Vol. 16 •Issue 8 • Page 23
Taking Charge of Charge Slips
With the constantly changing regulatory and billing guidelines and the expansion of services and technology, outpatient departments’ charge slips must become a dynamic entity.
The outpatient health care reimbursement process is complex and must be closely managed to ensure accurate reimbursement for the services provided. The billing and reimbursement process begins when the patient presents for service and continues to the point of payment or account resolution. The “capturing” or reporting of the services provided in the outpatient setting is generally accomplished through the use of forms or computer screens commonly referred to as charge slips or charge tickets. There is little regulatory guidance in the development or use of charge slips, but they are an essential tool in linking medical record documentation to the charge capturing process. The following will describe the structure and use of outpatient charge slips, pitfalls that can be encountered, which could result in inaccurate billing or expose the health care facility to regulatory review, and recommendations on how to organize and manage the charge slip process.
What Are Charge Slips?
The majority of a facility’s billing process has become automated over the last 15 years and, with the exception of coders, few staff members involved in the billing process ever see the medical record documentation. Charge slips serve as the data collection tool for commencing the billing process. It is vital that these forms be complete and accurate, thus contributing to successful reimbursement. Charge slips reflect the services performed and any associated charges (i.e., supplies, anesthesia, etc.). In addition, charge slips are historical records that are used in the event a charge must be researched to identify any discrepancy or billing errors.
Charge slip’s structure and development varies by facility, but they all should contain the essential information needed to accurately report the charges associated with the outpatient services provided in that department. The charge slips should provide:
• Patient tracking information (i.e., name, medical record number, encounter number and any other information needed to accurately link the charge slip to the correct patient);
• Date of service;
• Physician and/or medical staff/technician name, credentials and facility provider number for the individual(s) who provided the service;
• Place of service (department or clinic name);
• Complete list and description of service(s) provided by that department;
• Diagnosis(es), signs/symptoms or medical indications that supported the medical necessity of the service provided; and
• Supplies and/or medications provided (that are not integrated or bundled into the charge line for the service provided).
It should be noted that regardless of whether the charge slip is signed or not, the charge slip is not a substitute for complete and proper documentation in the patient’s medical record. Each outpatient department within the hospital should develop charge lines on the charge slip for all billable services that they provide to patients, even if the services are not paid or are packaged by Medicare or third-party payers. This information is utilized for calculations for outlier and transitional corridor payments, and the data can be used for cost analysis by the hospital. Also, just because a service is non-covered or non-billable by Medicare or Medicaid, other third-party payers may consider the services acceptable and eligible for reimbursement.
The use of charge slips is only as effective as the policies and procedures the facility develops for their use. The accuracy of the billing process can be significantly impaired by poor charge capturing procedures. Some of the problems that can result from an ineffective charge capture process include:
1. Services provided but not captured on charge slips;
2. Charges not supported by medical record documentation;
3. Incomplete charge slips;
4. Incorrect date or data on charge slips;
5. Double charging; and/or
6. Charges missed due to inaccurate or lack of modifier assignment.
A very good example of why this is important to include all services on a charge slip is in the observation area.
Coverage for observation services is as varied as there are insurance carriers. Medicare may not pay for observation services except when it meets certain criteria, but other services and treatments provided in the observation area may be billable. Services such as transfusions and non-chemotherapy infusion services are just two examples of treatments that should be reported regardless of whether the observation service is covered or not. Many facilities fail to have a complete list of services that are provided in this area included on their observation charge slip.
An example of a service being provided but not captured on charge slips occurs when a service is initiated in a department or clinic but not reported by that department. One outpatient encounter may include services from multiple departments in the hospital. If a service is being provided by staff members from multiple departments then policies need to be in place to assign accountability for capturing all charges incurred. Pooling of charging information is inconsistent from facility to facility. In some facilities, laboratory, pharmacy and central supply may require input from the various outpatient departments to directly record or enter the charges for services provided. Other facilities may allow the department to reflect these charges on their charge slip and the information system is programmed to sort and link the charges to the appropriate cost center when the data is entered. It is important to note that the more steps a facility puts into the process, the more susceptible the process is to errors or lost charges.
Managing Charge Slips
Management of the charge slips should be an element of the facility’s charge description master (CDM) team. Historically, departments have assigned a staff member to be responsible for billing issues and to ensure that the department remained current in billing opportunities. The individual usually had little billing knowledge and often had other primary responsibilities that negatively impacted the amount of time allocated to managing the department’s coding and billing changes and updates. Often departments operated in a vacuum, having no knowledge of how the changes they implemented impacted other areas of the hospital or whether the changes were integrated with the rest of the billing process. For optimum management of charge slips and the charge capturing process, it is recommended that the facility develop a team approach to managing the entire charge capturing process.
An individual from each of the outpatient departments should be assigned to the CDM team, as well as selected staff members from HIM and coding, the business office, registration and finance/accounting. The leader of this team should be an individual with advanced knowledge of the charge capturing and reporting process and whose primary responsibility is to manage this process. The coordinator would be responsible for:
• Reviewing changing carrier regulations and for disseminating them to the various departments;
• Promoting communication between the departments and facility coders and billing staff to help assess the impact of changes on department billing;
• Coordinating the addition or deletion of charges and updating the charge capturing process, including department charge slips; and
• Arranging training for department staff and physicians to ensure compliance and understanding of the billing changes.
A team approach is not the only solution to managing the department charge process, but it is important to understand that departments must coordinate their efforts and seek out technical expertise for assistance in promoting accurate charge capturing. Similar services are often provided in multiple departments so pricing and utilization should be compatible.
A Dynamic Entity
With the constantly changing regulatory and billing guidelines and the expansion of facility services and technology, outpatient departments’ charge slips must become a dynamic entity. Reductions in reimbursement are a reality that facilities must accept, and it is imperative that these facilities identify appropriate billing opportunities if they are to remain financially viable.
Only through effective communication between the coding, billing and clinical outpatient departments can a facility hope to understand and effectively identify and implement outpatient billing changes in a timely manner.
Above all else, the facility must understand and embrace the importance that accurate medical record documentation has on promoting effective, timely and accurate reimbursement.
Program Memorandum Intermediaries, Transmittal No. A-00-83, Nov. 9, 2000.
Program Memorandum Intermediaries, Transmittal No. A-02-129, Jan. 3, 2003.
2003 Hospital Chargemaster Guide, Ingenix/St. Anthony Publishing/Medicode.
Ruthann Russo is founder and CEO for HP3 Inc., a national health care consulting firm dedicated to providing documentation, coding and data solutions for improved reimbursement, compliance and patient care.