Coding Patterns and Implications for Reimbursement in Foot-and-Ankle Surgery

TL;DR

Foot-and-ankle surgeons show significant variation in medical coding practices, which can lead to large differences in reimbursement amounts.

Contribution

This study quantifies coding variability among foot-and-ankle surgeons and its impact on reimbursement using real-life patient cases.

Findings

Only 33.3% of cases had four out of five surgeons agreeing on the primary CPT code.

Reimbursement differences between surgeons reached up to $3,627.92 per case.

Coding variability was most pronounced in midfoot procedures.

Abstract

Introduction: Coding is an essential part of a foot-and-ankle surgeon’s responsibility and can quantify the amount of work done by the surgeon and influence compensation. The purpose of this study was to evaluate the coding patterns and variation among foot-and-ankle orthopedic surgeons and to quantify the potential effects of these on reimbursement using real-life patient cases. Our hypothesis was that there would be large variability between the coding of common foot-and-ankle cases between surgeons, with subsequent effects on reimbursement values.

Methods: A survey consisting of 12 patient cases was administered to all foot-and-ankle, fellowship-trained orthopedic surgeons of a large, combined academic-private practice group. The scenarios included pre-operative diagnostic imaging and reports, intra-operative imaging, and post-operative radiographs. Surgeons were asked which Current Procedural Terminology (CPT) codes would be applied and if any modifiers to these codes would be used. Total work-relative value units (RVUs) and the generated reimbursement values were calculated for each case and respondent using the 2024 Centers for Medicare & Medicaid Services conversion factor ($32.74 per RVU), with the primary procedure reimbursed at 100% and additional procedures reimbursed at 50%.

Results: Five surgeons completed the survey. Among case scenarios, wide variability in CPT coding was demonstrated, with only 33.3% (four out of 12) of cases having at least four of the five respondents in agreement on the primary CPT code, whereas only one case had 100% agreement. Similarly, only 41.7% (five out of 12) of cases had at least four of the five respondents in agreement regarding modifier usage, with only one case having 100% agreement. The total RVU and reimbursement difference between the respondents with the highest and lowest listed RVUs was 216.06 and $3,627.92, respectively.

Conclusion: Large variability exists between foot-and-ankle surgeons when coding common procedures, particularly those involving the midfoot. Surgeons should be aware of these differences and the large effect they can have on quantifying work and reimbursement. Increasing competency with coding and billing should continue to be emphasized in all medical specialties.

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