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Advanced Charge Capture: Clinical to Charge System Reconciliation

Correctly generating charges is one of the most important aspects of a hospital’s financial health, and today’s reality of complex clinical to charge system linkages in modern EHR platforms means that the integrity of your hospital’s charges is no longer a function of only the chargemaster. In this educational webinar, Craneware’s Elaine Dunn will outline an approach to reconciling your hospital’s clinical and charge system linkages, validating the accuracy between an order and what is ultimately reported on the patient account, and identifying common errors in your clinical system and CDM that prevent charge integrity.

Frequently Asked Questions:

Question:
Are there any best practice methods for charge capture/audit selection? Would you recommend highest volume/revenue items or would you incorporate compliance errors as well?

Answer:
If your audit plan is based on sample only – it is important to get a stratified sample across service lines and account types. This would include specifically targeting high volume and high dollar services, but layering that in with a statistically significant randomized sample with encounter selected for each account type. However, this type of audit is highly prone to not having a significant ROI and a higher probability that an issue will not be detected. You should consider a tool that will process a high volume of accounts and flag the potential errors for review. This increases the ability to identify a true revenue opportunity while minimizing the resources utilized.

Question:
Do you have a sample CDM request form you could share?

Answer:
Each CDM can have unique attributes that need addressed by the request process. Below are a set of minimum requirements for a request. You should add to this for your unique system needs. For more information about creating CDM policies, I recommend watching my colleague Katie Hartman’s presentation “CDM Policies 101”.

  • Required data elements for a CDM request should include:
    • Action requested (add, deactivation, modification)
    • Name and title of person making the request
    • Department name and number
    • Charge description
    • Description of item
      • If pharmacy or supply should include product details
    • HCPCS code (if known)
    • Revenue code (this is primarily for a placeholder – the actual revenue code used should be assigned by the CDM team)
    • Price (if priced by submitting department)
    • Cost (specific to supplies if procedures not costed by submitting stakeholder)
    • Clinical system that will be used to charge
    • Clinical system build details (preference list, department, etc.)
    • Clinical system descriptions

Question:
Do you have a sample charge capture policy that could be shared?

Answer:
Policies should be customized to your unique organization’s needs. I would try to avoid boiler plate policies where possible as you want that policy to truly direct your business operations, which are not going to be a one size fits all. Below are elements that should be addressed by your policy, with the details driven by your specific business needs.

  • Charge Capture Definitions
    • General statements about the organization’s commitment to timely, accurate, and compliance charging
    • What items are separately chargeable (i.e. what is included in room and board rate versus charged additionally)
  • Clinical department responsibilities to include:
    • Expectations around charge reconciliation (who is responsible, how often they will reconcile charges and what specifically they are reconciling (i.e. schedule to charges).
    • Timeline requirements for enter charges
    • Team education requirements for charging
    • Engagement expectations in responding to charge related questions from revenue integrity
    • Expectations that clinical department conduct charge audits to confirm their capture and reconciliation practices are following policy
  • Revenue Integrity responsibilities to include:
    • Expectations around maintaining a complete and compliant CDM
    • Expectations around what support will be provided to the clinical departments regarding charge capture questions
    • Expectations around conducting routine charge audits
    • Expectations around education for clinical departments

Question:
Do you have any advice on setting up exploding codes?

Answer:
We define exploding codes as a set of charges that live in the CDM or patient accounting system in which one master code resides in the clinical system, but once that is entered and passes to the billing system, it will drop 2 or more charge codes. The use of explode codes can assist in the charge capture process since only one action is needed to capture multiple services. However, it is difficult in most systems to keep visibility into the “child” codes and maintain those as needed. Some recommendations on the use of explode codes include:

  • Create strict rules around when an explode can be used – for example only when the charge relationship exists on 100% of the patients 100% of the time.
  • Maintain an approved list of charge codes with the code details.
  • Require a more extensive “business case” for approval beyond a normal CDM request in that the workflow should be reviewed to determine if use of the code really facilitates charge capture and is there an alternate workflow that would accomplish the same end result in the clinical system.
  • Ensure your CDM management tool allows for visibility into the child codes aligned with the master or parent code.
  • Update your CDM management policy and task lists to list review of explode codes with your annual CDM updates.
  • Request from IT a report that would show volume of the master code utilization so the same deactivation process can be followed for non-usage as regular CDM lines.

Question:
Do you have any advice on setting up exploding codes?

Answer:
This is a complex decision that involves clinical operations, IT, finance, compliance, and revenue integrity. Many times system limitations or current workflow may limit your organization to one decision to another. From strictly a revenue integrity and compliance perspective, charging on administration has a lower error rate since we are charging at the point we know the patient will receive that medication. Charging on dispense has to be accompanied by a strict reconciliation process so any un-administered doses are credited back to the patient’s account. If you are switching from charge on dispense to administration, you should review charges carefully and the potential impact of that change on revenue posting. It is recommended this be a collaborative review process with all of the stakeholders listed.

Question:
Is there any software vendors that offer tools to reconcile clinical system charge triggers?

Answer:
The best method for reviewing this is to incorporate it into your clinical system to CDM reconciliation process and the system used to maintain that information. In the case of Craneware, we would leverage our Chargemaster Management Software to assist with the relationship visibility between the clinical systems and your CDM. The accuracy of the charging process (i.e. missing charges) can validated through your charge capture tool.

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