Reviewing Charge Tickets

March 30, 2005

One part of management’s ongoing practice assessment process is to perform a review of the charge tickets the office uses. This includes the office charge ticket (which almost all practices have) and if applicable, the hospital charge ticket and the surgical charge ticket.  These tickets are used to record what services are rendered to patients and are then used as a tool to bill the physician’s services. Therefore, it is important to review these charge tickets since any mistakes on them could result in a billing error or missed billing opportunities.

When errors occur, the staff will have to spend time determining why the error was made and then either refile or appeal the denial for payment if the opportunity presents itself to do so. Some errors are in fact true errors and a payer will not reimburse the billing. In this situation however, at least there will be documentation of the error. When an inadequate charge ticket results in missed billing opportunities, most of the time the practice is totally unaware of when this happens; there is nobody saying to the practice “Hey, you just missed some revenue!”  This is why charge tickets must capture all services that can be rendered and related billing opportunities identified on it.

The Office Charge Ticket

An office charge ticket is commonly referred to in the physician community as a “superbill.”  You should obtain a copy of the office charge ticket and do or look for the following:

First, ask how long it has been since the superbill was updated. It should be updated at least once a year since CPT and ICD-9 codes change each year. If the answer is something other than “annually,” you can most likely assume there might be errors to be found on the charge ticket.

Take current office charge ticket and trace all CPT (service) and ICD-9 (diagnosis) Codes listed to the CPT and ICD-9 Books.

These codes are listed directly on the charge ticket. A doctor usually circles or checkmarks them after he or she has performed the service. This tells the office staff what the doctor did to the patient and this information is used to check the patient out of the office and bill their insurance. Therefore, the codes listed on the superbill must be correct.

As you trace the codes to a CPT book and an ICD-9 book, circle or highlight the errors you found directly on the charge ticket. Most commonly found during this step are deleted CPT codes are still on the superbill, descriptions are incorrect, and an ICD-9 code now has an extra digit. Trying to bill a deleted code will almost always result in a charge denial. Incorrect descriptions might cause the doctor to miscode a particular service, resulting in a missed revenue opportunity. Billing an ICD-9 code without use the code that goes out to the farthest digit might also result in a charge denial or a delay in the payment of the claim by the insurance company.

To document errors you find for presentation to the practice, you might to set up a worksheet like the one below; Errors found could be documented here:

ANALYSIS OF OFFICE CHARGE TICKET – CPT CODES

Practice Name: _____________________

Worksheet Preparation Date: ___________

CPT Code Code Description Error Found
_____________ _____________ _____________
_____________ _____________ _____________
_____________ _____________ _____________

ANALYSIS OF OFFICE CHARGE TICKET – ICD-9 CODES

Practice Name: _____________________

Worksheet Preparation Date: ___________

CPT Code Code Description Error Found
_____________ _____________ _____________
_____________ _____________ _____________
_____________ _____________ _____________

Make sure all CPT codes AND ICD-9 codes are included on the charge ticket.

Not only must a charge ticket be correct, but it also must be efficient. Inefficient superbills hinder the billing and collection process; efficient ones help it tremendously. An efficient office charge ticket is one that includes both CPT and ICD-9 codes on it. When a doctor has the ability to indicate what service was performed (the CPT code) and why the service was performed (the ICD-9 code), the office should be able to immediately bill the service.

There are many, many offices that only include CPT codes are their superbill. On these office tickets there is usually only a line item where the doctor will write in what the diagnosis was. When this happens, someone in the office is going to have to waste their time looking up the related ICD-9 code; this person might even select the wrong code, maybe resulting in a delay in payment by the insurance company. A practice wants to bill its services as quick as possible in order to speed up its cash flow and to be able to send a statement to a patient for their personal financial responsibility for the service. Office services should be billed no more than 2-3 days after the patient visited the office. If someone has to look up ICD-9 codes, this may delay the filing of the insurance claim.

The top half of the charge ticket could be used for CPT codes and the bottom half used for the diagnosis codes. However, you want to make it as easy as possible for the physician to record his or her office services; therefore, you will want as many codes as possible on the ticket. This is why some offices prefer to have the CPT codes on the front of the office charge ticket and the ICD-9 codes on the back.

Make sure all levels of service are included on the office charge ticket.

All levels of service must be included on the charge ticket, including those for new patient visits, established patient visits, and office consultations. The following are the codes that should be included; keep in mind some medical specialties might not need these codes (ex. Pathology) and that some practices might not perform consultative visits (ex. Family practice):

New patient office visit codes: 99201, 99202, 99203, 99204, 99205

Established patient office visit codes: 99211, 99212, 99213, 99214, 99215

Office consultation codes: 99241, 99242, 99243, 99244, 99245

There are two reasons why all of the levels of service should be included on the office charge tickets. The first is to make sure the doctor is not accidentally miscoding his or her services simply because all of the levels of service are not on the charge ticket. Specifically, you want to make sure the doctor is not accidentally “upcoding” his or her services. Upcoding means the doctor is recording a higher level of service than what was actually performed. Upcoding can result in the following:

  • Denial of the billed charge by an insurance company;
  • Downcoding of the service to a lower CPT code by an insurance company; or
  • An audit by an insurance company (or any other third party payer, such as Medicare).

The denial or downcoding of an “upcoded” charge are usually tied together in that usually the CPT code that was billed does not agree with the ICD-9 code that was billed with it. In these situations, the diagnosis code explains a condition or symptom that is much less than the CPT code that was billed. A real simple example is the patient who has the flu and the doctor bills code 99214 for the minor treatment (keep in mind as the levels go up, the patients are suppose to be sicker and sicker; i.e. have more complicated problems).

When upcoding occurs, the doctor could be risking an insurance audit as well, especially one from a governmental agency such as Medicare and Medicaid. This often occurs when a doctor utilizes one or two codes time after time again, and is usually the result of having few number of codes on the charge ticket (the ones actually on the charge ticket are the higher levels of service).

The level of service must always be supported by appropriate chart documentation. For evaluation and management services, for example, medical records must include documentation of the following:

  • The patient’s chief complaint;
  • The patient’s history;
  • The physical examination and review of systems;
  • Medical decision making
  • The treatment or management plan
  • The consultation/coordination of care

If the CPT code billed does not agree with the documentation in the patient’s medical record, the practice will usually owe monies back to the payer because he or she has been overpaid (i.e. a lower level of service should have been billed that supported the chart documentation). Civil penalties may also be assessed; a criminal investigation could occur if there was a deliberate attempt by the doctor to upcode the services.

The point should be clear: a good superbill helps avoid an insurance audit!

The second reason why all of the levels of service should be included on the office charge ticket is basically the opposite of the insurance audit discussion above: the practice wants to make sure it is not losing revenue because the higher levels of services are not included on the superbill. For example, many practices do not include code 99211 on their charge ticket because they feel they do not render this type of service; however, up further investigation, they do perform services at this level (ex. Blood pressure checks). At the opposite end, some practices in certain medical specialties will treat sicker patients more often than others. No matter, every practice wants the higher levels of service on the charge ticket in the event this type of treatment is ever rendered. One of the worst things that could happen in the situation where a doctor treats a very sick patient but checks only code 99213 because that is as high as the codes go on the charge ticket; codes 99214 and 99215 were left off.

A great indicator of these types of problems with the charge ticket is tied to your review of the practice’s service frequency. By paying close attention to how often these office codes are billed, you can get an idea if there might be a problem with how the office charge ticket is designed. The following is a good example:

CPT Code                       Frequency            Percent Used

99211                               55                          5

99212                               92                          9

99213                               761                        73

99214                               111                        11

99215                               22                          2

Total                                1,041                     100%

In this example, the doctor uses the established patient visit code 99213 73% of the time. Normally you will want to see a “bell shape curve” when first analyzing coding patterns for office visits. When you see this type of example, you want to make sure that the medical record documentation is supporting the code billed. On the other hand, if you see that certain of the codes were not billed at all, it is likely that not all of the codes are included on the charge ticket. Remember that the doctor is in the exam room and recording only those services that are on the ticket. This type of situation might be causing the practice to lose revenues and/or cause an audit.

A real life example was a urology practice. The doctors billed CPT code 99214 100% of the time when the CPT frequency report was looked at. When a doctor bills all his established patient visits at one CPT code, this was obviously incorrect. When the office charge ticket was looked at, guess what was listed as the only service for an established patient office visit: 99214!

Search for missing services

To reiterate, the doctor will only record services that are included on the charge ticket. As such, you want to make sure all office services that can be billed are on the charge ticket. If you are not experienced at CPT coding, we suggest you have the physician or an office nurse go through the entire CPT book and identify the procedures and services that can be performed in the office. This may identify additional procedures that will need to be added to the charge ticket. Examples include supply and injection codes.

For specialty practices, make sure the office consultation codes are properly aligned on the charge ticket.

Medical specialists are often asked by other doctors to “consult” on a patient. This often occurs when there is a suspected or unknown problem that needs the help of a medical specialist. In these situations, the doctor will send the patient to the specialist to find out what is really wrong with the patient. Under most of these circumstances, the specialist should bill a consultation code for the visit. However, many times a consultation code is not billed simply because the charge ticket is not designed properly.

First, make sure the consultation codes are listed first on the charge ticket. This will prompt the specialist to think whether or not the encounter should be billed as a consultation. When these codes are “buried” in the middle of the charge ticket, the doctor may not have a tendency to bill the appropriate code. Even more important however is to make sure the consultation codes are even on the charge ticket to begin with. If the doctor is a medical specialist, take a very close look at the usage of consultation services on the CPT frequency report. If the frequency report shows a lower amount of consultative services than the office visit codes, it might be because the codes are not aligned correctly on the charge ticket (or even included on the charge ticket in some cases). However, keep in mind it is usually the result of a lack of education about when a consultation code can be billed.

Make sure the office charge tickets are pre-numbered and missing tickets (i.e. numbers) accounted for.

Numbering charge tickets is a basic form of internal control. To prevent theft, all tickets should be numbered and accounted for. Evidence of missing tickets could be the result of employee embezzlement. Numbering and related accountability helps prevent the situation where an employee takes money from a patient, takes a superbill and gives it to the patient as a receipt, and then pockets the money. The charge and payment are never entered into the practice’s computer system.

Hospital and Surgical Charge Tickets

You will perform all of the same review functions mentioned above for these tickets as you will for the office charge ticket. You need to make sure all of these tickets are accurate and contain the services that the doctor will need to bill, along with related diagnosis codes. Keep in mind however that most doctors do not want to be burdened with a lot of paper when they perform their hospital rounds. This is why the hospital charge ticket is usually much smaller in size, often the size of an index card. The challenge here is to make the card as efficient as possible; usually CPT codes are used and the doctor will write in the diagnosis code.

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