Charge capture refers to the process of accurately recording and billing for the services provided to patients by healthcare providers. It involves capturing all billable services, procedures, and supplies rendered during a patient encounter to ensure proper reimbursement.
Current Procedural Terminology (CPT) codes are numeric codes used to identify medical procedures and services performed by healthcare professionals. These codes are essential for accurately billing and reimbursing healthcare services.
International Classification of Diseases (ICD) codes are alphanumeric codes used to classify and record diagnoses, symptoms, and medical conditions. They provide a standardized system for documenting patient conditions and are crucial for proper reimbursement and statistical analysis.
A superbill is a comprehensive form used by healthcare providers to capture patient encounters and services rendered during a visit. It typically includes details such as patient demographics, diagnosis codes (ICD), procedure codes (CPT), and other relevant information for billing purposes.
Reimbursement refers to the process of compensating healthcare providers for the services they have rendered to patients. It involves payment from insurance companies, government payers, or patients themselves for covered medical services based on agreed-upon rates and billing codes.
Documentation in charge capture refers to the thorough recording of all patient encounters, procedures performed, medications administered, and other relevant details in the medical record. Accurate and comprehensive documentation is crucial for billing compliance, patient care continuity, and legal purposes.
The Charge Description Master is a central database or document used by healthcare organizations to maintain a list of all billable services, procedures, and supplies along with their corresponding charges. It serves as a reference for charge capture, billing, and revenue cycle management.
Revenue cycle management encompasses the processes and strategies used by healthcare organizations to manage the financial aspects of patient care, including charge capture, billing, claims processing, and reimbursement. Effective RCM ensures optimal revenue generation and financial sustainability.
Compliance in charge capture refers to adherence to regulatory guidelines, coding standards, and billing requirements set forth by government agencies, insurance companies, and healthcare industry organizations. Ensuring compliance is essential to prevent fraud, errors, and penalties in billing practices.
An audit trail is a chronological record of all activities and changes made to patient records, billing documents, and financial transactions related to charge capture. It provides transparency, accountability, and traceability for review, analysis, and audit purposes.