Charge Capturing. Presented By: Edvernor Burney Chart Audit Manager Encino-Tarzana Regional Medical Center

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1 Charge Capturing Presented By: Edvernor Burney Chart Audit Manager Encino-Tarzana Regional Medical Center Diana Milan, MBA Business Manager, ED/Perioperative & Cardiology Services St. Vincent Medical Center 1

2 Charge Capturing Overview Tools Staffing CDM Documentation Conclusion 2

3 - Overview What is Charge Capturing? Definition Compliance 3

4 - Tools Facility Charging Policies and Procedures Facility Reports Chart Audit Committee Revenue Cycle Meetings Websites (CMS, Vendor) Organizational Support 4

5 Facility Reports Department Revenue APC Reports Charge Capture Report Daily Posted Revenue Late Charge Report Point of Service Report 5

6 Chart Audit Committee Chart Audit Committee Structure Chief Financial Officer Business Office Manager Medical Auditor Department Directors from Nursing and other ancillary departments. Representatives from other departments (ICU, Med/Surg Nursing, Medical Records, Registration, Emergency Room, etc.) should be requested to attend as problems are identified in those areas 6

7 Chart Audit Committee Chart Audit Committee Responsibilities Analyze the summarized concurrent audit findings presented by the Medical Billing Auditor Identify departments showing a trend of overcharges, undercharges, and late charges Discuss the possible reasons why the over and under charges are occurring; i.e., failure to properly document services, failure to process credits, failure to accurately capture charges, incomplete documentation Discuss ideas for corrective action to be taken by the departments with excessive errors. Department managers are responsible for establishing control mechanisms to ensure timely, accurate charging and documentation of services rendered 7

8 Hospital Revenue Cycle 8

9 CMS Website 9

10 CDM Charge Description Master Maintenance Coordination Errors 10

11 - Staffing Chart Auditors APC Coordinators Concurrent Quality Control Department Managers CDM Coordinators 11

12 - Staffing Revenue Management Department Charge Master Coordinator Define what is chargeable - policy Auditors Internal Medicare/MediCal Commercial Database of Information - Analyst Track dollars missed and how it translated into actual Net Revenue Identify trends for re-education of staff 12

13 Chart Auditor Job Description Assists and coordinates analysis of charts and performs focus reviews to support Performance Improvement and regulatory Activities of hospital. Services as a Consultant to Medical Staff Committees and Department Managers. 13

14 Chart Auditor Job Requirements Must be flexible to handle a variable workload, frequent work interruptions, deadlines, priority changes and multiple opinions/viewpoints. Must be able to deal effectively with management, administration, medical staff and ancillary departments. Participates in peer groups as necessary to keep current with Performance Improvement and regulatory standards. 14

15 Chart Auditor Qualifications Minimum Education: Bachelors degree in health care related field. Must have working knowledge of The Joint Commission and Department of Health Standards. Education and experience in statistical concepts, data management, variance tracking and analysis. Required Registry or License. Professional Nursing (RN) or related health care field. Minimum Experience: Performance Improvement experience of 3 years. 15

16 Documentation Facility Policies and Procedures Clinical Quality Management Assessment Utilization Management Risk Management Inpatient versus Outpatient 16

17 Documentation Continuation MD Orders Telephone Written Nursing Documentation Chart Content 17

18 Charge Capture Policy and Procedure Purpose To confirm that all patients scheduled were accounted for, procedures provided were charged and all charges entered into the department system transfer over to the billing system in a timely manner in the Surgery Information System. In order to accomplish this, a reconciliation and timely charge capture process should be performed, using the following procedures. 18

19 Charge Capture Policy and Procedure Policy It is the policy to reconcile charges applied to an account and make sure that the charges are captured within 3 business days after the patient is discharged. 19

20 Charge Capture Policy and Procedure Procedure Reconciliation process: Start running reports After this report is reconciled then run the Access Database and run query reports After validating data, save report to excel and print out Patient Name or OR Time Take document and make sure that intra-op has proper documentation of wasted items with reasons 20

21 Charge Capture Policy and Procedure Procedure Continuation If changed then reprint and send to Medical Records Run reports Reconcile with 3 reports: Error Report Surgery Interface Charge Error List Charge Interface Report 21

22 What do you need to get started? Identify key players Who are the people posting charges in the departments Do they know what reports are available? Educate compliance and what is hospital policy of what is chargeable Get Managed Care Manager/Director involved 22

23 Conclusion Questions? Questions? Questions? 23

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