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What is Charge Capture?

Hospitalists face many challenges in their daily work. They must navigate a complex healthcare system, including working with other healthcare providers, managing administrative tasks, and complying with regulations. One overarching challenge hospitalists manage is the charge capture process.

The charge capture process can be complex and time-consuming, and hospitalists may face many challenges in completing it accurately and efficiently. Incorrect or incomplete charge capture can lead to lost revenue and compliance issues, impacting hospitalists and their institutions. On the other hand, effective charge capture can help hospitalists to provide better patient care and optimize their billing practices.

Fortunately, hospitalists can leverage technology to improve the charge capture process and overcome these barriers. Here are some common challenges in charge capturing and how to work through them.

Common Challenges in App Billing

But what is charge capture? Capture billing is a vital aspect of modern healthcare for rounding physicians that determines the financial returns on the encounters with patients they perform. If they see a patient but don’t bill for that encounter they don’t get paid and the billing happens by capturing the financial aspects of that patient visit in a way the insurance companies can evaluate.

Charting is the process of entering the necessary medical data for appropriate patient care and treatment into the facility or hospital EHR. Billing is a separate data entry system to be reimbursed for the medical services provided to patients. Both processes are extremely important in different ways but only the charge capture process ensures that providers are compensated for the care they provide. The level of compensation depends on the quality of the charge capture process used and whether there are errors or issues or missing data.

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Charge capture is typically the responsibility of hospitalists. Hospitalists must have the tools and resources to effectively document and bill for the care they provide and strong time management and analytical skills to create a workflow.

With these considerations in mind, here are some common challenges in the charge capture process.

Lack of Standardization

One challenge that hospitalists often face in the charge capture process is the lack of standardization in documentation and coding practices. Hospitalists that travel between facilities are especially vulnerable to this issue, as one hospital may have vastly different systems and protocols than another.

A lack of standardization can lead to confusion and errors, resulting in billing errors, claim denials, and potential legal issues. Hospitalists should familiarize themselves with documentation and coding protocols. Additionally, hospitalists can build a rapport with administrators to recommend changes or better understand the reasons behind the current approach.

The Complexity of Billing Codes

Another challenge is the complexity of billing codes and the need to keep up with frequent changes. Hospitalists may need more time or resources to stay up to date on these changes, which can lead to incorrect coding and the potential for lost income.

To address this issue, hospitalists can invest in software or training programs that help them accurately code and bill for their services. Choosing software that has smart ICD-10 code searching and AI-driven recommendations can help hospitalists improve billing code accuracy.

Time Constraints

Hospitalists often have limited time to complete documentation and charge capture as they focus on patient care. This can lead to incomplete or inaccurate documentation, which can impact revenue and compliance.

Hospitalists can invest in technology solutions that streamline documentation and charge capture to complete these tasks more efficiently. Creating structure around visits and taking point-of-care documentation can also help.

Consider incorporating a pre-rounding routine to review patient notes, creating bulleted summaries to keep you informed as you complete your rounds. Dedicating the first and last five minutes of your visits to updating notes can also help improve accuracy in charge capturing.

Documentation Errors

Mistakes in documentation, such as incorrect codes or missing information, put the facility, hospitalist, and patient at risk. Errors could result in care gaps, adverse medication reactions, or misdiagnoses that result in a lawsuit.

Hospitalists can implement processes for reviewing and auditing documentation to ensure that it is accurate and complete. Conducting regular self-audits will help ensure accuracy in documentation.

Electronic health records (EHR) and centralized systems help minimize errors, but following proper documentation protocols is necessary. Take time at the end of each day to review notes and make updates as needed.

Consider that deleting information from an electronic record could cause more harm than good, as the original information will be stored in the metadata. Instead, amend the notes, leaving the original information intact. Add the reason for the change and the time and date you made it.

Limited Resources

Many hospitals need more resources, including staff and budget constraints. This can make it difficult for hospitalists to dedicate sufficient time and resources to the charge capture process. While hospitalists aren’t employees of the hospital, shortages will impact their workflow.

Hospitalists can invest in their own tools to make up for the issues at the healthcare facility and learn to adjust and adapt.

Communication Breakdowns

Hospitalists may work with multiple teams and departments, and poor communication can lead to errors in the charge capture process.

To improve this, hospitalists can implement processes for sharing information and coordinating care, such as using electronic medical records or establishing clear lines of communication between care providers.

Inconsistent Billing Practices

Different hospitals may have different billing practices, leading to inconsistencies in the charge capture process. This issue falls under the same umbrella as inconsistencies in coding and submission processes.

Hospitalists can take the time to research each hospital’s approach and work with administrators to follow the desired protocol. Using software with customization metrics that can be reshaped for different facilities is also recommended for hospitalists with large caseloads.

Poor Documentation of Care

Hospitalists may not always document their care in a way that accurately reflects the services they have provided. This can lead to lost income and liability risk should a lawsuit occur. Consider the golden rule of hospital documentation: if it’s not clearly stated, it didn’t happen.

Hospitalists should create documents with other care providers in mind. Consider what they need to know to provide consistent care to a patient after you’re gone for the day. Use definitive statements and avoid speculating in your notes. Remember to provide updates on potential diagnoses ruled out by the diagnostic process.

Poor Time Management

The charge capture process may be inefficient or time-consuming, but it’s up to the hospitalist to find ways to manage this process. Leveraging technology and implementing routines and strategies can help hospitalists overcome this barrier.

Final Thoughts

Hospitalists can improve the charge capture process by addressing pain points by leveraging technology and reflecting on personal time management skills. Consider these key challenges when looking for solutions to improve the charge capture process.

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