Billing Problems? Consider Your Charge Ticket

November 1, 2008

Deborah Grider, CPC/EM, president of the American Academy of Professional Coders National Advisory Board talks about what you aren’t billing that is costing you big.


Are you charging for every service you perform? If your practice is like most, the answer is probably no. Unlike every other industry - in which businesses do not make a habit of giving away their products - medical practices routinely provide services for free.

Do you realize that approximately one-fourth of all medical practice income is lost due to underpricing, undercoding, missed charges, or unreimbursed claims? Hundreds of millions of dollars is lost annually due to medical billing errors. Physicians and staff are consistently attending seminars just to stay on top of coding and regulatory issues, but are you paying attention to your billing? As much as 3 percent to 5 percent of annual practice revenue is lost because the practice simply did not bill for services and procedures that the physicians performed.

To avoid that scenario, start by asking yourself the following questions:

  • Who is doing the coding?

  • Are the patient encounters coded off-site or onsite?

  • How does the data-entry staff ensure that they receive all charge tickets in the office?

  • Do you use charge tickets?

  • If you use a coder, how does the coder ensure that all charges are captured correctly?

  • Does the coder code from a charge ticket/superbill, or from the actual chart note or operative note?

  • If the physician is seeing patients in the hospital, how is this information communicated to the person responsible for entering charges?

  • Is the person who enters the charges or codes on the claims properly trained to perform the service?

As a consultant, I encountered an OB/GYN practice recently in which deliveries were captured in a book in the hospital. It was the responsibility of the coder to check the book daily for deliveries and newborn care. The practice did not use charge tickets to capture hospital care. The frustrated coder was looking in six different places for the information she needed. She was fighting a losing battle. My question to the practice was, “Are you sure you are capturing everything? Do you think you could possibly miss some charges?” Of course, the answer was, “We don’t know.”

To avoid missing valuable revenue - whether in the hospital or office - the first step is to develop a mechanism for communicating the information from the provider to coder or data-entry staff. In a perfect world, every physician would have a certified coder follow her around and assist with coding for every patient. In the real world, this will never happen. However, all physicians should have an updated charge ticket for every setting they work in.

The key word is “updated.” So many practices are so busy they don’t take the time to update the charge ticket every year. This is one of the most important tools the practice will use. The charge ticket is the beginning of the revenue process. For example, if a physician routinely performs lesion excisions in the office, and the code is not on the charge ticket, the procedure will be frequently missed. What about urinalysis or venipuncture codes? Modifiers? Keep in mind that in the office setting, many practitioners perform minor procedures in addition to the initial evaluation and can report both with modifier -25.

Charge ticket tips

To ensure that you receive all the charge tickets from your providers, try supplying each provider with a set of unique, sequentially numbered charge tickets. You can design the charge tickets so they fit into a small book that the providers carry with them. It should be the responsibility of the office staff to make sure all the numbers are in sequence when the tickets come in; if a charge ticket is missing, staff should alert the provider.

Second, make sure your providers are trained on how to use the tickets. If you don’t explain what the provider can bill for, how can you expect the charges will be captured correctly?

Physicians and nonphysician practitioners typically document the services they provide to their patients on a progress note, patient encounter form, or in an electronic medical record. Once the patient encounter is completed, the physician typically checks off on the charge ticket what services were performed. In a perfect world, the physician will have a good understanding of coding and will know when services are bundled, when services can be reported, and when services are incidental. However, in the real world, that is not always the case.

Take vaccines, for example. Can you charge an administration code in addition to charging for the vaccine itself? The answer is no, unless the physician provides counseling regarding the vaccine; side effects, benefits, contraindications, and so on. Simply injecting the vaccine without that counseling is not a billable physician service. If your practice dispenses vaccines regularly, your physicians should be trained on the rules.

What about a Medicare patient who had a Pap test and pelvic exam last year and insists on another this year? Medicare, which covers this service every two years, will deny the claim. The patient is not responsible for the service and cannot be billed - unless the practice has obtained a signed Advanced Beneficiary Notification (ABN), which explains that the service is not covered, and that the patient will be responsible for payment. Physicians need to know when and if an ABN is required for Medicare, along with how to adjudicate the ABN.

The key is consistent communication between the coder, data-entry, billing staff, and providers. The staff should feel comfortable going to the physicians with questions about the coding and charges reported.

Avoiding data-entry errors

Faulty data-entry is another common cause of lost revenue. Charges are typically transferred through key-entry by a billing or data-entry specialist; it’s easy to make small errors that can lead to rejected claims. To reduce errors, data-entry staff should work uninterrupted in as quiet an area as possible while entering charges. Staff need to focus when entering data: Errors are bound to occur when the person entering the charges has other simultaneous responsibilities, like rooming patients and answering the phone. It might be a good time to take a look at office work flow and processes.

Lastly, maintain the accuracy of diagnosis codes. If the diagnosis code is incorrect or not reported to the highest level of specificity, the service might be denied and the process of getting the claim paid will cause unnecessary delays. Diagnosis codes are updated every October, CPT and HCPCS codes in January.

Deborah Grider, CPC/EM, is a healthcare consultant, author for the American Medical Association, and president of the American Academy of Professional Coders National Advisory Board, the nation’s largest education and credentialing association for medical coders.

This article originally appeared in the November 2008 issue of Physicians Practice.