Improving charge-capture in the physician office

You want to be sure you don’t miss ancillaries, such as lab and X-rays. Rule 1, decide who’s responsible for noting charges. If it’s your physician(s), instruct the doctor either to circle the item on your encounter form or to write it down if it’s not a common procedure in your office. Failure to note the services constitute the chief cause for lost of revenue among physician practices.

You may instruct a nurse to double-check whether the physician has noted everything that was done to a patient. Be sure you account for every encounter form used each day. Your computer system probably even can offer you a warning, to flag any encounter forms that don’t have corresponding charges in your system. If not, print out a report at the end of each day of any encounter forms that lack charges.

Run a tape of all charges listed and line them up to the daily report to make sure your charges match. A similar report by CPT code may be too difficult to use because of all the numbers.

Finally, make sure your encounter form includes all E/M codes for each category. Charges are often missed due to a failure to include appropriate CPT codes on the superbill. If it's not there, how can you bill it? Also, the HHS Office of Inspector General has cited practices that only, for example, give physicians the highest paying E/M codes to select.