The Art of Implementing Epic’s Facility Charge Calculator

Realizing the Full Value of Clinical Care

Emergency and outpatient departments provide complex, resource-intensive care that is vital for safe patient outcomes. Accurately capturing the value of this care within Epic is essential to ensure the organization has the financial resources to sustain the highest quality of service. 

The real opportunity lies in leveraging Epic’s native tools to create a direct link between clinical excellence and operational value. By optimizing documentation, we can ensure that the system reflects the true depth of care provided without adding administrative burdens to the clinicians at the bedside. As an Epic expert with a background in ASAP, Hospital Billing, and HIM, my role is to make these tools work for the care team, bridging the gap between clinical reality and the value required to support it. 

The Challenge: Replacing “Black Box” Systems with Automation 

Recently, I worked with a large healthcare organization to replace a proprietary third-party system (Lynx) with Epic’s native Facility Charge Calculator (FCC) across their enterprise. The organization was transitioning from a “black box” algorithm, where the logic for charging was hidden and proprietary, to a transparent and defensible system built directly into Epic. 

Achieving financial accuracy was critical, but it was important to do so without creating a “double documentation” burden. We needed a solution where nurses could focus on the clinical record without having to document care a second time purely for billing purposes. 

Industry Context: ED Level of Service Charging 

To understand the value of this transition, it helps to look at how the industry handles Emergency Department charging. Federal guidelines for the five levels of service haven’t been significantly updated in decades, which leads different organizations to adopt varying models to define patient acuity. 

• The “Bucket” Model (Common Industry Practice): Many organizations utilize a “bucket” approach. In this approach, if a patient receives a single high-acuity service, such as a specific complex infusion, that falls into the “Level 4 bucket,” the entire visit is charged at Level 4 regardless of other factors. 

• The “Points” Model (Our Implementation): We implemented a points-based system. Instead of one item dictating the charge, the system assigns weighted points to various clinical activities like orders, medications, and flowsheets. These points accumulate in the background to determine the final level. 

This shift from the proprietary algorithm, or “black box,” provides a more accurate representation of resources used based on the patient’s care, creating a fairer and more defensible charge for the patient. 

The “Fixer” Role: Bridging Strategy and Operations 

Technology is rarely the point of failure for projects of this magnitude. The real challenge lies in managing the competing interests of the diverse groups involved. Success required acting as a translator and mediator between five distinct groups, each with valid but often conflicting needs. 

• Third-Party Consultants: Provided the financial roadmap and scoring algorithm with a focus on maximizing revenue opportunities. 

• Nursing Informatics: Focused on protecting clinicians from administrative burnout and redundant workflows. 

• IT / Information Services: Prioritized system stability and ensuring new builds aligned with existing capabilities and configuration. 

• Revenue Integrity and Compliance: Required precise, defensible data to survive audits. 

• Operational Leadership: Needed high-level outcomes to meet the financial requirements that triggered the project. 

My role was to align these perspectives. When a proposed workflow didn’t align with Epic’s logic, I translated the requirement into technical reality. When Revenue stakeholders pushed for more data points, I collaborated with Nursing Informatics to find ways to capture that data without adding clicks. By translating technical impacts into business language, often using pros/cons tables to illustrate the downstream effects of a decision, we created a solution that met financial goals while respecting clinical reality. 

Technical Deep Dive: Architecting the Solution 

Transitioning to this model required a complex technical build across multiple care settings, ensuring that the logic was robust enough to handle high patient volumes. 

• Emergency Department (ED): The ED build was intricate, requiring approximately 70 rules at the top layer, with nested rules underneath to handle the complex logic of calculating points, all in one Facility Charge Calculator. A major focus was ensuring the calculator only counted time spent in the ED or respected the specific time range. We used specific rule properties to ensure ED charges stopped accruing the moment an admit order was placed. Without this “hard stop,” the system might inadvertently count inpatient vitals toward the ED level of service, creating compliance issues. 

• Observation Units: We implemented logic for “observation carve-out charges.” This involves automatically subtracting time when other billable procedures, like surgery or PT, occur during observation hours to prevent double billing. We established a workflow where 100% of these accounts route to a workqueue for manual verification, ensuring the automated “subtractions” are accurate before a bill drops. 

• Hospital Outpatient Departments (HODs): This massive undertaking involved bringing approximately 24 departments live on another specialized Facility Charge Calculator simultaneously. This allowed the organization to consolidate three legacy products into the single Epic platform they were already paying for, reducing technical debt. 

• Infusion Centers: We deployed Epic’s “Assisted Infusion Calculator” across Observation, Outpatient, and ED settings to automate the complex calculations required for medication run-times and infusion administration charging. 

The Implementation Strategy: Clinician-First 

We prioritized financial accuracy while strictly protecting the clinical workflow. To do this, we strategically avoided duplicate documentation wherever possible. We wanted to avoid the use of manual “charge sheets” or pick-lists at the end of a visit to capture information just for charging. Instead, we configured the algorithm to “scrape” data elements clinicians were already documenting in their standard flowsheets and orders. 

Discovery also took precedence over assumptions. Using tools like SlicerDicer, we analyzed actual order usage to ensure our rules matched reality. For example, rather than building rules based on a theoretical list of restraint orders, we looked at the data to identify the specific orders clinicians were actually placing in the system. We were able to use the data in the system to help us build a product that would work for the clinicians and healthcare system. This ensured the calculator gave credit for the work actually being done on the floor rather than missing potential charges due to a mismatch between the build and clinical practice. 

Measuring Success: Revenue vs. Operational Health 

Increased revenue is often the headline for these projects, ensuring the organization is fairly compensated for the work they do, but operational health is equally critical for long-term success. To validate the quality of the build, we tracked a critical operational metric: the percentage of charts with changed point values post-live. 

This data point serves as a canary in the coal mine. If auditors are manually changing the system-calculated score frequently, the automation is failing. We found that specific sites had change rates over 50%, which directly correlated with the departments that were reporting the most frustration. This data allowed us to pinpoint exactly where the build or workflow needed refinement, reducing the manual backlog and stabilizing the system far faster than if we had only focused on revenue totals. 

Conclusion: The Value of Integrated Expertise 

This project demonstrated that successful healthcare IT requires the convergence of technical skills and financial strategy. True success comes from having partners who understand the “boots on the ground” reality. We build comprehensive solutions that respect the clinical workflow while achieving financial goals.