Technological and clinical innovation, ‘new’ healthcare consumerism, and increasing financial incentives are all strong stimuli for the steadily rising preference toward outpatient care settings—which offer huge benefits for those seeking less costly and more convenient medical care. Surgeries and diagnostic procedures that once required pricey inpatient stays can be completed faster in an outpatient setting, and commercial claims data shows that patients are embracing these newly available opportunities.
Definitive Healthcare tracks and analyzes YTD data from the Medicare Quarterly Standard Analytics File (SAF), which has an approximate 93% of claims maturity for each quarter. Based on the near 40,000 outpatient procedures reported in the first half of 2019 (complete calendar year data is expected to be released and incorporated into our database in Fall 2020), observe the following top 10 outpatient procedures (with corresponding ICD-10 codes) ranked by both volume and total payment.
Top 10 outpatient procedures by volume, 2019
Rank | ICD-10 Code | ICD-10 Description | Number of Procedures |
| 1 | Z1231 | Screening mammogram for malignant neoplasm of breast | 7,884,853 |
| 2 | I10 | Essential (primary) hypertension | 5,363,911 |
| 3 | Z0000 | General adult medical examination without abnormal findings | 3,236,680 |
| 4 | Z23 | Immunization | 2,898,301 |
| 5 | E119 | Type 2 diabetes mellitus without complications | 2,739,610 |
| 6 | N390 | Urinary tract infection, site not specified | 2,455,430 |
| 7 | M545 | Low back pain | 2,308,636 |
| 8 | Z5111 | Antineoplastic chemotherapy | 2,223,564 |
| 9 | J069 | Acute upper respiratory infection, unspecified | 2,192,537 |
| 10 | Z01818 | Other preprocedural examination | 2,117,553 |
Fig 1 ICD-10 procedure data is from January through June 2019. Claims information retrieved from the 2019 Medicare Quarterly standard analytics files (SAF), most recent data available.
Many of the procedures listed above have become more commonplace and ranked similarly in past years as well (apart from antineoplastic chemotherapy which is new to the board with 2.2 million claims). For example, mammogram screenings have consistently topped these rankings since 2016, with immunizations and hypertension falling somewhere in the succeeding 5 slots.
As mentioned above, mammograms were the most reported procedure performed in 2019 so far with a count of over 7.8 million completed, representing both provider emphasis and consumer awareness toward regular breast cancer screening.
Management of chronic conditions also makes up a significant portion of this list—where hypertension, back pain, and type 2 diabetes combined to account for over 10 million total procedures. Hypertension and type 2 diabetes are common throughout the U.S. and frequently occur together, while chronic back pain is a symptom of various conditions including ruptured disks, arthritis, and traumatic injuries.
Top 10 outpatient procedures by total payments, 2019
| Rank | ICD-10 Code | ICD-10 Description | Total Payments |
| 1 | Z5111 | Antineoplastic chemotherapy | $7,742,945,859 |
| 2 | Z5112 | Antineoplastic immunotherapy | $5,584,004,298 |
| 3 | R0789 | Other chest pain | $1,587,550,742 |
| 4 | Z1211 | Screening for malignant neoplasm of colon | $1,527,182,583 |
| 5 | R079 | Chest pain, unspecified | $1,501,544,118 |
| 6 | Z510 | Antineoplastic radiation therapy | $1,468,822,864 |
| 7 | I2510 | Atherosclerotic heart disease of native coronary artery without angina pectoris | $1,395,511,672 |
| 8 | G35 | Multiple sclerosis | $1,155,259,471 |
| 9 | Z1231 | Screening mammogram for malignant neoplasm of breast | $1,107,437,026 |
| 10 | R55 | Syncope and collapse | $906,303,905 |
Fig 2 ICD-10 diagnosis data is from January through June 2019. Claims information retrieved from the 2019 Medicare Quarterly standard analytic files (SAF).
In terms of diagnoses by payments, cancer screening and treatments took half of the top 10 spots when ranked by total payments. These are followed closely by heart-related events such as chest pain and heart disease. This is unsurprising considering both the high cost of oncology drugs and other cancer-related treatments, as well as the prevalence of heart disease in the U.S.
Antineoplastic chemotherapy is the top ranked outpatient procedure (by total payments) again for the fourth time since 2015. In the first half of 2019 alone, payments totaled more than $7.7 billion—an increase of nearly 25 percent from the same time period in 2015. Both “chest pain, unspecified” and “other chest pain” saw an increase in total payments in the last 3 years, moving from spots 6 and 10 to spots 3 and 5, respectively. Colon screening payments increased from about $800 million in 2015 to over $1.5 billion during the same period in 2019, rising from the 9th spot to the 4th.
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