Are Foot & Ankle Surgeons Being Adequately Compensated for Ankle Fractures? - An Analysis of Relative Value Units

The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons - National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.