Defining Ambulatory Surgery: Responses from the Listserv

The following are responses to NAHDO's query on how ambulatory surgeries are defined.

The definitions came both based on admission status as well as various codes. For example:

Outpatient surgery is any surgery that does not require an overnight inpatient stay. "Outpatient Surgery" is any encounter in which the patient is not admitted as an Inpatient during the stay and incurs charges under Revenue Code 036x (where x is any digit).  Rev Code 036x represents the Operating Room.

Simply, the patient never met IP admission criteria and had services performed in the OR.  This causes some potential "false positives" as the Operating Room can often be used for pain management procedures and scoping procedures (such as endoscopies) but I see the beauty of our definition is that it is quite simple, non-ambiguous and all encompassing. Outpatient Surgery is a surgery that is performed in any oft the following:
Outpatient Department of a Hospital ,
a  freestanding ambulatory surgical facility, or a
Physician's office 

"Outpatient surgery" means all surgical procedures performed on an outpatient basis in a general hospital, ordinary hospital, outpatient surgical hospital or other facility licensed or certified or in a physician's office or oral and maxillofacial surgeon's office, as defined above. Outpatient surgery refers only to those surgical procedure groups on which data are collected by the nonprofit organization as a part of a pilot study

The string started with the following request from NAHDO:We have received a question from one of our members on the definition of outpatient surgery. I thought your replies to this posting may help clarify the situation. So here is the question: "We have been collecting OP data since 2002 and our criteria was a little vague the first year , but since then the criteria has expanded. Would you be able to tell where I can find a definition for OP surgeries , what some of the States currently use. I did go through some of the State websites , other than a couple not many define surgeries."

I would need more info in order to respond.  Are they looking for a specific list of surgeries that would be considered OP or just a definition of OP surgery?  Most surgeries are patient specific and their medical state would determine whether the service could be done on an OP basis versus IP.  There is possibly a list available (or could be compiled) as to what is "typically" considered OP, but there are too many factors involved in a patient's health status for the list to be a rule.

 Dedenroth, Allyssa [allyssa.dedenroth@benplan.fiserv.com]

Outpatient surgery is any surgery that does not require an overnight inpatient stay. e-Medicine Health http://www.emedicinehealth.com/outpatient_surgery/article_em.htm has a very good definition.

Outpatient Surgery Introduction

Outpatient surgery allows a person to return home on the same day that a surgical procedure is performed. Outpatient surgery is also referred to as ambulatory surgery or same-day surgery.

• Outpatient surgery eliminates inpatient hospital admission, reduces the amount of medication prescribed, and uses a doctor's time more efficiently. More procedures are now being performed in a surgeon's office, termed office-based surgery, rather than in an operating room.
• Outpatient surgery is suited best for healthy people undergoing minor or intermediate procedures (limited urologic, ophthalmologic, or ear, nose, and throat procedures and procedures involving the extremities). Recently, people with more complex medical problems are undergoing outpatient surgery, and the types and complexity of surgical procedures have expanded significantly.
• More than 60% of elective surgery procedures in the United States are currently performed as outpatient surgeries. Health experts expect this percentage will increase to nearly 75% over the next decade.
• Outpatient surgery has developed over the past 3 decades for a number of reasons, including the following:
  
• Improved surgical instruments
• Less invasive surgical techniques
• A team approach in preparing a person for surgery and home recovery that involves both a surgeon and an anesthesiologist (a medical doctor who specializes in administering anesthesia medications so the patient feels no pain and does not remember the surgery)

The desire to reduce health care costs

Beverly Molter-Sundock, M.S., PhD.c.
Data Management Administrator
Quality & Performance Improvement Department
St. Vincent Regional Medical Center

Some states (FL for example) define Ambulatory Surgery as a range of CPT codes. From their website:
“AS reportable events include those with a procedure that involves a valid Current Procedural Terminology (CPT) code occurring within the following ranges: 10000 through 69999, and 93500 through 93599”

Heath Umbach [mailto:HUmbach@webmd.net]

Here's the definition listed on the NYSDOH Website re Ambulatory Surgery.

Reporting Ambulatory Surgery in New York State
SPARCS Reporting Requirement for Ambulatory Surgery

The definition of Ambulatory Surgery has changed for discharges reported to
SPARCS effective April 2007.

Effective March 28, 2007, Paragraph (1) of subdivision (d) of Section
400.18 of Title 10 (Health) of the Official Compilation of Codes, Rules,
and Regulations of the State of New York (NYCRR) is amended to read as
follows:
      (1) All facilities licensed under article 28 of the Public Health Law
      that provide ambulatory surgery services shall submit in an
      electronic format for each patient surgical visit that requires a
      stay of less than 24 hours any procedure listed in the American
      Medical Association Current Procedural Terminology (CPT) as
      prescribed by the commissioner to be maintained on an annual basis,
      including but not limited to all procedures in the Surgery Section of
      CPT.

The Ambulatory Surgery Procedure Code list (effective 4/1/2007) for SPARCS
Reporting of the above is as follows:

                                                                         
 CPT-4 Category                                           Code Range     
                                                                         
 Surgery                                                  10021 - 69990  
                                                                         
 Medicine                                                                
                                                                         
 Cardiovascular                                           92973 - 92998  
                                                                         
 Cardiac Catheterization                                  93501 - 93581  
                                                                         
 Intra-cardiac Electrophysiological Procedures/Studies    93600 - 93662   
                                                                         

Previous Definition of NYS Collected Ambulatory Surgery Data
Brief Description

Sections 755.1 and 405.20(d) define an ambulatory surgery service as one
organized to provide surgical procedures performed for safety reasons in an
operating room on anesthetized patients requiring a stay of less than 24
hours. The regulations also explicitly exclude outpatient surgical
procedures that can be performed safely in an outpatient treatment room or
a private physician's office. These regulations are employed in the
licensure of freestanding and hospital-based ambulatory surgery centers, in
the oversight and surveillance of these facilities by the Department, and
are the foundation for Medicaid in reimbursement (the actual reimbursement
methodology for ambulatory surgery is found in Part 86-4.40). These rules
also served as the basis for the reporting of ambulatory surgical
procedures to the Statewide Planning and Research Cooperative System
(SPARCS) as required by Section 400.18 since the mid 1980's.

Historical Reason behind the Change

Since these regulations defining ambulatory surgery were enacted nearly
twenty years ago, progress in medical technology, surgical technique, and
medical practice have resulted in a dramatic broadening of site of service,
with a shift from the operating suite to procedure rooms, physician
offices, and outpatient clinics. This change has left the Department with a
set of regulations that were dramatically out of step with modern medical
practice. Consequently, the stipulation in the current Sections 755.1 and
405.20(d) that ambulatory surgical procedures are those performed in an
operating room in effect narrows the definition of ambulatory surgery by
excluding a large number of surgical procedures increasingly performed in
non-operating room settings.

Because the SPARCS reporting requirements in Section 400.18 employed the
definition of ambulatory surgery set forth in Sections 755.1 and 405.20(d),
operators of both hospital-based and freestanding ambulatory surgery
centers (ASCs) were required to report to SPARCS only those procedures
performed in an operating room. This resulted in the extensive
underreporting of ambulatory surgical procedures to SPARCS. This in effect
hampered the Department's efforts to develop appropriate mechanisms for
quality assurance of ambulatory surgical procedures carried out in Article
28 facilities. By changing the definition to explicitly state the codes
necessary for reporting ambulatory surgery procedures, the Department will
be able to conduct research into the epidemiology of diseases and
conditions amenable to surgical intervention and to identify changes and
trends in surgical practice over time.

Change Requested in Definition

Because Sections 755.1 and 405.20(d) are closely tied to reimbursement
regulations and methodologies for ambulatory surgery reimbursement in
Medicaid, they cannot be amended without statutory change to Medicaid
reimbursement structures. However, because of the urgent need to amend
SPARCS reporting requirements for ambulatory surgical procedures, the
Department proceeded with revision of Section 400.18, which did not require
legislative action. The revisions to Section 400.18 broadened the
definition of ambulatory surgery for SPARCS reporting purposes only. The
definition of ambulatory surgery in Sections 755.1 and 405.20(d) remains
unchanged until legislation to amend the Medicaid formula for ambulatory
surgery is proposed and passed.

The broader definition of ambulatory surgery in the revisions to Section
400.18 removes the stipulations that ambulatory surgical procedures are
those that must be performed for safety reasons in an operating room and on
anesthetized patients. It further removes the exclusion of those outpatient
surgical procedures that can be performed safely in an outpatient treatment
room or other non-operatory setting. The revisions retain the stipulation
that ambulatory surgical procedures require a stay of less than 24 hours'
duration.

The revised rule adds a list of American Medical Association's Current
Procedural Terminology (CPT) procedure codes; this list is to be prescribed
by the Commissioner and maintained on an annual basis, including but not
limited to, all procedures in the Surgery Section of CPT. Thus, the new
definition of ambulatory surgery services for SPARCS reporting purposes
covers all CPT surgery procedures performed in hospital-based and
freestanding Article 28 ambulatory surgery facilities, regardless of
whether carried out in an operating room, an outpatient treatment room, a
procedure room or other setting. It also covers other procedures, as
prescribed by the Commissioner, which may not currently be defined as
"surgery". Examples are certain cardiac catheterization procedures and some
procedures in the emergent field of radiosurgery. The scope of the
definition will help ensure the reporting to SPARCS of all ambulatory
surgical procedures conducted in Article 28 facilities, even as progress in
medical treatment results in the continued migration of these procedures
from the traditional operating room to other venues.

Mike Medvesky
Dir. Public Health Information Group
NYSDOH

General Definition: The ambulatory database shall contain all records for patients that sought care in an acute care hospital on an outpatient basis for ambulatory surgeries (ICD9-CM01 - 86.99) and 'non-scheduled visits' -- the keyword here is non-scheduled . This would include all: ambulatory surgeries (performed in the O.R., E.R., on-site clinic, or ambulatory surgery center)emergency room visitswalk-in care visitsobservation stay patients. Also included would be the following patients seen in the emergency room who were: triaged but who left before treatment (no diagnosis or procedure coded) seen by a physician after hours under a courtesy arrangement seen for a blood alcohol draw seen by a third party provider (such as a social worker) for psychiatric & careseen for medication refillsclassified as dead on arrival, if captured as a patient record. EXCLUSIONS: Cancelled surgeries (records with ICD9-CM diagnostic codes of V640 -V643) Hospital owned physician offices or private physician offices.Hospital owned off-site surgery centers.Scheduled diagnostic or therapeutic treatments such as chemotherapy, x-ray, lab, PT, OT, ST or services related to cardiac rehab, diabetes or nutritional counseling clinics, etc.
AChalsma@dhhs.state.nh.us [mailto:AChalsma@dhhs.state.nh.us]

I would encourage the use of a definition that may be in place on a national basis. Would the HCUP definitions be helpful?    Health Care: Healthcare Cost and Utilization Project (HCUP) Subdirectory Page      HCUP-US SASD Overview     SASD Database Documentation - Public  Additionally, perhaps this document from Wisconsin (2004 data) is useful.  The Hospital Association could be very helpful in definitions - Dana Richardson may be a helpful contact.     http://www.whainfocenter.com/data_resources/2004_hcdr/2004hcdr_chapvi.pdf  Finally, while I am not a data-guru, it seems to me that "outpatient" may be largely a simple date (same-day) issue & a setting question (hospital, ASC, etc.).  The definition of surgery is more intricate.  It appears that "Procedure" definitions may be what you are talking about.  If the Procedure definitions can be standardized to those used (as relevant) in the inpatient setting, this would help simplify matters. Hope this is helpful.If not, please toss; no hard feelings, since I recognize my background in this question is very limited. GretchenDahlengret@aol.com [mailto:Dahlengret@aol.com]

Illinois recently issued a Notice of Proposed Rule for its inpatient/outpatient reporting requirements. While the regulation has not been finalized yet, I thought it might be helpful for you to see what the Department proposed as definitions for "outpatient" and "outpatient surgery":

"Outpatient" means any health care service provided in a hospital to a patient who
is not admitted as an inpatient to the hospital, or any health care service provided
to a patient in a licensed ambulatory surgical treatment center.

"Outpatient surgery" means specific procedures performed on an outpatient basis
in a hospital or licensed ambulatory surgical treatment center. Specific ranges of
required procedure codes can be found in the Department's data submission
manual.

Attached is a copy of the Notice of Proposed Rules.(See attached file: register_volume31_issue10.pdf)

Cherie Haydock
Government Relations
Humana Inc.
770-350-2107

[chaydock@humana.com]

 

 

This can be a bit of a tricky area.   The "definition" that Renown uses as "Outpatient Surgery" is any encounter in which the patient is not admitted as an Inpatient during the stay and incurs charges under Revenue Code 036x (where x is any digit).  Rev Code 036x represenst the Operating Room.
 
Simply, the patient never met IP admission criteria and had services performed in the OR.  This causes some potential "false positives" as the Operating Room can often be used for pain management procedures and scoping procedures (such as endoscopies) but I see the beauty of our definition is that it is quite simple, non-ambiguous and all encompassing.

Al Herak [AHerak@renown.org]

Milliman's definition for Outpatient Surgery is a surgery that is performed in any oft the following:
Outpatient Department of a Hospital ,
a  freestanding ambulatory surgical facility, or a
Physician's office.

Richard Kipp, MAAA
Milliman Inc.
1550 Liberty Ridge Drive
Wayne, Pa  19087

“Outpatient surgery" means all surgical procedures performed on an outpatient basis in a general hospital, ordinary hospital, outpatient surgical hospital or other facility licensed or certified pursuant to Article 1 (§ 32.1-123 et seq.) of Chapter 5 of this title or in a physician's office or oral and maxillofacial surgeon's office, as defined above. Outpatient surgery refers only to those surgical procedure groups on which data are collected by the nonprofit organization as a part of a pilot study

Michael T. Lundberg
Executive Director
Virginia Health Information
1108 East Main Street, Suite 1201
Richmond, VA 23219

In FL, they specify ranges of CPT codes:  10000 through 69999 for ambulatory surgery.  They also collect cardiac catheterization codes 93500 – 93599.

Miller Betsy [mailto:Betsy.Miller@hcahealthcare.com]

The reference to a definition of “outpatient surgery” is under the definitions in the INSTRUCTIONS TO THE 2006 NEW JERSEY ACUTE CARE HOSPITAL COST REPORTS, that states: 

“Outpatient Surgery: Outpatient surgery involves a less intense level of care than that

required for same day surgery patients. These patients are not admitted or assigned to a DRG. There is no use of a fully equipped operating room and no operating room charges are generated.”

 

This differs from the definition of “same day surgery” as follows:

 

“Same Day Surgery Same Day Surgery is defined as patients who have been provided

surgery in a fully equipped operating room, have an operating room charge on UB-82 (HCFA-1450) and were discharged before midnight of the day of admission. Moreover, the discharge was routine in nature and not for transfer, leaving against medical advice, or death.”

Nadine Banks [mailto:NBANKS@NJHA.com]

We are currently working with 2 states that have varying definitions of outpatient surgeries, Florida and New Jersey.            In New Jersey discharges from acute care facilities that meet the following criteria are considered Same Day Medical or Same Day Surgical:1.    The patient was discharged on the day of admission. 2.    The discharge status was coded as 01, Routine discharge home. 3.    If the patient met the first 2 criterion, we look at the MDC type of the DRG.  If the MDC type was Surgical, it was a same day surgery otherwise it was a same day medical case.             Florida uses a different definition which would include either:1.    Patients who were treated in the hospital’s Emergency Room and not admitted to the hospital. 2.    Patients who were treated in a stand-alone ambulatory care facility. 3.    Patients who were treated in a Cardiac Catheterization lab. 4.    Patients who were treated in a Lithotripsy lab. 5.    All non-emergency visits in which surgery services were performed and the services provided correspond to a CPT code of 10000 – 69999 or 93500-93599.

            More detail can be found under Florida Statutes chapter 59B-7.  I think the list of CPT codes above may have been expanded recently.

 

Todd Puglise
Director, Data Integrity
Accuro Healthcare
210 Taylor St, Suite 124
Punta Gorda, Florida 33950 
tpuglise@accurohealth.comwww.accurohealth.com

It would be particularly interesting to know if any of these outpatient surgeries include patients involved in a motor vehicle crash and transported to the emergency room or if they always exclude this type of patient.

Sandy.Johnson@dot.gov [mailto:Sandy.Johnson@dot.gov