What do you know about the charge capture process in medical billing? Your healthcare practice can lose a lot of money due to unbilled procedures. From routine office visits to complex services, insurance companies require a record of everything. Charge capture is just that! It protects your revenue and minimizes your losses.
With the rising cost of healthcare, tight operating budgets, and increasing scrutiny from payers, poor billing practices can be quite damaging. Did you know that an average practice loses 1% of its revenue due to charge capture errors? We don’t want you to hurt your bottom line! That’s why we are here to help you understand the basics of this process, including how it works and the best practices for improvement.
What is Charge Capture in Medical Billing?
Want to get paid for your services? Accurately capture all the charges! Charge capture is a significant billing process. It involves accurately recording all provided services—such as surgeries, medications, tests, and supplies—to receive proper reimbursements. Moreover, it also includes collecting relevant patient information, like demographics and insurance coverage. Billing teams then use this information to generate and file accurate claims.
In simple words, healthcare providers use charge capture to take advantage of every revenue opportunity. However, this process is not just about securing financial stability; it is also important for maintaining compliance, transparency, and integrity. In short, we can say that this process is the backbone of your revenue cycle.
How Does Charge Capture Work?
The only way to improve any process is to understand how it works. Charge capture in healthcare allows doctors to record and bill all services. But how do they do that? They follow these four steps:
Interaction with Patients
The process begins with the initial patient-doctor interaction. Any time you spend on a patient should be compensated, whether an email, a telemedicine interaction, or purely an office visit. This takes us to the next step:
Documenting the Provided Services
Healthcare providers record every service, procedure, or treatment provided to the patient in the EHR system. This includes lab tests, imaging, surgeries, telemedicine sessions, and office visits. While it is quite easy to document tangible processes, you might have one confusion: how to note down E/M services? The answer is quite simple!
You should jot down everything that happens during the office visit or virtual consultation session, including details about the physical examination, the duration of the visit, and diagnoses. You can later enter these details into the patient’s record.
Assigning Appropriate Codes
Medical coders then apply the appropriate ICD-10, CPT, or HCPCS codes to documented services. In simple terms, they convert them into standardized codes to speed up the approval and reimbursement process.
Reviewing Charges
Validation is the most important step in the charge capturing. Billing teams or other clinical staff recheck captured charges for accuracy. They also review documentation and codes to avoid basic mistakes, like incomplete records or inaccurate codes, which can lead to underpayments.
After validation, medical coders translate these standardized codes into billable charges. In simple words, the process moves into the charge entry phase. Keep in mind that while many professionals confuse charge capture with charge entry, they are two different processes in revenue cycle management (RCM).
Difference Between Charge Capture & Charge Entry
Charge capture is the initial part of the RCM. It refers to recording and tracking all billable services. On the other hand, charge entry is the subsequent step. It involves entering captured charges into the practice management software.
During this process, a medical biller reviews the fee schedule for each billing code to enter the correct associated amount in the system. However, manual entry is always prone to human errors. Therefore, many healthcare practices utilize specialized software to automate the process.
Charge Capture Best Practices
As we said earlier, charge capture is an essential part of medical billing. However, many healthcare providers and practices struggle to capture billable services for several reasons. Lack of standardization and shortage of staff often make it challenging to maintain the flow of information. Want to improve your charge capture process? Simply implement these practices!
Use Specialized Technology
Technology can help you in more than one way. Let’s be real! Handwritten notes can have many mistakes and can get lost quite easily. Therefore, you should integrate your EHR into the charge capture workflow to reduce human errors. In addition to increasing your administrative and clinical efficiency, EHRs can reduce errors during charge capturing.
You can also find many specialized charge capture software online. Our advice? Invest in a reliable option and record important details on your smartphone.
Follow Standardized Documentation Practices
A healthcare organization has many departments and people. So, how can you reduce documentation mistakes? Standardize the entire process. Simply implement a consistent documentation format across your entire practice. This will not only improve your billing accuracy, but it will also allow healthcare providers to capture all the relevant services and procedures.
Conduct Regular Audits
Auditing can help you identify potential charge capture errors. Therefore, you should conduct periodic audits to find the hidden causes of revenue leakage. This may include duplicate entries, outdated patient information, missing information, or incorrect codes.
Educate Your Staff
How many times have you heard that knowledge is power? It is also true in the case of charge capture. Do not rely on a few team members to handle everything. The best proactive approach is to train everyone, including physicians and clinical staff, on the importance of this process.
Educate every person on documentation requirements and payer-specific guidelines to reduce missed or delayed charges.
Simplify Your Charge Capture Process with MediBillMD
Don’t have the time to record and enter all charges? You can trust MediBillMD to be your charge capture specialist. We understand that a high volume of patients, emergencies, and staff shortages may bar you from recording and translating every service on time. Instead of purely relying on your memory to document and bill every procedure or medication, let a professional handle everything.
At MediBillMD, we help you collect your rightful reimbursements. We become a part of your charge capture process and offer charge entry services to ensure error-free and accurate claim submission.
