clinical department staff is required to select charges from the charge description master (CDM), which has been developed to reflect items/services provided by each department. The CDM item for each item/service includes not only the charge for the service, but the associated HCPCS/CPT code and other billing elements that will be reflected on the patient claim. Therefore, the quality and accuracy of the charge capture function, provided by the coder or non-coder alike, has a direct effect on an organization’s coding and reimbursement – and, hence, the bottom line. 

Many of the RAC issues under review today relate to the appropriate reporting of services based on coding guidelines, billable units, etc. As such, organizations need to revisit charge capture practices to ensure that they are efficient and appropriate. While focus should be placed on the fundamental charge capture and reconciliation processes, department-specific education also must be provided to those involved in the processes related to coding and charging rules. 

This is particularly important in clinical areas where non-coders are involved in charge capture process. Organizations need to make sure that those individuals have a clear understanding of what each item within their department-specific CDM represents and the reporting rules surrounding each of those items. Specialty- or department-specific training should specifically identify:

  • What services can and should be billed together;
  • Which services are to be billed in multiples, and in what increment;
  • Which services are reported in specific time increments and the rules surrounding such reporting;
  • For pharmacy, billable units, wastage documentation requirements and associated acceptable billing practices; and
  • Bundling rules, or what is included in each CDM item/service that is not separately reportable.

Additionally, back-end processes to evaluate claim accuracy are imperative. Most organizations utilize a billing system to “scrub” claims before releasing them to a payer, but they often identify issues that can be traced back to specific charge capture activities. In addition to the corrective action steps needed to resolve specific claim issues, such as simply fixing the claims, organizations need to trend and analyze those issues and provide feedback directly to the charging department. This is an educational opportunity, and concrete data should be infused into the education process.

Lastly, periodic retrospective audits, or reviewing charges in comparison to the clinical documentation, should be utilized to further identify not only potential charge capture issues but potential documentation issues. These types of reviews assist in identifying improvement opportunities.

In the era of “doing more with less” and clinical department staff being required to complete a broad variety of tasks, organizations must provide support from within. Processes must be efficient, and data should be utilized to focus education initiatives. Let’s face it, no one has time anymore for general, theoretic education. Instead, where possible, education should be very specific, with the use of concrete examples. This is an opportunity to arm clinical departments with the right ammunition (background and prospective education, training through billing edits, as well as retrospective training) to ensure financial success. 

About the Author

Christina Panos is currently a Sales Engineer/ Customer Success Manager for Coding, Regulatory and Reimbursement software solutions. She has over twenty years of Revenue Cycle experience. Prior to joining Wolters Kluwer, Christina served as a Director of Patient Financial Services for West Penn Allegheny Health System (WPAHS) where she most recently had direct oversight of the multi-hospital System CDMs and charge capture initiatives.

© 2013 CCH Incorporated

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