Outpatient care has been in the spotlight for healthcare providers and regulators like the Centers for Medicare and Medicaid Services (CMS). Ambulatory Surgery Centers and retail clinics are gaining popularity with patients for being low-cost, convenient alternatives to primary care physicians and emergency departments. CMS is regularly updating its list of inpatient-only procedures as medical technology advances, allowing patients to receive surgeries such as joint replacements in outpatient facilities.
However, inpatient revenue still constitutes a significant percentage of hospitals' total patient revenues. Of the hospitals with the highest total patient revenues, inpatient earnings were greater for 6 of the top 10 according to Definitive Healthcare data. The top ten most common primary inpatient diagnoses were reported a total of 9.2 million times in 2016. The ten most common secondary diagnoses were reported nearly 93 million times, with nearly 10 secondary diagnoses for every primary diagnosis.
Top 10 Primary Diagnoses by DRG Code
|Description||DRG Code||# Primary Diagnoses|
|Major joint replacement or reattachment of lower extremity without major complication or comorbidity||470||1,328,567|
|Septicemia or severe sepsis without ventilation, 96 or more hours with major complication or comorbidity||871||1,323,063|
|Esophagitis, gastroenterology & misc. digestive disorders without major complication or comorbidity||392||621,104|
|Newborn with significant problems||794||598,781|
|Heart failure & shock with major complications or comorbidities||291||547,609|
|Cellulitis without major complication or comorbidity||603||427,079|
|Kidney & urinary tract infections without major complications or comorbidities||690||386,371|
|Pulmonary edema & respiratory failure||189||379,198|
Fig 1 Data from Definitive Healthcare based on Annual Medicare Data from the 2016 Medicare SAF (1/1/2016 - 12/31/2016). Complete Calendar Year 2017 data is projected to be released in fall 2018 by the Centers for Medicare and Medicaid Services (CMS).
A "primary" diagnosis is established by a physician as the principal reason for a patient's admittance, and governs a patient's initial course of treatment. The "secondary" diagnosis, or diagnoses as the case may be, are any condition that exist alongside the primary diagnosis at the time of admission, or that affect a patient's care after the initial diagnosis. The most common secondary diagnosis is, by far, "septicemia or severe sepsis" (DRG code 871). Septicemia, also called sepsis, is a severe blood infection that is most often contracted via wound infection. If left untreated, sepsis can lead to organ damage, organ failure, and even death. Sepsis is relatively common, with more than 25 million reported cases in 2016, and is often a hospital-acquired infection (HAI).
There is significant overlap between the most common primary and secondary inpatient diagnoses. Psychoses, major joint replacement, sepsis, heart failure, and pulmonary edema & respiratory failure are some of the most commonly-occurring conditions, and can be diagnosed simultaneously or as the result of another condition on the list. If a patient is admitted for a joint replacement, they could conceivably contract sepsis while in recovery, which could lead to heart and/or respiratory failure. Every primary diagnosis listed, with the exception of DRG codes 794 & 795, are diagnosed far more often as secondary diagnoses. While these conditions may be the initial reason for a patient visit, they are most commonly the result of underlying conditions or procedure complications.
Top 10 Secondary Diagnoses by DRG Code
|Description||DRG Code||# Secondary Diagnoses|
|Septicemia or severe sepsis without ventilation, 96 or more hours with major complication or comorbidity||871||24,557,164|
|Heart failure and shock with major complication or comorbidity||291||11,081,341|
|Major joint replacement or reattachment of lower extremity without major complication or comorbidity||470||10,740,580|
|Pulmonary edema & respiratory failure||189||6,640,176|
|Heart failure & shock with complication or comorbidity||292||6,533,820|
|Septicemia or severe sepsis without ventilation, 96 or more hours without major complication or comorbidity||872||5,903,548|
|Renal failure with complication or comorbidity||683||5,734,387|
|Chronic obstructive pulmonary disease with major complication or comorbidity||190||5,704,520|
|Esophagitis, gastroenterology & misc digestive disorders without major complication or comorbidity||392||5,661,275|
Fig 2 Data from Definitive Healthcare based on Annual Medicare Data from the 2016 Medicare SAF (1/1/2016 - 12/31/2016). Complete Calendar Year 2017 data is projected to be released in fall 2018 by the Centers for Medicare and Medicaid Services (CMS).
In the most recent reporting year, sepsis made up more than 6 percent of total inpatient diagnoses in the U.S., followed by psychoses (3 percent) and major joint replacements (2.9 percent).
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