The Conundrum Presented by Outpatient Surgeries

Do you keep them under inpatient status? Or do you bring them in as outpatients and just keep them overnight? 

For our Medicare populations, in all of our organizations, the ability to follow the CPT code of the applicable surgical procedure is the determining factor to bill inpatient surgeries correctly. We are probably not alone in that, over the years, a few patients have had surgery and were discharged from the recovery area, only to find out later that the procedure included a CPT code on the inpatient-only list. This happens because not all of the team members involved speak in coding language. It is a pretty significant loss when you cannot recuperate the costs of those cases.

On the other side of that coin, those patients who are brought in for an outpatient procedure that we provide care for overnight can be just as big of a financial drain on your system. And while I always advocate for doing what is right for the patient in your care, we all know that getting reimbursed for that care is tantamount to keeping your doors open for the next patient.

Let’s review what has been happening. I am going to use my favorite procedure, total hip replacements, for this review. And I will say in this case we’re talking about elective procedures, not fractures. Up until 2019, these procedures were on the inpatient-only list. Some traditional insurances began pushing for outpatient status prior to this, but let’s stick with 2019. What was your reaction to the change? Did you keep them under inpatient status? Or did you bring them in as outpatients and just keep them overnight? 

Most of our hospitals already had what was called “joint camp,” a process to have these patients come to a class prior to the elective procedure and assess them physically, then prepare them for a short stay in the hospital. That was prior to 2019. Some of our organizations were so adept at it that those patients were in and out overnight in about 20 hours, or at the most, 36 hours. The rehabilitation department was on board, and the teams used a really well-honed process. Some places could even close those units by Friday afternoon and start back up on Monday morning. 

But now, what has happened? Well, for most, the same process is used. But there is absolutely not the same reimbursement. Did the care change? No – a big, resounding no. Did the cost change? One could argue that if you limit the prosthetic choice to a few of them, you could affect the cost a bit, but the same nurses, PCTs, therapists, diet aides, housekeepers, maintenance workers, and transporters are all still used in this now very expensive outpatient stay. Oh, and if your contribution margin on these is as low as some of ours are, you are paying for these, not getting paid for them. 

There are other outpatient procedures going this way as well. And again, I advocate for safe care, but do all of your patients need to stay overnight? Just think about this from the patient’s point of view for a second. It involves going back to their own home, with no call lights and no noise in the middle of the night. Yes, they need support, but does it have to be nursing? So, what do we do? I have to give a shout-out to my friend Julie here, as I think they have figured it out. They are providing the surgery and all of the rehabilitation for these patients on dedicated days of the week so that everyone is ready to rehabilitate and educate – and they discharge the same day. This can make for a long day for your therapists, because that department is really used to eight-hour days, but if you do it correctly, you can probably add an extra afternoon shift on those dedicated days. What a great idea that is – and one I will be spreading in our organizations. That is forward thinking!


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