Charge Capture and Coding Accuracy: How to Stop Revenue Leakage (2026)

The Charge Capture Problem

Charge leakage is one of the most underestimated revenue problems in healthcare. Unlike claim denials, which are visible and trackable, missed charges are invisible. You cannot appeal a charge that was never submitted. You cannot follow up on revenue you do not know you lost.

The data on the scope of the problem is consistent across studies: 3-5% of billable services are never captured (MGMA, Advisory Board). For a solo physician generating $800,000 in annual charges, a 4% leakage rate is $32,000 per year. For a 10-provider group billing $8 million, that same rate means $320,000 in services delivered but never billed. Across a career, the cumulative loss for a single provider can exceed $1 million.

The sources of charge leakage fall into predictable categories:

• Missed ancillary services -- Injections, in-office labs, tray fees, supplies, immunizations, and EKGs performed during a visit but not documented on the charge ticket.
• Incomplete superbills -- Paper or electronic encounter forms that do not include all the codes a provider might need, leading to omitted services.
• Lag between encounter and charge entry -- When charges are not entered on the day of service, the probability of forgetting billable items increases significantly. Studies show that charges entered more than 3 days after the encounter have a 15-25% higher error rate.
• Rounding and hospital encounters -- Inpatient visits, nursing facility rounds, and after-hours calls are particularly vulnerable because they happen away from the office billing workflow.
• Undercoding -- Providers who routinely select lower E/M levels than their documentation supports, often out of fear of audits, lose $20,000-$50,000 per year in legitimate revenue.

The Charge Capture Workflow

Understanding where charges get lost requires mapping the complete workflow from patient encounter to paid claim. Each step in the chain introduces opportunities for leakage.

The most effective charge capture programs address every step in this chain, not just one. A practice with excellent coding but no reconciliation process will still leak revenue from missed encounters. A practice with rigorous reconciliation but poor superbill design will still undercode.

Superbill Design and Optimization

The superbill (also called an encounter form or charge ticket) is the bridge between clinical care and billing. Whether paper-based or electronic, it is the document providers use to indicate which services were performed and which diagnoses apply. A poorly designed superbill is the single most common structural cause of charge leakage.

What Makes a Good Superbill

• Specialty-relevant codes -- Include the CPT and ICD-10 codes that represent 90-95% of what the practice actually bills. Remove codes that have not been used in 12 months.
• Logical grouping -- Organize codes by visit type (new patient, established patient, procedure, preventive) rather than in numerical CPT order. Providers should be able to find the right code in under 10 seconds.
• Ancillary service prompts -- Include dedicated sections for injections, in-office labs, supplies, immunizations, and other services commonly performed alongside E/M visits. These are the charges most frequently missed.
• Modifier fields -- Provide clear fields for modifiers with brief descriptions (e.g., "-25: Significant, separately identifiable E/M") so providers select them correctly at the point of care.
• Time documentation fields -- Since E/M level can be based on total time, include a field for providers to record total encounter time, including pre-visit chart review and post-visit care coordination.
• Diagnosis linkage -- Make it easy to link each procedure to its supporting diagnosis. Incorrect diagnosis-to-procedure linkage is a top cause of claim denials.

How to Audit Your Superbill

Conduct a superbill audit at least annually, or whenever your payer mix, service lines, or provider panel changes:

1. Pull a frequency report of all CPT codes billed in the past 12 months. If a code on your superbill was never used, remove it. If a code was billed manually (not from the superbill) more than 10 times, add it.
2. Compare against payer fee schedules -- Ensure that every code on the superbill is covered by your top 5 payers. Remove codes that are consistently denied or not reimbursed.
3. Shadow 10-15 encounters per provider to identify services performed but not captured. Pay special attention to ancillary services, supplies, and procedures added mid-visit.
4. Review with providers -- Ask each provider: "What services do you perform that are hard to find on the superbill?" Their answers will reveal design gaps.

E/M Coding: Getting the Level Right

Evaluation and Management (E/M) services represent the largest volume of charges for most physician practices. Getting the level right is the single highest-impact coding decision. Undercoding leaves legitimate revenue on the table; overcoding creates compliance risk and audit exposure.

2021+ E/M Guidelines: The MDM Framework

The 2021 AMA/CMS guideline changes fundamentally restructured E/M level selection for office and outpatient visits (99202-99215). The key changes:

• History and physical exam no longer determine the level. Documentation of history and exam is still clinically important, but it does not drive code selection.
• Level is based on medical decision making (MDM) or total time. Providers choose whichever method supports the higher level.
• MDM has three elements: (1) number and complexity of problems addressed, (2) amount and complexity of data to be reviewed and analyzed, and (3) risk of complications, morbidity, or mortality of patient management.
• Two of three MDM elements must meet the level. The element that is met at the lowest level determines the overall level when all three differ.
• Time is total time on the date of encounter, including face-to-face and non-face-to-face activities such as chart review, order entry, care coordination, and documentation.

E/M Level Reference

Common Undercoding Patterns

Undercoding is more prevalent than overcoding in most practices. Providers undercode for several reasons: fear of audits, habit from pre-2021 guidelines, lack of education on current MDM criteria, and the perception that "erring on the side of caution" is safer. It is not. Consistent undercoding is itself a compliance red flag because it suggests the documentation does not match the code -- either the provider is not documenting what they did, or the code does not reflect the work performed.

• The 99213 default -- Many providers bill 99213 for nearly every established patient visit. If more than 50% of a provider's E/M volume is 99213, the distribution likely does not reflect their actual case complexity. A bell-curve distribution centered on 99214 is typical for most specialties.
• Ignoring data complexity -- Reviewing external records, discussing results with other providers, and independently interpreting imaging all count toward data complexity. Many providers perform these activities routinely but do not document them.
• Not counting non-face-to-face time -- Chart review before the visit, care coordination calls, and documentation time all count toward total time if the provider chooses time-based leveling.

Common Overcoding Patterns and Audit Triggers

• 99215 without documented high risk -- Level 5 requires that the patient's management carries high risk: drug therapy requiring intensive monitoring, decision regarding hospitalization, or decision regarding emergency major surgery. If the note does not reflect these elements, the code will not survive an audit.
• Cloned documentation -- Notes that are identical or near-identical across multiple visits suggest copy-forward without meaningful clinical update. Payers flag these patterns algorithmically.
• Outlier distribution -- A provider who bills 99215 at a rate significantly above their specialty's mean (typically 5-12% of established visits) will attract payer scrutiny.
• Time-based billing without time documentation -- If using time to select the E/M level, the total time must be documented in the note. A statement like "Total time: 45 minutes" is required; vague language like "extended visit" is insufficient.

Modifier Accuracy

Modifiers tell payers how a service was altered without changing its definition. Incorrect modifier usage is one of the most common causes of claim denials, audit findings, and compliance violations. The following modifiers are responsible for the majority of modifier-related errors in physician practices.

Specialty-Specific Charge Capture Challenges

Surgical Specialties

• Global surgery periods: Post-operative visits included in the global surgical package are not separately billable. The most common error is billing E/M visits during the 10-day or 90-day global period without modifier 24 (unrelated E/M during post-op period) when the visit addresses a condition unrelated to the surgery.
• Co-surgery and assistant surgeon modifiers: Modifiers 62 (co-surgery), 80 (assistant surgeon), and 82 (assistant when qualified resident unavailable) must be used correctly and supported by documentation of medical necessity for the assistant.
• Implant and supply charges: High-cost implants and surgical supplies are frequently under-captured. Establish par levels and a charge capture checklist integrated into the surgical workflow.

Behavioral Health

• Time-based codes: Psychotherapy codes (90834, 90837) and add-on codes (90833, 90836, 90838) are time-dependent. The note must document the exact duration of psychotherapy and, for add-on codes, the separate E/M service.
• Group therapy: Group therapy (90853) requires documentation of each patient's participation. Billing group therapy for patients who did not attend is a significant compliance risk.
• Crisis and same-day services: Crisis intervention (90839, 90840) and same-day E/M services are commonly underbilled because providers are unsure about same-day billing rules.

Primary Care

• Preventive vs. problem-oriented visits: When a patient presents for an annual wellness visit (AWV) and the provider also addresses a significant problem, both the preventive service and the problem-oriented E/M (with modifier 25) are billable. Many practices bill only one or the other.
• Chronic care management (CCM): CCM codes (99490, 99491, 99437, 99439) for ongoing care coordination are a significant revenue source that many primary care practices fail to capture because the workflow requires time tracking across the month, not just during visits.
• In-office ancillary services: EKGs, spirometry, rapid strep/flu tests, urinalysis, nebulizer treatments, and immunizations are commonly performed but not always captured on the charge ticket.

Procedural Specialties

• Multiple procedure discounts: When multiple procedures are performed in the same session, payers apply a multiple procedure payment reduction (MPPR) to the second and subsequent procedures. The claim must list the highest-value procedure first.
• Bilateral procedures: Modifier 50 (bilateral) must be applied correctly. Some payers want one line with modifier 50; others want two lines with RT/LT modifiers. Incorrect formatting causes denials.
• Add-on codes: Add-on codes (identified by + in CPT) cannot be billed without the primary procedure. Conversely, forgetting to bill the add-on code when the additional work was performed is a common charge capture gap.

Charge Reconciliation

Charge reconciliation is the process of comparing every scheduled appointment against submitted charges to identify encounters that were never billed. This is the safety net that catches everything the superbill, coding, and charge entry processes missed.

Without reconciliation, charge leakage is invisible. With it, every missed charge becomes a recoverable action item.

The Appointments-vs.-Charges Report

The core tool is a daily report that matches two data sets:

• Completed appointments -- Every appointment marked as "checked out" or "completed" in the scheduling system.
• Submitted charges -- Every charge entered into the billing system for the same date of service.

Any appointment without a corresponding charge is a potential missed bill. The report should be generated daily and reviewed by the billing team before the end of the following business day. The longer a missed charge goes unidentified, the harder it is to recover -- providers forget details, and timely filing deadlines approach.

Missing Charge Follow-Up Process

1. Daily report generation: Run the appointments-vs.-charges report each morning for the prior business day.
2. Categorize discrepancies: Not every missing charge is an error. Some represent no-shows not marked correctly, appointments rescheduled without canceling the original, or lab-only visits that do not generate a professional charge. Categorize each discrepancy.
3. Route to responsible party: True missing charges are routed to the provider for completion. Set a 48-hour turnaround expectation. If the provider has not responded, escalate to their department lead.
4. Track patterns: If the same provider consistently appears on the missing charges report, the root cause is usually a workflow issue (not using the EHR charge capture tool, relying on paper superbills that get lost) rather than negligence. Address the workflow, not the individual.
5. Measure charge lag: Track the average number of days between date of service and charge entry. Best practice is same-day or next-day. If your average exceeds 3 days, you have a systemic delay that needs process intervention.

Technology Solutions

EHR-Based Charge Capture

Integrated EHR systems are the strongest platform for charge capture because they connect documentation directly to coding and billing. Key capabilities to evaluate:

• Auto-populated charge tickets: The system generates a charge ticket from the documentation, pre-populating E/M codes based on MDM elements documented and suggesting procedure codes from orders entered during the visit.
• Real-time code validation: NCCI edit checks, LCD/NCD compliance, and modifier logic run before the charge is submitted, catching errors at the point of care rather than after denial.
• Missing charge alerts: The system flags encounters that have been documented but not yet had charges submitted, prompting providers to complete charge entry before signing the note.
• Batch charge review: Coding staff can review pending charges in a queue, comparing documentation against proposed codes before release to billing.

Mobile Charge Capture Applications

For providers who deliver care outside the office -- hospitalists, surgeons, long-term care physicians, and locum tenens providers -- mobile charge capture applications solve the rounding charge problem. These applications allow providers to enter charges from a smartphone immediately after an encounter, eliminating the end-of-day batching that leads to forgotten charges.

Key features to evaluate in mobile charge capture platforms:

• Census management with patient lists by facility and floor
• ICD-10 and CPT search with specialty-specific favorites
• Integration with the practice's EHR and billing system (charges flow directly without re-entry)
• Charge reconciliation against hospital ADT feeds
• HIPAA-compliant architecture with remote wipe capability

Clinical Documentation Improvement (CDI)

CDI programs use a combination of technology and human review to ensure clinical documentation accurately reflects the severity of illness, complexity of care, and services provided. Originally developed for inpatient DRG optimization, CDI programs are increasingly deployed in outpatient settings to improve charge capture and coding accuracy.

• NLP-driven documentation analysis: AI models scan completed notes and flag instances where the documentation supports a higher E/M level or additional billable services than what was coded.
• Concurrent query generation: CDI specialists send queries to providers in real time (before the encounter is finalized) asking for clarification or additional documentation to support more specific diagnoses.
• HCC gap closure: For practices in value-based contracts, CDI technology identifies chronic conditions documented in prior years but missing from the current year's records, prompting providers to reassess and document these conditions.

Building a Charge Integrity Program

Technology and process fixes are necessary but not sufficient. Sustainable charge capture improvement requires an organizational program with accountability, measurement, and continuous education.

1. Regular Coding Audits

Every practice should conduct routine coding audits, not just in response to payer requests. The audit framework:

• Prospective audits: Review 5-10% of claims before submission. This catches errors before they become denials or compliance issues.
• Retrospective audits: Review 10-20 charts per provider per quarter. Compare the documentation against the codes billed and identify patterns of overcoding, undercoding, and missed charges.
• New provider audits: Audit 20-30 charts for each new provider during their first 6 months. New providers are the highest risk for both coding errors and workflow gaps.
• Targeted audits: When a payer flags a specific code, provider, or service, conduct a targeted review of that area. Do not wait for an external audit to investigate.

2. Provider Education

Audit findings are only valuable if they drive behavior change. Deliver audit results to providers individually, confidentially, and within 2 weeks of the audit. Frame results as education, not punishment.

• Conduct quarterly coding education sessions covering the most common errors found in audits.
• Distribute specialty-specific coding tip sheets at least annually, updated for CPT and payer policy changes.
• Pair new providers with a coding mentor during their first year.
• Include charge capture and coding accuracy as a metric in annual provider performance reviews.

3. Dashboards and Metrics

Visibility drives accountability. Build dashboards that track:

• Charge lag -- Average days from date of service to charge entry, by provider.
• E/M distribution -- Each provider's E/M level distribution compared to specialty benchmarks and peer averages.
• Charges per encounter -- Average number of charge lines per visit, by provider and visit type. A provider who consistently has fewer charges per encounter may be missing ancillary services.
• Missing charge rate -- Percentage of completed appointments without corresponding charges, by provider.
• Modifier denial rate -- Denial rate for claims with modifiers, by modifier type.
• Coding error rate -- Percentage of audited charts with coding discrepancies, by provider and error type.

4. Accountability Structure

Assign clear ownership of charge integrity:

• Charge capture coordinator -- A designated role (often the billing manager or a senior coder) responsible for daily reconciliation, audit scheduling, and dashboard reporting.
• Physician champion -- A clinician who advocates for coding accuracy among peers, reviews audit findings with providers, and helps design documentation templates.
• Compliance officer linkage -- Coding audits should report findings to the compliance officer. Patterns of overcoding or unbundling must be addressed through the compliance program, not just the billing department.
• Monthly review cadence -- Practice leadership reviews charge integrity dashboards monthly, with action items assigned for any metric that falls outside acceptable thresholds.

Frequently Asked Questions

Your Action Plan

Charge capture and coding accuracy are not one-time projects -- they are ongoing disciplines that require process, technology, and accountability working together. The practices that eliminate revenue leakage share three characteristics: they measure it, they have someone responsible for it, and they address root causes rather than symptoms.