Wiki Charge Capture

[becka95]

I work for a multi-specialty trauma group and we are struggling with our hospital charge capture. We have part of our practice where the phyisicans accept the responsibility to hand over their charge slips for the patients that they see in the hospital. The other part of the practice does not. They feel that a coder should go through the hospital and pull the patient charts and code on the floor daily and capture the charges then. I do not have the staff that can do this. As it is we are already short staffed and have no approval to hire anyone.

I also get a census daily that is computer generated but that relies on the hospital staff to put in the request for the consult into the computer system and there are many times this is not done correctly.

I am looking to see how other people handle their charge capture. You can send me an email at rebecca.almquist@cmchealthsys.org

Thanks!

 

[bran1120]

I manage the practice for our hospital's trauma director. I use his daily census sheet to begin making an encounter form for each patient who is new to the list that day. The trauma patients are a little different since these patients come in through the ED and may or may not be admitted to the hospital so may or may not make his daily census sheets. A patient who is seen in the ED at midnight and discharged before 7am would be virtually impossible to capture without something from a physician indicating that patient had been seen.

My surgeon uses his copy of the daily census to indicate which patients he has seen, which have been taken to the OR, which have been discharged, etc. He turns these in to me usually on a weekly basis. Without the physician turning the sheets in to the office staff there is a good possibility that you could be missing visits.

Also, depending upon your particular hospital's bylaws/regulations, your office staff may not be allowed to go to the hospital floors to pull the info themselves. From my perspective, the best source of visit information is always from the physician as they are the ones who actually know what's happened with each patient.