Set teams up for charge capture success by refining roles
Managing charge capture in a multi-hospital system that spans a variety of service lines and charges can prove to be a daunting task both in terms of ensuring claims are accurate and ensuring team members are well versed in each service line and charge type. While some health systems may train staff across all areas of charge capture, Saint Luke’s Health System in Kansas City, Missouri, opted to assign each team member a role in which they could become experts.
“We found that having that many people across a big system, and trying to keep them educated and current didn’t make a whole lot of sense from an efficiency and revenue maintenance standpoint,” says Karen Taylor, RN, BSN, MHA, director of revenue integrity at Saint Luke's Health System. “We found it was more successful to have a small cluster of staff where this was their specialty.”
In the past, clinical and nonclinical employees across facilities with varying degrees of experience in service lines, charge capture, and coding were responsible for entering and reviewing charges. Given that Saint Luke’s is comprised of 10 hospital campuses and offers home care, hospital, behavioral health, and practice services, the idea of having a broad range of staff members involved in charge capture and charge audit proved inefficient. Ensuring that all staff members who worked with charges were educated on the nuances of their roles and were billing appropriate charges presented a challenge, says Taylor.
To ease the burden created by having too many cooks in the charge capture kitchen, the health system tasked a charge audit team of 16 charge audit nurse specialists and four charge analysts to review medical records and accurately enter charges under the direction of a manager. The health system also employs a charge management team with representatives across the its facilities. “We felt it was important to have a small cluster of staff who knew that this was their job and their specialty,” says Taylor, who oversees both teams. After rolling out this model in its hospitals, Saint Luke’s determined it was well suited for its physician practices as well and implemented the same process for those locations.
Because of their clinical backgrounds, the charge audit nurse specialists can identify ways incomplete medical record documentation can impact charge capture. They relay this information to a charge management team who then works with clinicians to improve documentation to ensure accurate charge capture for services provided. “We found it much easier to have a concentrated few,” says Taylor. “We have better accuracy and better charge capture that way.”
Taylor’s staff of charge audit nurse specialists have five days post-discharge to review documentation for 100% of records for specific departments, although she encourages the team to complete their work before the claim drops on day five. The team is typically looking at the medical record documentation to accurately charge ED level of care, facility charges, and procedures, says Taylor. Many of the services documented in the medical records are assigned charges that are hard coded in the chargemaster before the record is turned over to the coding team for review. “We enter the charge but the CPT® code is added after the coders review the record,” she says. For example, after the charge audit team enters the charge for performing a laceration repair in the ED, coders are called upon to use their expertise to assign the appropriate CPT code for the length and depth of the laceration needing repair.
The charge audit analysts who round out the charge audit team do not come from clinical backgrounds but have the expertise needed to perform charge capture tasks that are not related to clinical decision-making. The medical record review completed by charge audit team is divided up by department, such as ED or infusion therapy, says Taylor.
The charge management team works with clinical departments to update service lines and educate departments on chare updates. Each facility across the health system has an on-site charge management analyst who acts as a liaison with the CFO. Each member of the charge management team is assigned a designated service line for which he or she is responsible regardless of the facility he or she is actively working in.
“Charge management analysts are experts in Medicare regulations and requirements for support documentation and billing,” says Taylor. “They frequently collaborate with not only the clinic departments in their service lines, but also billing, utilization review, care progression, managed care, compliance, and IT.”
The charge management team is involved in the development of new procedures and service lines to determine reimbursement potential and charging requirements, and builds and maintains the consolidated chargemaster and pricing for the entire system.
“Even though they may be at one hospital, if their service line is surgery, they work with all the surgery managers at each hospital,” says Taylor. “It’s better to have folks that are well versed in a few service lines than trying to have everybody versed in every service line at the hospital they’re at.”
The two teams in the revenue integrity department work together and in collaboration with others to optimize gross revenue for the hospitals. This centralized approach enhances communication, maintains efficiencies, and identifies areas for improvement in a timelier manner, says Taylor.
The revenue integrity teams continue to grow and improve their processes. An internal auditor was recently added to preform annual charge reviews of each department to annually validate that staff continue to perform as expected and to identify areas for re-education or improved processes. “I foresee not only increased internal proactive audits but expansion in the area of denials management,” says Taylor.
Whether part of a large health system or a single hospital, all facilities can benefit from development of a core group that are the experts in chargemaster and charge capture. “The revenue integrity team can improve efficiencies within clinical departments by assuming the charge capture role, collaborating with IT services to automate charging in some departments, and improving gross revenues by leading ongoing process improvement,” says Taylor