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White Paper on Physician Charge Capture with Decision Support

Physicians annually lose $55,000 on inaccurate and incomplete charge capture as per HCFA.

In the past, coders made changes to physician claims to maximize revenues. Such changes are no longer performed as they are regarded as fraud and are being actively prosecuted by the Office of the Inspector General.

 Not captured – a physician rounds on a patient who is temporarily in the hospital and never fills out or cannot find an encounter form at the time of service. Later, the physician gets busy or forgets. A physician does not enter a charge for a patient on his schedule that he sees.
 Coded incongruently - a physician sees a patient who is 64yrs and 11months old and selects the CPT code for "Preventive Visit 65 and above" the claim will be denied.
 Coded in incorrect order – a physician performs a colonoscopy and an endoscopy and codes the colonoscopy with modifier 51. He is only paid half of the charge for the more expensive colonoscopy and the full charge for the less expensive endoscopy.
 Medical necessity coded incorrectly - a physician office performs an EKG and selects the ICD9 code for "Hypertension" as the diagnosis - many payers will deny the claim, however if the physician had selected "Hypertensive Heart Disease" the claim would be accepted. Of note, insurance companies will not state which diagnosis support what procedures - they simply say bill what you believe to be correct and we will process appropriately. Historically billing companies or coders changed what a physician selected, today they do not do so due to fear of litigation from the office of the inspector general.
 High Revenue medically appropriate services missed – for an elderly patient with pneumonia a 15 minute visit is compensated $40 and doing a 30 second pulse-oximetry is compensated $20.
 NCCI Bundled codes – a physician performs 2 procedures where the more expensive one is actually considered a bundled member of the less expensive one. Billing both codes results in rejection, billing only the less expensive one results in lost revenue.