As providers face increasing reimbursement challenges, many are reassessing charge capture workflows to reduce revenue leakage and denials. Baptist Health System centralized clinical and financial departments under one director and leveraged their EHR to streamline charge capture. Coders use applications to capture infusion and observation charges, improving productivity. Involving clinical staff like nurses in auditing charges helps ensure documentation supports charges.

1. November 2014Service Documentation revenue cycle academy Journal
Healthcare Business Insights
Asproviderscontinuetoexperienceincreas-
ing challenges regarding the attainment
of proper reimbursement, many leaders
are reassessing charge capture workflows
in order to reduce revenue leakage, deni-
als, and preventable delays in payment. To
this end, many organizations are creating
specialized charge-related roles and staff-
ing them with team members knowledge-
able in coding or clinical care to enhance
processes. To support these staff members,
providers are also looking to leverage capa-
bilities within their electronic health record
systems to reduce the amount of time spent
auditing charges and improve compliance
with payer regulations.
To learn more about how organiza-
tions are optimizing charge capture pro-
cesses, The Academy recently spoke
with Chloe Phillips, Director of HIM and
Clinical Revenue at Baptist Health System
(BHS)—a four-hospital provider based in
Alabama. By effectively allocating roles to
charge integrity and designing effective
work queues, this organization has been
Considerations for Improving Charge Capture Processes
able to improve its rate of charge capture
as well as staff performance.
Enhancing Outpatient Charge
Capture Process
Several departments—including coding,
HIM, clinical revenue, and chargemaster—
are centralized at the service level at BHS,
meaning that workflow and reporting struc-
ture is consolidated across the system.
Given the interrelatedness of clinical and
financial functions, these departments all
report up to Phillips. “While it may seem
unique to have these departments under
the same individual, it has been a successful
transition over the years,” Phillips explains.
“Our team works great together, and as a
result, we’ve seen huge success at BHS both
prior to and post-Epic implementation.”
The coding team is responsible for coding
impatient and outpatient services across
the enterprise, which includes its four hos-
pital campuses. One particular area of focus
for this team includes applying infusion,
injection, and observation hour charges
that are payer compliant and supported by
documentation. “We assumed responsibil-
ity of these functions years ago, so we were
in a great position to work with Epic when
As reimbursement challenges mount, many
providers are looking to enhance clinical
documentation improvement (CDI) pro-
grams as a way to ensure documentation
fully supports the quality of care provided
and promotes accurate coding, billing, and
clinical quality scores. With ongoing prepa-
rations being made for ICD-10, the level of
CDI Best Practices: Examining the Case for Daily Rounds
and Stratifying Specialists by Service Line
specificity required for documentation will
necessitate CDI staffing structures that
facilitate a strong alliance between clinical
documentation specialists (CDSs) and phy-
sicians to secure their compliance.
Recognizing this as an area for improve-
ment, two CDI trends providers may wish to
consider include having CDSs go on daily
roundswithphysiciansanddedicatingthem
to specific service lines. Understanding the
benefits and challenges of these strate-
gies can help leaders determine a best-fit
strategy that will help organizations meet
the increasing demands for specificity and
secure appropriate reimbursement.
Involving CDSs on Daily Rounds
Because physicians’ primary concern
revolves around patient care, they may be
apprehensive about revenue-centric ini-
tiatives like CDI programs. Physicians will
ultimately create the documentation, but
CDSs can help influence the inclusion of
necessary components and phrasing that
results in accurate coding. Therefore, build-
ing strong working relationships between
SEE CDI ON PAGE 3
SEE Charges ON PAGE 2
Given the complexity of charging for observa-
tion services, it may be beneficial to dedicate
staff members—often coders—to this task to
improve compliance.
Responsibility for Capturing
Outpatient Observation Charges
Source: Academy Survey Results
Nursing Staff
26.5%
HIM/Coding
Staff
36%
Charge
Capture
Staff
26.5%
Other
11%
Physician
Engagement
First-Hand
Experience
Education and
Feedback
Rounding Medical Staff can develop
personal relationships with CDSs
and grow to trust their input
CDSs can hear first-hand the
medical team discuss patients’
care—increasing overall
understanding of the case
CDSs can give medical
staff feedback in real-time
and reduce the need for
later follow-up or query
Service
Line
Allocation
If viewed as an interruption,
rounding may deter building
relationships; centralized
service line allocation may help
in this regard
Staff may be able to obtain the
same experience by simply
being housed in a clinical
workspace frequented by
physicians
Using a clinical
workspace allows staff
to be easily located at
any point in the day by
medical staff for questions
Common Benefits of Physician Rounding and Service Line Allocation

2. Service DocumentationCOPYRIGHT©HEALTHCAREBUSINESSINSIGHTS. ALLRIGHTSRESERVED.
2
we built our charge capture workflow and
work queues,” Phillips notes. Prior to its go-
live, BHS tested charge capture workflows
to ensure the system met organizational
needs. Such a review also gave the organi-
zation the opportunity to identify areas for
focused coder training—helping facilitate a
smooth transition.
For infusion and injection services, cod-
ers use an application in the EHR to pull
information captured by the Epic Mobile
Augmented Reality (MAR) browser
from emergency room and observation
accounts, which includes the specific
medication, route, dosage, and time it was
given. “Using this application for injections
and infusions charging as it is structured
ensures all the necessary documentation
and charging links are available within
one application,” Phillips explains. “This
function has helped us to improve coding
workflow, allowing staff to focus more on
diagnosis and procedure coding.”
The coding team then enters appropriate
charges into Epic’s charge capture appli-
cation. After observation hours are cal-
culated, coders select the correct charge,
quantity, and date. The time the patient
was in observation is noted within the
“Events Summary” section and excluded
from the total observation hours charged.
By using these applications, BHS was ulti-
mately able to improve productivity and
turnaround time on charge capture based
on payer specific guidelines—allowing the
organization to maintain its rate of A/R
held in coding at 1.6 days.
Involving Clinical Staff
To further promote charge integrity, orga-
nizations may find it beneficial to col-
laborate with clinicians to ensure that
root causes of charge capture issues are
promptly addressed. With this mind, BHS
elected to involve the chargemaster man-
ager, nurse auditors, and file specialists
within the clinical revenue department in
reviewing claim edits for user errors and
master file errors built into Epic, which
are driven to these staff members on a
daily basis through work queues. In addi-
tion, clinicians are in charge of reviewing
and resolving edits prior to billing based
on rules established to specifically pick
up on correct coding initiatives, medically
unlikely edits, and other procedure-related
errors regarding quantity or modifiers.
Phillips expresses the importance of hav-
ing department leaders and staff within the
clinical revenue department work together
to recognize charge-related errors. “There
must be department managers and front-
line staff supporting the daily audit of rev-
enue and usage reports,” Phillips notes.
“Working together is the key.” By including
clinical staff, like nurse auditors and the
chargemaster manager in the charge cap-
ture process, BHS has been able to more
effectively compare clinical and financial
records to ensure that documentation pro-
vided supports the patient charges listed.
Engaging CDM Staff
Before transitioning to Epic, BHS had one
charge description master (CDM) coor-
dinator in each facility that would handle
daily charge capture processes. However,
due to streamlined charge capture capa-
bilities, BHS has been able to consolidate
these responsibilities into one CDM man-
ager position for the entire system.
The CDM manager is responsible for hold-
ing department managers and clinical
leadership accountable for daily charge
reconciliation processes and ensuring
that services charged correspond with ser-
vices documented for each encounter. “We
have work queues that capture charges for
‘missing revenue codes’ and ‘not allowed
cost centers,’” Phillip states. “The area that
had the most volume after go-live was the
‘not allowed cost center,’ which was due to
users logging into the wrong departments
or picking charges from another depart-
ment using the search option.” As one
solution to address this issue, department
managers discussed proper log-in pro-
tocols with staff members via email and
onsite meetings to mitigate the need for
future rework.
Leaders looking to enhance charge capture
efficiency and accuracy may benefit from
the strategies discussed above. By part-
nering staff from both clinical and finan-
cial departments and developing effective
charge capture work queues, providers can
minimize the need for rework downstream,
promote payer compliance, and mitigate
denials—ultimately helping to improve
their financial health.
From Charges ON PAGE 1 Duties of Nurse Auditors in BHS’ Clinical Revenue Department
Front-End Claim Edits Back-End Claim Edits Review/Audit Process
• Work all claim edits for med-
ical necessity and CCI
• Identify missing or com-
bined charges, overcharges,
or those applied to the
wrong account and HCPCS
codes
• Combine outpatient
accounts to related inpatient
accounts within three days
• Correct quantity errors for
lab and pharmacy
• Identify combined charges
• Address any issues not
caught during front-end
claim edits
• Work back-end claims as
needed
• Review fiscal audits and
respond with appeal letters
as needed
• Audit to ensure documenta-
tion supports charge
• Additional reviews for dis-
crepancies for ED, radiol-
ogy, physical therapy, and
other services
BHS Organizational Chart Staff Involved in Charge Capture Process
By allocating individuals with specialized knowledge throughout various departments to charge
capture tasks, BHS has been able to better promote charge accuracy.
Vice President of Revenue Management
Director of HIM and Clinical Revenue (Phillips)
Clinical Revenue
Supervisor:
• Charge poster
• Nurse auditor
• IT file spec. HIM and Vendor Staff
HIM Site ManagerCoding Manager:
• IP/OP coders
and leads
• Training spec.
• Coding auditor
CDM Manager
IVR Coder

3. Service Documentation
COPYRIGHT©HEALTHCAREBUSINESSINSIGHTS. ALLRIGHTSRESERVED.
3
physicians and CDSs is essential to a pro-
gram’s success. To this end, many providers
have found it beneficial to include CDSs on
daily rounds with physicians.
For instance, one health system based in
Arizona has remote CDSs who take turns
working onsite Monday through Friday
(with coverage from 6:00 am to 6:00 pm) at
an assigned facility. When onsite, special-
ists conduct rounds with physicians to talk
through questions as they arise and seek
out in-person responses for pending doc-
umentation queries. On the other hand, a
526-bed organization in Vermont assigns
CDI staff to a core group of physicians
to work with over a long-term basis and
accompany them during patient rounds
when clinical evaluations are taking place.
This enables staff the opportunity to make
inquiries in real time, proactively pinpoint-
ing areas that may need further docu-
mentation specificity. Furthermore, this
approach allows for a bit of cross-train-
ing; not only do CDSs educate physicians
on what constitutes compliant documen-
tation, but physicians are afforded the
opportunity to educate CDSs on higher-
level anatomy and physiology—which will
be important for mastering ICD-10.
Completing rounds with physicians, how-
ever, can be a time consuming process.
An 860-bed academic organization in
Washington realized that physicians on
rounds were often more focused on creat-
ing their plans for the day and assessing
patients rather than thinking about what
exactly to document. In this respect, hav-
ing staff on rounds could potentially deter
relationship building, as physicians may
view the presence of a CDS as a detrac-
tion from their focus on patient care. “They
spent two to four hours in rounds, and
some physicians do very prolonged rounds
depending on their teaching style, so in the
end, we didn’t think it was the most effi-
cient use of [CDS’] time,” the CDI manager
at this organization notes.
As such, this organization opted to house
four CDSs in a general workspace on cam-
pus, while the other four CDSs are sta-
tioned among the various clinical staff
areas, which still affords them access to
medical staff and the opportunity to dis-
cuss cases with them personally. This
leader admits, however, that initially con-
ducting rounds did assist CDSs in building
credibility with physicians in their respec-
tive area, ensuring that physicians now
know where to find them regarding ques-
tions that arise.
Organizing Staff by Service Line
In addition to promoting physician engage-
ment, many organizations are looking to
organize CDI staff workloads in a mat-
ter that promotes specialization and, as
a result, drives documentation accuracy.
To this end, some revenue cycle leaders
have allocated CDSs by specific service
lines, which may also help to build more
personal relationships between specialists
and physicians. A 969-bed health system in
Pennsylvania that assigns CDI staff to spe-
cific service lines—including cardiology
and oncology services areas—found that
specification enabled it to increase capture
rates of complications and co-morbidities
and improved case mix index across mul-
tiple areas.
In addition, specializing by service line can
ease the leaning curve for the ICD-10 tran-
sition, as staff members would not have
to become experts in all 140,000 codes,
but rather a select subset. Working long-
term on a service line can also increase
staff’s knowledge of their specific clinical
area and give them a better understand-
ing of how their assigned team documents
patient encounters.
Specialization can lead to difficulties,
though, when it comes to covering CDS’
paid-time off. Because staff is highly spe-
cialized, it may be difficult to maintain
optimal coverage and productivity during
absences. The workload for various service
lines might be inconsistent, as well. “[A]
potential downside to doing service cov-
erage is that one person may get a light
couple of weeks or months because there
are major surgical conferences and all the
general surgeons are going to be out of
town, so their scheduling goes down, ver-
sus someone who works with a service that
[is focused on] whatever comes through
the ED—that person may get very high vol-
umes,” the CDI manager at the Washington
organization states.
Identifying a Best-Fit Model
By understanding the benefits and poten-
tial challenges of these CDI structures,
leaders can implement a best-fit strat-
egy for their provider. For instance, one
450-bed organization in North Carolina
employs nine CDSs, most of whom have
nursing backgrounds and are allocated by
service line—including general medicine,
surgical, and cardiac services; for instance,
three staff members work cases for cardiac
surgery and cardiac medicine. Specialists
work on their respective floors alongside
physicians, while additional specialists
were moved from being located within
case management to being physically
located within the HIM department to also
improve communication with coders.
By having CDSs complete rounds with
physicians and/or allocating staff by ser-
vice line—or a customized combination of
those strategies—organizations can pro-
mote accurate documentation in the face
of ICD-10. Regardless of the exact approach
taken, reviewing the tactics outlined in this
article may assist leaders in optimizing
their CDI programs to ultimately promote
documentation integrity and preserve their
financial health.
From CDI ON PAGE 1
• Ensure that documentation is accurate,
complete, and compliant
• Conduct chart reviews to assess pres-
ent documentation, and when nec-
essary, query physicians to resolve
documentation gaps
• Identify opportunities for and develop
education to help drive process change
• Expand physicians’ knowledge in what
constitutes accurate, complete
documentation
• Secure physician involvement
in initiatives
• Help track and trend data
related to financial outcomes
Common Dates of Clinical
Documentation Specialists
Rounding and service line specification,
can help promote physician response—the
Pennsylvania organization improved its query
response rate by 10% in one year due in part
to service line assignments.
Query Response Rates at
Organizations Featured in Article
Arizona
Organization
(Rounding)
94%
77%
Pennsylvania
Organization
(Service Line)

4. Service DocumentationCOPYRIGHT©HEALTHCAREBUSINESSINSIGHTS. ALLRIGHTSRESERVED.
4
Service Documentation
Resources & Tools • Tips • Trends – for HIM Leadership published monthly by Healthcare Business Insights
rca-research@hbinsights.com • 888.700.5223
Health information management lead-
ers have utilized The Academy’s ad hoc
research service this past quarter to gain
insight into a variety of industry topics—
from increasingly prevalent roles like
charge entry specialists and coding educa-
tors to educational materials on service-
specific coding scenarios and emerging
best practices in the realm of clinical
documentation improvement (CDI). The
Academy highlights five resources below
that were developed in response to recent
Analyst Advisory requests.
Charge Entry Specialist
Performance Appraisal
According to Academy
research, a growing
number of hospitals
and health systems are
relinquishing charge
entry duties from either
clinical staff or coders
in favor of a dedicated
charge entry or charge capture specialist.
Among those allocating charge responsi-
bilities in this way, many have experienced
tremendous increases in charge accu-
racy, and therefore, reimbursement. Given
the potential impact of this position, The
Academy provides a template with which
to rate charge entry specialists’ abilities in
areas like aligning applied charges against
charge sheets or encounter forms and
appropriately assigning modifiers.
Guidance on Modifiers GA, GX, GY,
and GZ
Given the expansive set
of codes charge cap-
ture and coding staff
need to know, learn,
and apply, items that
are simply informa-
tional versus necessary
to secure reimburse-
ment may be easily forgotten or misused—
especially modifiers. This sample reference
Ad Hoc Research Highlights: Assessing Charge Entry
Staff, Educating Coders, and Evaluating the CDI Program
sheet on “G” modifiers may assist leaders
in educating staff, as it provides explana-
tions of how scenarios related to medical
necessity and Advance Beneficiary Notice
of Non-coverage (ABNs) affect accurate
modifier application, as well as an easy-to-
understand decision tree.
Coding Tips for Biopsy Services
Similarly, this tips sheet
may help coders better
understand recent CPT
code changes for breast
localization, biopsy, and
imaging services. While
some codes in this fam-
ilywererecentlydeleted,
others were added to bundle these services
into a single CPT code. Included are several
key terms and updates, guidance on how to
code particularly complex biopsy services
or scenarios, and links to additional indus-
try resources on this topic. With nearly one
million breast biopsies provided nation-
wide each year, according to the Centers for
Medicare and Medicaid Services, this is an
area where coding could have significant
implications on reimbursement.
Coder Educator Job Description
With so many changes
occurring among cod-
ing regulations—from
annual updates to the
ICD-10 conversion set to
go live next October—
some organizations
have resorted to allo-
cating a full-time position to coder educa-
tion. This role provides a centralized avenue
of information, as they are typically required
to remain up to date on and disseminate
coding changes while also onboarding new
hires. In addition, coder educators may be
responsible for developing and providing
education related to ICD-10, as well as regu-
larly auditing coding and documentation to
remain attuned to staff performance and
ongoing training needs.
Checklist of CDI Best Practices
Even when coders are
highly trained, sea-
soned, and knowledge-
able, their ability to
code accurate diagno-
ses and level of ser-
vice rests squarely on
the quality of clinical
documentation. While most organiza-
tions now have a clinical documentation
improvement (CDI) program in place to
support documentation integrity, the rate
of variability regarding program staffing,
structure, and operation—even from one
organization to the next—reveals not just
its relative infancy within the industry, but
also how successful programs can differ
in their approach. While, in acknowledg-
ing the integral role CDI can play in both
financial and clinical performance, this
checklist examines various strategies lead-
ers have found to contribute to quantifiable
improvement and physician engagement.
Through the Analyst Advisory research
service, The Academy continues to assist
members in effectively allocating, edu-
cating, and assessing mid-cycle staff. As
leaders continue to develop new roles
and strengthen the knowledge of existing
staff in response to impending changes,
the above resources—along with other
Academy materials—can be leveraged to
support a well-allocated workforce, create
effective policies and procedures, and pro-
mote compliance with internal and exter-
nal standards.
If you would like to make a research
request or obtain copies of any resources
detailed in this article, please contact The
Academy at 888.700.5223 or log on to the
member portal to access the online archive
of Analyst Advisory Research Studies.