Between 2018 and 2023, the number of visits coded at higher complexity levels grew across all outpatient settings, according to a study from Trilliant Health, published May 14.
Here are five things to know about an increase in upcoding:
1. Between 2018 and 2023, higher complexity codes in emergency departments increased from 32.5% to 39.6%, urgent care centers rose from 34% to 40.6% and physician offices grew from 38.5% to 45%.
2. All outpatient centers saw an increase in high-acuity billing. The largest gains came in eye and ear-related diagnoses, circulatory and hematologic conditions and mental health diagnoses.
3. The smallest changes were observed in chapters that already account for the highest share of high-acuity coding, including circulatory system diseases (85.1% to 87.9%), endocrine, nutritional and metabolic diseases (82.3% to 86.4%), eye and adnexa (28.2% to 30.3%), injury and poisoning (30.1% to 33.6%), diseases of the ear and mastoid process (26.5% to 27.6%) and infectious diseases (24.5% to 27.0%).
4. Clinical coding of ambulatory care has significantly changed over recent years in parallel with increased utilization of ambulatory care sites. The increase may reflect real changes in patient acuity, driven in part by aging populations, higher rates of chronic illness and more complex presentations. Data also shows that comparable conditions are being billed at increasingly higher levels over time, possibly driven less by patient needs and more by systemic incentives, according to the report.
5. For payers, it may become more challenging to manage care costs, as high-acuity codes require higher payments from insurers. As a result, some insurers are implementing stricter claims review processes and using algorithms to identify questionable bills and introduce more prior authorization requirements. The impact of denials then puts more financial burden onto patients requiring outpatient care.
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