Carpal Instability Reconstruction and Wrist Procedures in the Medicare Population

Abstract

Purpose: We conducted a retrospective study to determine the annual number of patients undergoing various wrist procedures in the Medicare population as well as the revision rate and common revision procedures after carpal instability reconstruction surgeries (Current Procedural Terminology [CPT] billing code 25320). Methods: We examined the Medicare orthopedic datasets using the PearlDiver application to identify patients who underwent 12 different common wrist procedures, including carpal instability reconstruction procedures, from 2005 to 2014. Carpal instability reconstruction procedures were those identified by CPT 25320, which includes various methods of reconstruction such as capsulodesis, ligament repair, and tendon transfer or graft. Medicare covers approximately 51 million Americans and consists of those aged 65 years and older as well as younger patients enrolled in Social Security disability or with end-stage renal disease. Demographic and payment data were determined for the entire cohort. Patients with less than 3 months of active insurance records after the wrist procedure were excluded. Results: A total of 29,898 wrist procedures were performed over the study period. The most commonly performed procedure was wrist arthroscopy with joint debridement or triangular fibrocartilage complex repair (6,557 patients). A total of 2,949 patients underwent carpal instability reconstruction procedures, 174 of whom underwent revision or salvage surgeries (5.9%). The most common revision procedure was an additional reconstruction operation whereas the most common salvage procedure was proximal row carpectomy. Average Medicare payment was $4,107.67 for the index procedure and $3,760.95 for revision procedures. The number of wrist procedures increased 43% over the study period. Conclusions: Carpal instability reconstruction procedures and wrist arthroscopies with joint debridement or TFCC repair are performed more commonly in elderly patients than anticipated or indicated. Procedures such as these, without quality evidence supporting their use in elderly patients, are going to be scrutinized as the United States moves toward value-based health care. Although it appears that carpal reconstruction procedures have a low revision rate in the short to medium term in the Medicare population, the wide variety of procedures captured by CPT 25320 makes outcome measurements challenging. A more specific coding system should be created to reflect the surgeon’s effort more accurately, as well as better track revision rates. Type of study/level of evidence: Therapeutic III. Key words: carpal instability, carpal instability reconstruction, medicare, wrist arthroscopy