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Streamline Your Revenue Cycle: Part 3

Part 3: Billing problems? Consider your charge ticket.

by Linda Martien, CPC, CPC-H, CPMA
Are you charging for every service you perform? If your practice is like most, the answer is probably “No.” Many estimates suggest a significant portion of annual practice revenue is lost because practices simply do not bill for services and procedures that providers perform.
Keep Current
The charge ticket (a.k.a. the encounter sheet or superbill) is the beginning of the revenue cycle. In a perfect world, every provider would have a certified coder follow him or her around to assist with coding for every patient. This may not be possible in the real world, but providers can have an updated charge ticket for every setting in which they work.
The key word is updated. Many practices or departments don’t take the time to update the charge ticket every year (or more often, when necessary, such as when you have a new payer contract). Yet, the charge ticket is one of the most important tools your practice or department will use. Your superbill should list current CPT® and ICD-9-CM codes to reflect the majority of the services you provide. This allows providers to communicate to the office staff and, by extension, allows office staff to communicate with payers the services being provided and why those services are necessary.
Ensure Complete Charge Capture
Charge capture means that all encounters, and all the services and procedures provided, are accounted for. The medical practitioner should use pre-numbered encounter forms for office/clinic visits and other encounters. Most practice management systems can produce customized encounter forms and can track encounters within the system. Your practice or department should insist on having editing capabilities for the encounter form(s), if they are generated from the system. This saves system support costs and allows for timely encounter form edits.
Written policies and procedures should identify who is responsible for entering and maintaining the various services and procedures on the form. To capture the diagnoses, the encounter form may include pre-coded diagnoses (usually the top 25 to 50 for the practice or department). Update the encounter form as often as necessary to reflect correct, current diagnoses, services, and procedure codes. If your practice or department can customize the encounter form on the management system, collaborate with the providers on a design that will ensure accurate information capture.
It’s important for the medical record to support diagnoses, services, and procedures, and that visit circumstances and types are marked on the encounter form (e.g., new patients versus established patients, preventive visits, consultations, etc.). Perform internal audits (five to 10 records per provider, per month, at a minimum) to compare the documentation in the medical record with what has been captured on the encounter form, and maintain the written results. Immediately share the findings from audits with providers, and offer education, as needed.
In most practices, the bulk of the services provided are captured with evaluation and management (E/M) codes. Because Medicare beneficiaries constitute a significant segment of many practices, and because Medicare-covered preventive services (and the G codes that must be used to bill for them) are growing in number, these should be included on your superbill, as should consultations codes (99241–99245 and 99251-99255) for non-Medicare patients. Teleconference consultation codes (certain HCPCS Level II G codes) may be reported to Medicare, and also should be included.
It’s more difficult to track charge capture of a medial practitioner’s non-office encounters. Inpatient and outpatient encounters at the hospital, as well as nursing home visits, account for the majority of non-office encounters. Charges can include hospital inpatient care, observation stay care, consultations, surgeries and other procedures, and test or study interpretation and reports. Work closely with the providers and personnel in the non-office setting to develop a method to capture non-office charges. Hospital computer systems can generate a provider’s surgery schedule, ancillary outpatient schedules, and inpatient census. Constant monitoring is necessary to avoid losing non-office charges.
Keep Track of All Charge Tickets
To ensure you receive all the charge tickets from your providers, supply each with a set of unique, sequentially numbered charge tickets. You can design the charge tickets to fit into a small book they can carry with them. Office staff should ensure all numbers are in sequence when the tickets are delivered. If a charge ticket is missing, staff should alert the provider. Have each provider keep a log, in which the charge ticket series for each day can be entered. That way, a missing ticket can be identified easily.
Be sure your providers are trained to use the charge tickets, to capture all billable services. You can’t expect charges to be captured accurately if providers are unclear about the purpose of the tickets. Consider vaccines, for example: Can you charge 90460-90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional… in addition to the vaccine supply? Only if the provider counsels regarding the vaccine (i.e., side effects, benefits, contraindications, etc.). If your practice dispenses vaccines regularly, your practitioners should be knowledgeable about the rules.
Electronic Superbill/Charge Ticket
Superbills are the backbone of your medical practice’s financial dealings, and any labor and cost reductions in this area can affect your future immensely. It’s no surprise that electronic superbills are something to be excited about. They’re designed to save your practice time, money, and labor. Paper superbills, still commonly used today, represent more work and require more time to enter charges for billing. Paper superbills also boast a larger margin of human error. Electronic superbills mean less guesswork as to which CPT® codes were circled, or missing partially circled codes. Bad coding equals bad superbill, and vice versa.
Make no mistake: There’s considerable money at stake with bad superbills. The American Academy of Ophthalmology’s website offers a few real life cases, including a scenario where a surgeon’s staff coded all laser treatments using the same CPT® code. The initial loss of revenue was nearly $700, but was much greater when surgeries beyond the scope of the audit were considered.
Source: “Costly Coding Errors,” American Academy of Ophthalmology
EHRs Ease Charge Capture
Proper coding with an electronic health record (EHR) means you should always have a proper (paperless) superbill. EHR templates and superbills provide the platform necessary for daily use of codes. Automating charge capture via your EHR leads to more accurate, higher levels of E/M coding. Your EHR may automatically suggest codes at the time of the patient encounter, based upon the content present in the physician’s patient progress note.
ICD-10 May Prompt You to Go Paperless
The switch to ICD-10 is looming, whereby superbills will become the standard daily code use. Electronic superbills can help you make the switch. Because ICD-10 code descriptions sometimes take up significant space on a standard letter-sized form, printing fractions of superbills will be tedious and time-consuming. Early on, in discussions about transitioning to the ICD-10 superbill, it was estimated a current two-page superbill (front and back) would require up to 20 pages with ICD-10’s expanded specificity. In fact, when going over the case of one hospital on her team, Gayl Kirkpatrick of 3M Health Information Systems Consulting Services recently noted in a Government Health IT article, “We took a two-page superbill in ICD-9 and translated that into ICD-10. It became a 48-page superbill.” Multiple page encounter forms are impractical and costly, leading some to believe ICD-10 will make the superbill obsolete. But for most, the logical choice lies in converting to an EHR.
Superbill Summary

  • Update charge tickets at least annually.
  • Perform training to staff and providers after updates to avoid errors and misunderstandings.
  • Use sequentially numbered charge tickets for each provider and each type of encounter they perform.
  • Log charge tickets for each provider as a series for each day, identify any missing charge tickets, and report to the provider.
  • Decide if modifiers should be “hard coded” (linked to the code on the charge ticket or charge master), or if they will be added manually by the coder or health information management department.
  • Start looking now at ICD-10 transition for your charge tickets.

Encourage consistent communication between the coder, data-entry, office and billing staff, and providers. Everyone should be comfortable in going to each other with questions about charges and their coding.

Linda Martien, CPC, CPC-H, CPMA, is director of reimbursement at Cytomedix, and brings her 30-plus years of experience in coding, billing, auditing, management, and consulting to the table. She is a member of the AAPC Chapter Association board of directors for 2014-2017, and is a past member and officer of the National Advisory Board. She also has held various officer positions for Columbia and Jefferson City, Missouri, local chapters.

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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