5 Practical Tips for Improving the Charge Capture Process

5 Practical Tips for Improving the Charge Capture Process


Hospitalists have a unique role that offers the benefits of pursuing a medical career while acting as independent contractors. This approach provides several benefits, including scheduling flexibility, control over one’s income level, and tax leveraging. However, the role presents complexities as well.

The charge capture and billing process are a sticking point for many hospitalists. If not handled properly, charge capture issues could result in billing denials and delays in payment.

Here are some common causes of charge capture issues and five tips to improve the process.

1. Audit Breakdown Points

Hospitalists can rectify many issues with the billing process by capturing and billing encounters on a mobile application while improving time management and organization. However, it’s essential to understand the root cause of the challenges. Self-audits can help hospitalists understand whether their challenges are caused by internal or external factors and clarify their improvement priorities.  

Consider what barriers are negatively impacting the charge captures and billing. See some common causes below for guidance.

2. Implement the Right Tools

Once you’ve outlined the pain points and explored root causes, it’s time to consider which tools and systems can help overcome or correct them. 

The critical thing to look for when choosing a charge capture tool is centralization. A proverbial one-stop shop for the various administrative tasks in acute care is essential for success. Look for an app that manages charge capture and EHR documentation. Using a system with innovative technology, like intuitive ICD-10 searches and patient QR scanning, can also help improve accuracy and productivity.

Using a smart charge capture tool also offers the benefits of automation and analytics. Automation can streamline administrative tasks (like claim tracking and accounts receivable) and highlight issues in your workflow.

3. Practice Proper Note-taking Etiquette

Streamlining charge capturing starts with well-organized, detailed notes. Following proper etiquette when capturing progress notes is paramount for success during billing. Some key concepts to keep in mind include the following:

  • Documenting clinical notes at the point of care – incorporate detailed note-taking into your time with patients rather than trying to build on notes later.
  • Noting time details – note the time of the visit, when you took notes, and the duration of time spent with the patient.
  • Create bullet summaries – summarize broader notes with a few “must know” bullets to simplify review and streamline your rounding process.
  • Use proper amendments – don’t delete or scratch out the information you need to change. Cross it out neatly and add the changes. In the margin, note when and why you made the change.
  • Review and reflect – set aside time at the end of a visit to review, then again at the end of the day.

Using a progress note generator that allows for speech-to-text can also help you streamline this process. Detailed notes are crucial for proper billing.

4. Create Streamlined Systems

Tools are the implements you use to get things done. Systems are how you approach using those tools to maximize consistency and efficiency. Modern practice management systems are how hospitalists organize and streamline managerial and operational logistics such as coordinating care across facilities. 

Review your current process for taking notes and submitting billing reports. If you noticed issues with your time management and schedule during the initial audit, implementing systems can help correct them.

Start by creating pre-work and end-of-day routines to prepare for rounding and review notes, respectively. Taking the time to communicate and build a rapport with hospital staff can also be tremendously helpful, as it helps you instill trust, delegate, and stay on track.

Consider how you can batch your visits and work and do creative multitasking. Consider visiting all the patients in one area before moving to another or prioritizing discharge patients to clear up space. 

5. Conduct Regular Audits and Adjustments

Improvement is an ongoing process. Set aside time for regular follow-up audits using the data you collect after implementing changes. For example, you may try visiting patients on the same floor to batch your work but find issues with that approach. Alternatively, you may find that taking point-of-care notes throughout a visit detracts from your attention to the patient.

There’s no general productivity and improvement solution that fits all hospitalists. Monitor the results of your efforts and continue with those that enhance your charge capture process.

Common Causes of Charge Capture Issues

Several factors impact the integrity of the charge capture process. Some common barriers include the following:

  • Poor time management or prioritization – as charge captures and billing are administrative tasks, they often get deprioritized in a hospitalist’s busy schedule. This leads to incomplete records or errors or a lack of time to revisit and chase down billing.
  • Coding errors – medical coding is complex and nuanced. Choosing the proper coding for a diagnosis could be contingent on comorbidities and complications. Using the wrong coding could result in lost revenue or billing denials.
  • Inconsistency in facility approaches – many hospitalists work between facilities or departments, each with unique approaches to charging capture processing. 
  • Schedule disruptions – last-minute appointments or emergencies that disrupt the routine or note-taking.
  • Lost paperwork – hospitalists who aren’t yet paperless may misplace important documents, especially when traveling between facilities.

Having context around what could impact the charge capture process and accuracy can help hospitalists prioritize improvement points. These complications are just a few standard options to use as a starting point — there are likely many more. 

Impacts of Charge Capture Issues

Charge capture issues have various adverse effects that ultimately impact the hospitalist’s income. Some of the notable issues include:

  • Increased administrative workload – charge capture issues negatively impact productivity and time management, creating the potential for further problems.
  • Missed revenue or income – improper coding or missed information impacts the hospital’s revenue and the hospitalist’s income.
  • Liability risks – inaccurate charge captures or insufficient notes put the hospitalist at risk for charge disputes and legal action.
  • Decreased patient satisfaction – patients who have to dispute charges may feel less satisfied with their care and unwilling to recommend their acute physician to peers.
  • Diminished hospital relationship – hospitalists who need help with charge processes and accurate billing may have less room to negotiate or nourish relationships with medical facilities.

In summary, navigating the charge capture process smoothly and accurately is essential for ongoing success in the hospitalist career path. Using the tips listed above will help you improve your systems, productivity, and, ultimately, your income.