HI555 Unit 4 Charge Capture Review Example

Four Misses and Nineteen: A Unit 4 Charge Capture Review Comparing Two Emergency Departments That Charge in Different Ways

[Student Name]

Purdue University Global

HI555: Revenue Cycle Management

Unit 4 Charge Capture Review

[Instructor Name]

[Date]

Bellcourt Health, both emergency departments, the sample and every amount are composite; the sources cited are real.

Purpose

Bellcourt Health's two emergency departments use the same record system but capture facility charges differently. At the main campus, charges for infusions, injections, point-of-care tests and procedures drop automatically from nursing documentation. At the north hospital, nurses select charges from a discharge screen before the patient leaves. The question for this review was whether the two methods produce different results and, if so, what the difference is worth.

Method

Thirty treat-and-release visits per site were drawn at random from one month, excluding visits that ended in admission or transfer, because those accounts follow the inpatient claim. Each visit was reviewed against nursing notes, the medication administration record, procedure documentation and the posted charges. Variances were coded in three groups: a missed charge, meaning a documented, billable service with no charge; a charge without documentation, meaning a posted charge with no supporting record; and a late charge, meaning a charge posted after the claim had been sent. Rules for hydration and infusion timing follow the Medicare hospital billing instructions and the procedure code definitions (Centers for Medicare & Medicaid Services [CMS], 2024; American Medical Association [AMA], 2024).

A sample of thirty per site is enough to show a large difference between sites but not to estimate small categories precisely, and the revenue estimate below carries its range for that reason.

Findings by Site

Main campus, automatic drop: 4 of 30 visits had at least one missed charge, 5 missed items in all. One visit carried a charge without documentation. Two charges were late.

North hospital, discharge screen: 19 of 30 visits had at least one missed charge, 31 missed items in all. Two visits carried charges without documentation. Two charges were late.

The discharge-screen hospital missed more items in every category, which points to the charging method itself rather than to any one type of service.

Findings by Type

Missed items cluster in three places.

1. Hydration and infusion time. Fourteen misses at the north hospital and two at the main campus. In most cases the infusion was started and documented, but no stop time was ever charted. Without a stop time the duration cannot be shown, and hydration of 31 minutes or less is not separately billable, so the service cannot be charged as it was given.

2. Point-of-care tests run at the bedside. Eleven misses at the north hospital, two at the main campus. Glucose, urine pregnancy and rapid strep tests were documented in the record but not selected on the discharge screen.

3. Splint application. Six misses at the north hospital, one at the main campus. Splints applied by technicians were documented in a procedure note that the discharge screen does not display.

The infusion finding needs emphasis. Its root sits in nursing documentation, not in charging. Even the main campus, with automatic drop, missed two infusions because the stop time was absent. Changing the north hospital's charge method would fix the point-of-care and splint misses but would leave most infusion misses in place unless stop times are charted.

Charges Without Documentation

Three charges had no supporting record and are listed as credits owed. At the main campus, a critical care facility charge was posted for a visit whose documented critical care time was 22 minutes, below the threshold. At the north hospital, two intravenous push charges had no corresponding medication administration entry. Each will be corrected and the overpayment returned. Hospital compliance guidance treats charging for services not documented as a core billing risk (Office of Inspector General [OIG], 2005), and a review that reported only revenue owed to the hospital would invite doubt about its neutrality.

Late Charges

Four charges in the sample, about 7 percent of visits, posted after the claim had dropped, two at each site. Late charges do not lose revenue, since they are rebilled, but each causes a corrected claim and delays payment. They are treated separately because the remedy, a longer charge hold or a reconciliation before billing, differs from the remedy for missed charges.

Revenue Estimate

The estimate uses expected net payment per missed item, not the charge price, because charge prices overstate what payers actually pay. Expected payment was taken from Bellcourt's remittance history for each item across the payer mix: about $41 for a hydration or infusion unit, $8 for a point-of-care test and $55 for a splint application.

North hospital: 14 infusion items at $41, 11 tests at $8 and 6 splints at $55 total about $990 across 30 visits, or roughly $33 per visit. Across 16,000 treat-and-release visits a year, the expected loss is about $530,000, with a plausible range of $360,000 to $700,000 given the sample size.

Main campus: 2 infusion items, 2 tests and 1 splint total about $150 across 30 visits, roughly $5 per visit. Across 38,000 visits a year, the expected loss is about $190,000, with a range of $90,000 to $300,000.

Credits owed from the three unsupported charges are small in dollars but are reported in full and will be returned regardless of the revenue estimate.

What Produces the Gap

Two processes explain the difference. The discharge screen at the north hospital relies on a nurse remembering, at the busiest moment of a visit, every service given over several hours, and it does not display procedure notes written by technicians. The automatic drop at the main campus captures what is charted and misses only what is not. The second process, charting infusion stop times, is shared by both and is the larger source of loss in dollars.

How Confident the Comparison Is

Nineteen of thirty against four of thirty is a large difference, and with samples of this size it is very unlikely to be chance. The categories inside it are less certain: eleven missed tests at one site and two at the other could shift several points in another month. The review also drew only treat-and-release visits, so it says nothing about charge capture on visits that end in admission, where the inpatient claim absorbs most emergency services. Both limits are reasons to repeat the sample, not to doubt the main finding.

Recommendations for the Next Unit

Three steps follow from the findings: move the north hospital to automatic charge drop for point-of-care tests and splints, add a hard stop that prompts for an infusion stop time before discharge at both sites, and run a daily report of infusions without stop times for the charge nurse. Each will be measured in a repeat sample after one quarter.

References

American Medical Association. (2024). CPT 2025 professional edition. AMA Press.

Centers for Medicare & Medicaid Services. (2024). Medicare claims processing manual, Chapter 4: Part B hospital (including inpatient hospital Part B and OPPS) (Pub. 100-04). U.S. Department of Health and Human Services.

Office of Inspector General. (2005). OIG supplemental compliance program guidance for hospitals (70 Fed. Reg. 4858). U.S. Department of Health and Human Services.