News: Outpatient visits billed at increasingly higher levels, study suggests

Outpatient visits are being billed at a higher level of complexity than they were in the past, according to a recent study conducted by the Peterson-KFF Health System Tracker, Healthleaders reported.

The survey examined trends between medical level intensities and billing across private, larger employer-based insurance claims from 2004 to 2021, placing particular emphasis on how these trends have affected physician offices, urgent care centers, and emergency departments.

Generally, billing at a higher level means that the patient’s acuity required a higher intensity of care, which translates to a higher reimbursement rate. The researchers wrote, however, that they found “that claims across all those sites of care trended towards higher level codes even among specific, common diagnoses like urinary tract infections and headaches.” The report continued to state that these increased billing levels were present “even in diseases that are less likely to be worsening over time or in which co-morbidities have a smaller impact.”

The effect of higher billing has predictably translated into higher outpatient healthcare spending. For example, the report noted that if 2021 emergency and physician office visits had been coded at 2011 levels, aggregate spending wouldn’t have increased by 4%. For emergency room visits between 2001 and 2008, costs increased by $1 billion; for routine office visits between 2001 and 2010, Medicare costs increased by $6.6 billion.

With respect to the causes of these trends, the study’s authors voiced concern that “providers may be inappropriately billing for more complex—and thus more expensive—services”: in a word, upcoding. However, the researchers also noted that the trends could also “be explained by multiple factors beyond upcoding, such as increasing clinical acuity, changes in services provided, or care for some diseases shifting from the inpatient to outpatient setting.”

Editor’s note: To read HealthLeaders’ coverage of this story, click here. To access the full study, click here.