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Charge Capture Audit for Unbilled Services
Every completed encounter matched against the claim file, so the visits that produced no claim come back valued and ranked by days left to file.
River's charge capture and coding review reconciles what your providers documented against what your billing system actually submitted. Send the completed encounter records and the claims for the same period, and the encounters with no matching claim come back as a list, valued and sorted by how many days are left to file each one. A second sheet holds the claims whose codes disagree with the note, flagged for a certified coder to settle rather than quietly recoded.
Unlike the charge capture audit templates that rank for this search, this one does not start from the claims. Those templates hand you a sampling sheet: pull twenty claims per provider, check the codes against the note, score the accuracy. That sample can only contain services that were billed. A visit nobody billed is not in the claim file, so it is not in the sample, and an audit built that way is structurally blind to the thing it was commissioned to find.
This is for practice managers who suspect revenue is leaving without a denial attached, revenue cycle leads closing a month, and billing companies proving capture rates to a client. Run it monthly rather than annually, because the window to file closes on a schedule and a missed encounter has an expiry date. Where a service was billed and then refused, a denial root cause analysis is the other half, and a contract and fee schedule review covers the case where the claim was paid at the wrong rate.
An unbilled visit has an expiry date
An encounter that never became a claim is not a permanent asset. Medicare requires that a claim for a service furnished on or after 1 January 2010 be filed no later than one calendar year after the date of service, with a short list of exceptions. Commercial windows are usually shorter and set by the agreement rather than by regulation. That makes the useful sort order days remaining, not dollars, which is the opposite of how every other revenue report is ranked.
The other direction is the claims that were submitted and disagree with the note. Two mechanical checks catch most of it. CMS publishes procedure-to-procedure edits that pay one code in a pair and refuse the other without a modifier, and it publishes a maximum units figure per code. Worth knowing before you build a pre-submission screen: CMS says plainly that some of those unit values are confidential and not released, so no practice can check every one in advance.
Northbank Gastroenterology reconciled 14 months: 12,704 completed encounters carrying a signed note against 12,538 submitted claims. Of the 166 unmatched, 92 sat inside a surgical global period and 21 were no-charge nurse visits, both correctly unbilled. That left 53 encounters worth $9,737, of which $2,180 was already past the filing window and gone. A claims-side sample of 400 charts would have covered 3.2% of what was billed and none of the 53, because none of them was in the file to sample.
How it works
Send the encounters
The completed appointment list with the signed note status, from your schedule or your record system.
Send the claims
Every claim submitted for the same span, however it exports, with dates, codes and providers.
Get both directions
The unmatched encounters valued and aged, and the submitted claims whose codes disagree with the note.
Bill and fix
Work the queue by expiry, close the workflow step that let it through, and appeal what is then refused.
What you get
- Every completed encounter matched against the claim file, with the unmatched ones listed and valued
- The unbilled queue sorted by days left to file, not by dollar value
- Encounters correctly unbilled separated out, so a global period visit is not chased twice
- Claims whose codes disagree with the documented service, flagged for a certified coder to settle
- Capture gaps grouped by provider, service type and location, so the pattern names a workflow step
- The recoverable total in dollars, and the amount already lost to a closed filing window
Common questions
What counts as an encounter record for this?
Anything that tells you a service happened: the completed appointment list, the signed note log, the procedure log from a suite, the infusion schedule. It does not have to be one clean export. Two lists that overlap are better than one, because an encounter missing from both is a different problem worth naming.
Will it assign codes to the encounters that were never billed?
No. It names the documented service and the encounter, and stops there. Selecting a code and a level of service is a certified coder's judgement, and a tool that guesses at one creates a compliance problem larger than the revenue it recovers. What you get is a worked queue with the record attached, ready for a coder.
How does it know an encounter was correctly left unbilled?
From the record, and it shows its reasoning per row rather than in aggregate. A visit inside a surgical global period, a nurse visit your policy does not charge for, a service already rolled into a bundled code: each gets its own bucket. Anything it cannot explain lands in the unbilled queue rather than being quietly dropped.
How often should this run?
Monthly, and the reason is arithmetic rather than diligence. An encounter found eleven months late is worth the same as one found in a week, right up to the day the window shuts, after which it is worth nothing. A quarterly cadence puts a whole quarter of encounters closer to that edge than they need to be.
Does it find over-coding as well as under-coding?
It reports both, because the same comparison produces both. A note describing less than the claim billed is the exposure a payer audit looks for, and it is flagged the same way as one describing more. Both go to a coder with the note beside the claim. Where a payer has already refused the line, triage the remittance instead.
Can it work from a practice management export rather than the chart system?
Yes, and most practices start there. The requirement is one list of what happened and one list of what was billed, from any two systems. Where the encounter list carries no note status, the review says which rows it could not confirm were documented, since an undocumented service is a different finding from an unbilled one.
Charge Capture Audit for Unbilled Services
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