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The major advancements in the field of medicine have transformed the landscape of healthcare in the United States. Surgical services are now being provided in some cases on an outpatient basis. For instance, several urology procedures are conducted in an outpatient set up as they are a preferred alternative for many patients on account of benefits such as convenient schedule, personalized care, fewer delays, lesser cost and excellent service quality associated with the same. When compared with inpatient surgery that requires a patient to stay in the hospital overnight, an OP procedure does not require overnight stay and patients can leave the hospital the same day after the surgery.

OP services essentially include planned procedures, assessments, treatments, day surgery, chronic disease management and prevention and education services that are carried out by a specialist, which do not require overnight stay. These physicians or specialists are reimbursed for their services on the basis of the diagnostic and procedural codes they report on the medical claims of patients. Medicare uses ICD-9 codes to identify diagnoses and procedures in the hospital inpatient setting. Physician services are the same irrespective of whether they are provided on an outpatient or inpatient basis. However, facility resources used are quite different for outpatient vs. inpatient.

Facility outpatient services and physician services are reimbursed under Medicare Part B whereas facility inpatient services are paid under Medicare Part A. Facility observation services are also reimbursed under Medicare Part B unless the patient is later admitted as an inpatient. Significant variation exists between Medicare Part A Inpatient Prospective Payment System (IPPS) and Part B Hospital Outpatient Prospective Payment System (HOPPS). IPPS payment for the facility is based on MS-DRGs (Medicare Severity Diagnosis Related Groups), whereas HOPPS payment for the facility is based on APCs (Ambulatory Procedure Classifications).

For e.g. “Prostatectomy” MS-DRG codes:

  • MS-DRG 665 – Prostatectomy with MCC
  • MS-DRG 666 – Prostatectomy with CC
  • MS-DRG 667 – Prostatectomy without CC/MCC
  • MS-DRG 707 – Major male pelvic procedures with CC/MCC
  • MS-DRG 708 – Major male pelvic procedures without CC/MCC
  • MS-DRG 713 – Transurethral prostatectomy with CC/MCC
  • MS-DRG 714 – Transurethral prostatectomy without CC/MCC

Prosthetic Urological Procedures APC codes:

  • 0385 – Level I Prosthetic Urological Procedures
  • 0386 – Level II Prosthetic Urological Procedures

As per 2012 statistics from the Journal of Urology, more than 53 million OP procedures are performed annually in the United States. Even though most of these procedures were generally carried out in hospital OP departments, many of them are being performed at non-hospital based facilities like physician offices or ambulatory surgery centers.

Any complications arising from OP surgery may increase the number of patient readmissions. With the Hospital Readmission Reduction Program (which is part of the 2010 Patient Protection and Affordable Care Act), Medicare payments are reduced by penalizing hospitals with excessive readmission rates. This will affect the revenue of healthcare providers. Another risk with inaccurate coding is the patient’s health. Failure to assign appropriate codes will significantly affect patient health.

Shift from Inpatient to Outpatient Setting Involve Higher Death Rates

A recent survey found that the trend of hospitals shifting urological surgeries from inpatient to outpatient setting has led to an increase in the number of preventable death following complications. The study led by researchers at the “Henry Ford Hospital” utilized nationwide medical records of patients (between the years 1998 and 2010) discharged following a urologic surgery.

Researchers analyzed a pool of 7.7 million surgeries to assess both overall and FTR (failure to rescue) mortality rates (a death that occurred due to a complication that was potentially recognizable and preventable) of these patients.

The study results were published online in the official journal of the British Association of Urological Surgeons. The core details and the findings of the study are mentioned below –

  • A 5% increase in FTR mortality rate was recorded while both admissions for urologic surgery and overall mortality rates decreased slightly. A shift from inpatient procedures to OP surgery may have spiked the FTR rate.
  • Researchers analyzed each patient’s age, race and health insurance status (including private insurance, Medicare, Medicaid and self pay). The severity of illness of each patient was also verified based on co-morbidity or the presence of other chronic diseases at the time of their surgery.
  • Older patients who belonged to the minority group, having public insurance and who suffered from other diseases were at higher risk of suffering death after detection of complications from a surgery.

It is crucial for urology surgeons and support staff to understand the possible risks and disadvantages associated with OP procedures and further complications that may arise leading to even a patient’s death. The findings of the study signify the need to provide a higher level of attention and care for those patients who have undergone urology procedures. Accurate documentation of diagnoses and various services provided is also crucial. This will help to reduce the mortality rate and other complications related to urology procedures.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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