Featured Infographic   Providers Increasingly Code Outpatient Care at Higher Complexity Levels   Outpatient visits to a physician’s office, urgent care center or emergency department were coded at higher levels from 2004 to 2021, leading to substantial increases in health care spending, according to Peterson-Kaiser Family Foundation Health System Tracker. Providers and facilities bill outpatient evaluation and management claims based on visit complexity at five levels. Level 1 visits have the lowest complexity cases, with less time required or straightforward medical decision-making, while level 5 visits are the highest complexity cases, with more time required or very complex medical decision-making. Payers generally pay larger reimbursements, and patients with deductibles may pay more out-of-pocket, for visits with higher complexity. The researchers analyzed private, large-employer-based insurance claims from the Merative MarketScan Commercial Claims and Encounters database for non-elderly people from 2004 to 2021, and found that the share of claims billed at level 4 rose from 21% in 2004 to 37% to 2021. The share of moderate intensity (level 3) claims dropped from 60% to 45% over the 18-year study period. The shares of claims at all levels remained relatively stable during the COVID-19 pandemic.

Click to enlarge   The trend toward higher level claims was most pronounced in emergency departments. Level 3 claims were the most common in 2004, yet by 2021, level 4 claims accounted for over one third of claims and the share of level 5 claims more than tripled. Average evaluation and management costs in emergency departments also saw the largest relative increase at all levels. In outpatient physician offices, the share of higher level claims also increased. Level 3 claims remained the most common, but the share of those types of claims dropped from 61% in 2004 to 48% in 2021. The average cost of the highest complexity claims increased by 79%, from $134 to $240, while the cost of level 1 visits remained flat.   If outpatient visits were billed at the same levels in 2021 as 10 years ago, both physician office and emergency department evaluation and management spending would have been 4% lower. If using 2004 levels, overall emergency department spending would be 11% lower and physician office spending would be 10% lower.   Click to enlarge   NOTES: Level 1-5 refers to CPT codes 99281-99285 for emergency department evaluation and management. Cost includes amount paid by insurer and out-of-pocket cost.   SOURCES: “Outpatient Visits Billed at Increasingly Higher Levels: Implications for Health Costs,” Peterson-KFF Health System Tracker. “How Have Healthcare Prices Grown in the U.S. Over Time?” Peterson-KFF Health System Tracker.   From Health Plan Weekly Learn more about subscribing to AIS Health's publications.