Hierarchical Condition Categories (HCCs) – Success Story

A Southern California IPA hired Hirschl and Associates to audit 700 medical records for possible HCC revisions. The purpose of the initial assessment was to evaluate the appropriateness of ICD-9-CM coding and physician documentation practices and to correct claims data to generate appropriate risk-adjusted reimbursement.

  • H&A:
    • Performed data analysis,
    • Identified probability factors,
    • Selected accounts to be reviewed,
    • Conducted audit of 700 medical records,
    • Identified 246 omitted or incorrectly assigned HCCs,
    • Provided physician and coding staff education,
    • Increased capitated contract revenue by 12%
    • Initially recovered $1.2 million of additional HCC revenue ,
    • Continues to provide IPA's HCC Management service and performs on-going, monthly data analysis, auditing, and education.

Emergency Department – E/M Success Story

Hirschl and Associates has assisted health systems improve Emergency Department revenue by developing or revising standardized criteria used to determine facility-based Evaluation and Management Level of Service charges. H & A assisted client hospitals in establishing criteria that generate compliant and appropriate E/M level assignments that typically result in correspondingly higher payments. Project metrics indicate H&A clients have realized net revenue increases ranging from $2-19 million.

  • H&A:
    • Performed data analysis,
    • Conferred with Emergency Department leadership,
    • Developed and/or revised compliant E/M guidelines,
    • Created E/M criteria tools,
    • Implemented charge capture and coding best practices,
    • Provided physician and coding staff education, and
    • Increased revenue by $2-$19 million.

Emergency Department – Billing Success Story

By identifying billing and information system glitches, Hirschl and Associates helps clients improve revenue. At one large health system, H&A uncovered unbilled Emergency Department CPT-4 procedures that had been coded properly in Health Information Management but did not transfer to the UB-92.

  • H&A:
    • Generated and analyzed HIM “soft-coded” database reports (over a period of 16 months),
    • Linked all CPT codes and accounts,
    • Developed and updated ED CDM to include charges for all ED CPT-4 procedures,
    • Identified and helped to correct billing form logic glitch,
    • Created pre-billing edits,
    • Generated $2 million recovered APC payment

Outpatient Infusion and Injection Services - Success Story

Charge Capture for Infusion and Injections services is challenging for all outpatient service areas. H&A has worked with hospitals nationally in developing and implementing best practices in infusion and injection services charge capture.

At a large health system in Texas, the Pediatric Oncology clinic routinely omitted charges for Epoetin injections. Correction of the charge ticket and training of department staff compliantly generated $1M in increased revenue.

  • H&A:
    • Generated and analyzed revenue and usage reports,
    • Audited accounts,
    • Corrected Charge Ticket and provided charge capture training to point of service staff, and
    • Generated $1 million recovered gross outpatient revenue

Cardiac Cath Lab – Success Story

Interventional Cardiology services present billing challenges for many hospitals. H&A has worked with facilities nationally to identify Interventional Cardiology revenue improvement opportunities and implement best practices as needed.

At one client hospital, the Cardiac Cath Lab routinely omitted charges for cardiac catheterization injection supervision and interpretation services. Revision of charge capture protocols and correction of the CDM compliantly generated an additional $2.7M in increased revenue.

  • H&A:
    • Generated and analyzed database reports using ICD-9-CM cardiac catheterization procedure codes,
    • Analyzed payer mix reports and forecasted revenue improvements,
    • Audited accounts,
    • Developed pre-billing edits, and
    • Generated $2.7 million in additional commercial payer reimbursement.

Cancer Center/Oncology Services - Success Story

Charge Capture for Chemotherapy services can be troublesome for any organization. H&A has worked with hospitals across the country in developing and implementing best practices in chemotherapy services charge capture and documentation.

At one Massachusetts hospital, the Cancer Center inappropriately charged for “initial” rather than “additional/subsequent” hours of IV hydration and/or therapy services during Chemotherapy encounters. In 2006, this client decided that CPT and HCPCS codes that did not generate APC payments would be assigned a $0 charge. As a result of the $0 charge assignment, Chemotherapy HCPCS codes did not transfer to the bill when the Cancer Center properly charged for additional hours of infusion and Chemotherapy services. In addition, nursing documentation did not support the duration of Chemotherapy services as infusion ‘discontinue time’ was not routinely noted. Correction of the CDM and training of department staff compliantly generated $870,000 in increased revenue.

  • H&A:
    • Generated and analyzed revenue and usage reports,
    • Audited sample accounts to verify documentation and charge capture and determined extrapolation opportunities,
    • Evaluated charge protocols,
    • Improved clinical documentation,
    • Updated and revised charge ticket,
    • Provided training to point of service staff,
    • Created in-house billing edits, and
    • Generated $870,000 increased net revenue

Interventional Radiology - Success Story

For many hospitals, proper coding and billing of Interventional Radiology services is the most challenging area of all. H&A has worked with numerous hospitals to identify Interventional Radiology revenue improvement opportunities.

At a large community hospital, the Interventional Radiology CDM was incomplete, improperly listing just one charge and corresponding CPT-4 code for non-tunneled vascular access device (VAD) insertion. Tunneled VAD insertions are performed routinely at this hospital and billing this CPT code generates an additional $300 in APC payment. Correction of the CDM and re-submission of corrected bills generated $777,240 in increased APC revenue.

Procedure Non-Tunneled VAD Tunneled VAD Variance
Charge $1,700.00 $3,000.00 $1,300.00
APC $ $1,371.00 $1,752.00 $381.00
2006 APC Totals $2,796,840.00 $3,574,080.00 $777,240.00
  • H&A:
    • Generated and analyzed database reports using ICD-9-CM VAD procedure codes,
    • Audited accounts to verify documentation and accurate charge capture and determine extrapolation opportunities,
    • Corrected CDM,
    • Trained charge capture staff, and
    • Generated $777,240 in additional APC reimbursement.

Radiation Therapy Brachytherapy – Success Story

Charge capture, coding and billing of Brachytherapy services presents significant risk avoidance and revenue improvement opportunities. At one large health system, charges for prostate brachytherapy services including radioactive seeds and needles did not transfer to the final bill. Correction of billing/information system interfaces generated $2.5M in increased APC revenue.

  • H&A:
    • Generated and analyzed revenue and usage reports,
    • Audited accounts to verify documentation and charge capture and determine extrapolation opportunities,
    • Forecasted revenue and reimbursement outcomes,
    • Identified billing interface glitch, and
    • Generated $2.5M in additional APC reimbursement.

Clinics – Success Story

H&A assists client hospitals in establishing criteria that generate compliant and appropriate E/M level assignments that typically result in correspondingly higher payments for hospital-based clinic services. Project summary metrics confirm that our clients have realized net revenue increases ranging from $250,000 to $2 million. At one client hospital, H&A discovered missing facility E/M charges for CHF and Wound Care clinic services. Development of E/M criteria and training of charge assignment staff compliantly generated an additional $500,000 APC reimbursement.


  • H&A:
    • Generated and analyzed revenue and usage reports,
    • Audited accounts to verify documentation and charge capture and determine extrapolation opportunities,
    • Forecasted revenue and reimbursement outcomes,
    • Developed meaningful and compliant CHF Clinic E/M criteria, and
    • Generated at least $500,000 of additional APC reimbursement.

Recovery Audit Contractor (RAC) DRG Audits – Success Story

A California based multi-hospital, health care system contracted with Hirschl and Associates to conduct pro-active, strategic RAC DRG auditing.

  • H&A:
    • Performed DRG data-mining to identify cases most likely to be targeted for RAC review,
    • Generated database reports to identify volume and coded details of accounts in initial RAC-targeted DRGs,
    • Conducted pre-emptive, focused RAC DRG audits on 350 accounts using clinical and administrative documentation,
    • Encountered 21% DRG over-code variance with $737 in net Medicare reduction per audited account,
    • Identified systemic contributors,
    • Provided education to coding staff, case managers, and physicians as needed, and
    • Continues to perform periodic QA reviews on high-profile DRGs.

GI Lab - Success Story

A large, urban teaching hospital hired Hirschl and Associates to identify opportunities in outpatient GI Lab revenue improvement.

  • H&A:
    • Assessed the GI Lab CDM,
    • Evaluated efficacy of charge protocols,
    • Analyzed claim data,
    • Conducted drill-down audits of medical records, itemized bills, electronic claims, and remittance advices,
    • Identified omitted charges for radiological Supervision and Interpretation ERCP procedures,
    • Identified several immediate process and performance improvement opportunities, and
    • Extrapolated data and forecasted $1M in revenue enhancement.