Health Policy and Health Services Research
Background: Prior work with Medicare claims data has demonstrated rising level of service partially correlated with intensity of services provided. We aimed to characterize how the distribution of billed level of service (LOS) for emergency department visits evolved nationally in the period from 2006 to 2014 among all-payer treat-and-release visits for chest pain, abdominal pain, and headache.
Methods: Analysis of adult ED visit-level claims data in the Nationwide Emergency Department Database from 2006 to 2014. Our sample is limited to ED visits that resulted in discharge, with any one of three common chief complaints: chest pain, abdominal pain, and headache. We used advanced cardiac imaging, computed tomography (CT) of the abdomen and pelvis, and lumbar puncture defined as simple proxies for work up utilization and complexity care. LOS was defined according to the Current Procedural Technology billing code reported for each visit, from 1 (lowest complexity) to 5 (highest complexity). We estimated ordered logistic regression models for LOS using year, age, sex, income, primary payer as independent variables to obtain adjusted odds ratios (OR) and associated confidence intervals (CI). To provide some adjustment for care complexity, we estimated ordered logistic regression models for LOS within each chief complaint and including the diagnostic procedure for that complaint as a covariate. Finally, we estimated the overall combined cost of chest pain, abdominal pain, and headache treat-and-release visits for 2006 versus 2014 using the Medicare reimbursement schedule for those years.
Results: Analysis included 1.7 million visits over 9 years. Adjusting for age, sex, income, and primary payer, each additional year was associated with increased LOS reported (OR 1.094 95% CI [1.093 to 1.095]). This increase in billing persists in subgroup analyses by chief complaint even when including procedure utilization as a covariate. Were all such visits nationally covered according to Medicare reimbursement schedule for physician and facility billing, this would correspond to an additional cost of $980 million in year of 2014 as compared to 2006.
Conclusion: Treat-and-release visits for chest pain, abdominal pain, and headache were billed at a higher level of service in 2014 than they were in 2006. Whether this reflects changes in coding practice or care complexity is unclear.