Performance Measurement in the Hospital Outpatient Setting. Services/Procedures and Associated Diagnoses Representing the Largest Share of Costs in the Hospital Outpatient Setting and Emergency Department

02/01/2008

Tables 3.4 and 3.5 highlight the 20 costliest services/procedures in the HOPS and ED, respectively, as well as the associated diagnoses based upon analysis of 2005 Medicare data with 2007 APC payment rates applied.25 These data show that, had 2007 payment rates been in force in 2005, many of the most common services/procedures also would have accounted for a substantial share of total costs, although there are some changes in distribution given the relative weight of the more costly services. For example, while Level I plain films (APC 0260) and Level III Pathology (APC 0343) are the first and second most frequent APCs billed in the HOPS, APC 0260 ranks only sixth in cost and APC 0343 is not among the top 20 most costly services/procedures. Similarly, neither cataract surgery (APC 0246) nor cardiac catheterization (APC 0080), the two services/procedures accounting for the greatest share of payments for HOPS services, are among the 20 most frequent services/procedures provided in the HOPS. In the ED, CT scans were found to be the costliest (vs. X-rays which were most frequent). No single service/procedure accounted for a large proportion of the total cost; however, given the magnitude of the costs involved, even one to two percent of total costs remains significant.

 
Rank Total Cost Percent of Total APC APC Description Most Common Clinical Categories Within APC Specialty Providing Service
Table 3.5. Services/Procedures Accounting for the Largest Fraction of Costs in the HOPS and Associated Diagnoses, Medicare 200526
1 $998,098,614 5.24% 246 Cataract Procedures with IOL Insert Ophthalmology Ophthalmology
2 $893,140,496 4.69% 80 Diagnostic Cardiac Catheterization Medicine-Cardiology, Medicine-General Cardiology
3 $790,845,474 4.15% 143 Lower GI Endoscopy Medicine-GI, Medicine-General, Medicine-Oncology/Neoplasia, Surgery-General Gastroenterology, General Surgery, Internal Medicine
4 $721,166,930 3.78% 283 Computerized Axial Tomography with Contrast Material Medicine-General, Medicine-Oncology/Neoplasia, Medicine-GI, Orthopedics, Urology Radiology, Facility
5 $460,378,894 2.42% 141 Level I Upper GI Procedures Medicine-GI, Medicine-General, Medicine-Oncology/Neoplasia, Surgery-General Gastroenterology
6 $415,343,018 2.18% 260 Level I Plain Film Except Teeth Medicine-General, Orthopedics, Medicine-Oncology/Neoplasia, Medicine-Cardiology, Urology Radiology, Facility
7 $408,942,846 2.15% 301 Level II Radiation Therapy Medicine-Oncology/Neoplasia, Medicine-General Radiation Oncology
8 $371,722,046 1.95% 280 Level III Angiography and Venography Medicine-General, Neurology, Medicine-Cardiology Cardiology, Facility
9 $347,637,485 1.82% 107 Insertion of Cardioverter-Defibrillator Medicine-General, Medicine-Cardiology Cardiology
10 $345,378,970 1.81% 336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast Orthopedics, Medicine-General, Neurology, Medicine-Oncology/Neoplasia, Neurology/Neurosurgery Radiology, Facility

 

Rank Total Cost Percent of Total APC APC Description Most Common Clinical Categories Within APC Specialty Providing Service
Table 3.5. Services/Procedures Accounting for the Largest Fraction of Costs in the HOPS and Associated Diagnoses, Medicare 2005 (continued)
11 $305,728,764 1.60% 207 Level III Nerve Injections Orthopedics Anesthesia, Pain Management
12 $304,144,743 1.60% 337 MRI and Magnetic Resonance Angiography without Contrast Material followed Medicine-General, Orthopedics, Neurology, Medicine-Oncology/Neoplasia, Ophthalmology Radiology, Facility
13 $283,460,736 1.49% 131 Level II Laparoscopy Surgery-General Surgery-General, OB/GYN
14 $282,675,723 1.48% 81 Non-Coronary Angioplasty or Atherectomy Medicine-General, Medicine-Nephrology, Medicine-Cardiology Radiology, Nephrology
15 $282,329,852 1.48% 154 Hernia/Hydrocele Procedures Surgery-General Surgery-General
16 $272,367,293 1.43% 41 Level I Arthroscopy Orthopedics Orthopedics, Hand Surgery
17 $256,608,392 1.35% 412 IMRT Treatment Delivery Medicine-Oncology/Neoplasia, Medicine-General Radiation Oncology
18 $238,689,974 1.25% 108 Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads Medicine-Cardiology, Medicine-General Cardiology
19 $221,360,707 1.16% 377 Level III Cardiac Imaging Medicine-Cardiology, Medicine-General Cardiology
20 $220,392,959 1.16% 332 Computerized Axial Tomography and Computerized Angiography without Contrast Medicine-General, Medicine-Oncology/Neoplasia, Orthopedics, Urology, Neurology Radiology, Facility

 

Rank Total Payment Percent of Total APC APC Description Most Common Clinical Categories Within APC Specialty Providing Service
Table 3.6. Services/Procedures Accounting for the Largest Fraction of Costs in the ED and Associated Diagnoses, Medicare 200527
1 $348,624,430 20.40% 332 Computerized Axial Tomography and Computerized Angiography without Contrast Medicine-General, Head and Neck, Urology, Orthopedics, Neurology Radiology, Facility
2 $289,417,454 16.93% 260 Level I Plain Film Except Teeth Medicine-General, Orthopedics, Medicine-Cardiology, Medicine-GI, Surgery-General Radiology, Facility
3 $136,094,122 7.96% 440 Level V Drug Administration Medicine-General, Medicine-GI, Urology, Orthopedics, Medicine-Cardiology  Radiology, Facility
4 $127,458,198 7.46% 283 Computerized Axial Tomography with Contrast Material Medicine-General, Medicine-GI, Orthopedics, Urology, Surgery-General Radiology, Facility
5 $93,423,075 5.47% 438 Level III Drug Administration Medicine-General, Medicine-GI, Orthopedics, Medicine-Cardiology, Urology Facility
6 $83,737,588 4.90% 99 Electrocardiograms Medicine-General, Medicine-Cardiology, Medicine-GI, Orthopedics, Neurology Internal Medicine, Cardiology
7 $48,117,432 2.82% 437 Level II Drug Administration Medicine-General, Orthopedics, Surgery-General, Head and Neck, Medicine-GI Facility
8 $44,164,587 2.58% 261 Level II Plain Film Except Teeth Including Bone Density Measurement Medicine-General, Orthopedics, Surgery-General, Head and Neck, Medicine-GI Radiology, Facility
9 $34,926,490 2.04% 24 Level I Skin Repair Head and Neck, Surgery-General, Medicine-General Dermatology
10 $31,091,509 1.82% 80 Diagnostic Cardiac Catheterization Medicine-Cardiology, Medicine-General Cardiology

 

Rank Total Payment Percent of Total APC APC Description Most Common Clinical Categories Within APC Specialty Providing Service
Table 3.6. Services/Procedures Accounting for the Largest Fraction of Costs in the ED and Associated Diagnoses, Medicare 2005 (continued)
11 $29,406,190 1.72% 266 Level II Diagnostic and Screening Ultrasound Medicine-General, Orthopedics, Dermatology, Medicine-GI, Urology Urology, Radiology
12 $19,823,305 1.16% 333 Computerized Axial Tomography and Computerized Angiography without Contrast Medicine-General, Medicine-GI, Urology, Orthopedics, Surgery-General Radiology, Facility
13 $19,371,442 1.13% 662 Computerized Tomography Angiography Medicine-General, Orthopedics, Medicine-Cardiology, Neurology, Medicine-GI Radiology, Facility
14 $17,646,836 1.03% 58 Level I Strapping and Cast Application Orthopedics, Medicine-General Emergency Medicine, Podiatry
15 $17,331,919 1.01% 377 Level III Cardiac Imaging Medicine-General, Medicine-Cardiology  Cardiology
16 $17,313,659 1.01% 269 Level II Echocardiogram Except Transesophageal Medicine-General, Medicine-Cardiology, Neurology, Orthopedics, Medicine-GI Cardiology
17 $17,241,882 1.01% 336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast Medicine-General, Orthopedics, Neurology, Head and Neck, Dermatology Radiology, Facility
18 $16,854,241 0.99% 267 Level III Diagnostic and Screening Ultrasound Medicine-General, Orthopedics, Neurology, Dermatology, Medicine-Cardiology Cardiology, Vascular Surgery
19 $16,440,588 0.96% 141 Level I Upper GI Procedures Medicine-General, Medicine-GI Gastroenterology
20 $16,401,852 0.96% 77 Level I Pulmonary Treatment Medicine-General Family Practice, Internal Medicine

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