Charge Capture

Business problem
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.

What to fix
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:

• increased revenue from better documentation; and,
• reduced staff expense from automating the entry process.

Working on the two processes simultaneously, we soon hit a roadblock on automating the entry process. Professional charges are

We 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.

So 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."

Quick and easy
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.

"Short 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 selections.

As 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:

• Many descriptions had arbitrary abbreviations or terminology that was not commonly used (at least by our physicians).
• Many physicians used shorthand descriptions of procedures or diagnoses, but the shorthand descriptions were not included in the official descriptions.

Without a solution, the charge capture process was doomed.

By coincidence, we had just seen a presentation about a new product from IMO 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.

We 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.

Getting started
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).

[Click the partial image above to see the full charge capture screen]

First the correct patient is selected, either with eSignout filters or by searching for a specific patient.

With 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).

If 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.

To 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).

To 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).

Select Submit. The charge and diagnosis will be displayed at the top of the screen (shown below).

• Be sure that the correct date was selected.
• To add modifiers, click "Modifiers."
• To add Resident Participation, check the box.
• To see the full description of any CPT code or ICD-9 code, click the code (see second and third images below).

Clicking the CPT code exposes or hides the description (shown below).

Clicking the ICD-9 code exposes or hides the description (shown below).

This process is repeated for every CPT code and/or ICD-9 code for this day for this patient.

Charges 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).

[Click the partial image above to see the full image]

Outcomes

• The 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).
• Surgery 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.
• Psychiatry recently asked to use the application and is just beginning to plan implementation.

Lessons learned

• Standard descriptions for CPT and ICD-9 codes are fairly useless for quick searching by clinicians.
• Although clinicians are famously skeptical about new processes, a well-designed bit of automation with clear benefits can be very quickly adopted.
• Stay 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 time.

Posted 04 June 2008