The Outpatient Shift: An Operational Checklist for Department Leadership

Thursday, OR planning meeting. On next week's schedule: two laparoscopic cholecystectomies, scheduled as always, with two overnight stays each. Since January, cholecystectomy has been in the Hybrid-DRG catalog — hybrid DRGs are uniform flat rates paid for defined procedures regardless of whether they are delivered as inpatient or outpatient cases: the same procedure, one payment, whether the patient stays overnight or goes home in the evening [1]. What was a routine question of ward organization for decades has become a calculation question — the operational core of what the German debate calls Ambulantisierung, the shift of formerly inpatient procedures into outpatient settings. And it is decided in the department, not in the administrative wing.

The state of the catalogs

Three sets of rules determine which procedures leave the inpatient frame. The AOP-Katalog under Section 115b SGB V — the catalog of operations hospitals may perform on an outpatient basis — covers around 3,000 defined procedures and is adjusted annually to the OPS, the German procedure classification; the 2026 AOP contract applies in the version of 17 December 2025 [2, 3]. For a catalog service that is to be delivered as an inpatient case, a documented context factor under Annex 2 or an individual medical justification is required — otherwise the case can hardly be defended in a billing audit. That 86 percent of hospitals consider the context factors unsuited to capturing the necessity of inpatient care [4] makes the individual-case documentation all the more important.

The hybrid DRGs under Section 115f SGB V, introduced in 2024, are the real growth item: the 2026 catalog comprises 69 billable hybrid DRGs with 904 OPS codes — the year before, it was 583 codes. New additions include appendectomy, cholecystectomy, minimally invasive procedures on coronary arteries and peripheral vessels, and fracture osteosyntheses; services for children and for people with disabilities were removed [1]. The legislative mandate: the catalog was to cover at least one million formerly fully inpatient cases; the political target is around two million by 2030 [5].

The third building block: the cross-sector care facilities under Section 115g SGB V. Their service catalog has been agreed since March 2026; the first facilities are expected to start operating in 2027 [6]. For most departments, this is a watching brief for now — for sites whose future in hospital planning is open, considerably more.

The uncomfortable interim balance

The Krankenhaus Barometer 2025 of the Deutsches Krankenhausinstitut (DKI — the German Hospital Institute; a survey of 376 general hospitals with 100 or more beds) shows how far implementation has come — and how expensive it is: 92 percent of hospitals already bill hybrid DRGs. Around 70 percent are currently not covering their costs on these services; only 5 percent operate at least predominantly cost-covering. By 2028, around 40 percent of hospitals expect more than 10 percent of formerly inpatient cases to shift; by 2030, 56 percent do. Most hospitals have adapted revenue management and patient steering — physically separating outpatient procedures from inpatient operations, by contrast, is only rarely fully implemented [5].

The payment form, then, has arrived across the board; the process redesign behind it barely. The two findings explain each other: an outpatient case that runs through inpatient structures — the full admission pathway, the ward as a waiting zone, staff planned for overnight stays — carries costs the hybrid DRG does not pay for. Exactly in between lies the work of department leadership.

The checklist

Seven points, from analysis to implementation. None of them presupposes that the hospital has a strategy department.

1. Portfolio inventory, annually. Lay the department's case-number list against the AOP catalog and the 904 OPS codes of the 2026 hybrid DRG catalog: which procedures are affected, how many cases, what share of revenue? The catalogs are updated every year — the inventory belongs in the department's annual rhythm.
2. Make the admission decision documentation-proof. For catalog services, "inpatient" requires justification: a context factor or a medical or social justification, documented on the day of admission with findings. The context factor belongs in the admission documentation like the allergy in the premedication record: collected, named, dated. Whoever leaves this to the day of discharge gives cases away to the audit — and the 2027 audit quota is being created now (in German).
3. Know the 2026 bilateral change. The OPS marker "bilateral" has been dropped; bilateral procedures now need two OPS codes [3]. A footnote — until the coding of a bilateral procedure decides catalog assignment and payment.
4. Process before price. The 70 percent figure is the benchmark argument: outpatient surgery only becomes cost-covering with a rebuilt process — a paced OR line, adapted staffing, lean documentation, clear same-day discharge criteria. Whoever runs the inpatient process at outpatient prices subsidizes it from the rest of the budget.
5. Separate physically and organizationally where possible. The rarest implementation according to the DKI — and the difference between an outpatient program with its own line and a disturbance in the inpatient flow that slows both sides down.
6. Replan residency training. When appendectomy and cholecystectomy migrate out of the inpatient spectrum, training procedures migrate with them. The question of where residents will learn these procedures in future, and how the outpatient area is integrated into training, should be answered by the department before the catalog answers it. The question of which procedure volumes will support the training authorization in future belongs on the same table.
7. Take the referrers along. Outpatient pathways change what practices have to expect: preparation, aftercare on the day of discharge, availability in case of complications. Whoever converts without involving the referring practices risks the capital that occupancy lives on — more on this in the article on the referrer base (in German).

How to recognize progress

The number of billed hybrid DRGs is hardly a useful yardstick — almost every hospital reaches that. Three questions are more informative: does the department know its catalog case share? Is every inpatient delivery of a catalog service justified on the day of admission? And is there a process for the most frequent outpatient procedures that differs from the inpatient one? Whoever answers all three with yes already belongs to the minority.

We write regularly about the interface of documentation, economics and organization — our weekly briefing Visite (German; English edition Grand Rounds is in preparation) is our letter on exactly that.

Sources

1. Kassenärztliche Bundesvereinigung. Hybrid-DRG für 2026 stehen fest — das sind die Neuerungen. 13.11.2025. https://www.kbv.de/praxis/tools-und-services/praxisnachrichten/2025/11-13/hybrid-drg-fuer-2026-stehen-fest-das-sind-die-neuerungen
2. GKV-Spitzenverband. Ambulantes Operieren nach § 115b SGB V. https://www.gkv-spitzenverband.de/krankenversicherung/ambulant_stationaere_versorgung/ambulantes_operieren_115_b/ambulantes_operieren_115_b.jsp
3. Kassenärztliche Bundesvereinigung. AOP-Vertrag an aktuellen OPS und EBM angepasst. 18.12.2025. https://www.kbv.de/praxis/tools-und-services/praxisnachrichten/2025/12-18/aop-vertrag-an-aktuellen-ops-und-ebm-angepasst
4. Deutsches Krankenhausinstitut. Krankenhaus Barometer 2023, Kap. 4. https://www.dki.de/fileadmin/user_upload/DKI_Krankenhaus_Barometer_2023_final.pdf
5. Deutsches Krankenhausinstitut. Krankenhaus Barometer 2025, Kap. 5. https://www.dkgev.de/fileadmin/default/Mediapool/1_DKG/1.7_Presse/1.7.1_Pressemitteilungen/2025/2025-12-29_Anlage_DKI-Krankenhaus-Barometer.pdf
6. GKV-Spitzenverband. Sektorenübergreifende Versorgungseinrichtungen nach § 115g SGB V. https://www.gkv-spitzenverband.de/krankenversicherung/ambulant_stationaere_versorgung/sektoruebergr_versorgung_115g/suev_115g.jsp