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Inpatient vs. Outpatient: Comparing Two Types of Patient Care

More than ever, patients are engaged in their medical care, which is encouraging when you consider most medical school mission statements emphasize patient communication and education. It’s also worth noting that research shows providers are able to drive positive patient outcomes using a teach-back method that involves caring and clear language. Yet even well-informed individuals lack some knowledge, such as the distinction between inpatient versus outpatient care.

So what’s the difference, and why does it matter? This overview can help you advance your health literacy.

Inpatient vs. outpatient: Distinguishing the differences in care

What is an inpatient ? In the most basic sense, this term refers to someone admitted to the hospital to stay overnight, whether briefly or for an extended period of time. Physicians keep these patients at the hospital to monitor them more closely.

With this in mind, what is outpatient care? Also called  ambulatory care , this term defines any service or treatment that doesn’t require hospitalization. An annual exam with your primary care physician is an example of outpatient care, but so are emergent cases where the patient leaves the emergency department the same day they arrive. Any appointment at a clinic or specialty facility outside the hospital is considered outpatient care as well.

While there’s a clear difference between an inpatient and an outpatient, there is a little bit of gray area as well. Occasionally, physicians will assign a patient  observation status while they determine whether hospitalization is required. This period typically lasts for no more than 24 hours.

Also note that the location itself doesn’t define whether you’re an inpatient versus outpatient. It’s the duration of stay, not the type of establishment, that determines your status.

Inpatient vs. outpatient: Comparing services

You’re probably starting to get a sense of the varying circumstances that fit under each category. To further recognize the difference between inpatient and outpatient care, review the below treatments and services that are common for these two types of care.

Inpatient care examples

• Complex surgeries, as well as some routine ones
• Serious illnesses or medical issues that require substantial monitoring
• Childbirth, even in cases that don’t require a cesarean section
• Rehabilitation services for psychiatric illnesses, substance misuse, or severe injuries

Outpatient care examples

• X-rays, MRIs, CT scans, and other types of imaging
• Lab tests, such as bloodwork
• Minor surgeries, particularly ones that use less invasive techniques
• Colonoscopies
• Consultations or follow-ups with a specialist
• Routine physical exams
• Same-day emergent care, often treated at an urgent care facility versus the ER
• Chemotherapy or radiation treatment

Inpatient vs. outpatient: The providers in each setting

Primary care physicians  have traditionally been considered outpatient providers, while specialists are thought of as inpatient physicians. But that’s really an oversimplification, particularly when you consider that  hospitalists bridge the gap  by providing general medical care to inpatients. Effective care requires that doctors work together and effectively leverage health care technology , regardless of their specialties and settings.

Many physicians also divide their time between inpatient and outpatient services. OB/GYNs , for example, provide inpatient care when delivering babies and outpatient care when consulting with pregnant women during prenatal checkups.

Generally speaking, inpatients have contact with a larger group of providers. During a hospital stay, you could interact with physicians, nurse practitioners, lab technicians, physical therapists, pharmacists, and physician assistants.

Inpatient vs. outpatient: Cost considerations

The difference between inpatient versus outpatient care matters for patients because it will ultimately affect your eventual bill.

Outpatient care involves fees related to the doctor and any tests performed. Inpatient care also includes additional facility-based fees. The most recent cost data included in the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality (AHRQ) shows the average national inpatient charges can vary considerably depending on the length of stay and the treatment involved. The exact amount you pay also hinges on your insurance.

Things get a little more complicated  if you have Medicare . Outpatient care and physician-related services for inpatient care are covered by Part B. Hospital services like rooms, meals, and general nursing for inpatients are covered by Part A.

But if you stay overnight in the hospital under observation status, Medicare still considers you an outpatient and will not cover care in a skilled nursing facility. It can certainly be confusing, so don’t be afraid to ask the medical team about your status. They’re used to these types of questions.

Expand your medical knowledge

Hopefully, you now have a little more clarity concerning the definition of inpatient versus outpatient. It can go a long way towards helping you understand what you should expect during and after any sort of medical treatment.

You can further deepen your understanding of the health care world by reading our article “50 Must-Know Medical Terms, Abbreviations, and Acronyms .”

*This article was originally published in June 2019. It has since been updated to reflect information relevant to 2021.

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Outpatient care (ambulatory care) in the U.S. - Statistics & Facts

Will outpatient revenue outpace inpatient revenue, outpatient care during the coronavirus pandemic, key insights.

Detailed statistics

Industry revenue of “ambulatory health care services“ in the U.S. 2012-2024

Employment in U.S. ambulatory health care services 1998-2021

Ambulatory health care establishments U.S. total number 2007-2020

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Number of U.S. Community Health Centers (CHCs) in 2021, by state

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Revenue of outpatient care in U.S. hospitals 2017-2021, by type of hospital

Number of Medicare-certified ambulatory surgery centers by state 2022

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Number of outpatient visits in U.S. hospitals 2015-2021, by type of hospital

Number of outpatient visits in the United States from 2015 to 2021, by type of hospital structure (in millions)

Number of outpatient visits in U.S. 2021, by ambulatory health care service

Number of outpatient visits in the United States in 2021, by ambulatory health care service (in millions)

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Total number of health center patient visits in the U.S. from 2010 to 2020 (in millions)

Total number of U.S. ambulatory health care establishments from 2007 to 2020

Health center sites in U.S. 2010-2020

Number of health center sites in the U.S. from 2010 to 2020

Number of Community Health Centers (CHCs) in the U.S. in 2021, by state*

Number of Medicare-certified ambulatory surgery centers (ASCs) as of 2022, by state

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Employment in U.S. ambulatory health care services from 1998 to 2021 (in 1,000)*

Federally funded health center staff distribution in the U.S. 2020

Percentage of U.S. community health center staff that provided select services as of 2020

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Percentage of U.S. health center medical staff by type as of 2020

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Percentage of U.S. health center dental staff by type as of 2021

Health center behavioral health staff distribution by type U.S. 2020

Percentage of U.S. health center behavioral health staff by type as of 2020

Total employee compensation in U.S. ambulatory health care services 1998-2021

Total employee compensation in ambulatory health care services in the U.S. from 1998 to 2021 (in million U.S. dollars)

Industry revenue of ambulatory health care services

• Premium Statistic Industry revenue of “ambulatory health care services“ in the U.S. 2012-2024
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• Premium Statistic Gross output of ambulatory health care services 1998-2022
• Basic Statistic Gross operating surplus of ambulatory health care services 1998-2020
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Value added by ambulatory health care services in the U.S. from 1998 to 2022 (in billion U.S. dollars)

Gross output of ambulatory health care services 1998-2022

Gross output of ambulatory health care services in the U.S. from 1998 to 2022 (in million U.S. dollars)

Gross operating surplus of ambulatory health care services 1998-2020

Gross operating surplus of ambulatory health care services in the U.S. from 1998 to 2020 (in million U.S. dollars)

Total employer firm revenue in ambulatory health care services 2001-2021

Total employer firm revenue in the U.S. ambulatory health care service sector from 2001 to 2021 (in million U.S. dollars)

Revenue in U.S. ambulatory health care service sector by tax category 2001-2021

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Revenue of emergency & other outpatient care centers in the U.S., 2009-2014

Revenue of emergency & other outpatient care centers (NAICS 62143) in the United States from 2009 to 2014 (in billion U.S. dollars)

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Distribution of health center patients in the U.S. in 2020, by age group

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Share of visits to community health centers in the United States in 2020, by number of present chronic conditions

Community health center visit in the U.S. 2020, by chronic condition

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Observation, Outpatient, or Inpatient Status Explained

• How Long Is a Stay?
• Types of Admission
• Admission Status Determination
• Dealing With Insurance

If you receive medical treatment that involves an overnight hospital stay, you are being treated on an inpatient basis. If you are treated in a hospital but don't need to stay, you are being admitted on an outpatient basis.

In between, a person may receive treatment and be admitted to a hospital so they can be watched and reassessed to determine if further treatment is needed. This is admission on an observation basis.

The decision on how you are admitted is largely directed by your condition and approvals by your insurance company. Based on medical codes that classify your condition and treatment (called CPT and ICD-10 codes), your insurer will decide how long—or if—you need to stay in a hospital.

This article explains when you need to be admitted on an outpatient, inpatient, or observation basis and how the decision is made.

How Long Is Your Hospital Stay?

For the purpose of insurance billing, the length of a hospital stay is based on how many midnights you will spend in the hospital. It is not based on the number of hours you are hospitalized.

So, even if you are admitted at 11:00 p.m., you will be billed for one hospital day (along with any accrued charges) the second it turns midnight.

The hospital bill you receive is separate from the bill you receive from your surgeon or anesthesiologist . The bill not only includes the daily room charge but also charges for food, medical supplies, medical services, and any tests or procedures, such as X-rays.

Definitions of Hospital Stays

Specific definitions are assigned to your admission status, some of which are not as straightforward as they seem. The definitions matter because they have a direct impact on both your billing and out-of-pocket costs .

By definition:

• Outpatient is when a person leaves the hospital after treatment on the same day. It can also be applied a someone who spends the night in the hospital for whom a doctor has not written an order for inpatient admission. They are still admitted and billed as an outpatient.
• Inpatient is when a person treated in a hospital is admitted for at least two midnights. It can also be applied to a person who was discharged or transferred to another hospital before two midnights and didn't occupy the bed. They are still admitted and billed as an inpatient.
• Observation is when a person is admitted to the hospital but has an unclear need for longer care. The purpose is to determine within the span of one midnight whether further treatment or inpatient admission is needed.

In practice, the term "admitted" generally infers inpatient care but can be applied to anyone who is admitted for treatment in a hospital.

Insurance and How Admission Status Is Determined

Every time you are scheduled to have a hospital-based treatment or procedure—such as surgery or to deliver a baby—your healthcare provider will submit prior authorization to your health insurance company. This is to ensure that the procedure is covered along with any hospitalization that may be needed.

The decision to pay and how much to pay is largely based on two codes submitted by your healthcare provider:

• ICD-10 code : This is an international classification of all medical diagnoses used for insurance claims processing. The U.S. version is issued by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS).
• CPT code : Otherwise known as the current procedural terminology (CPT) codes, these classify medical services and procedures. These codes were designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) .

The codes are used by the insurer to determine what services are authorized for coverage of your condition, including whether the treatments are administered on an inpatient or outpatient basis. If inpatient care is indicated, the codes will also direct how many days you are authorized to stay.

If you require emergency care, the ER department will submit a specific CPT code after treatment designating the need for hospital observation. The code can be transitioned to inpatient care if it is decided that further treatment is needed after an overnight stay.

Asking About Overnight Hospital Bills

The amount you pay for a hospital stay is based on your insurance plan, including the deductible . If you have private or employer-sponsored insurance, there may be copayment or coinsurance costs you will need to pay out of pocket.

If out-of-pocket costs are a factor, there may be an outpatient procedure that can be used in place of an inpatient procedure. As long the treatment is appropriate and effective, it is a reasonable option to discuss with your healthcare provider.

For people with Medicare , outpatient services are covered as part of Medicare Part B , while inpatient services are covered under Medicare Part A . Medications may fall under Medicare Part D .

Because there are many rules and regulations governing payment based on the type of Medicare you have, you can reach out for assistance by calling the Medicare Helpline at 1-800-MEDICARE (1-800-633-4227).

The same applies to other federal programs like Medicaid , Children's Health Insurance Program (CHIP) , Tricare , and Veteran's Health Administration (VHA) .

On the other hand, if you have been discharged from the hospital and are confused about your bill, the hospital billing department can explain the charges and may be able to direct you to financial assistance if you foresee problems paying the bill.

A hospital outpatient, inpatient, or observation status is about more than just how long you are in hospital. The definition of each can place you in a different category of billing.

The determination of outpatient, inpatient, and observations is based on your condition and treatment recommendation. Based on the CPT and ICD-10 code assigned by your healthcare provider, your insurer will determine what form of treatment they will cover and how many days of hospitalization are needed, if any.

Centers for Medicare and Medicaid Services. Billing and coding: acute care: inpatient, observation and treatment room services .

Medicare.gov. Are you a hospital inpatient or outpatient?

Centers for Medicare and Medicaid Services. Hospital outpatient quality reporting program .

Centers for Medicare and Medicaid Services. Advanced copy- revisions to state operations manual (SOM) hospital appendix A .

Centers for Medicare and Medicaid Services. Hospital coverage under Part B .

American Medical Association. ICD-10 .

American Medical Association. CPT overview and code approval .

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

• Article Information

The dotted vertical line in panel B indicates the week of March 17, 2020, (week 11), when Medicare expanded reimbursement for telemedicine visits due to the COVID-19 pandemic. 4

a Week 21 (May 20 to May 26, 2020) includes Memorial Day, a federal holiday in the US. The work week was likely 4 days for many practices resulting in a decrease in visit volume.

• Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic JAMA Original Investigation January 18, 2022 This retrospective study compares ambulatory care patterns before and in the first year of the COVID-19 pandemic among patients insured by public and private insurance programs. John N. Mafi, MD, MPH; Melody Craff, PhD, MB, BChir; Sitaram Vangala, MSc; Thomas Pu, MHI; Dale Skinner, MSc; Cyrus Tabatabai-Yazdi, MSc; Anikia Nelson, MD; Rachel Reid, MD, MPH; Denis Agniel, PhD; Chi-Hong Tseng, PhD; Catherine Sarkisian, MD, MSPH; Cheryl L. Damberg, PhD; Katherine L. Kahn, MD
• Federal Plan Proposes Improving Rural Health Care Through Telehealth JAMA Health Forum In the News September 22, 2020 Joan Stephenson, PhD

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Patel SY , Mehrotra A , Huskamp HA , Uscher-Pines L , Ganguli I , Barnett ML. Trends in Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US. JAMA Intern Med. 2021;181(3):388–391. doi:10.1001/jamainternmed.2020.5928

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Trends in Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US

• 1 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
• 2 Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
• 3 OptumLabs Visiting Fellow, Eden Prairie, Minnesota
• 4 RAND Corporation, Arlington, Virginia
• 5 Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
• 6 Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
• Original Investigation Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic John N. Mafi, MD, MPH; Melody Craff, PhD, MB, BChir; Sitaram Vangala, MSc; Thomas Pu, MHI; Dale Skinner, MSc; Cyrus Tabatabai-Yazdi, MSc; Anikia Nelson, MD; Rachel Reid, MD, MPH; Denis Agniel, PhD; Chi-Hong Tseng, PhD; Catherine Sarkisian, MD, MSPH; Cheryl L. Damberg, PhD; Katherine L. Kahn, MD JAMA
• In the News Federal Plan Proposes Improving Rural Health Care Through Telehealth Joan Stephenson, PhD JAMA Health Forum

The coronavirus disease 2019 (COVID-19) pandemic has dramatically altered patterns of health care delivery in the US. In the context of declining in-person outpatient visits, many clinicians began using telemedicine for the first time, spurred in part by regulatory changes that expanded public and private insurer reimbursement for a wider range of telemedicine services. 1 , 2 To understand how telemedicine compensated for declining outpatient volume and geographic variation in changing patterns of outpatient care, we examined telemedicine and in-person outpatient visits in 2020 among a national sample of 16.7 million individuals with commercial or Medicare Advantage insurance.

We used insurance claims from the OptumLabs Data Warehouse 3 to capture all outpatient visits over a 24-week period from January 1, 2020, to June 16, 2020. We included enrollees with 12 months of continuous enrollment (July 2019-June 2020). We assessed data completeness using weekly childbirth rates (eAppendix in the Supplement ). We defined outpatient visits as Medicare’s list of Common Procedural Terminology (CPT) codes eligible for telemedicine 4 and telemedicine visits via modifier codes GT, GQ, or 95 or CPT codes 99441-99443.

We assessed changes in outpatient visit volume by capturing weekly rates per 1000 enrollees of telemedicine, in-person, and total visits over the study period. For each state, during the final 4 weeks of the study period (May 20 to June 16), we calculated the percent of total weekly visits delivered by telemedicine and the percent change in total weekly visits compared to the 4 week period preceding expansion of telehealth coverage by Medicare (February 12 to March 10). 5 The Harvard Medical School institutional review board exempted this study from review and informed consent because all data were deidentified.

Among 16 740 365 enrollees, the weekly rate of telemedicine visits increased during the pandemic period, peaking in the week of April 15, 2020, before declining by the week of June 10, 2020 ( Figure 1 ). From the weeks of January 1 to June 10, the rates for telemedicine visits increased from 0.8 to 17.8 visits per 1000 enrollees (increase of 17.0 or 2013% change); in-person visits dropped from 102.7 to 76.3 (decrease of 26.4 or −30.0% change); total visits (telemedicine and in-person visits combined) decreased from 103.5 to 94.1 (−9.1% change).

By the last 4 weeks of the study period, May 20 through June 16, there was wide geographic variation in the percent of total visits delivered by telemedicine (ranging from 8.4% in South Dakota to 47.6% in Massachusetts) and the percent change from baseline in total visit rates (ranging from −73.2% in Hawaii to −16.0% in Alaska) ( Figure 2 ). Some states, especially in the South, had a small decline in total visits and lower rates of telemedicine use (ie, Tennessee, −23.6% change in total visits with 10.4% of all visits as telemedicine; Alabama, −21.5% and 13.4%, respectively).

In this national study of a commercially insured population, growth in telemedicine use offset roughly two-thirds of the decline in in-person visit volume during the COVID-19 pandemic. Although there was geographic variation in the magnitude of changes, every state experienced a drop in total visits, illustrating the broad scope of deferred care during the first months of COVID-19. Although some deferred care may have represented discretionary care that could be postponed without harm, these results also substantiate concerns that patients may fall behind in chronic illness management or face complications from deferred acute medical issues. This would be consistent with evidence from natural disasters resulting in decreased access to care associated with greater morbidity and mortality not directly related to the disaster itself. 6

An important limitation is that results may not generalize to other populations (eg, traditional Medicare or Medicaid). Telemedicine use during the early COVID-19 pandemic only partially offset a drop in total outpatient care.

Accepted for Publication: August 31, 2020.

Published Online: November 16, 2020. doi:10.1001/jamainternmed.2020.5928

Corresponding Author: Michael L. Barnett, MD, MS, Department of Health Care Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Kresge 411, Boston, MA 02115 ( [email protected] ).

Author Contributions: Dr Patel had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Patel, Mehrotra, Barnett.

Acquisition, analysis, or interpretation of data: Patel, Huskamp, Uscher-Pines, Ganguli, Barnett.

Drafting of the manuscript: Patel.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Patel, Barnett.

Obtained funding: Mehrotra, Huskamp, Uscher-Pines.

Administrative, technical, or material support: Patel.

Supervision: Mehrotra, Uscher-Pines, Barnett.

Conflict of Interest Disclosures: Dr Mehrotra reported grants from the National Institutes of Health during the conduct of the study. Dr Huskamp reported grants from the National Institute of Mental Health during the conduct of the study. Dr Ganguli reported personal fees from Haven and personal fees from Blue Cross Blue Shield Massachusetts outside the submitted work. No other disclosures were reported.

Funding/Support: This project was supported by the National Institute on Aging of the National Institutes of Health (K23 AG058806-01) and the National Institute of Mental Health (R01 MH112829, T32MH019733). We thank Rebecca Shyu for contributing to data analysis, visualization, and manuscript preparation efforts.

Role of the Funder/Sponsor: The National Institute on Aging of the National Institutes of Health (K23 AG058806-01) and the National Institute of Mental Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Ambulatory Care Use and Physician office visits

Data are for the U.S.

• Percent of adults who had a visit with a doctor or other health care professional in the past year: 83.4% (2022)

Source: Interactive Summary Health Statistics for Adults: National Health Interview Survey, 2019-2022

• Percent of children who had a visit with a doctor or other health care professional in the past year: 93.9% (2022)

Source: Interactive Summary Health Statistics for Children: National Health Interview Survey, 2019-2022

• Number of visits: 1.0 billion
• Number of visits per 100 persons: 320.7
• Percent of visits made to primary care physicians: 50.3%

Source: National Ambulatory Medical Care Survey: 2019 National Summary Tables, table 1 [PDF – 865 KB]

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• Experiences Related to the COVID-19 Pandemic Among U.S. Physicians in Office-based Settings, 2020–2021 [PDF – 305 KB]
• Characteristics of Office-based Physician Visits by Age, 2019 [PDF – 411 KB]
• Urgent Care Center and Retail Health Clinic Utilization Among Adults: United States, 2019
• Characteristics of Office-based Physician Visits, 2018
• Urban-rural Differences in Visits to Office-based Physicians by Adults With Hypertension: United States, 2014–2016 [PDF – 276 KB]
• Physician Office Visits at Which Benzodiazepines Were Prescribed: Findings From 2014–2016 National Ambulatory Medical Care Survey [PDF – 376 KB]
• Characteristics of Asthma Visits to Physician Offices in the United States: 2012–2015 National Ambulatory Medical Care Survey [PDF – 876 KB]
• Ambulatory Health Care Data
• National Health Interview Survey
• American Medical Association

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Outpatient visits billed at increasingly higher levels: implications for health costs

By Hope Schwartz Twitter ,  Gary Claxton ,  Matthew Rae Twitter , and  Cynthia Cox Twitter

February 27, 2023

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The cost of an outpatient visit to a physician’s office, urgent care center, or emergency department depends in part on the level of service provided. Providers and facilities generally charge higher prices for more complex visits, and insurers pay larger reimbursements. Patients with deductibles or co-insurance may have higher out-of-pocket costs for more complex visits, too. Although there are standardized guidelines for how to determine the complexity of a visit, there is a trend towards visits being billed at higher levels over time. This could reflect increases in actual acuity and the intensity of services required, or changes in billing practices, or both. There is concern that providers may be inappropriately billing for more complex—and thus more expensive—services, a practice known as “ upcoding .”

In this analysis, we review the literature on coding practices, and using claims data we examine trends in complexity coding across outpatient practice settings from 2004 to 2021. We look at private, large employer-based insurance claims from the Merative MarketScan Commercial Claims and Encounters database for non-elderly people. We examine the distribution of code levels in physician offices, urgent care centers, and emergency departments over time, for all evaluation and management claims and for specific diagnoses. This analysis only includes evaluation and management claims and does not include additional visit-associated bills such as laboratory tests or other services.

Over the 18-year period of our analysis, we find that claims across all three sites of care trended towards higher level codes, even among specific, common diagnoses like urinary tract infections and headaches. The average age of this population stayed consistent over time. However, we do not assess whether health status worsened with time, so we are not able to assess whether increases in billed complexity represent actual changes in clinical characteristics. These trends could therefore 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 the outpatient setting.

These changes are contributing to higher outpatient health spending. We find that in 2021, outpatient evaluation and management spending was 4% higher in both physician offices and emergency departments than it would have been if visits were coded at the same levels as in 2011.

How is visit complexity determined, and how might it affect costs?

Visit complexity is determined by the level of evaluation and management services billed by the provider or hospital. Evaluation and management services are billed using American Medical Association Current Procedural Terminology ( CPT ) codes, and AMA guidelines for assigning these codes are approved by the Center for Medicare and Medicaid Services . Level 1 visits are 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 reimburse a higher rate for more complex cases to reflect the increased resources and time required to treat these cases.

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Several prior studies have shown that outpatient costs are increasing and that providers are billing for more complex services. A KFF analysis of U.S. healthcare price growth found that the average price of an outpatient office visit grew faster than inflation from 2003-2019, and that the share of level 4 visits increased from less than 1-in-5 (19%) to more than 1-in-3 (36%) during the same period. Similar trends have been documented in the emergency department and inpatient hospital setting. While the reasons behind increasing visit complexity are likely multifactorial, these trends have raised concerns whether some providers might be “ upcoding ,” or inflating medical complexity to receive higher payments.

Some of this trend toward more complex coding may be explained by an aging and more medically complex population requiring more outpatient services. In the emergency department, there is some correlation between number of services provided and complexity billed, but this relationship does not completely explain the increases in complexity levels billed. One study found that of all physicians who provided outpatient, inpatient, or other evaluation and management services for Medicare beneficiaries in 2010, physicians who consistently bill at the highest complexity levels treat patients who are similar in age and diagnoses to their counterparts.

Regardless of the reason behind it, the trend toward billing for higher complexity services appears to have led to increased spending on outpatient services. The Center for Public Integrity found that higher codes for routine office visits led to a $6.6 billion increase in Medicare payments from 2001-2010, and that higher codes in the emergency department increased costs by $1 billion from 2001-2008. 

Outpatient claims are billed at higher levels over time  

In this analysis, we find a trend toward higher level claims in physician offices, urgent care centers and emergency departments, though this trend is most pronounced in emergency departments. Taking claims from all three settings, we find that the share of moderate intensity (level 3) claims decreased from the majority (60%) of claims in 2004 to less than half (45%) in 2021. Meanwhile, higher intensity level 4 claims almost doubled in frequency, from 19% in 2004 to 37% in 2021. The shares of claims at each level remained relatively stable during the COVID-19 pandemic in 2020 and 2021. Levels 3 and 4 claims continued to be the most common during this time; however level 5 claims continued to increase in frequency to 6% in 2021. During the pandemic, level 1 and 2 claims also increased to 4% and 7% respectively by 2021.

In emergency departments, level 4 and 5 codes now make up the majority of claims

In the emergency department, the most common claim in 2004 was level 3. However, by 2021, level 4 was the most common and accounted for over one third (35%) of claims. Level 5 claims increased in frequency from 8% of emergency department claims in 2004 to a quarter of claims by 2021. The growing number of urgent care centers in the past two decades may contribute to increased acuity in emergency departments by siphoning less sick patients away from emergency departments. However, we also find that visit complexity is rising outside of the emergency department.

In outpatient physician offices, the share of level 4 claims has grown

In outpatient physician offices, the share of higher level claims also grew over time. Level 3 claims remained the most common from 2004 to 2021, but the share of level 3 claims reduced from 61% in 2004 to 48% in 2021. In 2004, level 4 claims accounted for 1-in-5 outpatient office claims, which increased to over one third of claims in 2021 (38%). Across the period of our study, outpatient physician offices had a relatively low proportion of the lowest level (level 1) and the highest level (level 5) claims.

In urgent care centers, higher level claims are also becoming more common

In urgent care centers, level 3 and 4 claims accounted for 76% of claims in 2004 and reached 93% of claims by 2019, before down trending during the pandemic years. Level 4 claims grew from less than a quarter (21%) of all urgent care claims in 2004 to almost half (49%) before the pandemic. The share of lower complexity claims decreased during this time. In 2004, almost a quarter of claims (23%) were level 1 or level 2. By 2019, level 2 claims made up 5% and level 1 claims made up 0% of all claims in urgent care centers. During 2020 and 2021, we observed a growth in level 1-3 claims at urgent care centers, and a decrease in level 4 claims. These changes may represent shifting health care utilization during the pandemic, changes in billing practices, or a combination of multiple factors.

Even for specific diagnoses, trends in claim levels are consistent over time

Over time more people in the U.S. have been diagnosed with comorbid conditions , which may make patients more complex or resource intensive to treat and may contribute to the increasing complexity of outpatient claims. However, we find that trends in coding levels are reflected even in diseases that are less likely to be worsening over time or in which comorbidities have a smaller impact. We restrict our analysis to younger people (<65), who are less likely to have chronic conditions , and we also find that the average age of our population remained consistent during our analysis, suggesting that the aging population is not a contributor to the increases in billing complexity we find.

For urinary tract infections visits are increasingly coded at higher levels

For urinary tract infections, moderate complexity (level 3) claims were over half (54%) of emergency department claims and two-thirds (67%) of all outpatient office claims in 2004. By 2021, level 3 claims accounted for only 31% of emergency department claims and 57% of outpatient office claims. In the emergency department, 1-in-5 claims for urinary tract infections was level 5 in 2021.

The majority of headache claims are now level 4 or 5

For headache, level 3 claims were the most common in 2004 in both physician offices (58%) and emergency departments (41%). By 2021, level 4 claims were the majority in both settings. In the emergency department, the share of level 5 claims more than tripled from 2004 to 2021.

Emergency evaluation and management claims are 4.5 times as expensive as office claims, on average

In 2021, the average cost of evaluation and management services was almost 5 times as expensive in the emergency department ($556) compared to outpatient physician offices ($125). Emergency department claims also have the most variation in cost by level. The average level 5 claim is over $400 more expensive than the average level 1 claim. Urgent care evaluation and management claims cost $147, on average.

The cost of higher level claims are growing faster than the cost of lower level claims

For each practice setting, costs of claims are growing at different rates. The emergency department saw the largest relative increase in evaluation and management costs at all levels. Level 1 claims increased in cost by 138%, and level 5 claims increased by 185% from 2004 to 2021. In offices, the cost of Level 1 visits remained relatively flat, increasing by 3%, while the cost of the highest complexity (Level 5) outpatient office claim increased by 79%. In urgent care centers, the gap between the lowest complexity and highest complexity claims also widened. The cost of level 1 claims remained flat, while the cost of level 5 claims increased by 59%.

Implications for outpatient spending

Next, we examine how much lower 2021 spending would have been if visits were billed at the same levels as 10 years earlier. To do this, we multiply the average cost of each level claim in 2021 (e.g., the average level 5 emergency visit in 2021 was $556) times the share of visits that were billed at that level in 2011 (e.g., 16% of emergency visits were billed at level 5 in 2011). We calculate hypothetical total spending on evaluation and management services for the 2021 population using 2021 costs and 2011 levels, and we compare this to the actual 2021 spending using 2021 levels.

We find that if outpatient visit levels were coded the same in 2021 as they were in 2011, there would have been significant cost-savings in 2021. Both physician office and emergency department evaluation and management spending would have been 4% lower in 2021 than 2021 actual spending. Using 2004 levels instead of 2011 levels, emergency department spending would be 11% lower and office spending would be 10% lower in 2021 than actual 2021 spending. The majority of the cost saving would come from outpatient office claims because they make up a larger share of the outpatient evaluation and management spending we studied (69%) compared to emergency departments (27%) and urgent cares (3%). These numbers do not identify the portion of cost savings related to changes in services provided versus changes in billing patterns, since we did not control for clinical characteristics of the population.

Discussion  

Over time, outpatient visits are being coded at higher levels, thus resulting in higher costs. We find that if the distribution of claim levels had stayed consistent over the prior ten years, outpatient evaluation and management costs would have been 4% lower in 2021. Of the outpatient settings we studied, emergency department evaluation and management claims are coded at the highest levels and are the most expensive, on average; however, outpatient office visits are the largest contributor to aggregate outpatient health expenditures because of the larger number of office visits.

The trend toward higher levels is seen across all outpatient settings, including emergency departments, urgent care centers, and physician offices. Increasing levels of visit complexity could reflect changes in billing, services provided, patient acuity, or a combination of factors. We did not control for clinical acuity; however, we did observe a trend towards higher claim levels even for specific conditions that are less likely to be worsening over time or for which comorbidities have a smaller impact, like headaches and urinary tract infections.

Overall, our findings demonstrate that regardless of the driving factors, increasing billing at higher levels for outpatient care has led to substantial increases in outpatient visit spending at the health system level. For consumers who bear the marginal costs of more expensive services—those with co-insurance or deductibles —this trend impacts out-of-pocket costs in addition to overall health system costs.

This analysis is based on data from the Merative MarketScan Commercial Database, which contains claims information provided by a sample of large employer plans. This analysis used claims for almost 14 million people representing about 17% of the 85 million people in large group market plans (employers with a thousand or more workers) from 2004-2021. To make MarketScan data representative of large group plans, weights were applied to match counts in the Current Population Survey for enrollees at firms of a thousand or more workers by sex, age and state. Claims were included if they were below the 99.5 th percentile of costs.

Claims were included and classified by location if their place of service was in the emergency department, office, or urgent care. We included claims that were classified as both professional and facility charges, if they were associated with evaluation and management procedure codes. Evaluation and management claims in the emergency department included 99281-99285, which are evaluation and management CPT codes that are specific to the emergency department. Note that in 2023 , 99281 is no longer being used for physician encounters and these codes are now based only on complexity of medical decision-making; however these changes do not affect the time period included in our analysis. In the office, we included the outpatient established patient evaluation and management codes, which are 99211-99215, because the vast majority of visits in outpatient physician offices were for established patients. In urgent care, visits were relatively evenly divided between new and established patients, so we created an aggregate complexity level from 1-5 combining CPT codes 99211-99215 (established patients) and 99201-99205 (new patients). Primary headache, upper respiratory tract infection and urinary tract infection were defined by ICD-9 and ICD-10 codes included in each claim. Enrollees were considered to have a certain diagnosis if the relevant ICD code appeared in the “Diagnosis 1” on the claim.

This analysis has some limitations. First, we analyzed only spending that happened within the specific place in our analysis (emergency department, office, or urgent care). Some visits, especially emergency department visits, have testing such as imaging or lab studies that occur outside of the emergency department in a different part of the hospital, and these are not included in our analysis. Second, the MarketScan database includes only charges incurred under the enrollees’ plan and do not include balance billing to enrollees which may have occurred during the study period.

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Inpatient or outpatient hospital status affects your costs

Your hospital status—whether you're an inpatient or an outpatient—affects how much you pay for hospital services (like X-rays , drugs , and lab tests ). Your hospital status may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) following your hospital stay.

• You're an inpatient starting when you're formally admitted to the hospital with a doctor's order. The day before you're discharged is your last inpatient day.
• You're an outpatient if you're getting emergency department services , observation services, outpatient surgery , lab tests, or X-rays, or any other hospital services, and the doctor hasn't written an order to admit you to a hospital as an inpatient. In these cases, you're an outpatient even if you spend the night in the hospital.

Observation services are hospital outpatient services you get while your doctor decides whether to admit you as an inpatient or discharge you. You can get observation services in the emergency department or another area of the hospital.

The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care. An inpatient admission is generally appropriate when you’re expected to need 2 or more midnights of medically necessary hospital care. But, your doctor must order such admission and the hospital must formally admit you in order for you to become an inpatient.

Each day you have to stay, you or your caregiver should always ask the hospital and/or your doctor, or a hospital social worker or patient advocate if you’re an inpatient or outpatient.

Here are some common hospital situations and a description of how Medicare will pay. Remember, you pay your deductible , coinsurance, and copayment .

Remember, even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital. If you have a Medicare Advantage Plan, your costs and coverage may be different. Check with your plan.

You may get a Medicare Outpatient Observation Notice (MOON) that lets you know you’re an outpatient in a hospital or critical access hospital. You must get this notice if you're getting outpatient observation services for more than 24 hours. The MOON will tell you why you’re an outpatient getting observation services, instead of an inpatient. It will also let you know how this may affect what you pay while in the hospital, and for care you get after leaving the hospital.

The copayment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, your total copayment for all outpatient services may be more than the inpatient hospital deductible.

Part B Outpatient Physical Therapist- Senior Living Visits

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• Area: Physical Therapy
• Employment Type: Full-time
• Published: May 01 2024
• Location: Landisville / Pennsylvania

Description

BAYADA Home Health Care is currently seeking an experienced Physical Therapist, PT, for a full time opportunity performing O utpatient - Part B - home health visits for our Central PA Senior Living Office. This position will be servicing clients on an outpatient basis in the following Senior Living Facilities:

Oak Leaf Manor North, located in Landisville, PA (Lancaster County).

Autumn House East + Autumn House West (York County)

One year prior clinical experience as a licensed Physical Therapist is required. As a home care Physical Therapist, you will be an integral member of a multi-disciplinary health care team that provides rehabilitative care and skilled nursing to clients, affording them the opportunity to receive the medical care required to remain at home.

At BAYADA, we believe our employees are our greatest asset. We are committed to investing in people and nurturing their desire to grow. Watch this video to learn more about field employee career pathing:

Responsibilities for a PT - Physical Therapist include:

• Make outpatient home visits to clients in designated geographic territories.
• Perform diagnostic tests and measurements, such as the mobility/range of joints, transfer status, stability, patterns and appearance of ambulation, strength and endurance of muscles, balance testing, and safety assessments.
• Develop and implement appropriate individualized care plans, including manual therapeutic exercises, gait training, balance, and other interventions.
• Continually assess and revise the Physical Therapy - PT care plan, and participate with nursing in the multidisciplinary care plan, as appropriate.
• Educate and instruct clients, family members, or other client representatives, in rehabilitative care and activities necessary to promote the client's health, safety, and independent living.
• Accurately document observations, interventions, and evaluations pertaining to client care management and services provided, utilizing a state-of-the-art touch pad tablet.

Qualifications for a PT - Physical Therapist include:

• A current PA Physical Therapist - PT license.
• A minimum of one year of recent work experience as a Physical Therapist - PT.
• Graduation from a program approved by the American Physical Therapy Association or the Committee on Allied Health Education and Accreditation of the American Medical Association, as indicated by school transcript or diploma.
• Ability to work independently and manage time effectively.
• Strong interpersonal, organizational, and problem solving skills.
• Solid computer skills; prior experience with electronic medical records (EMR) preferred.

BAYADA believes that our employees are our greatest asset:

• BAYADA offers a comprehensive benefits plan that includes the following: Paid holidays, vacation and sick leave, vision, dental and medical health plans, employer paid life insurance, 401k with company match, direct deposit and employee assistance program
• To learn more about BAYADA Benefits, click here
• Enjoy being part of a team that cares and a company that believes in leading with our values.
• Feel confident, safe, and supported with PPE supplies, comprehensive infection prevention protocol, daily pre-screens, and close monitoring of the COVID-19 outbreak.
• Develop your skills with training and scholarship opportunities.
• Advance your career with specially designed career tracks.
• Be recognized and rewarded for your compassion, excellence, and reliability.
• Benefits may include medical, dental, and life insurance; mileage reimbursement; paid time off; weekly pay and direct deposit; scholarship opportunities; one-on-one training; recognition programs; referral bonuses; 401(k) with company match; and opportunities for career advancement.

As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates.

BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.

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White House says GOP debt ceiling plan would cause largest VA benefits cuts in US history

WASHINGTON – The White House slammed Republican-backed legislation to raise the debt ceiling for not explicitly protecting veterans' health benefits from massive spending cuts, warning Tuesday of proposed historic slashes to the Department of Veterans Affairs.

The bill, which the Republican-controlled House approved last week, would eliminate 81,000 Veterans Affairs jobs, produce 30 million fewer Veterans Affairs outpatient visits and increase the disability backlog of veterans by 134,000, the White House said in a memo.

“These draconian cuts to America’s veterans have no precedent in America’s history,” White House spokesman Andrew Bates said. "And prioritizing tax welfare for wealthy special interests over honoring our commitments to those who have put their lives on the line for our country is as backwards as politics gets.”

The legislation, pushed by House Speaker Kevin McCarthy, does not target veterans’ services by name but would keep government spending in fiscal year 2024 at the same level as 2022.

McCarthy's office rejected the White House's claims. Chad Gilmartin, McCarthy's deputy spokesman, said House Republicans "will not cut veterans benefits" and will "responsibly prioritize" spending in the upcoming appropriations process.

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"Democrats have been playing games with veterans for years in order to make room for their pet projects elsewhere in the budget," Gilmartin said. "We should prioritize meeting our veterans’ needs instead of trying to leverage their benefits for unrelated spending."

The Republicans' bill includes $4.5 trillion in cuts to government programs – a 22% reduction overall in domestic spending, according to the White House – as part of raising the debt ceiling by $1.5 trillion to avert a government default.

Shalanda Young, director of the White House Office of Management and Budget, issued an analysis of the bill saying that because Republicans are unwilling to cut defense spending “everything else in annual appropriations” would be subjected to cuts including cancer research, education and veterans' health care.

The Department of Veterans Affairs is an agency of the federal government that provides benefits and health care services to approximately 9 million veterans. The department's projection came from applying the cuts “across the board” to federal agencies.

“I hear House Republicans out on TV saying they would never vote to cut veterans’ benefits,” President Joe Biden said in a tweet Tuesday with an attached flow chart. “In case there’s any confusion, I made a little chart that could help them out.”

Rep. Mike Bost, R-Ill., who chairs the House Committee on Veterans' Affairs, called Democrats' warnings of veterans cuts "dangerous rhetoric."

"Simply put, they are playing politics with our veterans," Bost said during last week's debate on the bill. "Veterans are not political pawns to advance a political agenda."

But 24 veterans' groups signed a letter to Congress expressing “grave concerns” about potential veterans' benefit cuts before the House voted 217-215 last Wednesday to approve the debt ceiling bill.

The organizations − which include the Air Force Sergeants Association, VoteVets and Easterseals − asked lawmakers to explicitly exempt Veterans Affairs from future cuts. That change, however, wasn’t made.

“Without specific language to explicitly protect VA from the impact of the proposed budget reductions, it would leave many veteran resources open to cuts, potentially undoing years of progress VA has made for those that have earned it,” the groups wrote. 

Biden has promised to veto McCarthy's debt ceiling bill, which is unlikely to pass the Democratic-controlled Senate, warning that cuts would hurt “hardworking Americans” who depend on the targeted programs and benefits.

Biden wants the debt ceiling to be raised by Congress without conditions as it has under past presidencies, but he’s been unable to sway McCarthy and Republicans who are demanding spending cuts.

Treasury Secretary Janet Yellen warned Monday that the U.S. could reach its borrowing limit by June 1 unless the debt ceiling is raised, putting the nation at risk of going into default. McCarthy agreed to meet with Biden and other congressional leaders on May 9 at the White House.

“Unless moderates are willing to stand up to the extreme MAGA groups that have taken over the conference,” Bates said, “the House GOP is going to define themselves as so indentured to multinational corporations and billionaires that they’re willing to make the biggest cuts to veterans benefits in American history.”

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Southern Federal District, Russia

Southern federal district - overview.

The Southern Federal District is a federal district of the Russian Federation located in the south of its European part, in the lower reaches of the Volga River, north of the Greater Caucasus Range. The city of Rostov-on-Don is the administrative center of the district. The main sea resorts of Russia (Sochi, Anapa, Gelendzhik) are located on the territory of this federal district.

The population of the Southern Federal District is about 14,086,000 (2016), the area - 420,876 sq. km.

South district map, Russia

Southern federal district - features.

The federal district under the name of the North Caucasian Federal District was formed by the decree of the Russian President on May 13, 2000. On June 21, 2000, it was renamed the Southern Federal District. Initially, this federal district included the republics of the North Caucasus and the Stavropol Krai, which, in 2010, became parts of a separate North Caucasian Federal District.

In 2016, the Crimea and the city of Sevastopol were included in the Southern Federal District. Today, the Crimea is the object of territorial disagreements between Russia, de facto controlling this territory since March 2014, and Ukraine. Most of the UN member states continue to consider the entire Crimea as part of Ukraine.

In the west, the Southern Federal District borders Ukraine, in the east - Kazakhstan. In the east, it is also washed by the Caspian Sea, in the west - by the Azov Sea and the Black Sea.

South of Russia is characterized by a variety of landscapes (mixed, coniferous, deciduous forests, steppes, subalpine meadows). The average temperature in January is minus 4.4 degrees Celsius, in July - plus 24.6 degrees Celsius.

The Southern Federal District has significant reserves of thermal and mineral waters, tungsten, coal, oil on the shelf of the Caspian Sea.

The main branches of the local economy are extraction and processing of thermal and mineral waters, mining industry, tourism, agriculture, production of building materials.

Nature of the Southern Federal District

Krasnodar region

Author: Vladislav Shutyy

Rostov region

Author: Igor Tartanov

Astrakhan region

Author: Dvornikov Mikhail

Southern Federal District - Cities and Regions

South Federal District includes the following 6 federal subjects of Russian Federation:

The largest cities of South Federal District are:

• Novorossiysk

South district of Russia photos

Sights of the southern federal district.

Cathedral in the Rostov region

Author: Nikolay Sevastyanov

Church in the Volgograd region

Author: Aleksandr Tuznichenko

Mosque in Maykop

Author: Radjeb Tsey

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