Purpose: Postaxial polydactyly type B (PPB) is characterized by a supernumerary digit attached to the small finger by a thin skin/neurovascular pedicle. It can be excised in-office with local anesthesia or in the operating room (OR) under general anesthesia. No existing studies have analyzed the factors contributing to cost differences between these two treatment strategies. Therefore, this study compared charges, reimbursements, and outcomes of in-office vs. OR surgical excisions. We hypothesized that in-office excisions are more cost-effective.
Methods: Demographics, treatment strategy, and complications were extracted from records of all cases of PPB excision at a single children’s hospital from fiscal year (FY) 2018-2023. Charge and reimbursement data were obtained from the finance department. In-office billing charges only included surgeon charges (no facility or anesthesia charges applied), but OR charges additionally included the associated hospital charges (facilities, anesthesia, etc.). Charges/reimbursements before FY2023 were adjusted for inflation using the Consumer Price Index and reported in FY2023 USD. Reimbursements were specific to the payor mix and insurance coverage of the patients analyzed and are subject to change for other populations. They were obtained as summary statistics (mean [SD]) by financial year, so weighted averages and pooled standard deviations were calculated to represent total reimbursements. Independent t-tests and Fisher’s exact tests were conducted.
Results: Of 620 patients, 30 (4.8%) underwent OR excisions (22 bilateral, 8 unilateral), and 590 (95%) underwent in-office excisions (346 bilateral, 244 unilateral). The cohort had a 1.3:1.0 male-to-female ratio and primarily identified as Black (72%). Median age at excision was 12.2 (6.1-171) months in the OR and 1.1 (0.1-15) months in-office. Average total charges were 78% (p < 0.001) and 84% (p < 0.001) less for bilateral and unilateral excisions, respectively, in-office than in the OR. In-office surgeon charges were ~40% (Bilateral: p < 0.001, Unilateral: p = 0.002) less than OR charges. Insurance companies and families paid less, on average, for in-office excisions. Specifically, insurance companies paid 83% less for bilateral (p < 0.001) and 88% less for unilateral in-office excisions (p = 0.01). Accordingly, surgeon reimbursements were 55% (p < 0.001) and 48% (p = 0.3) less for bilateral and unilateral in-office excisions, respectively.
One OR patient (3.3%) and eight in-office patients (1.4%) faced complications. The treatment strategy did not significantly impact outcomes (p = 0.4).Current Procedural Terminology (CPT) code usage varied. In the OR, 90% of procedures were booked with code 26587 or “reconstruction of polydactylous digit, soft tissues, and bone,” 6.7% with 11420 or “excision of a benign lesion,” and 3.3% with 11200 or “removal of skin tags, up to 15 lesions.” In-office, 63% of procedures were booked with code 26587, 37% with 11420, and 0.2% with 11200.
Conclusions: Given the cost efficacy and safety of in-clinic excision, OR excision should be limited to patient-specific factors requiring general anesthesia or non-standard equipment.