It can be quite challenging for medical practices today to maintain revenue, let alone increase profits. Practices have had to become creative in developing ways to increase patient volume while decreasing fee schedules and expenses. It is imperative to seize any revenue opportunities available, and one method to doing this is an effective charge capture process.

On the surface, the charge capture process seems simple. So why do hospitals and physicians have so many problems capturing charges? After all, we know the work we do and we certainly want to get paid for that work. Sounds easy enough, right? Wrong. And it’s probably safe to say that slipups are due to human error. With limited time treating patients, managing our business, visiting so many different hospitals, maintaining team communication and productivity…how can you blame us? Mistakes are bound to happen and missed charges are nearly inevitable.

It’s all too common for hospitals and physicians to miss charges for all services provided, or overlook unbilled encounters.

Long before computers and current software technology, there was the archaic paper charge capture. In a nutshell, this tedious charge capture process consisted of something that went like this:

  • Using billing sheets or cards the doctor writes down the patient’s name and date of service
  • The doctor would scan through a long mental diagnosis list, write it in and describe what it was that they did without providing a code or check related boxes of what transpired with the patient
  • The doctor was responsible for physically handing in these charge capture sheets

Let’s breakdown the problems, noticing opportunities for missed revenue, with a paper charge capture:

  • Doctors are working in a vacuum. We are unable to share patient info and diagnosis codes with other doctors rounding on the same patient.
  • Demographics are often hand-written and incorrect. This causes problems downstream for the billing staff.
  • Vague diagnosis. The diagnosis is often vague and there is a handwritten description but no ICD code. If there is a code, it often is picked off a list, which may not be the most accurate code. It’s also difficult to remember codes, and there is no way to search them, so we may settle on a code that is close enough.
  • Procedures are often missed. If not on the list, it can be hard to remember everything. It’s easier when there is a comprehensive menu to choose from.
  • Doctors lose billing sheets. If we lose our billing sheets, the charges are now gone and billers have no idea what was done or they have to go search through EMR systems at every hospital the doctor went to.
  • Doctors turn in billing sheets late. Sometimes it’s too late to get paid if billing sheets are turned in late. This delays the billing department significantly—they try to close out the month, then someone shows up 3 weeks later with charges from the previous month.
  • Billers can misplace sheets or forget to enter charges. If this happens, there is no true denominator of what the doctor did—no accountability.
  • Billers may mistype charges. It’s easy for billers to mistype charges into the billing software which may result in denied charges.

When considering charge capture it is important to be proactive. Features of an effective charge capture include:

Accuracy. Patient information and diagnosis are more accurate with use of an effective charge capture system. The more precise the code, the more likely you are to get paid and get paid more. It enables you to make sure the exact procedure or service performed is charged and in turn will be less likely to be rejected. Charges will be submitted in a timely manner—ideally in real-time. Having an electronic transfer into billing software eliminates human error. Those typing errors by billers trying to decipher notes are now gone!

Thoroughness. With an effective charge capture process in place, there will be no more missing patient information such as MRN and DOB. It allows you to include all appropriate diagnosis codes and all appropriate charge/CPT codes. A thorough charge capture system is crucial since any missed charge results in lost revenue.

Efficiency. Your system should allow you to reuse information so it doesn’t need to be re-entered over and over or lost in translation over time. Sharing of information is especially easy amongst physicians of the same practice.

Transparency. When you have thorough and accurate data, you can use it for meaningful reporting and identify where breakdowns occur so they can be fixed in a timely manner.

The HybridChart Way

Having an effective charge capture process in place allows you to implement improvement actions and control your improvements. HybridChart helps you do just that. Here’s how HybridChart can improve charge capture at your medical practice or hospital:

  • cloud based patient lists, accessible to whole practice
  • easy to add commonly used diagnoses
  • ability to search whole list of ICD10 codes
  • diagnoses “stick” with patient so that they can be reused
  • comprehensive , organized and customizable menu of inpatient charges including complex procedures
  • 5 layers of safeguards to prevent missed charges
  • integration with billing software to minimize chance for human error
  • robust and meaningful reporting

We continuously improve the healthcare process to achieve operational excellence, expedite the revenue cycle and generate smart data for providers in order to achieve operational excellence, expedite the revenue cycle and generate smart data to improve patient outcomes.

Understanding the value of purposeful rounding can bring an unmatched value to your practice or hospital. Here are 5 ways you can streamline your patient hospital rounding through purposeful rounding.



Dr. Gregory Sanders is a Harvard-trained, practicing cardiologist and founder and CEO of HybridChart. He has been coding since the 1980s and has spent his medical career focusing on improving processes. His patient care skills earned him recognition as one of Phoenix Magazine’s TOP DOCs. He lives in Scottsdale with his family.