Association of Neurosurgical Work Relative Value Units with Objective Markers of Operative Complexity

Abstract

Relative value units (RVUs) form the backbone of health care service reimbursement calculation in the United States. However, it remains unclear how well RVUs align withobjective measures of procedural complexity within neurosurgery. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for neurosurgical procedures with >50 patients, using Current Procedural Terminology (CPT) codes. Length of stay (LOS), operative time, mortality, and readmission and reoperation rates were collected for each code and a univariate correlation analysis was performed, with significant predictors entered into a multivariate logistic regression model, which generated predicted work RVUs, which were compared with actual RVUs to identify undervalued and overvalued procedures. Among 64 CPT codes, LOS, operative time, mortality, readmission, and reoperation were significant independent predictors of work RVUs and together explained 76% of RVU variance in a multivariate model (R2= 0.76). Using a difference of >1.5 standard deviations from the mean, procedures associated with greater than predicted RVU included surgery for intracranial carotid circulation aneurysms (CPTs 61697 and 61700; residual RVU= 12.94 and 15.07, respectively), and infratemporal preauricular approaches to middle cranial fossa (CPT 61590; residual RVU= 15.39). Conversely, laminectomy/foraminotomy for decompression of additional spinal cord, cauda equina, and/or nerve root segments (CPT 63048; residual RVU= -21.30), transtemporal craniotomy for cerebellopontine angle tumor resection (CPT 61526; residual RVU= -9.95), and brachial plexus neuroplasty (CPT 64713; residual RVU= -11.29) were associated with lower than predicted RVU. Work RVUs for neurosurgical procedures are largely predictive of objective measures of surgical complexity, with few notable exceptions.