Orthopedics

Feature Article Supplemental Data

Relative Value Unit Compensation Rates for Hospital-Based Shoulder/Elbow Surgery Versus Hand Surgery

Suresh K. Nayar, MD; Keith T. Aziz, MD; Matthew J. Best, MD; Avi M. Giladi, MD, MS; Dawn M. LaPorte, MD; Umasuthan Srikumaran, MD, MBA, MPH; John V. Ingari, MD

Abstract

Upper extremity surgeons perform diverse operations, including hand surgery, microsurgery, and shoulder/elbow arthroscopy and arthroplasty. Declining orthopedic reimbursement rates may encourage surgeons to adjust their case mix, favoring a shift toward procedures with higher compensation. To determine whether upper extremity surgeons and hand-fellowship trainees may be financially incentivized to perform more shoulder/elbow procedures than hand procedures in a hospital-based setting, relative value unit (RVU) compensation rates were compared for these 2 fields. Using Centers for Medicare & Medicaid Services–assigned work RVUs (wRVU) and National Surgical Quality Improvement Program operative time data, wRVU compensation rates per minute of operative time were determined for common shoulder/elbow surgeries. Overall nonweighted and weighted wRVU/min averages were calculated for hospital-based shoulder/elbow and hand surgery. A total of 27 shoulder/elbow procedures and 53 hand surgery procedures were analyzed. Nonweighted comparison showed shoulder/elbow surgery had a higher wRVU/min (0.19±0.03 vs 0.14±0.05, P<.0001) vs hand surgery. When weighted by procedure frequency, shoulder/elbow surgery also had higher wRVU/min (0.19±0.02 vs 0.15±0.05, P<.0001). Fourteen of the 27 shoulder/elbow procedures were compensated either the same wRVU/min or more than all hand procedures except for epicondyle debridement and flexor tendon bursectomy. Almost half of commonly performed shoulder/elbow procedures were compensated at greater rates than most hand procedures in a hospital-based setting. This disproportionate compensation may affect upper extremity surgeons' case mix and motivate providers and hand-fellowship trainees to seek additional training in shoulder arthroplasty and arthroscopy to supplement their practice. [Orthopedics. 2021;44(x):xx–xx.]

Abstract

Upper extremity surgeons perform diverse operations, including hand surgery, microsurgery, and shoulder/elbow arthroscopy and arthroplasty. Declining orthopedic reimbursement rates may encourage surgeons to adjust their case mix, favoring a shift toward procedures with higher compensation. To determine whether upper extremity surgeons and hand-fellowship trainees may be financially incentivized to perform more shoulder/elbow procedures than hand procedures in a hospital-based setting, relative value unit (RVU) compensation rates were compared for these 2 fields. Using Centers for Medicare & Medicaid Services–assigned work RVUs (wRVU) and National Surgical Quality Improvement Program operative time data, wRVU compensation rates per minute of operative time were determined for common shoulder/elbow surgeries. Overall nonweighted and weighted wRVU/min averages were calculated for hospital-based shoulder/elbow and hand surgery. A total of 27 shoulder/elbow procedures and 53 hand surgery procedures were analyzed. Nonweighted comparison showed shoulder/elbow surgery had a higher wRVU/min (0.19±0.03 vs 0.14±0.05, P<.0001) vs hand surgery. When weighted by procedure frequency, shoulder/elbow surgery also had higher wRVU/min (0.19±0.02 vs 0.15±0.05, P<.0001). Fourteen of the 27 shoulder/elbow procedures were compensated either the same wRVU/min or more than all hand procedures except for epicondyle debridement and flexor tendon bursectomy. Almost half of commonly performed shoulder/elbow procedures were compensated at greater rates than most hand procedures in a hospital-based setting. This disproportionate compensation may affect upper extremity surgeons' case mix and motivate providers and hand-fellowship trainees to seek additional training in shoulder arthroplasty and arthroscopy to supplement their practice. [Orthopedics. 2021;44(x):xx–xx.]

Depending on their training, upper extremity surgeons may perform a diverse set of operations, ranging from common hand surgeries to advanced microsurgery as well as shoulder and elbow arthroscopy and arthroplasty. Declining orthopedic reimbursement rates during the past two decades1 may encourage surgeons to shift their practice distribution toward procedures with higher compensation. In fact, a survey of newly graduated hand-fellowship applicants found a heavy demand for shoulder and elbow exposure, with 48% seeking such training.2 A second survey of hand-fellowship applicants echoed this, with 58% believing that shoulder and elbow exposure would be beneficial.3

One presumed notion among hand-fellowship applicants seeking such experience is that it adds increased “marketability” or financial success.4 To determine whether upper extremity surgeons and hand-fellowship trainees may be financially incentivized to perform more shoulder and elbow procedures over hand procedures, this study compared work relative value unit (wRVU) compensation rates for the most common procedures performed in a hospital-based setting between the 2 fields.

Materials and Methods

To determine the most common surgeries from each field, the authors analyzed isolated Current Procedural Terminology (CPT) codes tracked by the Accreditation Council for Graduate Medical Education performed in a facility (nonoffice) setting with volumes greater than 1000.5 After excluding CPT codes uniformly associated with orthopedic shoulder trauma, the authors identified 29 shoulder and elbow CPT codes. To identify the most common hand procedures, the authors included CPT codes for any orthopedic trauma distal to the elbow and any soft-tissue procedures distal to the shoulder, yielding 83 CPT codes.6

Actual “real-world” operative times (from skin incision to closure) were recorded from the National Surgical Quality Improvement Program (NSQIP). No entries for shoulder manipulation under anesthesia (23700) were present in NSQIP. After excluding subacromial decompression (29826) because it is no longer universally considered a stand-alone primary code, there were 27 shoulder and elbow codes for analysis. Because NSQIP only collects perioperative data for inpatient hospital-based hand surgery, routine outpatient elective hand surgeries, such as carpal tunnel release and trigger finger release, could not be included. This narrowed the analysis to 53 hand surgeries.

Compensation rates were determined by dividing each procedure wRVU by operative time to calculate compensation per minute. Compensation rates were analyzed in isolation (vs multiple codes per surgery) due to a high level of heterogeneity when determining whether additional procedures during a single surgery were considered bundled or not by different payers. Nonweighted and weighted overall wRVU/min averages for both fields were determined as well as average operative times. Weighted means were calculated according to the volume and frequency of each procedure divided by the total volume of all procedures performed (Figure 1). Both nonweighted and weighted Student t tests were used to determine whether there was a difference in compensation between the 2 fields.

Equation—weighted relative value unit (wRVU) per minute for 27 shoulder and elbow procedures. In this equation, more commonly performed procedures will affect the mean wRVU/min more than less commonly performed procedures. This formula also was used to calculate the weighted RVU/min rate of all 53 hand procedures and average operative time of both fields. Abbreviations: Proc, procedure; rTSA, revision total shoulder arthroplasty; SLAP, arthroscopic superior labral tear from anterior to posterior repair.

Figure 1:

Equation—weighted relative value unit (wRVU) per minute for 27 shoulder and elbow procedures. In this equation, more commonly performed procedures will affect the mean wRVU/min more than less commonly performed procedures. This formula also was used to calculate the weighted RVU/min rate of all 53 hand procedures and average operative time of both fields. Abbreviations: Proc, procedure; rTSA, revision total shoulder arthroplasty; SLAP, arthroscopic superior labral tear from anterior to posterior repair.

Results

For the 27 shoulder and elbow procedures analyzed, revision shoulder arthroplasty (23473) had the highest wRVU assignment as well as wRVU/min (Table A, available in the online version of the article). All but 2 of the top half of the highest earning procedures, in terms of RVU/min, consisted of arthroplasty, shoulder arthroscopy (superior labral tear from anterior to posterior repair, rotator cuff repair, capsulorrhaphy, biceps tenodesis, debridement, and lysis of adhesions), or open rotator cuff repair.

wRVUs/min Rates based on NSQIP Operative Time for 27 of the Most Common Shoulder/Elbow CPT Codes, According to Centers for Medicare and Medicaid Services.wRVUs/min Rates based on NSQIP Operative Time for 27 of the Most Common Shoulder/Elbow CPT Codes, According to Centers for Medicare and Medicaid Services.

Table A.

wRVUs/min Rates based on NSQIP Operative Time for 27 of the Most Common Shoulder/Elbow CPT Codes, According to Centers for Medicare and Medicaid Services.

Among the 53 hand and upper extremity procedure codes surveyed, upper extremity flaps (15736), carpal stabilization procedures (25320), distal radius open reduction and internal fixation for intraarticular comminuted fractures (25609), both-bone open reduction and internal fixation (25575), and interposition arthroplasty (25447) had the greatest wRVU assignments (Table B, available in the online version of the article). However, when factoring in operative time, none of these 5 procedures were compensated as well as the top 14 shoulder and elbow procedures (all ≥0.20 RVU/min). Only 7 of the 53 hand procedures earned 0.20 wRVU/min or greater.

wRVUs/min Rates Based on NSQIP Operative Time for 53 of the Most Common Hosptial-based Hand Procedures, According to Centers for Medicare and Medicaid Services.wRVUs/min Rates Based on NSQIP Operative Time for 53 of the Most Common Hosptial-based Hand Procedures, According to Centers for Medicare and Medicaid Services.

Table B.

wRVUs/min Rates Based on NSQIP Operative Time for 53 of the Most Common Hosptial-based Hand Procedures, According to Centers for Medicare and Medicaid Services.

Both nonweighted and weighted overall wRVU/min averages for shoulder and elbow surgery were greater than hospital-based hand surgery (P<.0001 for both) (Figure 2). The nonweighted average operative time was greater for shoulder and elbow surgery compared with hand surgery (65.9±27.5 min vs 55.0±21.6 min, P<.05) but similar when weighted for procedure frequency (63.9±21.5 min vs 56.9±20.7 min, P=.16). Although operative time remained unchanged across all shoulder and elbow surgeries surveyed when sorted by decreasing RVU/min (R=0.002; Figure 3), operative time tended to increase for lower-compensating hand procedures (R=0.5; Figure 4).

Nonweighted and weighted (by surgical volume and frequency) average weighted relative value unit (wRVU) per minute compensation rates of 27 shoulder and elbow procedures and 53 hand procedures. Error bars show standard deviation; P<.0001 for nonweighted and weighted comparisons.

Figure 2:

Nonweighted and weighted (by surgical volume and frequency) average weighted relative value unit (wRVU) per minute compensation rates of 27 shoulder and elbow procedures and 53 hand procedures. Error bars show standard deviation; P<.0001 for nonweighted and weighted comparisons.

Weighted relative value unit (wRVU) per minute and operative times for 27 of the most common shoulder and elbow surgery Current Procedural Terminology codes. Secondary axis shows operative time (in red) with a linear regression trend line (R=0.002). Procedures sorted by descending wRVU/min rates. Abbreviations: CA, coracoacromial; SA, subacromial; SLAP, superior labral tear from anterior to posterior; TSA, total shoulder arthroplasty.

Figure 3:

Weighted relative value unit (wRVU) per minute and operative times for 27 of the most common shoulder and elbow surgery Current Procedural Terminology codes. Secondary axis shows operative time (in red) with a linear regression trend line (R=0.002). Procedures sorted by descending wRVU/min rates. Abbreviations: CA, coracoacromial; SA, subacromial; SLAP, superior labral tear from anterior to posterior; TSA, total shoulder arthroplasty.

Weighted relative value unit (wRVU) per minute and operative times for 53 of the most common hand surgery Current Procedural Terminology codes. Secondary axis shows operative time (in red) with a linear regression trend line (R=0.5). Procedures sorted by descending wRVU/min rates. Note the upward trend of increased operative time for lower RVU/min cases, which is not observed in Figure 3. Abbreviations: CMC, carpometacarpal; EA, extra-articular; IA, intra-articular; IC, intercarpal; IPJ, interphalangeal joint; MC, metacarpal; MCPJ, metacarpal phalangeal joint; ORIF, open reduction and internal fixation; TFCC, triangular fibrocartilage complex.

Figure 4:

Weighted relative value unit (wRVU) per minute and operative times for 53 of the most common hand surgery Current Procedural Terminology codes. Secondary axis shows operative time (in red) with a linear regression trend line (R=0.5). Procedures sorted by descending wRVU/min rates. Note the upward trend of increased operative time for lower RVU/min cases, which is not observed in Figure 3. Abbreviations: CMC, carpometacarpal; EA, extra-articular; IA, intra-articular; IC, intercarpal; IPJ, interphalangeal joint; MC, metacarpal; MCPJ, metacarpal phalangeal joint; ORIF, open reduction and internal fixation; TFCC, triangular fibrocartilage complex.

Discussion

In this analysis of wRVU compensation rates, nonweighted and weighted averages for hospital-based shoulder and elbow surgery were greater compared with hand surgery when using real-world NSQIP operative times. Half of the shoulder and elbow codes compensated the same or more than all but 2 hand procedures. In addition, when comparing operative times, average operative times were longer for shoulder and elbow procedures compared with hand procedures. Although this difference did not remain significant after weighting for procedure frequency, it suggests that total compensation from hand procedures can be more vulnerable to increased turnover time and to more frequent turnovers between shorter cases. This can be particularly problematic in operative settings where turnover time is relatively slower. Furthermore, the financial implications of these results may help explain the heavy preference for shoulder and elbow exposure among hand-fellowship trainees2,3 and corroborates other findings showing higher earning potential for shoulder and elbow-trained surgeons compared with hand-fellowship trained surgeons.7

Despite this stated preference for shoulder and elbow exposure among hand-fellowship trainees, the majority of hand-fellowship directors do not consider shoulder pathology as an essential competency for a hand-fellowship trainee. In a national survey of 62 fellowship directors, only 8% considered upper arm and shoulder conditions as an essential area of practice,8 suggesting that obtaining adequate exposure to shoulder and elbow elective experience may be a challenge for interested hand-fellowship trainees. This disconnect highlights the need to improve or redesign traditional fellowship programs to better serve trainees' goals.

One factor that may explain higher compensation for shoulder and elbow procedures is that relatively newer CPT codes may be allotted higher RVU designations. The advent of shoulder arthroscopy is relatively recent and has generated several new CPT codes. In contrast, the vast majority of hand procedures are still based on open techniques without a notable expansion of CPT codes over the same time.

In an assessment of Medicare reimbursement for orthopedic procedures, relatively newer CPT codes, such as shoulder arthroscopy and decompression, were among the procedures that underwent the greatest mean annual decreases in reimbursement.1 On the other hand, procedures such as carpal tunnel saw the least annual reimbursement decrease. In 2012 after the Centers for Medicare & Medicaid Services changed arthroscopic acromioplasty (CPT 29826) from a stand-alone code to an add-on code, Medicare reimbursement dropped 36.3% during a 1-year period from 2011 to 2012.9 These studies suggest future periodic reevaluation of orthopedic CPT codes by the Centers for Medicare & Medicaid Services may narrow the compensation gap between the 2 fields.

There were limitations in the current analyses. One limitation in the authors' methodology was not accounting for surgeries where multiple CPT codes were used. This practice can be particularly common in arthroscopic shoulder surgery, and accounting for this would likely further increase the overall wRVU averages for shoulder and elbow surgery. For example, CPT code 29823 (extensive arthroscopic debridement) may be routinely added to codes 29824 (distal claviculectomy), 23430/29828 (open/arthroscopic biceps tenodesis), 29827 (rotator cuff repair), and 29826 (subacromial decompression),10 which also are commonly grouped together during a single surgery when indicated.

However, add-on codes typically are reimbursed at diminished value under Medicare's multiple code rule (eg, 50% for second code, 50% or 25% for third code, and beyond) because of shared operative preparation and approach. There is a large heterogeneity among different payers in how they reimburse multiple codes, with many insurers bundling procedures under a parent code. Furthermore, because the current analysis used wRVU compensation rates per minute of operative time instead of total wRVU collected per case, the benefits of multiple codes was minimized. For example, adding on a mini-open biceps tenodesis requires a separate incision and additional separate work during the diagnostic arthroscopy.

Other limitations included an inability to completely capture all procedures performed in each field. Some shoulder and elbow codes were not accounted for, such as open Bankart repair (23455) or a superior capsular reconstruction (29999, unlisted procedure). Similarly, some hand procedure codes, including all replants, which have high RVU assignments but are generally lengthy cases, were not included in this study due to low volume. However, not all upper extremity and hand surgeons perform these types of surgeries, and the low volumes at which these surgeries are performed would not likely significantly affect the overall averages.

The current analysis also did not account for postoperative care and work in the 90-day global period, although these aspects are factored into the wRVU calculations. Because most upper extremity procedures require some form of postoperative immobilization, wound check, and physical therapy, postoperative care and physician effort are likely similar between the 2 fields. Finally, the case volume and frequencies used to compute the weighted means are based on Medicare populations and may shift depending on the patient population of the treating surgeon.

Conclusion

Hospital-based shoulder and elbow procedures compensate significantly higher wRVU rates per operative time compared with hand surgery. These findings have important implications for both providers and hand-fellowship trainees and may explain the heavy demand for shoulder and elbow experience. These findings are important for practice managers in designing equitable pay structures and the recruitment and retention of upper extremity surgeons.

References

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wRVUs/min Rates based on NSQIP Operative Time for 27 of the Most Common Shoulder/Elbow CPT Codes, According to Centers for Medicare and Medicaid Services.

CPT CodeProcedure*wRVUs/minwRVUMedian Operative Time (min) (NSQIP)No. CMS Procedures
23474TSA revision (humerus and glenoid)0.2427.211123401
24358Tenotomy, elbow, debridement (open)0.246.66281153
29807SA: SLAP repair0.2314.67654290
23420Rotator cuff reconstruction, complete0.2313.54606740
23473TSA revision (humerus or glenoid)0.23251111778
29806SA: capsulorrhaphy0.2215.14702144
23472TSA0.2122.1310568977
29827SA: rotator cuff repair0.2015.5977114023
29828SA: biceps tenodesis0.2013.166523551
23412Rotator cuff repair, chronic (open)0.2011.935928734
29822SA: debridement, limited0.207.63826064
29825SA: adhesion lysis with or without manipulation0.207.79395077
23120Claviculectomy, partial0.207.393714103
29823SA: debridement, extensive0.208.364245835
23405Tenotomy, shoulder area (single)0.198.54443900
23410Rotator cuff repair, acute (open)0.1811.39627047
23470Hemiarthroplasty0.1817.89994648
23130Acromioplasty w/wo CA ligament release0.187.77433651
29821SA: synovectomy, complete0.177.89463238
23020Capsular contracture release0.179.36551982
23440Biceps tendon resection0.1610.64652691
29824SA: distal claviculectomy0.168.985572833
29819SA: foreign body removal0.167.79502285
23430Tenodesis, biceps0.1510.176725312
24342Biceps/triceps tendon rupture reinsertion0.1510.86722914
24363Total elbow arthroplasty0.15221461025
24343Lateral collateral ligament repair0.139.16681029

wRVUs/min Rates Based on NSQIP Operative Time for 53 of the Most Common Hosptial-based Hand Procedures, According to Centers for Medicare and Medicaid Services.

CPT CodeProcedure**wRVUs/minwRVUMedian Operative Time (min) (NSQIP)No. CMS Procedures
25115Excision of bursa, flexor tendons, wrist0.3710.09274,802
24359Epicondyle debridement w/tendon repair0.268.98351,749
25295Tenolysis, forearm/wrist0.206.72332,295
26952Amp thumb/finger phalanx, w/local flap0.206.48322,086
26951Amp thumb/finger phalanx, direct closure0.206.04308,011
26727Phalanx percutaneous pinning0.205.42272,896
25116Excision of bursa, wrist/forearm0.207.56381,391
25609Distal radius IA (>3 fragments) ORIF0.1914.387521,878
25076Excision tumor, forearm/wrist0.196.74361,087
25000Incision extensor tendon (deQuervain's)0.193.551912,383
26746MCPJ or IPJ ORIF0.179.80571,207
15736Muscle flap, upper extremity0.1717.041001,583
64702Neuroplasty, digital0.176.26371,247
25020Decompression fasciotomy forearm/wrist0.176.06361,408
25608Distal radius IA (2 fragments) ORIF0.1711.076710,229
25447Arthroplasty, interpostion, IC or CMC0.1611.146929,021
26910Ray amp0.167.79501,409
25118Synovectomy, extensor, wrist0.154.51302,627
26540Collateral ligament repair MCPJ or IPJ0.156.60441,731
25607Distal radius EA ORIF0.159.566413,066
26765Distal phalanx ORIF0.155.86401,506
25320Carpal stabilization0.1412.75901,180
25545Ulna shaft ORIF0.147.94581,802
26437Realignment of extensor tendon, hand0.135.99452,447
25290Tenotomy, forearm/wrist0.135.43412,994
26440Tenolysis, flexor tendon, palm/finger0.135.16392,988
24341Tendon/muscle repair upper arm/elbow0.139.49731,219
26615Metacarpal ORIF0.137.07552,548
23030Abscess drainage shoulder0.133.47271,139
26418Extensor tendon finger repair0.134.47352,804
25111Excision of ganglion, wrist0.133.53288,498
26735Phalanx shaft (proximal or middle) ORIF0.127.42601,932
29846Arthroscopy, wrist, TFCC repair/excision0.126.89562,181
24105Excision of olecranon bursa0.123.78315,708
26356Repair flexor tendon (Zone 2)0.129.56801,454
26410Extensor tendon hand repair0.124.77401,629
26445Tenolysis extensor tendon, hand or finger0.124.45382,038
24685Proximal ulna ORIF0.128.37729,065
25575Radial and ulnar shaft ORIF0.1212.291061,336
24305Tendon lengthening, upper arm/elbow0.127.62661,079
25260Tendon/muscle repair forearm/wrist0.118.04711,153
25210Carpectomy, single bone0.116.12553,093
26525Capsulectomy/capsulotomy IPJ0.115.50502,044
26593Release, intrinsic muscles0.115.50501,234
25280Lengthening/shortening tendon, forearm/wrist0.117.39681,678
24666Radial head or neck ORIF0.119.86921,236
26480Tendon transfer, CMC area or dorsal hand0.116.906513,601
25215Proximal row carpectomy0.108.14801,751
25310Tendon transplant/transfer, forearm/wrist0.108.088211,830
26520Capsulectomy/capsulotomy MCPJ0.095.47591,033
26531Arthroplasty MCPJ0.098.13942,838
26536Arthroplasty IPJ0.096.56761,763
25240Excision distal ulna (Darrach)0.085.31661,655
Authors

The authors are from the Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

The authors have no relevant financial relationships to disclose.

The authors thank Ms Rachel Box, MS, Ms Jenni Weems, MS, and Ms Kerry Kennedy, BA, for manuscript preparation and editorial services.

Correspondence should be addressed to: Suresh K. Nayar, MD, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287 ( snayar2@jhmi.edu).

Received: November 12, 2019
Accepted: February 17, 2020
Posted Online: November 25, 2020

10.3928/01477447-20201119-08

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