Abstract
Background:
Many US health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. Among other factors, a major determinant of payment and wRVU assignments is operative time. Our objective was to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common hospital-based hand and upper extremity procedures.
Methods:
Data on wRVUs, surgeon payment, and estimated operative times were collected from CMS for 53 procedures. We used regression models to compare relationships between these variables, in addition to actual median operative times as reported in the NSQIP database, from 2011 to 2016. We then determined the relative valuation of each procedure based on operative time.
Results:
There was a wide discrepancy between CMS and NSQIP operative times (R2=0.49), with 60% of CMS times being longer than NSQIP times. Payment correlated more strongly with CMS operative times (R2=0.55) than with NSQIP operative times (R2=0.24). Similarly, wRVUs more strongly correlated with CMS operative times (R2=0.84) than with NSQIP operative times (R2=0.51). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) had the highest valuation while any ORIF proximal to the distal radius had lower valuation in analysis of both databases. While 61% of trauma procedures were highly valued, 70% of elective procedures had a low valuation, including nearly all elective tendon procedures. Notable compensation differences were found between trapeziectomy versus ligament reconstruction and tendon interposition, epicondyle debridement with tendon repair versus denervation, proximal row carpectomy versus four corner fusion, and distal radius open versus percutaneous fixation.
Conclusions:
CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate operative time estimates. By identifying which procedures are misvalued in terms of payment and wRVU per operative time, providers and payors may be able to address these imbalances and maximize appropriate care delivery incentives.
Level of Evidence: III
Keywords: Centers for Medicare & Medicaid Services, National Surgical Quality Improvement Program, operative time, payment, relative value unit, hand surgery, proximal row carpectomy, ligament reconstruction tendon interposition, four corner
Introduction
Over the past two decades, reimbursement rates in hand surgery have been declining.1 During the same period, there has been continued pressure for providers to reach and maintain productivity and revenue goals. Many measures of surgeon productivity are based on the work relative value unit (wRVU), a metric that the Centers for Medicare & Medicaid Services (CMS) uses to quantify the work associated with procedures based on Current Procedural Terminology (CPT) codes. Despite the many criticisms of this system2,3 and multiple studies showing a poor correlation with perioperative workload, surgical complexity, and operative time4-10 in various surgical fields, no viable alternative has been presented. Currently, the wRVU-based compensation model continues to be a primary measure of surgeon productivity and forms the basis of many employment contracts.
While wRVU valuation is multifactorial, a major component is based on operative time. CMS estimates operative time for each CPT code based on surveys conducted by surgical specialty societies on behalf of the American Medical Association (AMA). These estimates may not correlate well with actual, “real world” operative times recorded in other databases, such as the National Surgical Quality Improvement Program (NSQIP). NSQIP was developed in part to track hospital complications and serves as a robust resource for perioperative variables from actual patient surgical encounters, including operative time. There have been efforts led by CMS to identify services that are misvalued because of inaccurate operative times.11 Imbalances between procedure effort and associated reimbursement may potentially create incentives that guide practice patterns away from procedures supported by available evidence.12-14
In this study, we determine how well CMS payment and wRVU allotment for common hospital-based hand procedures correlate to both CMS (estimated by surgical specialty societies on behalf of the AMA) and NSQIP (aggregate of actual recorded operative times taken from patient medical records) operative times. We then determine payment and wRVU rates based on operative time and assess which procedures may have higher or lower valuation based on inconsistencies across these two databases. Our objective was to determine whether inaccuracies in estimated CMS operative times compared to reported NSQIP operative times are associated with payment and wRVU misvaluation for the most common hospital-based hand and upper extremity procedures.
Methods
Work relative value units15 and physician payment16 were collected from CMS for all isolated, hospital-based hand and upper extremity procedures (by CPT code). These procedures were performed in a facility, non-office setting. To include the most commonly performed surgeries, we only included surgeries from CMS with total recorded volumes greater than 1,000. These institutions include all facilities, academic and non-academic, that participate in Medicare. These procedures included any orthopaedic trauma distal to the elbow and any elective soft tissue procedures distal to the shoulder joint. This yielded 83 CPT codes. Both operative time (defined as skin incision to closure) and perioperative time (which includes pre-evaluation, positioning, draping, scrubbing, skin incision to closure, and post-service times)17 estimates from CMS were recorded for these codes.
Median operative times (variable, “optime,” defined as skin incision to closure) were similarly collected from the NSQIP database for 2011 through 2016 using the same list of 83 procedures. Thirty procedures had zero entries in the NSQIP database, giving a final procedure count for 53 CPT codes (Appendices 1 and 2). Median operative time was used to exclude any particular procedure that was excessively long, short, or potentially miscoded. Median time was also used to indirectly reflect average surgeon experience. Only procedure encounters with a single CPT code were used in our analysis. NSQIP does not collect perioperative data for routine hand surgeries with low morbidity and complication rates, such as carpal tunnel release, trigger finger release, and ulnar nerve decompression.
Relationships between wRVU, physician payment, CMS operative and perioperative time, and NSQIP operative time were explored with linear regression analysis for the common 53 procedures shared among both databases. wRVU and payment rates (wRVU/min and $/min) were determined from operative time for both databases. The relative valuation for each procedure was determined by comparing actual versus calculated payment derived from the regression equations based on operative time. This valuation reflects how much each procedure deviates from the calculated or predicted payment against similar surgeries that carry comparable levels of effort, risk, and skill. Payments and operative times were evaluated independently from patient factors, such as comorbidities and associated CPT modifiers (e.g., for case complexity).
Results
wRVU, payment amounts, and operative times for these 53 procedures are shown in Appendices 1 and 2. There was a wide discrepancy between CMS and NSQIP operative times (R2=0.49) (Table 1), with 60% of CMS times being longer than NSQIP times. Payments were more strongly correlated with CMS operative times (R2=0.55) than with NSQIP operative times (R2=0.24). Similarly, wRVUs were more strongly correlated with CMS operative times (R2=0.84) than with NSQIP operative times (R2=0.51). Payments versus operative times are shown in (Figures 1A & B). How far each procedure deviates above or below the regression line shows the extent to which the procedure has a higher or lower valuation compared to all other procedures analyzed, respectively (Figures 2A and B). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) was found to be more highly valued while any ORIF proximal to the distal radius was valued relatively lower, according to both CMS and NSQIP operative times. Per NSQIP operative time, 39% of trauma procedures had a valuation lower than the predicted payment (lower than the regression line) in comparison to 70% of elective procedures.
Table 1.
Correlations (R values) Between Payments, wRVUs, and Operative Times for 53 Hand and Upper Extremity Procedures Using CMS and NSQIP Dataa
| Variable | CMS operative time | CMS perioperative time | NSQIP operative time | wRVU |
|---|---|---|---|---|
| Payments | 0.55 | 0.57 | 0.24 | 0.66 |
| wRVUs | 0.84 | 0.85 | 0.51 | NA |
| CMS operative time | NA | NA | 0.49 | NA |
CMS, Centers for Medicare & Medicaid Services; NA, not applicable; NSQIP, National Surgical Quality Improvement Program; wRVU, work relative value unit
aThe table is presented as a matrix. Each value represents the coefficient of determination (R2) of the intersecting variables.
Figure 1.
Payment versus operative time according to A, Centers for Medicare & Medicaid Services (CMS) and B, National Surgical Quality Improvement Program (NSQIP) data for 53 hand and upper extremity procedures. Data points above the regression lines represent procedures that are compensated at a higher amount per operative time compared with the other procedures analyzed. Conversely, data points below the regression lines are compensated at a lower amount.
Figure 2.
Calculated procedure compensation based on Centers for Medicare & Medicaid Services (CMS) and National Surgical Quality Improvement Program (NSQIP) operative time data. CPT codes are divided into A, trauma and B, elective subsets. Codes to the right of the y-axis are more highly-compensated, whereas those to the left have lower compensation. These percentages show how much each procedure deviates from the regression lines shown in Figure 1. For example, an intra-articular distal radius fracture (>3 fragments, code 25609) has an associated payment of $1,286, which is 84% more than that calculated by using NSQIP operative time ($701, Figure 1B) and 29% more than that calculated by using CMS operative time ($998, Figure 1A). IA, intra-articular; EA, extra-articular; ORIF, open reduction internal fixation; amp, amputation; MCPJ, metacarpophalangeal joint; IPJ, interphalangeal joint; CMC, carpometacarpal joint; TFCC, triangular fibrocartilage complex; IC, intercarpal.
Notable elective procedures where NSQIP operative time was shorter than CMS included: upper extremity muscle flaps (CPT 15736, 50-minute difference) epicondyle debridement with tendon repair (CPT 24359, 25-minute difference), and extensor tendon release (CPT 25000, 14-minute difference). Common elective procedures where NSQIP operative time was longer than CMS included tendon transplant/transfer at the forearm/ wrist (CPT 25310, 22-minute difference), distal ulna excision (CPT 25240, 20-minute difference), and metacarpophalangeal joint arthroplasty (CPT 26531, 32-minute difference). Notable trauma-related procedures where NSQIP operative time was shorter than CMS included: intra-articular distal radius ORIF with >3 fragments (CPT 25609, 45-minute difference), phalangeal percutaneous pinning (CPT 26727, 20-minute difference), and metacarpal (ray) amputation (CPT 26910, 38-minute difference). Trauma procedures where NSQIP operative time was longer than CMS included: metacarpal ORIF (CPT 26615, 10-minute difference), flexor tendon repair in Zone 2 (CPT 26356, 20-minute difference), tendon/muscle repair in the forearm and wrist (CPT 25260, 21-minute difference).
Amongst this list of 53 surgeries, there were pairs of procedures that have similar indications with appreciable differences in valuation. In the discussion, we focus on trapeziectomy versus ligament reconstruction and tendon interposition (LRTI), epicondyle debridement with tendon repair vs. denervation, proximal row carpectomy (PRC) vs. four corner fusion (4CF), and distal radius ORIF versus percutaneous fixation of distal radius fractures (Appendices 1 and 2). While these comparisons do not represent an exhaustive list, there is robust evidence in the literature showing equivalent patient outcomes between these surgeries.
Discussion
For the most common hospital-based hand and upper extremity procedures, there is a wide difference between CMS and NSQIP operative times, indicating potential misvaluation of certain procedures in terms of wRVU and payment per minute of operative time. Although the expected strong correlation between wRVU and CMS operative time was seen in our results, there was a weaker correlation with actual (NSQIP) operative time. Further, poor correlation was observed between payment and NSQIP operative time. Distal radius ORIF tended to be more highly valued while ORIF proximal to the distal radius was less valued. Nearly all tendon procedures had a lower valuation relative to other procedures based on surgical time (Fig. 2), a concerning finding given the extensive post-operative rehabilitation requirements not included in our analysis. The majority (70%) of elective procedures analyzed in the NSQIP database had lower valuation than predicted. A thorough understanding of these findings is important to establish appropriate revenue goals for providers. This may be particularly beneficial in a scenario where a patient has two surgical options with similar or equivocal indications, but when each surgery has different payment rates and wRVU assignments.
The findings in Figure 2A and B illustrate several examples where compensation can be augmented to better align provider and patient incentives. For example, the treatment of thumb CMC arthritis with either simple trapeziectomy (single bone carpectomy without pinning or other fixation) versus trapeziectomy with LRTI has long been debated, yet multiple studies have shown nearly equivalent outcomes for pain, mobility, and strength.18-23 Another study showed that LRTI has added risk of infection, reoperation, or other aggressive interventions.24 Despite this, national trends of LRTI utilization have increased since 2001.25 In comparing payment and wRVU rates, our study shows that LRTI (CPT 25447, CMC interposition) is the third highest valued elective procedure at +48% (0.16 RVU or $14.34/ min) while a single bone carpectomy (CPT 25210) had a relatively low valuation at -33% (0.11 RVU or $7.29/min) per NSQIP operative time (P<0.001 for both RVU and $/ min). This comparison also excludes the additional CPT code and compensation for tendon transfer, which further increases the relative value of LRTI. This discrepancy may incentivize LRTI when trapeziectomy alone can be used.
In another example, epicondyle debridement with tendon repair (CPT 24359) was the second highest reimbursing procedure in terms of wRVUs (0.26/ min) and payment ($23.60/min), and the third highest valued surgery at +67% per NSQIP operative time. Indications for this procedure include medial or lateral epicondylitis. While most presentations of epicondylitis resolve with conservative treatment, debridement and tendon reattachment may be offered in recalcitrant cases. However, the efficacy of these surgeries has been questioned. A study comparing extensor carpi radialis brevis debridement and repair versus sham treatment (muscle belly exposure only) showed no difference between treatment groups.26 In a letter to the editor, it was noted that the sham procedure was likely a lateral denervation treatment.27 Of note, coding as a denervation procedure (CPT 64708) would yield far less payment per CMS operative time at a valuation of -41% compared to +41% for epicondyle debridement.
Our results showed that 70% of elective procedures had relatively low payment in-line with recent findings showing declining hand surgery reimbursement rates.1 This may help explain the motivation to shift procedures to the in-office/procedure room setting. First, surgeons may offset decreased compensation by negotiating higher professional fees because they are saving insurance companies facility fees by performing these surgeries outside of the hospital. Second, lower payment may pressure surgeons to seek operative settings where turnover time is minimized to maximize the number of cases performed in an operative day to achieve the same revenue targets. This may also favor the practice of minimizing surgical resources, such as wide-awake local anesthesia no tourniquet (WALANT) techniques, that have demonstrated reliable and safe cost-saving measures.28,29 This shift in surgical setting makes it even more challenging to estimate accurate “real world” operative times due to the high degree of heterogeneity in practice and office setting.
One limitation of this study is that NSQIP does not collect perioperative data on several common hand and upper extremity procedures, and therefore a complete analysis for these procedures by operative time cannot be undertaken. For example, NSQIP does not collect data for four-corner fusion (4CF) (CPT 25825). Proximal row carpectomy (PRC) (CPT 25215) and 4CF have both been offered as salvage procedures for wrists with scaphoid nonunion or scapholunate advanced collapse. These procedures have comparable long-term results in terms of grip strength, pain relief, and other subjective measures.30 However, 4CF carries the added risk of nonunion, hardware issues, and dorsal impingement. When analyzed by CMS operative time data, payment for 4CF has a higher valuation of +35% compared to PRC, which is lower at -18%. There were also zero NSQIP entries for percutaneous fixation of distal radius fractures (CPT 25606). Multiple studies have shown nearly equivalent one-year outcomes between percutaneous fixation and volar locking plate fixation despite ORIF costing substantially more than percutaneous fixation.31,32 When analyzed by CMS operative time data, extra-articular distal radius ORIF (CPT 25607) was more highly valued (+77%) than percutaneous fixation (+40%). Although there is some coding heterogeneity for these procedures and the nature of fracture and treatment, this payment difference suggests that percutaneous fixation may be under-compensated.
Other limitations in this study include the inability to capture physician work in the post-operative global care period, which is typically 90 days. This is particularly problematic for tendon procedures because tendon transfers/lengthening can require extensive postoperative rehabilitation and aftercare. We also analyzed CPT codes in isolation from single-code cases when, in practice, multiple codes may be billed in a single case which may decrease per-procedure operative times if a shared surgical approach is used. There is also the possibility that procedures may have been miscoded in the CMS and NSQIP databases. Further, capturing accurate “real world” operative time may be challenging because several factors, such as surgeon experience and type of surgical setting, may affect efficiency. Using NSQIP to estimate operative times may also be inaccurate for other practice types as most NSQIP sites are academic centers or larger institutions; however, as healthcare systems across the country continue to consolidate, NSQIP may become more representative of surgical centers nationally. Finally, we used operative time as a basis for determining procedure valuation. There are other metrics in determining compensation for procedures. However, we aimed to minimize this limitation as we determined valuation of a surgery by comparing payment to similar types of procedures that carry comparable levels of effort, risk, and skill. Although we are unable to directly quantify and include these metrics in our analysis, higher levels of surgeon effort and skill are typically associated with increased operative time.
Despite the limitations of this study and the complex nature of the topic, we have demonstrated multiple scenarios where CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate CMS operative time estimates. By revising CMS operative times for certain procedures, associated changes in payment may improve physician compensation models, correct misvaluation-based incentives, and serve as a catalyst to improve the quality and value of elective and trauma-related hand surgery.
Appendix 1. Work relative value units (wRVU) and operative times for common hand and upper extremity procedures by CPT code according to CMS (2015) and NSQIP (2011–2016) data.
Procedures sorted by decreasing wRVU.
| CPT Code | ACGME Description | wRVUs | Mean CMS-allowed Amount, $ | CMS | NSQIP | |||
|---|---|---|---|---|---|---|---|---|
| Operative Time, mina | Perioperative Time, minb | Total Procedures | Operative Time, mina,c | Total Procedures | ||||
| 15736 | Muscle flap, upper extremity | 17.04 | $993.75 | 150 | 396 | 1,583 | 100 (58-171) | 386 |
| 25609 | Distal radius IA (>3 fragments) ORIF | 14.38 | $1,286.34 | 120 | 358 | 21,878 | 75 (55-103) | 3765 |
| 25320 | Carpal stabilization | 12.75 | $988.07 | 120 | 452 | 1,180 | 90 (63-128) | 492 |
| 25575 | Radial and ulnar shaft ORIF | 12.29 | $797.80 | 90 | 342 | 1,336 | 106 (80-138) | 725 |
| 25447 | Arthroplasty, interposition, IC or CMC | 11.14 | $989.30 | 100 | 278 | 29,021 | 69 (49-94) | 3981 |
| 25608 | Distal radius IA (2 fragments) ORIF | 11.07 | $1,154.27 | 90 | 305 | 10,229 | 67 (50-91) | 3826 |
| 25115 | Excision of bursa, flexor tendons, wrist | 10.09 | $731.57 | 90 | 257 | 4,802 | 27 (18-43) | 322 |
| 24666 | Radial head or neck ORIF | 9.86 | $719.56 | 85 | 286 | 1,236 | 92 (68-134) | 331 |
| 26746 | MCPJ or IPJ ORIF | 9.80 | $739.02 | 83 | 303 | 1,207 | 57 (37-84) | 507 |
| 26356 | Repair flexor tendon (Zone 2) | 9.56 | $891.11 | 60 | 277 | 1,454 | 80 (56-111) | 949 |
| 25607 | Distal radius EA ORIF | 9.56 | $1,039.80 | 60 | 275 | 13,066 | 64 (49-86) | 4420 |
| 24341 | Tendon/muscle repair upper arm/elbow | 9.49 | $730.83 | 90 | 318 | 1,219 | 73 (54-97) | 1408 |
| 24359 | Epicondyle debridement with tendon repair | 8.98 | $826.00 | 60 | 213 | 1,749 | 35 (26-49) | 729 |
| 24685 | Proximal ulna ORIF | 8.37 | $587.19 | 60 | 252 | 9,065 | 72 (52-100) | 2233 |
| 25215 | Proximal row carpectomy | 8.14 | $626.75 | 86 | 269 | 1,751 | 80 (58-106) | 304 |
| 26531 | Arthroplasty MCPJ | 8.13 | $502.42 | 62 | 215 | 2,838 | 94 (61-141) | 266 |
| 25310 | Tendon transplant/transfer, forearm/wrist | 8.08 | $406.06 | 60 | 235 | 11,830 | 82 (56-121) | 435 |
| 25260 | Tendon/muscle repair forearm/wrist | 8.04 | $450.28 | 50 | 215 | 1,153 | 71 (46-109) | 257 |
| 25545 | Ulna shaft ORIF | 7.94 | $480.60 | 60 | 286 | 1,802 | 58 (44-84) | 464 |
| 26910 | Amp ray | 7.79 | $637.05 | 88 | 251 | 1,409 | 50 (30-80) | 194 |
| 24305 | Tendon lengthening, upper arm/elbow | 7.62 | $532.12 | 63 | 209 | 1,079 | 66 (46-90) | 35 |
| 25116 | Excision of bursa, wrist/forearm | 7.56 | $561.26 | 60 | 249 | 1,391 | 38 (22-67) | 250 |
| 26735 | Phalanx shaft (proximal or middle) ORIF | 7.42 | $592.56 | 60 | 237 | 1,932 | 60 (40-83) | 1510 |
| 25280 | Lengthening/shortening tendon, forearm/wrist | 7.39 | $398.36 | 53 | 195 | 1,678 | 68 (56-107) | 51 |
| 26615 | Metacarpal ORIF | 7.07 | $824.64 | 45 | 217 | 2,548 | 55 (38-77) | 2637 |
| 26480 | Tendon transfer, CMC area or dorsal hand | 6.90 | $478.64 | 60 | 222 | 13,601 | 65 (45-94) | 249 |
| 29846 | Arthroscopy, wrist, TFCC repair/excision | 6.89 | $565.72 | 72 | 179 | 2,181 | 56 (39-81) | 1067 |
| 25295 | Tenolysis, forearm/wrist | 6.72 | $384.28 | 48 | 191 | 2,295 | 33 (20-62) | 266 |
| 26540 | Collateral ligament repair MCPJ or IPJ | 6.60 | $533.19 | 54 | 204 | 1,731 | 44 (32-61) | 818 |
| 26536 | Arthroplasty IPJ | 6.56 | $806.22 | 65 | 211 | 1,763 | 76 (50-62) | 266 |
| 26952 | Amp thumb/finger phalanx, w/ local flap | 6.48 | $548.28 | 43 | 173 | 2,086 | 32 (23-52) | 475 |
| 64702 | Neuroplasty, digital | 6.26 | $369.10 | 50 | 212 | 1,247 | 37 (23-62) | 257 |
| 25210 | Carpectomy, single bone | 6.12 | $400.82 | 53 | 194 | 3,093 | 55 (40-87) | 301 |
| 25020 | Decompression fasciotomy forearm/wrist | 6.06 | $730.36 | 54 | 204 | 1,408 | 36 (22-61) | 146 |
| 26951 | Amp thumb/finger phalanx, direct closure | 6.04 | $547.96 | 30 | 203 | 8,011 | 30 (21-45) | 988 |
| 26437 | Realignment of extensor tendon, hand | 5.99 | $444.13 | 51 | 183 | 2,447 | 45 (31-70) | 99 |
| 26765 | Distal phalanx ORIF | 5.86 | $511.19 | 45 | 217 | 1,506 | 40 (26-61) | 505 |
| 26593 | Release, intrinsic muscles | 5.50 | $349.85 | 68 | 233 | 1,234 | 50 (25-99) | 25 |
| 26525 | Capsulectomy/capsulotomy IPJ | 5.50 | $479.07 | 44 | 175 | 2,044 | 50 (32-83) | 251 |
| 26520 | Capsulectomy/capsulotomy MCPJ | 5.47 | $431.69 | 45 | 176 | 1,033 | 59 (29-86) | 133 |
| 25290 | Tenotomy, forearm/wrist | 5.43 | $337.44 | 35 | 164 | 2,994 | 41 (26-61) | 83 |
| 26727 | Phalanx percutaneous pinning | 5.42 | $541.91 | 47 | 174 | 2,896 | 27 (19-41) | 1115 |
| 25240 | Excision distal ulna (Darrach) | 5.31 | $434.73 | 46 | 176 | 1,655 | 66 (45-109) | 169 |
| 26440 | Tenolysis, flexor tendon, palm/finger | 5.16 | $453.35 | 43 | 162 | 2,988 | 39 (19-68) | 576 |
| 26410 | Extensor tendon hand repair | 4.77 | $413.17 | 43 | 162 | 1,629 | 40 (28-60) | 570 |
| 25118 | Synovectomy, extensor, wrist | 4.51 | $527.53 | 40 | 158 | 2,627 | 30 (19-52) | 220 |
| 26418 | Extensor tendon finger repair | 4.47 | $436.57 | 39 | 153 | 2,804 | 35 (24-50) | 1029 |
| 26445 | Tenolysis extensor tendon, hand or finger | 4.45 | $382.51 | 37 | 137 | 2,038 | 38 (23-62) | 457 |
| 24105 | Excision of olecranon bursa | 3.78 | $431.00 | 35 | 143 | 5,708 | 31 (21-44) | 1075 |
| 25000 | Incision extensor tendon (deQuervain’s) | 3.55 | $431.99 | 33 | 135 | 12,383 | 19 (13-27) | 1888 |
| 25111 | Excision of ganglion, wrist | 3.53 | $431.68 | 41 | 140 | 8,498 | 28 (20-39) | 4327 |
| 23030 | Abscess drainage shoulder | 3.47 | $238.03 | 36 | 152 | 1,139 | 27 (17-48) | 303 |
ACGME, Accreditation Council for Graduate Medical Education; CMS, Centers for Medicare & Medicaid Services; CPT, Current Procedural Terminology; NSQIP, National Surgical Quality Improvement Program; wRVU, work relative value unit; IA, intra-articular; EA, extra-articular; MC, metacarpal; ORIF, open reduction internal fixation; amp, amputation; MCPJ, metacarpophalangeal joint; IPJ, interphalangeal joint; CMC, carpometacarpal joint; TFCC; triangular fibrocartilage complex; IC intercarpal. CMS data for CPT 64708 (release of nerve of arm): CMS data, 6.36 wRVU; allowed payment $348.65; intraservice time: 60 min; perioperative service time: 220 min; total procedures: 34.
aNSQIP Both NSQIP and CMS measure operative time from skin incision to closure.
Data presented as median (interquartile range).
bCMS perioperative time includes pre-evaluation, positioning, scrubbing, intra-service, and immediate post-service time.
cMedian operative time
Appendix 2. Payments and wRVUs per minute of operative time according to CMS and NSQIP data for 53 common hand and upper extremity procedures.
Procedures sorted by decreasing payment/minute per CMS operative time. Note that payment and wRVU rates may value substantially when using NSQIP operative time.
| CPT Code | ACGME Description | CMS | NSQIP | ||
|---|---|---|---|---|---|
| Payment/minute, $ | wRVUs/minute | Payment/minute, $ | wRVUs/minute | ||
| 26615 | Metacarpal ORIF | $18.33 | 0.16 | $14.99 | 0.13 |
| 26951 | Amp thumb/finger phalanx, direct closure | $18.27 | 0.20 | $18.27 | 0.20 |
| 25607 | Distal radius EA ORIF | $17.33 | 0.16 | $16.25 | 0.15 |
| 26356 | Repair flexor tendon (Zone 2) | $14.85 | 0.16 | $11.14 | 0.12 |
| 24359 | Epicondyle debridement with tendon repair | $13.77 | 0.15 | $23.60 | 0.26 |
| 25020 | Decompression fasciotomy forearm/wrist | $13.53 | 0.11 | $20.29 | 0.17 |
| 25118 | Synovectomy, extensor, wrist | $13.19 | 0.11 | $17.58 | 0.15 |
| 25000 | Incision extensor tendon (deQuervain’s) | $13.09 | 0.11 | $22.74 | 0.19 |
| 25608 | Distal radius IA (2 fragments) ORIF | $12.83 | 0.12 | $17.23 | 0.17 |
| 26952 | Amp thumb/finger phalanx, w/ local flap | $12.75 | 0.15 | $17.13 | 0.20 |
| 26536 | Arthroplasty IPJ | $12.40 | 0.10 | $10.61 | 0.09 |
| 24105 | Excision of olecranon bursa | $12.31 | 0.11 | $13.90 | 0.12 |
| 26727 | Phalanx percutaneous pinning | $11.53 | 0.12 | $20.07 | 0.20 |
| 26765 | Distal phalanx ORIF | $11.36 | 0.13 | $12.78 | 0.15 |
| 26418 | Extensor tendon finger repair | $11.19 | 0.11 | $12.47 | 0.13 |
| 26525 | Capsulectomy/capsulotomy IPJ | $10.89 | 0.13 | $9.58 | 0.11 |
| 25609 | Distal radius IA (>3 fragments) ORIF | $10.72 | 0.12 | $17.15 | 0.19 |
| 25076 | Excision tumor, forearm/wrist | $10.71 | 0.15 | $13.39 | 0.19 |
| 26440 | Tenolysis, flexor tendon, palm/finger | $10.54 | 0.12 | $11.62 | 0.13 |
| 25111 | Excision of ganglion, wrist | $10.53 | 0.09 | $15.42 | 0.13 |
| 26445 | Tenolysis extensor tendon, hand or finger | $10.34 | 0.12 | $10.07 | 0.12 |
| 25447 | Arthroplasty, interposition, IC or CMC | $9.89 | 0.11 | $14.34 | 0.16 |
| 26735 | Phalanx shaft (proximal or middle) ORIF | $9.88 | 0.12 | $9.88 | 0.12 |
| 26540 | Collateral ligament repair MCPJ or IPJ | $9.87 | 0.12 | $12.12 | 0.15 |
| 24685 | Proximal ulna ORIF | $9.79 | 0.14 | $8.16 | 0.12 |
| 25290 | Tenotomy, forearm/wrist | $9.64 | 0.16 | $8.23 | 0.13 |
| 26410 | Extensor tendon hand repair | $9.61 | 0.11 | $10.33 | 0.12 |
| 26520 | Capsulectomy/capsulotomy MCPJ | $9.59 | 0.12 | $7.32 | 0.09 |
| 25240 | Excision distal ulna (Darrach) | $9.45 | 0.12 | $6.59 | 0.08 |
| 25116 | Excision of bursa, wrist/forearm | $9.35 | 0.13 | $14.77 | 0.20 |
| 25260 | Tendon/muscle repair forearm/wrist | $9.01 | 0.16 | $6.34 | 0.11 |
| 26746 | MCPJ or IPJ ORIF | $8.90 | 0.12 | $12.97 | 0.17 |
| 25575 | Radial and ulnar shaft ORIF | $8.86 | 0.14 | $7.53 | 0.12 |
| 26437 | Realignment of extensor tendon, hand | $8.71 | 0.12 | $9.87 | 0.13 |
| 24305 | Tendon lengthening, upper arm/elbow | $8.45 | 0.12 | $8.06 | 0.12 |
| 25320 | Carpal stabilization | $8.23 | 0.11 | $10.98 | 0.14 |
| 25115 | Excision of bursa, flexor tendons, wrist | $8.13 | 0.11 | $27.10 | 0.37 |
| 24341 | Tendon/muscle repair upper arm/elbow | $8.12 | 0.11 | $10.01 | 0.13 |
| 26531 | Arthroplasty MCPJ | $8.10 | 0.13 | $5.34 | 0.09 |
| 25545 | Ulna shaft ORIF | $8.01 | 0.13 | $8.29 | 0.14 |
| 25295 | Tenolysis, forearm/wrist | $8.01 | 0.14 | $11.64 | 0.20 |
| 26480 | Tendon transfer, CMC area or dorsal hand | $7.98 | 0.12 | $7.36 | 0.11 |
| 29846 | Arthroscopy, wrist, TFCC repair/excision | $7.86 | 0.10 | $10.10 | 0.12 |
| 25210 | Carpectomy, single bone | $7.56 | 0.12 | $7.29 | 0.11 |
| 25280 | Lengthening/shortening tendon, forearm/wrist | $7.52 | 0.14 | $5.86 | 0.11 |
| 64702 | Neuroplasty, digital | $7.38 | 0.13 | $9.98 | 0.17 |
| 25215 | Proximal row carpectomy | $7.29 | 0.09 | $7.83 | 0.10 |
| 26910 | Amp ray | $7.24 | 0.09 | $12.74 | 0.16 |
| 25310 | Tendon transplant/transfer, forearm/wrist | $6.77 | 0.13 | $4.95 | 0.10 |
| 15736 | Muscle flap, upper extremity | $6.62 | 0.11 | $9.94 | 0.17 |
| 23030 | Abscess drainage shoulder | $6.61 | 0.10 | $8.82 | 0.13 |
| 26593 | Release, intrinsic muscles | $5.14 | 0.08 | $7.00 | 0.11 |
ACGME, Accreditation Council for Graduate Medical Education; CMS, Centers for Medicare & Medicaid Services; CPT, Current Procedural Terminology; NSQIP, National Surgical Quality Improvement Program; wRVU, work relative value unit; IA, intra-articular; EA, extra-articular; MC, metacarpal; ORIF, open reduction internal fixation; amp, amputation; MCPJ, metacarpophalangeal joint; IPJ, interphalangeal joint; CMC, carpometacarpal joint; TFCC; triangular fibrocartilage complex; IC intercarpal.
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