Buyer beware: analysis of changes to the 2021 Center for Medicare and Medicaid Services physician fee schedule for shoulder surgeons Medicare physician fee schedule changes

Abstract

BackgroundBecause of budget neutrality rules in the United States Congress, the rates for reimbursable medical expenses with Medicare have been on a recent and consistent decline. The Center for Medicare and Medicaid Services (CMS) continued to proceed with cuts to the 2021 physician fee schedule. There has been an overall 3.3% decrease in the valuation of work relative value units per CMS guidelines. Conversely, CMS has increased the value of certain in office evaluation and management (E/M) services and changed the criteria for level of visit based on complexity of decision-making. The direct effects of these changes to shoulder and elbow surgeons are unknown. This study evaluates the effect of these changes in Medicare reimbursement from 2020 to 2021 among a group of high-volume shoulder and elbow surgeons. MethodsBilling data were queried for 9 fellowship-trained shoulder & elbow surgeons at a high-volume surgical practice from 2020 to 2021. Office-based E/M and surgical codes for shoulder arthroplasty and other common shoulder and elbow codes were used. We compared volume data and change to reimbursement using the 2020 and 2021 Medicare physician fee schedule. The impact of increased E/M billing levels using the new 2021 CMS criteria was also calculated and compared between years. ResultsComparing 2020 to 2021, there was a 18.7% decrease in level 3 visits (17,208 vs. 13,990) and a corresponding 371% increase in level 4 visits billed (1138 vs. 5362). Evaluating the overall impact of this shift on reimbursement from office-based E/M codes, there was a significant increase with an average of $57,954 per surgeon (range = $20,394-$118,916) for this group of 9 surgeons. However, surgical reimbursement for most commonly performed arthroscopic and open shoulder and elbow procedures decreased for 5 of 9 surgeons, with an average decrease of $13,015 (range = −$80,980 to $44,246). When arthroplasty reimbursements were combined with those for other common procedures, there was a decreased surgical reimbursement, totaling $117,135 for all surgeons combined. ConclusionIn this practice of 9 high-volume shoulder and elbow surgeons, a significant decrease in CMS reimbursement related to surgical procedural reimbursement from 2020 to 2021 was experienced. However, increasing the rates of E/M reimbursement and the augmented visit level rules helped offset and exceed the lost revenue from surgical procedures. Caution must be taken: this one time increase in office-based billing coupled with continued annual cuts to surgical procedure valuation is not a sustainable model moving forward. Level of EvidenceLevel IV; Retrospective Case Series; Economic Model.