Forgetting is Costly: How Clinicians Can Improve Charge Capture at the Point of Care
Introduction: The Unsung Hero of a Healthy Practice
You just finished a complex procedure, saved a life, and moved on to the next patient. You did your job perfectly. But did you get paid for it?
This is one of the most common disconnects in healthcare. Clinicians focus — rightly — on patient care, often seeing administrative tasks like documentation as a necessary evil rather than a critical part of their role. But the truth is, a missed charge is a service provided for free. Collectively, those missed charges can mean the difference between a thriving practice and one that struggles to keep the lights on.
According to the Healthcare Financial Management Association (HFMA), hospitals and health systems lose 1–3% of net revenue annually to missed or incomplete charge capture. For a $50M practice, that’s $500K to $1.5M — gone. And much of that loss happens at the point of care.
Table of Contents
Clinicians are the first and most critical link in the charge capture process. By adopting a few simple best practices in real time, you can protect your organization’s revenue, reduce compliance risks, and ensure your hard work is financially recognized.
The Clinician’s Guide: 6 Best Practices for Charge Capture
1. Know the “Why” Behind the “What”
Your documentation isn’t just a medical record — it’s the legal and financial justification for every charge submitted. It tells the story of the patient’s care, supports the complexity of the service, and provides coders with the details needed to select the correct CPT/HCPCS and ICD-10/ICD-11 codes.
Example: A missing detail such as wound size or the number of views on an X-ray could drop the reimbursement by hundreds of dollars or trigger a denial. When you understand that, the motivation to document thoroughly rises.
“The accuracy of your documentation is as important as the accuracy of your diagnosis — both affect the health of the patient and the health of the organization.”
2. Document in Real Time
One of the top and most preventable causes of revenue leakage is simply waiting too long to record what happened during a patient encounter. Human memory, especially during a packed clinic schedule or a hectic shift, is unreliable. Even small omissions — a secondary procedure, the use of a specific supply, the precise timing of a medication administration — can mean hundreds or thousands of dollars lost over time.
Real-time documentation means entering charges and clinical notes while the patient is still in front of you or immediately after, before starting your next task. This minimizes the risk of forgetting important details and ensures your coders have the complete picture from the start.
Best Practices:
Use mobile charge capture tools or workstations on wheels so you can document at the bedside or in the procedure room.
Leverage voice dictation for quick, accurate note-taking if typing is impractical.
Build the habit of completing documentation for one patient before opening the chart for the next.
In fast-paced environments like the ED, designate short “documentation pauses” between cases to stay current.
By making real-time documentation part of your standard workflow, you close the gap between care delivery and charge capture, dramatically reducing missed or underbilled services. of the top reasons for missed charges is “memory fade.” A day full of back-to-back patients makes it nearly impossible to recall every minor procedure or supply used.
Pro Tip: Document and capture charges as soon as the service is performed, or immediately after the encounter, before moving on. Use mobile charge capture apps, workstations on wheels, or dictation tools to make this seamless.
3. Be Specific and Detailed
Vague notes equal vague billing, and vague billing equals missed revenue. Coders are bound by what is explicitly documented — if it’s not written, it’s as if it never happened. That means every relevant detail counts: the exact nature of the procedure, the size and location, the complexity, the instruments or materials used, and any relevant clinical circumstances.
Instead of: “Cut on face repaired”
Use: “Single-layer laceration repair of a 3.5 cm wound on the left cheek using 5-0 nylon sutures after irrigation with sterile saline.”
Including details like wound dimensions, anatomical specificity, procedural complexity, anesthesia used, and materials ensures accurate — and often higher — reimbursement. It also strengthens compliance by clearly supporting the billed code. A coder working from this kind of note can confidently select the most specific CPT code, apply correct modifiers, and avoid downcoding.
Pro Tip: When in doubt, over-describe rather than under-describe. The extra seconds it takes to add detail can save hours of follow-up, denials management, or lost revenue later.
4. Leverage Your EHR’s Smart Tools
Modern EHRs are more than digital filing cabinets — they’re powerful allies in capturing every billable service. When used to their full potential, these tools can close documentation gaps before they lead to lost revenue.
Procedure-specific templates: These prompt you for all the clinical and billing details required for specific services, reducing omissions. For example, a laceration repair template might require wound length, location, anesthesia used, and suture type.
Smart phrases and macros: Standardize repetitive documentation while ensuring required elements are included, improving both speed and completeness.
Embedded checklists and alerts: Automatically flag missing information or unsigned orders before you can close the encounter, preventing incomplete records from moving forward.
Integrated charge capture prompts: Some EHRs suggest billable items based on your orders, notes, and procedure logs, giving you a safety net against missed charges.
By intentionally leaning on these tools, you not only save documentation time but also strengthen coding accuracy, reduce compliance risk, and increase the likelihood of capturing all legitimate revenue. Regularly review updates or new features in your EHR — even small enhancements can have a measurable impact on your bottom line.
5. Close the Loop on All Orders
An order is not truly complete until it’s signed, dated, and finalized — including all related documentation, test results, and final diagnoses. Leaving notes unsigned or diagnoses incomplete doesn’t just delay care continuity; it creates financial bottlenecks, keeping claims stuck in DNFB (Discharged Not Fully Billed) status and increasing the risk of missing payer deadlines.
Even small delays in finalizing orders can snowball into larger operational issues: delayed coding, missed revenue targets, and unnecessary staff rework to track down missing signatures.
Daily Habit: Before ending your shift, perform a systematic review of your EHR “In Basket,” pending orders queue, and unsigned note list. Clear or finalize each item, confirm all linked orders are closed, and ensure the patient encounter is ready for coding and billing. This proactive end-of-day routine can prevent timely filing denials, accelerate reimbursement, and give the next care team accurate, complete information.
6. Partner with Your Coders
Coders are your allies, not auditors — think of them as your translators between clinical excellence and compliant reimbursement. They live and breathe CPT, ICD, and modifier rules, and their insights can help you avoid costly denials and optimize legitimate reimbursement.
Instead of only interacting when there’s a coding query or a claim rejection, build a regular cadence of collaboration. Schedule short but consistent feedback sessions (even 15 minutes) to:
Clarify documentation requirements for high-complexity or high-value procedures, including exact terminology, measurements, and time-based elements.
Spot denial patterns together so you can address them at the source rather than in appeals.
Co-develop quick-reference documentation tips or smart phrases tailored to your workflow, ensuring you hit the required elements without slowing down patient care.
Share wins — review examples where excellent documentation led to faster payment or prevented a denial, reinforcing good habits.
By maintaining this two-way dialogue, you turn coding from a back-end checkpoint into a front-line partner in protecting both compliance and revenue.
Technology to Support Clinician-Friendly Charge Capture
Mobile charge capture apps for bedside documentation, enabling clinicians to quickly enter CPT/HCPCS codes, link them to diagnoses, and capture supplies without leaving the patient’s side. These tools often work offline and sync later, so even in low-connectivity areas, charges aren’t lost.
AI-powered prompts that scan notes in real time for missing billable elements, such as procedure details, wound measurements, or time-based service durations. Some systems highlight gaps before you sign off, guiding you to add what’s needed to support full reimbursement.
Integration with ancillary systems to automatically link lab, imaging, pharmacy, and supply charges to the encounter. For example, if the lab processes a specimen ordered during the visit, the charge is pulled into the bill automatically, eliminating manual reconciliation and reducing missed ancillary revenue.
Clinician’s Quick Daily Charge Capture Checklist
Conclusion: From Burden to Responsibility
These six practices are simple, but their impact is profound. They turn charge capture from a reactive scramble into a disciplined, proactive habit that safeguards revenue, reduces compliance risk, and ensures every service you provide is recognized and reimbursed.
A financially healthy organization can reinvest in technology, staffing, and resources — directly improving patient care. By making charge capture part of your clinical identity, you’re not just protecting your paycheck; you’re supporting the sustainability and growth of your entire practice.
MBW RCM can help your team implement point-of-care charge capture training, build customized checklists, and optimize your technology for maximum accuracy and speed.
Contact us today to protect your hard work — and your revenue.
