Practice Management Alert

No matter how many claims you send out, if your practice fails to capture all its charges, you're going to lose revenue. Physician services rendered in the hospital are a big source of missed charges. Although most practices have a system to produce charge tickets for surgeries, many lack a system for physicians to communicate to their billing departments what they did during hospital visits and consultation.
 
"Most practices have an encounter form, encounter ticket, a charge slip, a charge ticket, fee slip, or whatever they may call it that contains common codes that the physician checks off to indicate what services were rendered while seeing a patient," says Jennifer Bever, MS, a consultant with Karen Zupko & Associates Inc., a health-care consulting firm based in Chicago. "Practices have one for their offices, and one for their surgeries. But, they frequently don't have a charge ticket for their hospital visits, and that's the problem." As a result, E/M codes for inpatient, follow-up, emergency-room and consultation visits often aren't reported to the practice's billing department.
 
Without an inpatient-charge capture system, physicians who try to report their hospital charges submit random slips of paper sometimes containing indecipherable handwriting to their billing departments. "When the physicians don't have a charge ticket, they write things on Post-It notes, napkins, fact sheets from the hospital system, or labels the hospital prints that may be attached to the chart, and anything," Bever observes. Some of those bits of paper get lost, and others aren't sent to the billing department for weeks, she adds.

To solve these problems, set up a standard system to capture hospital charges, Bever advises. You can either add inpatient E/M codes to your surgical charge ticket or create a dedicated, hospital-visit charge ticket. On a hospital-visit form, include spaces for the patient's name and date of birth, place of service, date of visit, date of procedure, a list of hospital E/M codes, and space to write diagnoses. Print the charge ticket on cards that will fit in the doctor's lab-coat pocket, and ask that they be turned into the billing department regularly. "I've seen them spiral-bound so the doctor could keep track of multiple patients for multiple days for a week, and then turn in their book each Friday," Bever says. Some practices use different-colored charge-ticket cards for each hospital. Similar charge-ticket systems could be developed for physicians to capture charges during nursing-home visits.

For such charge-ticket systems to work, Bever admits, the practice has to expect that the physicians will use the cards and turn them in by a specific time. "Another problem occurs when the physicians capture all the charges but don't turn them in on time. This is especially a problem for practices in academic settings in which the physicians have clinical duties along with teaching and research responsibilities," she says. When doctors hang on to their charge tickets so long, it's possible for the billing department to miss the insurer's timely-claim-filing deadline. It's easier in managed care to miss the timely-filing deadline for hospital charges, she adds, because managed-care organizations generally have a short time in which to file claims, such as 45 days from the date of service.
 
Instead of using charge tickets or paper forms, you can recommend to your physicians that they use small handheld computers to record their hospital charges, and electronically send the data directly into the billing department, Bever suggests.
 
If your practice uses surgical notes, surgical charge tickets or inpatient-charge tickets to record services rendered in the hospital, ask the physicians to double-check them and sign off on them, advises Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a medical consulting company in Spring Lake, N.J. "Don't forget, it's the physician who is ultimately responsible for the codes that are picked," she says.
 
To determine whether you are capturing all your hospital charges, ask the hospital to fax you a census for all your physicians, Bever recommends: "You can go through the census and double-check that you have charges for all of the people the hospital says the physicians performed surgery on in the operating room, or are listed as inpatients under your physicians." If you find that a patient has been hospitalized for a week under your physician but you have no charges for that patient, discuss with the doctor what is happening with that patient and what charges have been missed. "This gives you a double check. Otherwise, how can you tell you're not capturing hospital charges without some point of comparison?" Bever asks. If your office and your hospital have Internet access, ask if the hospital will allow you to access your physician's census electronically. Then, you don't have to wait for someone in the hospital to look up the information for you and send it to you.

You can ensure that you're capturing all your charges and avoiding revenue leaks with two methods:
 
1. Update your office's encounter form. Check that the CPT and diagnosis codes on your form are accurate and up-to-date and in your billing department's computer system. A good time to review your form and system is when the new CPT codes are issued each year, Brink advises. Don't forget to update your Medicare-specific codes, and make sure your claims meet the requirements of your local Medicare carrier, she adds.
 
Make sure your encounter form is doctor-friendly and easy to use. "You want to make it efficient," she says. "You don't want to have office visits mixed in with procedures. Instead, set it up in blocks, with an area for office visits for new patients, established patients and consults. List your procedures by name alphabetically instead of by code, so the doctor doesn't have to search down a list of numbers."
 
3. Conduct prospective audits. Before you send claims for processing, take a sample of your encounter forms and pull those patient charts to see if the physician documented what was charged, and whether anything was missed, Brink suggests. The practice should develop a policy to conduct this audit regularly, e.g., weekly. "At the end of the designated day before you send out the claims, pull the records, look at the encounter form, and make sure everything is documented," she adds. "If your physicians dictate their office notes, but don't do it for a day or so, you might want to decide not to send out those claims until the doctor has dictated the notes and they can be compared to the encounter forms."