Relative Value Units Research Articles

Comparison of Full-Time Equivalent and Clinic Time Labor Input Measures in Productivity Metrics.

A lack of improvement in productivity in recent years may be the result of suboptimal measurement of productivity. Hospitals and clinics benefit from external benchmarks that allow assessment of clinical productivity. Work relative value units have long served as a common currency for this purpose. Productivity is determined by comparing work relative value units to full-time equivalents (FTEs), but FTEs do not have a universal or standardized definition, which could cause problems. We propose a new clinical labor input measure-"clinic time"-as a substitute for using the reported measure of FTEs. In this observational validation study, we used data from a cluster randomized trial to compare FTE with clinic time. We compared these two productivity measures graphically. For validation, we estimated two separate ordinary least squares (OLS) regression models. To validate and simultaneously adjust for endogeneity, we used instrumental variables (IV) regression with the proportion of days in a pay period that were federal holidays as an instrument. We used productivity data collected between 2018 and 2020 from Veterans Health Administration (VA) cardiology and orthopedics providers as part of a 2-year cluster randomized trial of medical scribes mandated by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018. Our cohort included 654 unique providers. For both productivity variables, the values for patients per clinic day were consistently higher than those for patients per day per FTE. To validate these measures, we estimated separate OLS and IV regression models, predicting wait times from the two productivity measures. The slopes from the two productivity measures were positive and small in magnitude with OLS, but negative and large in magnitude with IV regression. The magnitude of the slope for patients per clinic day was much larger than the slope for patients per day per FTE. Current metrics that rely on FTE data may suffer from self-report bias and low reporting frequency. Using clinic time as an alternative is an effective way to mitigate these biases. Measuring productivity accurately is essential because provider productivity plays an important role in facilitating clinic operations outcomes. Most importantly, tracking a more valid productivity metric is a concrete, cost-effective management tactic to improve the provision of care in the long term.

Comparison of current relative value unit-based prices and utility between common surgical procedures, including orthopedic surgeries, in South Korea

BackgroundThe medical pricing system strongly influences physicians’ job satisfaction and patient health outcomes. This study aimed to investigate the current relative value unit (RVU)-based pricing and utility of patients in commonly performed surgical procedures in South Korea.MethodsFifteen common surgical procedures were selected from OECD statistics, and three additional orthopedic procedures were examined. The current pricing of each surgical procedure was retrieved from the Korea National Health Insurance Service, and the corresponding utilities were obtained as quality-adjusted life year (QALY) gains from previous studies. The relationship between the current prices (RVUs) and the patients’ utility (incremental QALY gains/year) was analyzed. Subgroup analysis was performed between fatal and non-fatal procedures and between orthopedic and non-orthopedic procedures.ResultsA significant negative correlation (r = − 0.558, p < 0.001) was observed between RVU and incremental QALY among all 18 procedures. The fatal subgroup had a significantly higher RVU than the non-fatal subgroup (p < 0.05), while the former had a significantly lower incremental QALY than the latter (p < 0.001). Orthopedic procedures showed higher incremental QALY values than non-orthopedic procedures, but they did not show higher prices (RVU).ConclusionsThis paradoxical relationship between current prices and patient utility is attributed to the higher pricing of surgical procedures for fatal and urgent conditions. Orthopedic surgery has been found to be a cost-effective treatment strategy. These findings could contribute to a better understanding of the potential role of incremental QALY in pursuing value-based purchasing or reasonable modification of the current medical fee schedule.

Comparative Analysis of Learning Curve, Complexity, Psychological Stress, and Work Relative Value Units for CPT 62380 Endoscopic Lumbar Spinal Decompression vs Traditional Lumbar Spine Surgeries: A Paired Rasch Survey Study.

Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT) code 62380. However, no work relative value units (RVUs) are currently assigned to the procedure. An international team of endoscopic spine surgeons conducted a study, endorsed by several spine societies, analyzing the learning curve, difficulty, psychological intensity, and estimated work RVUs of endoscopic lumbar spinal decompression compared with other common lumbar spine surgeries. A survey comparing CPT 62380 to 10 other comparator CPT codes reflective of common spine surgeries was developed to assess the work RVUs in terms of learning curve, difficulty, psychological intensity, and work effort using a paired Rasch method. The survey was sent to 542 spine specialists. Of 322 respondents, 150 completed the survey for a 43.1% completion rate. Rasch analysis of the submitted responses statistically corroborated common knowledge that the learning curve with lumbar endoscopic spinal surgery is steeper and more complex than with traditional translaminar lumbar decompression surgeries. It also showed that the psychological stress and mental and work effort with the lumbar endoscopic decompression surgery were perceived to be higher by responding spine surgeons compared with posterior comparator decompression and fusion surgeries and even posterior interbody and posterolateral fusion surgeries. The regression analysis of work effort vs procedural difficulty showed the real-world evaluation of the lumbar endoscopic decompression surgery described in CPT code 62380 with a calculated work RVU of 18.2464. The Rasch analysis suggested the valuation for the endoscopic lumbar decompression surgery should be higher than for standard lumbar surgeries: 111.1% of the laminectomy with exploration and/or decompression of spinal cord and/or cauda equina (CPT 63005), 118.71% of the laminectomy code (CPT 63047), which includes foraminotomy and facetectomy, 152.1% of the hemilaminectomy code (CPT 63030), and 259.55% of the interlaminar or interspinous process stabilization/distraction without decompression code (CPT 22869). This research methodology was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the Mexican Society of Spinal Surgeons (AMCICO), the International Society For Minimally Invasive Spine Surgery (ISMISS), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Surgery (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS). This study provides an updated reimbursement recommendation for endoscopic spine surgery. Level 3.

A Nurse Practitioner–Led Consultation Service for Patients With Brain Metastasis

BackgroundThis project assessed a nurse practitioner (NP)-led consultation service in neuro-oncology at an academic medical center. MethodsA 6-month pilot was implemented. Referring providers rated the NP consultant’s skill with a posttest survey. The number of monthly referrals and clinic visits were compared with the 6 months preintervention. Salary comparison and billing charges highlighted relative value unit (RVU) productivity and cost-avoidance. ResultsTen responses yielded an 80%–90% agree/strongly agree rating in support of the NP-led model. Referrals were sustained; RVU productivity and clinic follow-up increased. ConclusionThe NP-led model generated value, provided skillful consultations, and maintained referrals while increasing clinic follow-up.

Paired Comparison Survey Analysis Utilizing Rasch Methodology of the Relative Difficulty and Estimated Work Relative Value Units of CPT Code 0202T.

In anticipation of Food and Drug Administration (FDA) approval of the Total Posterior Spine (TOPS) system, the International Society for the Advancement of Spine Surgery (ISASS) conducted a study to estimate the work relative value units (RVUs) for facet arthroplasty. The purpose of this study was to establish a valuation of work RVU for Current Procedural Terminology (CPT) Code 0202T in the interim until the Relative Value Scale Update Committee (RUC) can determine an appropriate value. The valuation established from this survey will assist surgeons to establish appropriate procedure reimbursement from third-party payers. A survey was created and sent to 52 surgeons who had experience implanting the TOPS system during the investigational device exemption clinical trial. The survey included a patient vignette, a description of CPT Code 0202T along with a video of the TOPS system, and a confirmation question about the illustration's effectiveness. Respondents were asked to compare the work involved in CPT Code 0202T to 8 lumbar spine procedures. A Rasch analysis was performed to estimate the relative difficulty of CPT 0202T using the work RVUs of the comparable procedures. Forty-one surgeons responded to the survey. Of all the procedures, CPT Code 0202T received the most responses for equal work compared with posterior osteotomy (46%) followed by transforaminal lumbar interbody fusion (41%). The results of the regression analysis indicate a work RVU for CPT 0202T of 39.47. The study found an estimated work RVU of 39.47 for CPT Code 0202T using Rasch analysis. As an alternative to this Rasch methodology, one may consider a crosswalk methodology to the work RVUs for transforaminal lumbar interbody fusion procedurally, not as an alternative code. These recommendations are not a substitute for RUC methodology but serve as a reference for physicians and third-party payers to understand work RVU similarities for charge and payment purposes temporarily until RUC methodology provides accurate RVUs for the procedure.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons

BackgroundA survey was conducted at the 2023 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to assess practice management strategies among current AAHKS members. MethodsMembers of AAHKS used an app to answer both multiple-choice and “yes or no” questions related to a variety of issues related to their practices. ResultsThe number of AAHKS members in private practice (37%) continues to decline, and 4% are now in private equity–employed practices. Fee for service (30%) and relative value units (30%) are the major forms of compensation. The number of AAHKS members that perform total joint arthroplasties at ambulatory surgery centers continues to increase, and supply chain issues (91%) remain a problem. There has been a decrease in surgeon participation in bundled payment programs and gainsharing arrangements with hospitals. ConclusionsThis member’s survey provides valuable information regarding practice patterns. The shift to outpatient surgery has continued. Future surveys will be performed to monitor changes in practice patterns over time.

A Claims-Based Method for Identification and Characterization of Practicing Interventional Radiologists

PurposeTo propose a research method for identifying “practicing interventional radiologists” using 2 national claims data sets. Materials and MethodsThe 2015–2019 100% Medicare Part B data and 2015–2019 private insurance claims from Optum’s Clinformatics Data Mart (CDM) database were used to rank-order radiologists’ interventional radiology (IR)-related work as a percentage of total billed work relative value units (RVUs). Characteristics were analyzed at various threshold percentages. External validation used Medicare self-designated specialty with Society of Interventional Radiology (SIR) membership records; Youden index evaluated sensitivity and specificity. Multivariate logistic regression assessed practicing IR characteristics. ResultsIn the Medicare data, above a 10% IR-related work threshold, only 23.8% of selected practicing interventional radiologists were designated as interventional radiologists; above 50% and 90% thresholds, this percentage increased to 42.0% and 47.5%, respectively. The mean percentage of IR-related work among practicing interventional radiologists was 45%, 84%, and 96% of total work RVUs for the 10%, 50%, and 90% thresholds, respectively. At these thresholds, the CDM practicing interventional radiologists included 21.2%, 35.2%, and 38.4% designated interventional radiologists, and evaluation and management services comprised relatively more total work RVUs. Practicing interventional radiologists were more likely to be males, metropolitan, and earlier in their careers than other radiologists at all thresholds. ConclusionsMost radiologists performing IR-related work are designated in claims data as diagnostic radiologists, indicating insufficiency of specialty designation for IR identification. The proposed method to identify practicing interventional radiologists by percent IR-related work effort could improve generalizability and comparability across claims-based IR studies.

Costs and Productivity Benefits of the Department of Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act Scribes Trial

ObjectivesTo improve access, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 mandated a 2-year study of medical scribes in Veterans Health Administration specialty clinics and emergency departments. Medical scribes are employed in clinical settings with the goals of increasing provider productivity and satisfaction by minimizing physicians’ documentation burden. Our objective is to quantify the economic outcomes of the MISSION Act scribes trial. MethodsA cluster-randomized trial was designed with 12 Department of Veterans Affairs (VA) medical centers randomized into the intervention. We estimated the total cost of the trial, cost per scribe-year, and projected cost of hiring additional physicians to achieve the observed scribe productivity benefits in relative value units and visits per full-time-equivalent over the 2-year intervention period (June 30, 2020 to July 1, 2022). ResultsThe estimated cost of the trial was $4.6 million, below the Congressional Budget Office estimate of $5 million. A full-time scribe-year cost approximately $74 600 through contracting and $62 900 through VA hiring. Randomization into the trial led to an approximate 30% increase in productivity in cardiology and 20% in orthopedics. The projected incremental cost of using additional physicians instead of scribes to achieve the same productivity benefits was nearly $1.7 million more, or 75% higher, than the observed cost of scribes in cardiology and orthopedics. ConclusionsAs the largest randomized trial of scribes to date, the MISSION Act scribes trial provides important evidence on the costs and benefits of scribes. Improving productivity enhances access and scribes may give VA a new tool to improve productivity in specialty care at a lower cost than hiring additional providers.

Perspective: Women's leadership and salary inequality in sleep medicine.

Shawa J, Ehsan Z. Perspective: women's leadership and salary inequality in sleep medicine. J Clin Sleep Med. 2024;20(3):475-477.

(373) Economic Benefits of Patient Care for Prostate Cancer Survivors with Stress Urinary Incontinence and/or Erectile Dysfunction: A Physician Reimbursement Analysis

Abstract Introduction Reconstructive urological procedures play a vital role in enhancing the satisfaction and quality of life of patients with prostate cancer (PCa) following radical prostatectomy (RP). Providing comprehensive postoperative care for common side effects of post-RP, including stress urinary incontinence (SUI) and erectile dysfunction (ED), may result in a greater number of patients with PCa receiving needed consultations and therapies. This analysis sought to explore the potential economic benefits of offering men’s health consultations and reconstructive care for PCa survivors. Objective This study quantified the relative value units (RVUs) generated from providing patient care to PCa survivors covered by Medicare Fee-for-Service who may experience SUI and/or ED due to RP. Methods This physician reimbursement analysis was based on typical patient care pathway scenarios for patients at risk of developing SUI or ED post-RP. Current Procedural Terminology (CPT) codes were utilized to identify and describe the care provided to patients in each scenario, leading to an artificial urinary sphincter (AUS) or male sling for SUI and/or an inflatable penile prosthesis (IPP) for ED. The 2023 CMS Physician and Clinical Laboratory Fee Schedule and Medicare reimbursement rates were used to obtain the most recent RVUs and reimbursement for each CPT. RVUs represent the value assigned to a service or procedure performed by a physician and are used to capture the relative cost values associated with patient care. For each scenario, we reported the total RVUs, which include work, non-facility or facility, and malpractice RVUs, and the total physician reimbursement. The 2023 Physician Conversion Factor was used to calculate the Medicare physician reimbursement. The Medicare physician reimbursement was used as a conservative estimate. Results The four clinical pathway scenarios were patients who did not experience recurrent SUI or ED (no recurrent SUI/ED), patients who only experienced SUI (only SUI), patients who only experienced ED (only ED), and patients who experienced both SUI and ED (SUI + ED). For the no SUI/ED scenario, the total RVUs from providing patient care were 5.26 RVUs, resulting in $205 in physician reimbursement. For the only SUI scenario, the total RVUs were 56.20 RVUs with an average of $1,996 in physician reimbursement for those receiving AUS and 55.54 RVUs with an average of $1,974 in physician reimbursement for those receiving male sling. For the only ED scenario, the total RVUs were 42.51 RVUs, resulting in $1,550 in physician reimbursement. For the SUI + ED scenario, the total RVUs were 98.71 RVUs with an average of $3,547 in physician reimbursement for those receiving AUS and 98.05 RVUs with an average of $3,524 in physician reimbursement for those receiving male sling. Conclusions This study justified the economic benefits of expanding patient care to men who underwent RP for PCa and provided urology practice insight into the potential physician reimbursement when PCa survivors were seen by reconstructive urologists. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific. Clarification: Industry initiated, executed and funded study. Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

A Relative Value Unit–Based Model for Targeted Nipple–Areola Complex Neurotization in Gender-Affirming Mastectomy

Background: For transmasculine individuals, double-incision mastectomy with free nipple grafts is the most common procedure for gender-affirming chest masculinization. However, patients report decreased sensation postoperatively. Direct coaptation of intercostal nerves to the nipple–areolar complex (NAC) is an experimental technique that may preserve postoperative sensation, yet whether reimbursements and billing codes incentivize hospital systems and surgeons to offer this procedure lacks clarity. Methods: A retrospective cross-sectional analysis of fiscal year 2023 Medicare physician fee schedule values was performed for neurotization procedures employing Current Procedural Terminology codes specified by prior studies for neurotization of the NAC. Additionally, operative times for gender-affirming mastectomy at a single center were examined to compare efficiency between procedures with and without neurotization included. Results: A total of 29 encounters were included in the study, with 11 (37.9%) receiving neurotization. The mean operating time was 100.3 minutes (95% CI, 89.2–111.5) without neurotization and 154.2 minutes (95% CI, 139.9–168.4) with neurotization. In 2023, the average work relative value units (wRVUs) for neurotization procedures was 13.38. Efficiency for gender-affirming mastectomy was 0.23 wRVUs per minute without neurotization and 0.24 wRVUs per minute with neurotization, yielding a difference of 0.01 wRVUs per minute. Conclusions: Neurotization of the NAC during double-incision mastectomy with free nipple grafts is an experimental technique that may improve patient sensation after surgery. Current reimbursement policy appropriately values the additional operative time associated with neurotization relative to gender-affirming mastectomy alone.

The Evaluation of Payment for Obstetric and Gynecology Services: From ACOG.

To perform an environmental scan of the current status of reimbursement for obstetric and gynecology services and identify problematic issues and opportunities for change. The areas that were evaluated include the American Medical Association (AMA) relative value unit assignment process, payer rates (where available), and trends in employment and salary determination for obstetrician-gynecologists (ob-gyns). This report was developed by members of the American College of Obstetricians and Gynecologists' (ACOG) Committee on Health Economics and Coding using public-facing payment data from the Medicare Physician Fee Schedule and state Medicaid programs, as well as published research and commentary on payment for physicians, maternal health, and gynecologic surgery. Data from the Centers for Disease Control and Prevention were used to describe typical patient characteristics, and practice survey reports from the AMA were analyzed. Finally, an anonymous online survey was distributed to 27,854 members of ACOG in March 2022, with a response rate of 10.8% (3,018 members) and a CI of ±1.7%. The evaluation found that payment for ob-gyns is heavily influenced by the values and rates set by third-party payers, a patient case-mix that includes a higher-than-average number of patients with Medicaid insurance, and the increase of employed physicians reliant on salary contracts that include productivity requirements and bonuses. The Committee identified action items, including payment reform for obstetric services; advocating for gynecologic surgery time as a priority for hospital administration; developing resources to assist employed physicians with payment, practice, and business management; developing a business and coding curriculum for students and early-career physicians; and continued advocacy with private and public policymakers who influence physician payment.

Resident dictation of operative notes: a reimbursement comparison and mixed-methods analysis

PurposeSurgical documentation is crucial to ensure quality patient care and accurate coding and billing. Operative dictation also serves as a valuable educational opportunity for surgical trainees. However, resident dictations may not fully capture procedural details and complexities, resulting in missed revenue opportunities. On July 1, 2021, our university-based surgery department implemented a policy requiring attendings to dictate all operative reports. The purpose of this mixed-method study was to investigate the financial impact of this policy and explore differences in resident and attending dictations.MethodsCore general surgery operations performed by the Department of Surgery between July 1, 2020 and June 30, 2022 were identified from billing data. The surgeon, current procedural terminology (CPT) and modifier codes, and relative value units (RVUs) for each case were acquired. Surgeons not present for the entire study period or cases requiring multiple surgeons were excluded. Descriptive statistics and Kolmogorov–Smirnov (KS) non-parametric tests compared pre- and post-policy RVU distributions on overall charges and 18 key general surgery operations. Targeted thematic analysis was performed on operative reports pre- and post-policy to explore resident and attending differences.ResultsA total of 42 attendings performed 16,233 cases, billing 28,560 CPT codes (50.3% pre- vs. 49.7% post-policy). There was a small but statistically significant increase in RVU distribution post-policy, mean 20.2 pre- vs. 20.3 RVUs post-, $4372 pre- vs. $4418 per case post-, KS = 0.02 (p = 0.009). Specifically, higher RVU distributions were seen among attending-dictated cases for melanoma (p = 0.009), minimally invasive ventral hernia repair (VHR, p = 0.008), parathyroidectomy (p < 0.001), anorectal incision and drainage (p = 0.003) and anorectal exam under anesthesia (p = 0.029). Higher RVU distributions were noted among resident-dictated, attending-edited cases for partial colectomy (p = 0.043), and open VHR (p = 0.004). No differences were noted among the remaining operations (p > 0.05). Three major themes were noted from focused sampling of 112 operative reports: billable items, clinical/surgical reasoning, and technical details. Differences in billable items and clinical and surgical reasoning were the most influential on modifying clinical implications of operative notes. Themes and differences were consistent regardless of surgeon or specialty.ConclusionAdopting an attending-only operative dictation policy yielded a small increase in billable RVUs, predominantly from select operations. Gaps in coding-directed language and depth of clinical reasoning were noted in resident dictations. These findings reveal an educational opportunity that concomitantly optimizes patient care, resident education, and procedural revenue.

Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX)

BackgroundPerceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement. MethodsA prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units. ResultsCompared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts. ConclusionsRevision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

Medicare Volume Growth and Shift in Payments From Physicians to Non-Physician Practitioners Under Statutory Budget Neutrality

Volume increases, inflation, statutory freezes in physician payments, and the budget neutrality requirement for the Medicare Physician Fee Schedule have resulted in persistent inflation-adjusted conversion factor decreases. This study aimed to determine if relative value unit (RVU) volume increases on a per beneficiary basis has counteracted conversion factor decreases and inflation to maintain Medicare reimbursement per beneficiary, overall and across specialties. Using aggregated data for 100% of Medicare part B claims (2005-2021), we computed the percentage change in reimbursement per beneficiary, nominal and inflation-adjusted, by specialty. These trends were then adjusted by separately holding constant RVUs per beneficiary and the conversion factor to demonstrate the impact of budget neutrality. Inflation-adjusted reimbursement per beneficiary increased 9.9% over the 2005 to 2021 period; this trend encapsulated a 64.8% increase in RVUs per beneficiary, offsetting a 33.6% inflation-adjusted conversion factor decline. RVU changes per beneficiary varied widely across clinicians (+45.5% for physicians to +328.2% for non-physician practitioners) and by specialty (−36.1% for cardiac surgery to +1106% for nurse practitioners). Given RVU increases, conversion factor decreases, and inflation combined, reimbursement per beneficiary decreased 2.3% for physicians and increased 16.3% for limited-license physicians and 206.5% for non-physician practitioners. Overall, increased RVU volume per beneficiary has offset conversion factor declines within the budget neutral system. However, substantial redistribution has occurred across provider types, with reimbursement declining slightly for physicians while tripling for non-physician practitioners. Certain physician specialties, particularly procedural specialties, have declined most. Future research should assess the impact of specialty-specific reimbursement changes on patients’ access to care.

Analysis of Medicaid and Medicare Reimbursement Variations for Common Orthopaedic Trauma Procedures

OBJECTIVES: Medicaid (MCD) reimbursement for surgery is determined by state governments and is subject to substantial variation in comparison to Medicare (MCR), which is determined by the federal government and invariable across the United States. This mismatch in reimbursement has previously been described as a component of the disparity in access to care in orthopaedics. While this variation has been previously quantified for general orthopaedics and orthopaedic hand surgery, no such analysis has been performed for orthopaedic trauma. This study aims to quantify the variation in MCD and MCR reimbursement for common orthopaedic trauma procedures.&#x0D; DESIGN: Billing data obtained from a Level I trauma center were retrospectively reviewed and the ten most commonly billed Current Procedural Terminology (CPT) codes were extracted. State and federal physician fee schedules were collected and assessed to determine MCD- and MCR-specific reimbursement rates, or relative value units (RVUs), for these ten procedures. An economic analysis was then conducted to evaluate the disparities between MCD and MCR reimbursement.&#x0D; MAIN OUTCOME MEASURES: MCD and MCR RVUs for each procedure were compared using dollar difference and coefficient of variation (CV).&#x0D; RESULTS: Our analysis showed considerable variance in MCD reimbursement rates between states. Additionally, we found that the majority of RVUs for MCD were higher than MCR for the evaluated trauma procedures.&#x0D; CONCLUSION: The variance in MCD reimbursement values may be driven by differences in the underlying characteristics of each systems’ patient population. This variance, particularly in bordering states, could represent a barrier to healthcare access for some populations.

Are Gender-Affirming Plastic Surgeons Adequately Compensated? An Analysis of Relative Value Units.

Gender-affirming surgery (GAS) has a complicated history within US health care. As GAS procedures and reimbursement availability continue to uptrend, the present study aims to investigate whether compensation is equitable between GAS procedures and general plastic surgery procedures. The National Surgical Quality Improvement Program database was queried for all surgeries performed by plastic surgeons from 2016 to 2020. Cases were assigned to the GAS or non-GAS cohort using ICD-10 codes. Duplicate Current Procedural Terminology (CPT) codes were removed for analysis. Operative time, total wRVUs, wRVUs per hour (wRVU/h), reoperation/readmission rate, and number of concurrent procedures were compared between the cohorts. A total of 132,319 non-GAS and 3,583 GAS were identified. After duplicate CPT removal, 299 cases (21 unique CPTs) remained in the GAS cohort and 20,022 (37 unique CPTs) in the non-GAS cohort. Operative time was higher in the GAS cohort (262.9 vs 120.7 min, P < 0.001), as were total wRVUs (59.4 vs 21.6, P < 0.001). Reoperation/readmission rate (7.0% vs 6.0%) and wRVU/h (15.8 vs 15.1) were not significantly different (all P > 0.05). There was a positive correlation between total operative time and total wRVUs (P < 0.001) and a negative correlation between total operative time and wRVU/h (P < 0.001). Proportional wRVUs are allocated to gender affirming plastic procedures. However, the RVU scale does not allocate proportional wRVUs to longer operative times for both GAS and general plastic surgeries. Compensation for gender affirming plastic surgeries is higher than that of general plastic surgeries; however, there is no difference in wRVUs per hour on comparison.

Trends of Medicare reimbursement rates for gender affirmation procedures.

While nearly 1 in 5 Americans receives health insurance coverage through Medicare, literature suggests that Medicare reimbursement is lagging behind inflation for many plastic surgery procedures. This article evaluates trends in Medicare reimbursement for gender affirmation procedures. The most common gender affirmation procedures performed at an urban academic medical center were identified in this cross-sectional study (level 4 evidence). Five nongender surgery codes were evaluated for reference. A standardized formula utilizing relative value units (RVUs) was used to calculate monetary data. Differences in reimbursement between 2014 and 2021 were calculated for each procedure. The main outcome was inflation-adjusted difference of charges from 2014 to 2021. Between 2014 and 2021, Medicare reimbursement for gender affirmation procedures had an inflation-unadjusted average change of -0.09% (vs +5.63% for the selected nongender codes) and an inflation-adjusted change of -10.03% (vs -5.54% for the selected nongender codes). Trends in reimbursement varied by category of gender-affirming procedure. The overall average compound annual growth rate had a change of -0.99% (vs -0.53% for the selected nongender codes). The average changes in work, facility, and malpractice RVUs were -1.05%, +9.52%, and -0.93%, respectively. Gender surgeons and patients should be aware that the decrease in reimbursement may affect access to gender-affirming care. Our study is one of the first evaluating the reimbursement rates associated with the full spectrum of gender affirmation surgery. However, our study is limited by its cross-sectional nature. From 2014 to 2021, Medicare reimbursement for gender affirmation procedures lagged inflation.

2024 Current Procedural Terminology Updates: Female Pelvic Examination

An equity initiative of the Current Procedural Terminology® Editorial Panel includes recognition that female pelvic examinations have a greater practice expense (eg, the cost of providing speculums and chaperones) than evaluation and management (E/M) services that do not include a female pelvic examination. To provide a means of reporting the increased practice expense, new add-on code 99459 (pelvic examination) may be reported for services provided on and after January 1, 2024. This article reviews the appropriate use of code 99459. Reporting in conjunction with a preventive medicine E/M service Reporting in conjunction with a problem-oriented E/M service Utilization instructions Assigned relative value units (RVUs) for 99459

Inflation-adjusted medicare physician reimbursement for adult spinal deformity surgery substantially declined from 2002 to 2020.

Physician fees for orthopaedic surgeons by the Centers for Medicare and Medicaid Services (CMS) are increasingly scrutinized. The present retrospective review aims to assess whether adult spinal deformity (ASD) surgeries are properly valued for Medicare reimbursement. Current Procedural Terminology (CPT) codes related to posterior fusion of spinal deformity of ≤ 6, 7-12, and ≥ 13 vertebral levels, as well as additional arthrodesis and osteotomy levels, were assessed for (1) Compound annual growth rate (CAGR) from 2002 to 2020, calculated using physician fee data from the CMS Physician Fee Schedule Look-Up Tool; and (2) work relative value units (RVUs) per operative minute, using data from the National Surgical Quality Improvement Program. From 2002 to 2020, all CPT codes for ASD surgery had negative inflation-adjusted CAGRs (range, - 18.49% to - 27.66%). Mean physician fees for spinal fusion declined by 26.02% (CAGR, - 1.66%) in ≤ 6-level fusion, 27.91% (CAGR, - 1.80%) in 7- to 12-level fusion, and 28.25% (CAGR, - 1.83%) ≥ 13-level fusion. Fees for both 7-12 (P < 0.00001) and ≥ 13 levels (P < 0.00001) declined more than those for fusion of ≤ 6 vertebral levels. RVU per minute was lower for 7- to 12-level and ≥ 13-level (P < 0.00001 for both) ASD surgeries than for ≤ 6-level. Reimbursement for ASD surgery declined overall. CAGR for fusions of ≥ 7 levels were lower than those for fusions of ≤ 6 levels. For 2012-2018, ≥ 7-level fusions had lower RVU per minute than ≤ 6-level fusions. Revaluation of Medicare reimbursement for longer-level ASD surgeries may be warranted. III.