Hand and Upper Extremity Procedures Are Significantly More Cost Effective When Performed in Ambulatory Surgery Centers Versus Hospital Outpatient Departments


  • Vincent P. Federico Rush University Medical Center
  • Shelby R. Smith Rush University Medical Center
  • John Higgins Rush University Medical Center
  • Vince Morgan Rush University Medical Center
  • Xavier Simcock Rush University Medical Center




ambulatory surgery center, costs, hand, hospital outpatient departments, upper extremity



Orthopaedic surgery has high rate of utilization of the outpatient settings including ambulatory surgery centers (ASC) and hospital outpatient departments (HOPD). We seek to compare costs at these outpatient facilities, ASC versus HOPD, for hand and upper extremity procedures.


Database review was performed with publicly available data from Center for Medicare and Medicaid Services (CMS) via the Medicare Procedure Price Lookup Tool and Current Procedural Terminology (CPT) codes for hand and upper extremity procedures. Total costs, facility fees, Medicare payments, and patient payments were obtained for each procedure code. Descriptive statistics were used to calculate means and standard deviations. Differences were analyzed using Mann Whitney U test.


Thirty-seven CPT codes were divided into arthroscopy, fracture, arthroplasty/arthrodesis, and other. Arthroscopy demonstrated cost savings in total cost of procedure (1,886.00±58.72 vs 3,418.00±58.78; p=0.009), facility fees (1,360.00±0 vs 2,892.00±0; p=0.021), Medicare payments (1,509.00±47.27 vs 2,734.00±47.27 p=0.021), and patient payments (376.75±11.87 vs 682.75±11.87; p=0.021) in ASCs compared to HOPD. Fracture procedures had lower total costs (3,886.58±1,527.61 vs 5,975.92±1,890.96; p=0.021), Medicare payments (3,109.17±1,221.21 vs 4,780.75±1,511.90; p=0.021), facility fees (3,055.17±1,503.23 vs 5,228.67±1,725.74; p=0.018), and patient payments (776.92±305.46 vs 1,194.75±377.97; p=0.021) in ASCs. When CPT codes were grouped all together, there was 35% savings in total cost, 41% savings for facility fees, and 36% savings in Medicare payments, and 28% in patient payments for procedures performed at ASCs.


ASCs demonstrate cost-savings across multiple procedures for the hand and upper extremity in a variety of areas including total costs, facility fees, Medicare payments, and patient payments when compared to HOPDs.

Author Biographies

Vincent P. Federico, Rush University Medical Center

Department of Orthopaedics

Resident Physician

John Higgins, Rush University Medical Center

Department of Orthopaedics

Resident Physician

Vince Morgan, Rush University Medical Center

Department of Orthopaedics

Resident Physician

Xavier Simcock, Rush University Medical Center

Department of Orthopaedics

Attending Physician


National Healthcare Expenditure Data. Centers for Medicare & Medicaid Services. December 1, 2021. Accessed February 11, 2023. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData

Health Expenditure. Organisation for Economic Co-operation and Development. Accessed February 12, 2023. https://www.oecd.org/els/health-systems/health-expenditure.htm

Health Expenditures. Centers for Disease Control and Prevention. October 17, 2022. Accessed February 1, 2023. https://www.cdc.gov/nchs/fastats/health-expenditures.htm

Friedlander DF, Krimphove MJ, Cole AP, et al. Where Is the Value in Ambulatory Versus Inpatient Surgery? Ann Surg. 2021;273(5):909-916.

Crawford DC, Li CS, Sprague S, et al. Clinical and Cost Implications of Inpatient Versus Outpatient Orthopedic Surgeries: A Systematic Review of the Published Literature. Orthop Rev (Pavia). 2015;7(4):6177.

Massey PA, McClary K, Zhang AS, et al. Orthopaedic Surgical Selection and Inpatient Paradigms During the Coronavirus (COVID-19) Pandemic. J Am Acad Orthop Surg. 2020;28(11):436-450.

Peacock S, Wolfstadt J, Peer M, et al. Rapid implementation of an outpatient arthroplasty care pathway: a COVID-19-driven quality improvement initiative. BMJ Open Qual. 2022;11(1).

Boehmer P, Wirtz DC, Burger C, et al. Economic Effects of the SARS-CoV-2 Pandemic in 2020. Z Orthop Unfall. 2022.

Hoffmann JD, Kusnezov NA, Dunn JC, et al. The Shift to Same-Day Outpatient Joint Arthroplasty: A Systematic Review. J Arthroplasty. 2018;33(4):1265-1274.

Helseth Ø, Lied B, Halvorsen CM, et al. Outpatient Cervical and Lumbar Spine Surgery is Feasible and Safe: A Consecutive Single Center Series of 1449 Patients. Neurosurgery. 2015;76(6):728-737; discussion 737-728.

Pugely AJ, Martin CT, Gao Y, et al. Outpatient surgery reduces short-term complications in lumbar discectomy: an analysis of 4310 patients from the ACS-NSQIP database. Spine (Phila Pa 1976). 2013;38(3):264-271.

Nguyen C, Milstein A, Hernandez-Boussard T, et al. The Effect of Moving Carpal Tunnel Releases Out of Hospitals on Reducing United States Health Care Charges. J Hand Surg Am. 2015;40(8):1657-1662.

Munnich EL, Parente ST. Procedures take less time at ambulatory surgery centers, keeping costs down and ability to meet demand up. Health Aff (Millwood). 2014;33(5):764-769.

Sandrowski K, Kwok M, Gallant G, et al. A Prospective Evaluation of Postoperative Readmissions After Outpatient Hand and Upper Extremity Surgery. Cureus. 2021;13(5):e15247.

Medpac: Ambulatory surgical center services: Assessing payment adequacy and updating payments.

Carey K. Price Increases Were Much Lower In Ambulatory Surgery Centers Than Hospital Outpatient Departments In 2007-12. Health Aff (Millwood). 2015;34(10):1738-1744.

Centers for Medicaid & Medicare Services. What’s Medicare?. Accessed February 2, 2023.https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare

Haglin JM, Zabat MA, Richter KR, et al. Over 20 years of declining Medicare reimbursement for spine surgeons: a temporal and geographic analysis from 2000 to 2021. J Neurosurg Spine. 2022 Mar 25:1-8. doi: 10.3171/2022.2.SPINE211368. Epub ahead of print. PMID: 35334463.

Acuña AJ, Jella TK, Samuel LT, et al. Inflation-Adjusted Medicare Reimbursement for Revision Hip Arthroplasty: Study Showing Significant Decrease from 2002 to 2019. J Bone Joint Surg Am. 2021 Jul 7;103(13):1212-1219. doi: 10.2106/JBJS.20.01643. PMID: 33764932.

Pollock JR, Richman EH, Estipona BI, et al. Inflation-Adjusted Medicare Reimbursement Has Decreased for Orthopaedic Sports Medicine Procedures: Analysis From 2000 to 2020. Orthop J Sports Med. 2022 Feb 11;10(2):23259671211073722. doi: 10.1177/23259671211073722. PMID: 35174250; PMCID: PMC8842183.

Miskiel S, Bye M, Freeland EC, et al. Declining Trends in Medicare Reimbursement in Orthopaedic Foot and Ankle Surgery. Foot Ankle Orthop. 2022 Jan 20;7(1):2473011421S00048. doi: 10.1177/2473011421S00048. PMID: 35097542; PMCID: PMC8795046.

Thornburg DA, Gupta N, Chow N, et al. An Analysis of Procedural Medicare Reimbursement Rates in Hand Surgery: 2000 to 2019. Hand (N Y). 2021 Feb 25:1558944721990807. doi: 10.1177/1558944721990807. Epub ahead of print. PMID: 33631979.

Moore ML, Pollock JR, Haglin JM, et al. A Comprehensive Analysis of Medicare Reimbursement to Physicians for Common Arthroscopic Procedures: Adjusted Reimbursement Has Fallen Nearly 30% From 2000 to 2019. Arthroscopy. 2021 May;37(5):1632-1638. doi: 10.1016/j.arthro.2020.11.049. Epub 2020 Dec 2. PMID: 33278531.

Tanaka MJ. Ambulatory surgery centers versus hospital-based outpatient departments: What's the difference? AAOS. Retrieved January 5, 2023, from https://www.aaos.org/aaosnow/2019/sep/managing/managing02/

Wang KY, Puvanesarajah V, Marrache M, et al. Ambulatory Surgery Centers Versus Hospital Outpatient Departments for Orthopaedic Surgeries. J Am Acad Orthop Surg. 2022 Mar 1;30(5):207-214. doi: 10.5435/JAAOS-D-21-00739. PMID: 35143432.

Koenig L, Doherty J, Dreyfus J, et al. An analysis of recent growth of am- bulatory surgery centers: final report. 2009 Jun 5. http://citeseerx.ist.psu.edu/viewdoc/download?doi=

"The CMS New Rule On Ambulatory Surgical Centers Earns Only Partial Credit", Health Affairs Blog, June 2, 2021. DOI: 10.1377/hblog20210527.32226

Goyal KS, Jain S, Buterbaugh GA, et al. The Safety of Hand and Upper-Extremity Surgical Procedures at a Freestanding Ambulatory Surgery Center: A Review of 28,737 Cases. J Bone Joint Surg Am. 2016;98(8):700-704.

Kaye AD, Okeagu CN, Pham AD, et al. Economic impact of COVID-19 pandemic on healthcare facilities and systems: International perspectives. Best Pract Res Clin Anaesthesiol. 2021;35(3):293-306.

Colenda CC, Applegate WB, Reifler BV, et al. COVID-19: Financial Stress Test for Academic Medical Centers. Acad Med. 2020;95(8):1143-1145.

Fabricant PD, Seeley MA, Rozell JC, et al. Cost Savings From Utilization of an Ambulatory Surgery Center for Orthopaedic Day Surgery. J Am Acad Orthop Surg. 2016;24(12):865-871.

Wang KY, Puvanesarajah V, Marrache M, et al. Ambulatory Surgery Centers Versus Hospital Outpatient Departments for Orthopaedic Surgeries. J Am Acad Orthop Surg. 2022;30(5):207-214.

Hair B, Hussey P, Wynn B. A comparison of ambulatory perioperative times in hospitals and freestanding centers. Am J Surg. 2012;204(1):23-27.



How to Cite

Vincent P. Federico, Shelby R. Smith, John Higgins, Vince Morgan, & Xavier Simcock. (2024). Hand and Upper Extremity Procedures Are Significantly More Cost Effective When Performed in Ambulatory Surgery Centers Versus Hospital Outpatient Departments. Journal of Orthopaedic Business, 4(3). https://doi.org/10.55576/job.v4i3.59