Charge capture can help you improve the delivery of patient care by alleviating the stress from the business side of health care. What happens after the patient is taken back by the provider? That is the point at which charge capture and charge and diagnosis capture occurs.
How Charge Capture Works
Obviously the services have been provided or are being provided. During that time period, the provider of service is completing their notes and they’re possibly doing that during the visit and or right after the visit. They’re diagnosing the patient and deciding what charges are appropriate to assign to the services that they have performed. That would then be the representative services that would translate from the services provider to procedure codes. All of those codes would be represented for the billing team. So at some point after that charge capture is when that information gets transmitted to the coder, if there is a coder on staff at your practice or organization.
Who Provides Charge Capture?
So, what is charge capture? Charge capture diagnoses something that’s done with the patient by the provider of service. It is not something that someone else in the practice should be doing unless that is a direct team member that is partnering with the provider, for example, a nurse or a nurse’s aide.
How to Record Charge Capture
Charges are captured generally on a fee slip, a day sheet, a charge master sheet, or encounter form; there are all kinds of names that mean exactly the same thing. They’re on a sheet of some sort of electronic form where that information gets captured or transmitted to the billing system. There are a lot of organizations that still use physical forms for this process. The provider of service indicates the services or the charges they’re capturing and the diagnoses that they believe most appropriate for that patient. That goes then to the billing team and/or gets transmitted through the EHR for the billing team to capture it.