Coding Patterns and Implications on Reimbursement in Foot & Ankle Surgery

Abstract

Category: Other; Midfoot/Forefoot Introduction/Purpose: Coding is an essential part of a foot and ankle surgeon’s duties and can both quantify the amount of work done by the surgeon and influence compensation. The purpose of this study was to evaluate the coding patterns among foot and ankle orthopaedic surgeons and to quantify the effects of these on reimbursement using real-life patient cases. Methods: A survey consisting of 12 commonly encountered real deidentified patient cases was administered to all foot and ankle fellowship-trained orthopaedic surgeons of a large, combined academic-private practice orthopaedic 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 utilized. If multiple CPT codes were utilized, surgeons were asked to list the codes in the same order as would be theoretically listed on their operative notes. Respondents were allowed to use any sources of information they desired to complete the survey. 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 (CMS) conversion factor ($32.74 per RVU), with the primary procedure reimbursed at 100%, with additional procedures reimbursed at 50%. Results: Five surgeons completed the survey. Among case scenarios, four of the 12 cases had at least four of the five respondents in agreement on the primary CPT code, whereas only one case had 100% agreement among respondents on the primary CPT code. Similarly, only five of the 12 cases had at least four of the five respondents in agreement regarding modifier usage, with only one case having 100% agreement among respondents on modifier utilization. Modifier 59 was most utilized. The total RVU and reimbursement difference between the respondents with the highest and lowest listed RVUs was 216.06 and $3,627.92, respectively (Table 1). The cases with the most variability among both RVUs and modifiers involved a Lisfranc injury, Charcot reconstruction, and midfoot fracture-dislocation. Conclusion: Great variability exists between foot and ankle surgeons when coding common foot and ankle procedures. Surgeons should be aware of these differences and the large effect they can have on quantifying reimbursement. Increasing competency with coding and maximizing reimbursement for work performed should continue to be emphasized.