When a physician visits a patient in the hospital, the hospital
captures the charges for any tests or procedures ordered by the
physician. The physician must track the charges for professional
services s/he provides to that patient during the encounter. Notes
are often jotted on index cards or scraps of paper and stuffed into
the physician's pocket, resulting in delayed or lost charges. This
can add up to a significant amount of money "left on the table."
We needed a process that made it easy to submit professional charges
and ensure that all charges were submitted.
There are two basic processes in capturing charges. First the physician
documents the charges and give the documentation to a biller. Then
the biller inputs the charges to the billing system. Each process
offers a potential return from automation:
revenue from better documentation; and,
staff expense from automating the entry process.
on the two processes simultaneously, we soon hit a roadblock on
automating the entry process. Professional charges are
input to Meditech's PRV module,
to the B/AR module, and finally
in a file which is sent to a billing vendor for cleaning and submission
could easily prepare a file for direct submission to the billing
vendor, but bypassing Meditech meant that certain internal processes
in Meditech would lack essential data, and that was unacceptable.
Scripting the data into Meditech PRV (using automation software
such as Boston
Workstation or Automate
to simulate a human user with the Meditech client software) was
also impractical, because there are enough variations in the process
to make scripting too complex to be worth the effort.
we had to give up (temporarily) on automating the entry process.
Fortunately, this was not the primary reason for undertaking the
project. Compared with the potential impact of capturing more physician
charges, saving some biller time was a "nice-to-have."
Meanwhile, the charge capture process had its own challenges. Working
first with the hospitalist group, we used a combination of existing
encounter forms and actual charge data to identify the CPT
(procedure) codes most frequently used by the hospitalists. The
same process identified the most frequently used ICD-9
(diagnosis) codes for diagnoses.
lists" of these frequently used codes were used to develop
an on-line form. However, the hospitalists quickly discovered that
they needed more flexibility with both procedure and diagnosis codes.
The paper forms allowed them to simply write in the codes that were
not on the form, but the on-line process (deliberately) did not
offer that option. We wanted the physician to make 100% of the code
an alternative to offering defined lists of codes, we tried offering
searches of the complete lists of procedure and diagnosis codes.
This quickly failed when it became painfully clear that the standard
descriptions of these codes were nearly useless for two reasons:
descriptions had arbitrary abbreviations or terminology that was
not commonly used (at least by our physicians).
physicians used shorthand descriptions of procedures or diagnoses,
but the shorthand descriptions were not included in the official
a solution, the charge capture process was doomed.
coincidence, we had just seen a presentation about a new product
which we were licensing as an add-in for the Epic outpatient EMR.
Our Epic users were also struggling to find correct diagnoses, and
the IMO add-in seemed to solve the problem.
learned that IMO had a version of their ICD-9 search that we could
integrate into our intranet application, and we moved quickly to
test and then license this application. When we hit the same problem
with searching for CPT codes, we also licensed a search for CPT
codes from the same vendor. Both applications use proprietary databases
which seem to contain all the familiar search terms used by physicians
and are very fast.
The hospitalist group was the first to adopt charge capture. The
overall charge capture form is shown below (click the partial image
below to see the full image).
the partial image above to see the full charge capture screen]
the correct patient is selected, either
with eSignout filters or by searching
for a specific patient.
the correct patient displayed, the date is
selected for which the physician wishes to input charges
(the selected date is always displayed at the bottom of this section,
as shown below). If there are notes for this
patient in eSignout, there will be an option to display those
notes (shown below).
charges have been input for a previous day, the most recent diagnoses
are offered for one-click cloning to
the selected day (shown below). Specific cloned diagnoses can easily
be removed if necessary.
find a CPT code, input the search term,
then Tab, then Enter (or click Search). CPT codes matching the search
term are listed (shown below).
"Charge"or "Description" heading to sort the
see full CPT description, hover over or click "more
each relevant CPT code and change quantity if relevant.
add modifiers, click "Modifiers"
for each selected CPT code as appropriate (second image below).
find a specific ICD-9 code, input the
search term for the first diagnosis for the encounter, then the
Tab key and Enter (or click search). ICD-9 codes matching the search
term are listed (shown below).
whether 1° Dx
Submit. The charge and diagnosis will be displayed at the top of
the screen (shown below).
sure that the correct date was selected.
add modifiers, click "Modifiers."
add Resident Participation, check the box.
see the full description of any CPT code or ICD-9 code, click
the code (see second and third images below).
the CPT code exposes or hides the description
the ICD-9 code exposes or hides the description
process is repeated for every CPT code and/or ICD-9 code for this
day for this patient.
may be modified
by the physician who submitted the charges until the charges have
been submitted to the billing system. Once charges have been submitted
to the billing system, they are flagged as "Submitted"
and no longer can be modified (shown below).
the partial image above to see the full image]
entire hospitalist group has used Charge Capture for about six
months. An analysis of the first four months of full use showed
a substantial increase in captured charges over the same period
during the prior year, even after adjusting for changes in volumes
and rates. The rate of charge submission improved from 83% to
100%, with a corresponding increase in charges for professional
services (a substantial sum when annualized).
is in the process of implementing Charge Capture, and it is expected
that the impact on revenue will be even greater than for the hospitalists.
recently asked to use the application and is just beginning to
descriptions for CPT and ICD-9 codes are fairly useless for quick
searching by clinicians.
clinicians are famously skeptical about new processes, a well-designed
bit of automation with clear benefits can be very quickly adopted.
focused on achieving the primary benefits from the project, and
find a way to sidestep issues like outdated charge procedure dictionaries
or barriers to achieving secondary goals like saving inputter
Posted 04 June 2008