Is Your Charge Capture Process (Over) Due for a Review?

Each month, millions of dollars in supplies come into the OR and hundreds to thousands of procedures are performed. Are you confident that all of your billable supplies and procedures are being accurately captured and submitted?

Continuing decreases in reimbursement and unending increases in costs have compressed already tight surgical department operating budgets. However, demands for cost effective quality care, the latest technologies and hybrid ORs make it imperative for OR managers to ensure optimal charge capture processes are in place. If it has “been a while” since your last review and/or if your department has gone through a periop system and/or material system upgrade or conversion, you should absolutely consider conducting a charge capture review (a.k.a. “risk assessment").

We recommend conducting an annual review/assessment and quarterly chart audits. The following is an outline of a Risk Assessment process:

I.  Examine the Entire Charge Capture Process

  1. Review charge capture workflows, policies and procedures from point of care charge capture through bill submission. Areas to assess include:
    • Procedure Charges
      • CPT codes - are these captured at time of scheduling?
      • ICD-10 - what potential challenges with migration to ICD-10?
      • Time-based charges vs flat fee charges - what are charge components?  Is your algorithm for calculating time charges appropriately scaled for case complexity and/or resources required?
    • Supply Charges
      • Clinical workflows
        • Are clinicians capturing the charges?  Is additional training required?
        • How difficult is it to find correct codes? (accuracy of doctor preference cards)
      • Does the facility have Hybrid ORs (indicating that minimally invasive procedures with high dollar disposables and implants are performed)?
      • Are there software limitations (e.g. Interface data transfer - Materials Management to Surgery Item Master; Surgery to HIM; Medication Management i.e. Omnicell; Use of Bar Code and/or RFID technology)
      • Are processes still being performed on paper?
    • Charge Reconciliation Process
      • Is a daily reconciliation performed?
      • Is the reconciliation process based on auto-generated reports or is it a manual process?
    • Chart Audit
      • Conduct a detailed chart audit-top service lines/procedures; Review OP notes, OR records, charges, preference cards, claims reimbursement/denials
  2. Review the Chargemaster (CDM). Key items to look for:
    • No charge or statistical codes
    • New codes, inactive/obsolete codes, revised codes & corresponding maintenance schedule
    • Improper code assignment
    • Inconsistent pricing across departments/services
    • Use of miscellaneous codes

 II.  Evaluate Findings

  1. Summarize assessment findings and consider opportunities to eliminate
    • Multiple decentralized processes (Inadequate communication /collaboration between HIM and Surgical Services
    • Inconsistent policies and procedures
    • Missing charges, denied claims
    • Missing, inactive and/or obsolete codes
    • Poor reconciliation processes

 III.  Develop a Plan

  1. Assess the organizational impact and prioritize a plan
    • What are the urgent/immediate needs?
    • Where are the "quick wins"?
    • What needs to be put in place to ensure sustainable practices and improvements
  2. Develop a collaborative team approach (Surgical Services, IT, HIM, Finance, Materials Management)
  3. Engage end-users via participation in chart audits (errors and denials can be converted into teaching moments)
  4. Establish processes and procedures to minimize compliance risk

Time, effort and resources spent on a charge capture risk assessment = time, effort and resources “well spent”. Take charge of your surgical services reimbursement by conducting a charge capture risk assessment – especially if you have upgraded or converted to a new perioperative or material management system. Be proactive and make sure every billable dollar is captured - and captured accurately.