Claims data analysis suggests that physicians may be identifying more patients in the coding system as being at high risk of complications from some outpatient procedures in order to ensure payment for anesthesia services.

Upcoding and Anesthesia Risk in Outpatient Gastrointestinal Endoscopy Procedures

Xiaoyu Nie, Soeren Mattke, Zachary Predmore, Harry H. Liu

ResearchPosted on rand.org May 9, 2016Published in: JAMA Internal Medicine, Research Letter, May 2, 2016

A substantial increase in the use of anesthesia services for outpatient gastrointestinal (GI) procedures may represent low-value care. Some investigators have argued that this increase reflects increases in patient risk, whereas others state that it may come from physicians "upcoding" risk because anesthesia services are often covered only for patients for whom sedation or anesthesia carries a high risk of complications. A study was conducted to assess whether coding practices on claims for anesthesia services have changed with time.

Key Findings

  • Analysis of anesthesia service claims for outpatient gastrointestinal procedures between 2005 and 2013 shows that physician coding practices changed over time.
  • The predicted probability of being coded as having a high risk of complications from sedation or anesthesia more than doubled in the studied time frame.
  • Severity of patients' conditions and changes in the physician population cannot explain the increases in patients being coded as high risk.
  • Study results suggest that physicians have been systematically changing coding practices to ensure payment of claims.
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Document Details

  • Copyright: American Medical Association
  • Availability: Non-RAND
  • Year: 2016
  • Pages: 2
  • Document Number: EP-66470

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