How has reduced reimbursement for acromioplasty impacted your patients and practice?
Negative financial impacts
Although reduced reimbursement for acromioplasty has negatively impacted me financially, it has not impacted my patients.
I still use the patient’s clinical history, symptoms and surgical findings to perform acromioplasty when I consider it to be helpful based on evidence-based medicine, logic and my experience.
In 2012, code 29826 was changed to an add-on code and was reduced from 9.16 relative value units (RVUs) to 3 RVUS. That reduction in reimbursement had a moderate negative financial impact on my practice for Medicare patients. More recently, some insurance companies have started to deny reimbursement for this procedure based on studies that call into question its efficacy. These studies have some merit, but also have intrinsic flaws. These flaws include lack of power, arbitrary definition of minimal clinically important difference, variable follow-up and crossover between groups. Additionally, many of these studies show improved outcome in the surgical group compared with the nonsurgical group (possible placebo effect). None of these studies have been done in the United States and several of these are meta-analyses that refer to the same original studies. These unilateral actions by payers have had a significant impact reducing reimbursement and increasing the burden on myself and staff with appeals. Additionally, payer comments in their denials, such as the procedure is “not medically necessary,” can result in an awkward conversation with our patients.
Unfortunately, this trend of reduced reimbursement in fee-for-service models or using third-party payers will continue until orthopedic surgeons collectively take a stand.
Hussein A. Elkousy, MD, is with the division of OrthoLoneStar at Fondren Orthopedic Group in Houston; volunteer faculty at Baylor College of Medicine, University of Texas Medical Branch – Galveston and University of Houston; and the director of the Texas Education and Research Foundation for Shoulder and Elbow Research Fellowship.
Role for acromioplasty remains
The decision by some commercial payers to deem subacromial decompression “not medically necessary” means this surgical treatment is no longer an option for some of my patients. I think this sets a dangerous precedent. Most surgeons would agree subacromial decompression is not necessary for all or even most patients. However, it appears the position held by some payers is that this procedure is never beneficial, at least not to their bottom line. This is not a new or experimental procedure. It is a procedure that has been vetted and valued by the AMA CPT editorial panel and performed for decades by expert shoulder surgeons.
Critical examination of the literature demonstrates there is still a role for subacromial decompression in my practice. For example, in bursal-sided tears with adjacent subacromial spurring, massive rotator cuff tears or patients with critical shoulder angle greater than 35°. It is the duty of the provider to examine the literature, apply it to their individual technique and identify subsets of patients in whom this procedure is medically indicated.We have more than 20 years of literature supporting improved outcomes, and the more recent level-1 studies comparing subacromial decompression to treatment options like physical therapy or simple bursectomy, show improved pain and functional outcomes in both study arms. In other words, it’s not that the literature demonstrates that subacromial decompression doesn’t work; it’s that it doesn’t work better than other less costly or invasive procedures for most patients. So, we are responsible for identifying the patients who fail conservative treatments or fall outside of the statistical trends presented in the literature. This is evidence-based practice.
We have a payment policy that impacts clinical decision-making. Stakeholders on the payment side may argue the procedure is overutilized. If payers want to develop their own clinical practice guidelines to compare surgeons’ performance, it is their prerogative. However, it is inappropriate to create sweeping payment policies that impact the care of the individual patient. This is not a procedure I routinely perform during every shoulder arthroscopy, but, when I think it is medically indicated, it should be an option for my patients.
Eric M. Stiefel, MD, is with Valdosta Orthopaedic Associates in Valdosta, Georgia.