EPIC Workflow for Charge Capture (Step-by-Step Guide)
- Alexis Wilkinson CPC
- Jan 15
- 3 min read
Updated: Mar 15
Step-by-step Epic MAR Workflow for Infusion and Injection Charge Capture
Accurate infusion and injection review for charge capture in Epic does not begin in the Medication Administration Record (MAR).
It begins with validating the entire encounter.
Before reviewing IV infusions, IV pushes, IM injections, or SubQ administrations, coders must confirm patient status, location, posted charges, and order timing. Failure to review these elements can result in status sequencing errors, incorrect observation time, and compliance red flags.
This guide outlines what to review step-by-step Epic workflow — and why it matters for defensible charge capture.
1. Review Patient Status First (ER, Observation, or Inpatient)
Patient status drives billing.
Before reviewing the MAR, confirm:
Emergency Room (ER) status
Observation (OBV) status
Inpatient admission
Exact time of the status order
Any status changes during the encounter
Why This Matters
Inpatient charges can never be posted before observation charges.
If inpatient charges appear before observation services, that is a red flag and requires immediate review.
Additionally, if a patient:
ER → Inpatient → Downgraded back to Observation
There must be a documented Code 44.
A missing Code 44 in this scenario is a compliance issue.
Status sequencing must make regulatory and clinical sense before reviewing medication administration.
2. Review Posted Charges on the Patient Account
Before analyzing documentation, review what has already been charged.
Inside Epic, confirm:
Charges already dropped to the account
Department associated with each charge
Date and time tied to posted services
Why This Matters
The account reflects what the system believes occurred.
You must validate that:
Charges align with patient status
Inpatient services are not billed before observation
Services are not posted outside the authorized encounter window
Departments align with the patient’s physical location
If the charges do not match the documented status and timing, the account is not defensible.
3. Review Event Management (Patient Location in Epic)
Location validation is critical for observation charge capture and infusion billing compliance.
In Epic Event Management, confirm:
Physical patient location
Transfer times between departments
Time spent in each unit
Carving Out Observation Time
For observation billing, you must carve out time when the patient was not physically in the observation bed or assigned unit.
For example:
Procedures performed in another department
Transfers to another unit
Time outside the observation area
Observation hours must reflect accurate, supported time.
Location supports time.Time supports charges.
Without validating location, observation billing cannot be defended.
4. Verify Orders in Doc Review
Orders define authority and encounter boundaries.
In the Doc Review tab, confirm:
Observation order time
Inpatient admission order time
Discharge order time
Status change documentation
Any Code 44 documentation (if applicable)
Non-Negotiable Documentation Requirements
Infusion and injection coding must be supported by:
1. Physician Order
Must include:
Drug name
Dose
Route
Frequency
Valid authentication
Must include
Drug name
Dose
Route
Start and stop times (for infusions)
3. Medical Necessity
Documentation must support why the service was required, such as:
Clinical signs and symptoms
Abnormal labs
Provider assessment
Why This Matters
Orders establish:
When billing can begin
When billing must stop
Whether status transitions are valid
Anything documented outside order timestamps requires reconciliation.
Status changes without proper documentation create compliance exposure.
5. Review the MAR (Medication Administration Record)
Only after validating status, charges, location, and orders should you move to the MAR.
Inside the MAR, review:
Medication name
Route of administration (IV, IM, SubQ)
Administration times
Start and stop times for infusions
Pauses, restarts, and rate changes
The MAR reflects clinical workflow.
Your responsibility is to extract a clear, defensible administration timeline.
Detailed CPT application for infusion and injection services should only occur after this validation process is complete.
Common Red Flags in Epic Charge Capture
When reviewing infusion and injection workflows in Epic, watch for:
Inpatient charges posted before observation charges
Missing Code 44 when downgrading from inpatient to observation
Observation time not carved out for off-unit procedures
Charges posted outside admission or discharge timestamps
Department mismatches with patient location
Infusion documentation without supporting status validation
These issues are not coding errors.
They are workflow validation failures.
Why This Epic Workflow Matters
Infusion and injection coding compliance depends on encounter validation.
alignment
The defensibility of a claim depends on alignment between:
Status → Orders → Location → Posted Charges → MAR Documentation
If these elements do not align, the account is vulnerable during audit or payer review.
Accurate charge capture in Epic is not about clicking through screens in order.
It is about validating that the encounter makes sense from a regulatory, billing, and clinical perspective.
When coders understand what to review and why infusion and injection charge capture becomes defensible, compliant, and audit-ready.
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