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Top 10 Outpatient Diagnoses

Outpatient care has taken up an increasingly larger share of hospitals’ overall revenue and resources, especially as organizations try to reduce unnecessary admissions and lower costs. In 2014, over half of hospitals’ net patient revenue came from outpatient care. Based upon a review of Definitive Healthcare, the current state of hospital-level outpatient care is dominated by management of chronic conditions, preventative medicine, cancer therapy, and cardiac treatment.

Top 10 ICD9 Outpatient Diagnoses by Volume, 2015

ICD9 Code Description Estimated Total Claims One-Year Trend Estimated Total Payments (M) Estimated Total Payment/Claim
1 VO53 Need for prophylactic vaccination and inoculation against viral Hep 13,255,431 $55.9* $100*
2 4019 Unspecified essential hypertension 8,665,767 12.2% $1,135.3 $131
3 25000 Diabetes w/o complication, type II or unspecified, not uncontrolled 6,798,192 -2.0% $1,112.2 $164
4 42731 Atrial fibrillation 6,243,201 -1.2% $1,531.1 $245
5 V7612 Other screening mammogram 6,124,206 6.5% $8,993.2 $1,468
6 V5883 Encounter for therapeutic drug monitoring 4,899,255 -4.8% $272.8 $56
7 V700 Routine medical examination 4,676,250 27.7% $88.9* $101*
8 V5811 Encounter for antineoplastic chemotherapy 4,607,250 10.7% $10,700.5 $2,322
9 2724 Other and unspecified hyperlipidemia 3,781,198 2.1% $264.9 $70
10 5990 Urinary tract infections, unspecified site 3,496,395 -0.8% $483.1 $138

*Medicare data only

Primary and preventive care as well as disease screening are all high-volume areas for hospital-based outpatient care. In 2015, the most common ICD-9 outpatient claim was for vaccinations, with an estimated 13.3 million all-payer claims for 2015. Mammograms and routine general examinations also ranked within the top ten with a combined 10.8 million claims. They all represent high-growth diagnoses because providers view services like vaccinations and primary care visits as critical and relatively easy ways to improve and maintain good public health, which is increasingly tied to their reimbursement. The same reasoning applies to mammograms, which, despite their cost, can be an effective way of detecting breast cancer early when performed on the right patient population.

Chronic care management is undoubtedly an important aspect of outpatient care and visits for hypertension, diabetes, and atrial fibrillation make up three of the top four most common outpatient claims. Given how widespread such conditions are in the US population, it’s not surprising that they would be among the numerous diagnoses for outpatient visits, but what is interesting is that outpatient claims for many chronic conditions are on the decline, with the exception of hypertension. Hyperlipidemia, atrial fibrillation, and diabetes all show slight decreases from 2014, though the exact reasons for improvement are unknown. According to some analysts, the lower rates correspond to reported increases in exercise and nutritious diets, and new diagnoses of diabetes have been on a steady decline since 2008.

Top 10 ICD9 Outpatient Diagnoses by Total Estimated Payments, 2015

ICD9 Code Description Estimated Total Payments (M) Estimated Total Payment/Claim Estimated Total Claims One-Year Trend
1 V5811 Encounter for antineoplastic chemotherapy $10,700.5 $2,322 4,607,653 10.7%
2 V7612 Other screening mammogram $8,993.2 $1,468 6,124,206 6.5%
3 41401 Coronary atherosclerosis of native coronary artery $3,461.0 $1,783 1,940,981 27.2%
4 V5812 Encounter for anitneoplastic immunotherapy $3,267.0 $4,784 682,964 40.2%
5 1749 Malignant neoplasm of breast (female), unspecified $2,238.8 $927 2,415,515 0.6%
6 78650 Chest pain, unspecified $1,941.6 $740 2,623,513 -2.5%
7 V580 Encounter for radiotherapy $1,880.2 $1,578 1,191,656 13.2%
8 185 Malignant neoplasm of prostate $1,741.9 $869 2,004,010 5.1%
9 V7651 Special screening for malignant neoplasms of colon $1,645.2 $1,190 1,382,797 15.0%
10 78659 Other chest pain $1,560.5 $996 1,567,198 6.0%

In terms of total estimated reimbursements by all payers, chemotherapy, related cancer services, and chest pain diagnoses had the highest overall payments. The most expensive ICD-9 outpatient visit was encounters for antineoplastic chemotherapy, with an estimated total reimbursement amount of $10.7 billion. Mammography followed with a total of nearly $9 billion in reimbursements, due largely to the significant volume of visits (slightly over 6.1 million). Six of the top ten codes involve cancers or tumors, which is attributable to the growing cost of oncology drugs and because the hospital setting traditionally commands higher costs for cancer-related visits, according to at least one study. Five of the six also show significant year-over-year claims increases, driven in part by an older population and greater screening efforts.

It’s important to note that all of the above ICD-9 codes represent outpatient diagnoses given at hospital outpatient departments, rather than physician offices. For hospitals, the distinction usually means a higher reimbursement rate, a well-documented trend that CMS is trying to eliminate through site-neutral payment rules that were finalized in early November 2016. Though CMS has not specified exactly which services may be affected, it’s likely that many hospitals will reassess how and where they deliver outpatient care in the near future. In a few years, it’s entirely possible that the most common and most expensive outpatient ICD-9s will be very different.

Definitive Healthcare has the most up-to-date, comprehensive and integrated data on over 7,700 hospitals, 1.4 million physicians, and numerous other healthcare providers. We offer detailed analytics on inpatient and outpatient hospital metrics.

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