Reimbursement for Hip Fractures: The Impact of Varied Current Procedural Terminology Coding Using Relative Value...

Area of Science:

• Orthopedic Surgery
• Healthcare Reimbursement
• Medical Coding

Background:

• Many orthopedic practices incorrectly use Current Procedural Terminology (CPT) code 27125 for hip fracture hemiarthroplasty.
• The correct CPT code for this procedure is 27236.
• This coding error has significant financial implications for surgeon reimbursement.

Purpose of the Study:

• To determine the financial impact of using the incorrect CPT code (27125) versus the correct CPT code (27236) for hip fracture hemiarthroplasty on surgeon reimbursement.

Main Methods:

• Utilized data from the 2016-2017 American College of Surgeons National Surgical Quality Improvement Program database.
• Included cases with International Classification of Diseases, Tenth Revision codes S72.001A through S72.035A and CPT codes 27125 or 27236.
• Calculated reimbursement per case using Centers for Medicare and Medicaid Services reported RVU conversion factor ($36.0896 per 1 RVU).

Main Results:

• Analyzed 12,287 National Surgical Quality Improvement Program cases.
• Identified 4,185 cases (34%) of hip fracture hemiarthroplasty incorrectly coded as CPT 27125.
• Found that incorrect coding resulted in a reimbursement decrease of $35.01 per case (5.51% difference).

Conclusions:

• Accurate CPT coding is crucial as the healthcare reimbursement model relies on it for determining Relative Value Units (RVUs).
• Correctly coding hemiarthroplasty procedures for hip fractures is a simple yet critical fix.
• Emphasizes the need for increased attention to coding practices within orthopedic surgery to ensure appropriate financial compensation.