Charge Capture Optimization: Target Five Hotspots to Boost the Bottom Line

This article is based on awebinarby William Malm, Senior Vice President of Client Strategy at Vitalware®, titled, “Charge Capture-Hotspots in Your Facility.”

TheHealthcare Financial Management Associationreports thatup to 1 percentof a health system’s net charges comes from lostcharge captureopportunities, a significant amount of money for any healthcare organization. Charge capture is the process of getting paid for the services a health system provides and is based on a health system’s master list of all billable services and associated costs, also known as thechargemasteror charge description manager (CDM).

Unfortunately, due to its complex nature, charge capture leaves much room for error. Typically, the EHR or a team member will assign a code to a specific service (e.g., a primary care visit) and then submit that as a claim for reimbursement topayers, insurance companies, orCMS. However, due to commonplace coding errors in healthcare, many claims are inaccurate, delay reimbursements, or decrease payment, negatively impacting a health system’s revenue stream.

收取费用或获得报酬的过程是企业运营的一项基本功能，尤其是在医疗保健行业，医院的利润率很低——由于COVID-19，现在甚至更低。因此，卫生系统应该投资改善电荷捕获过程，以减少泄漏，并导致更大的底线。

Improve Charge Capture Processes: Five Hotspots

With every department at a hospital directly affecting a health system’s financial state, organizations struggle to know where the lost 1 percent of revenue goes. However, there are five hot spots—areas susceptible to poor charge capture processes—that health systems can target to improve charge capture and decrease charge loss:

#1: Emergency Services

Emergency services(ES) are a loss leader in charge capture due to high volume. Patients are always the priority, meaning that providers often forget documentation and coding or leave it to the last minute, especially on a busy emergency department (ED) day.

Poor documentation also occurs in the ED when providers fail to adequately document procedures. For example, a nurse might document a laceration repair as “suture by physician” in the EHR when the charge capture actually requires more information to qualify forreimbursement例如伤口的位置、深度和大小。Toimprove this process, the charge capture team could create a laceration template in the EHR so that a nurse includes the correct information when he documents a laceration. This not only eases the burden on providers by eliminating any guesswork about sufficient laceration documentation but ensures adequate documentation for reimbursements.

Other frequent causes of lost charges in the ED include:

• Confusion around trauma activation (e.g., Did the trauma officially start in or outside of the hospital?).
• Following the CMS-defined medical coding process,Evaluation and Management Services, that doesn’t always align with the reimbursement guidelines of theOutpatient Protective Payment System.

#2: Operating Room Services

Similar to ES, poor documentation can become even more complicated with the combination of hard- and soft-coded items. For example, an item is hard coded when the CDM automatically assigns a code to a service, and an item is soft-coded when a team member manually assigns a code to a service. Unclear documentation processes (e.g., Is the item hard- or soft-coded and if soft-coded, who is responsible for assigning a code?) can lead to confusion in the operating room (OR).

To decrease confusion and improve documentation in these areas, charge capture software, such as Vitalware®VitalIntegrity™, allows teams to easily analyze charge capture within any department, such as the OR, to identify missed charges and over or under charges that have downstreamrevenueimplications.

Other areas of the OR that charge capture teams can improve include the following:

• Removing unused items (e.g., drape large sheet) from physician preference cards can save money because as much as30 percent根据经验生命值报告，列出的物品中有一部分未使用。
• Keeping up to date with new vendor model numbers andHealthcare Common Procedure Coding System(HCPCS) coding to ensure teams use the correct codes for reimbursement.
• Ensuring the devices in the OR match the implant list and have the correct identification code. For example, a clinician might charge a dual-chamber pacemaker when the implant log clearly listed the item as an automatic implantable cardioverter defibrillator pacemaker, resulting in an erroneous charge and lost revenue.

#3: Pharmacy Services

Thepharmacy众所周知，它是医疗系统最大的成本中心，也是收费制度改善可以增加收入的最大领域之一。The pharmacy has unique charge capture challenges because of its own coding convention, theNational Drug Code(NDC)是一种清洁发展机制，通常不会随着上市的新药或修订的代码而更新，其自身的收入周期必须与更大的卫生系统的收入周期同步。这些不同的收入循环导致了许多费用捕获问题，因为通常卫生系统的收入循环团队并不完全了解药房收入循环是如何工作的。

It is best practice for leaders to regularly review the pharmacy’s purchase history and what they submit to the charge master. However, most of the errors in pharmacy occur during the conversion from dispensing units to billing units (the red triangle in Figure 1, below). Many facilities use a category system where all NDC with the same HCPCS are in the same category. These categories then require a specific equation to convert the NDC dispensing units to the specific billing units. This conversion factor is a common reason for failed pharmacy charge capture.

图1:药房收入循环。

防止药房收费捕获错误的关键是确保NDC始终使用最新的HCPCS代码。Another way to avoid pharmacy charge capture errors is to leverage pharmacy charge capture software (e.g., VitalwarePharmacy Analysis) that has a low- and high-dosage range to capture billing units that are out of normal ranges for the average adult.

#4: Supply Chain and Devices

Supply chainand device charge capture is difficult because it relies on charging for the correct device with the correct HCPCS code. Team members must confirm they assign the correct code to the device, so they charge for the correct device. While this sounds simple, the manufacturer and model determine the device charge, and many manufacturers will provide a “suggested HCPCS” code. While the suggested code might be correct, team members should treat these as coding guidelines and always confirm the code.

Other examples where supply chain and device charge capture fall short include insufficient current procedural terminology (CPT) coding for devices and failing to manually document charges in the OR. The OR is the most likely area where charge capture will fail because most devices are not on a preference card, therefore, providers must manually enter the codes, leaving room for delayed submission and human error.

#5: CDM Mapping

EffectiveCDMmapping includes testing that can drive smoother charge capture processes, leading to increased savings and new financial opportunities. For example, documentation-driven charging begins in the clinical module. After documentation, the charge goes to the CDM to assign the HCPCS/CPT code and patient charge. The transition from the clinical system to the CDM occurs because the two systems are mapped. However, the mapping system is prone to problems if team members seldom review or test the maps with a new charge to ensure charges are generated correctly.

The other critical piece of CDM mapping is maintenance. Most facilities use an automated CDM software maintenance system. However, the CDM analyst usually sends the hospital department (e.g., cardiology) the report of changes, adds, deletions, and audit findings, showing that most departments lack procedural coding skill. The analyst should meet with the department leaders once a year and ensure they have a charge for all services rendered. Other areas to improve maintenance include working with departments to identify and remove zero-volume usage items that are more than 18 months past their last use.

Eliminate Charge Capture Leakage

Effective charge capture is a health system operational essential, as it generates income from services or procedures. Instead of letting charge capture fall behind other priorities, health systems should prioritize understanding the nuances of charge capture best practices to identify corrective actions and decrease charge capture leakage.

Focusing on the five hot spots—ES, OR, pharmacy, supply chain and devices, and CDM mapping—allows health systems to target loss leaders and decrease common charge capture leakage (the 1 percent of lost revenue). Implementing charge capture best practices can directly increase a health system’s earnings, putting the organization’s financial state back in the hands of hospital leaders.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. The 100-Percent Solution to Improving Healthcare’s Operating Margins
2. Healthcare Financial Transformation: Five Leading Strategies
3. 减少坏账:COVID-19期间限制风险暴露的四种策略
4. Healthcare Price Transparency: Three Opportunities for Transformation
5. Six Strategies to Navigate COVID-19 Financial Recovery for Health Systems

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