Modifier 22 Use in Fee-for-Service Medicare.

Importance: Modifier 22 is a mechanism designed for surgeons to identify cases that are more complex than their Current Procedural Terminology code accounts for. However, empirical studies of the use and efficacy of modifier 22 are lacking. Objective: To assess the use of modifier 22 in common surgical procedures and the association of use with compensation. Design, Setting, and Participants: This was a cross-sectional analysis of the 2021 Physician/Supplier Procedure Summary Limited Data Set including all Part B carrier and durable medical equipment fee-for-service claims. Claims for 10 common surgical procedures were evaluated, including mastectomy, total hip arthroplasty, total knee arthroplasty, coronary artery bypass grafting, laparoscopic right colectomy, laparoscopic appendectomy, laparoscopic cholecystectomy, kidney transplant, laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy, and lumbar laminectomy. Data were analyzed from August to November 2023. Main Outcomes and Measures: Rate of modifier 22 use, rate of claim denial, mean charges, mean payment for accepted claims, and mean payment for all claims. Results: The sample included 625 316 surgical procedures performed in calendar year 2021. The proportion of modifier 22 coding for a procedure ranged from 5725 of 251 521 (2.3%) in total knee arthroplasty to 1566 of 18 459 (8.5%) in laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy. Submitted charges were 11.1% (95% CI, 9.1-13.2) to 22.8% (95% CI, 21.3-24.3) higher for claims with modifier 22, depending on the procedure. Among accepted claims, those with modifier 22 had increased payments ranging from 0.8% (95% CI, 0.7-1.0) to 4.8% (95% CI, 4.5-5.1). However, claims with modifier 22 were more likely to be denied (7.4% vs 4.0%; P < .001). As a result, overall mean payments were mixed, with 4 procedures having lower payments when modifier 22 was appended, 4 procedures having higher payments with modifier 22, and 2 procedures with no difference. The largest increase in mean payment for modifier 22 claims was for kidney transplant with an increased payment of $71.46 (95% CI, 55.32-87.60), which translates to a relative increase of 3.4% (95% CI, 2.9-4.6). Conclusions and Relevance: The findings in this study suggest that modifier 22 had little to no financial benefit when appended to claims for a diverse panel of surgical procedures. In the current system, surgeons have little reason to request modifier 22, and no mechanisms currently exist for surgeons to recoup payment for difficult operations.

Insurance Disparities in Access to Robotic Surgery for Colorectal Cancer.

BACKGROUND: The use of the robotic approach is increasing for colorectal cancer operations, but the added cost of the platform has the potential to introduce challenges in its dissemination. We hypothesized that adoption of the robot is introducing new disparities in access to minimally invasive surgery (MIS) for colorectal cancer, especially across patient insurance groups. METHODS: This cross-sectional study analyzed surgical cases of stage I-III colorectal cancer from the National Cancer Database (NCDB) between 2010 and 2019. The primary outcome was surgical approach (robotic, laparoscopic, or the composite "MIS"). The predictor was a patient's primary payor. Potential confounders included sociodemographics, tumor characteristics, and the facility. Hierarchical multivariable models were generated, and sensitivity analyses were performed. RESULTS: For colorectal cancer operations, the MIS approach increased from 39% in 2010 to 73% in 2019, driven predominantly by an increase in the robotic approach from 2 to 24%. For laparoscopy, the size of the disparity between patients with Private insurance and Medicaid shrank from 11% (2010) to 4% (2019), whereas this disparity increased for the robotic approach from 1% (2010) to 5% (2019). On adjusted analysis, patients with Medicaid (odds ratio [OR] 0.86 [CI 0.79-0.95]) and the Uninsured (OR 0.67 [CI 0.56-0.79]) had lower odds of receiving a robotic operation than those with Private insurance in 2019. This disparity remained consistent across five sensitivity analyses. CONCLUSIONS: As the field of colorectal cancer surgery shifts away from laparoscopy and toward robotics, new inequities across patient insurance are emerging. Proactive efforts are needed to ensure all patients benefit from a minimally invasive approach.

Compliance of National Cancer Institute-Designated Cancer Centers With January 2021 Price Transparency Requirements.

This cross-sectional study investigates the compliance rate of hospitals with National Cancer Institute­designated cancer center status with the Centers for Medicare & Medicaid Services January 2021 price transparency requirements.

Clinical outcomes and cost of robotic ventral hernia repair: systematic review.

BACKGROUND: Robotic ventral hernia repair (VHR) has seen rapid adoption, but with limited data assessing clinical outcome or cost. This systematic review compared robotic VHR with laparoscopic and open approaches. METHODS: This systematic review was undertaken in accordance with PRISMA guidelines. PubMed, MEDLINE, Embase, and Cochrane databases were searched for articles with terms relating to 'robot-assisted', 'cost effectiveness', and 'ventral hernia' or 'incisional hernia' from 1 January 2010 to 10 November 2020. Intraoperative and postoperative outcomes, pain, recurrence, and cost data were extracted for narrative analysis. RESULTS: Of 25 studies that met the inclusion criteria, three were RCTs and 22 observational studies. Robotic VHR was associated with a longer duration of operation than open and laparoscopic repairs, but with fewer transfusions, shorter hospital stay, and lower complication rates than open repair. Robotic VHR was more expensive than laparoscopic repair, but not significantly different from open surgery in terms of cost. There were no significant differences in rates of intraoperative complication, conversion to open surgery, surgical-site infection, readmission, mortality, pain, or recurrence between the three approaches. CONCLUSION: Robotic VHR was associated with a longer duration of operation, fewer transfusions, a shorter hospital stay, and fewer complications compared with open surgery. Robotic VHR had higher costs and a longer operating time than laparoscopic repair. Randomized or matched data with standardized reporting, long-term outcomes, and cost-effectiveness analyses are still required to weigh the clinical benefits against the cost of robotic VHR.

Underrepresentation of pediatric operations in the relative value unit updating process.

BACKGROUND: The Relative Value Unit (RVU) system was designed and implemented by Medicare to standardize physician payments for a given service. Because Medicare primarily cares for older adults, RVU assignments and updates may not consider pediatric-specific procedures, despite the fact that private insurers and Medicaid often base their payments on these RVU valuations. METHODS: The CPT codes of index pediatric operations were retrieved from the ACGME. We categorized these procedures into "Peds-specific" (eg, Ladd Procedure) versus those that could be performed in both children and adults, or "Non-specific" (eg, fundoplication). We merged these codes with RVU information from publicly available CMS files and the Resource-based Relative Value Scale Data Manager. Variables included were the date of last RVU update and the vignette used by survey respondents when asked to update the RVU valuation. RESULTS: Among 85 procedures, nearly three-quarters were Peds-specific (74%), with the remainder Non-specific. Approximately half of the 85 procedures (52%) had never been updated. Compared to Non-specific CPT codes, Peds-specific CPT codes were less likely to have been updated (38% vs. 91%, p < 0.001) and, among those that were updated, were updated more remotely (median year 2000 vs. 2005, p = 0.02). Among updated Non-specific CPT codes, the vignette written to justify the valuation was based on an adult patient in 85% of cases. CONCLUSIONS: Peds-specific surgical CPT codes have either never been updated or have not been updated in decades. Procedures performed in both children and adults have been updated more often and more recently, but the vignette on which this valuation is based on is typically an adult patient. In order to remain relevant and reimburse pediatric surgeons accurately, the RVUs for pediatric procedures need to also be prioritized for revision and updating.

Inaccuracies in Postoperative Inpatient Stays Assumed in the Valuation of Surgical RVUs.

OBJECTIVE: The aim of this study was to assess the accuracy of inpatient postoperative visits assumed in the valuation of surgical relative value units (RVUs). SUMMARY BACKGROUND DATA: Medicare reimburses physicians based on the number of RVUs assigned to a service. For surgical procedures with a 10- or 90-day global period, the RVU valuation is based, in part, on a presumed number of inpatient postoperative visits whether or not those visits occur. The Centers for Medicare and Medicaid Services (CMS) have recently proposed changing all surgical procedures to a 0-day global period. METHODS: We combined 2017 National Surgical Quality Improvement (NSQIP) data with physician time and RVU files from CMS. We then compared the number of inpatient postoperative visits assumed in the valuation to actual length of stay (LOS) information from the surgical registry. RESULTS: The analysis included 10 specialties and 601 distinct current procedural terminology codes. The number of patient observations underlying NSQIP LOS estimates ranged from 50 to 57,904. Eighty-three percent of procedures had median NSQIP LOS values that were shorter than the values assumed in the global period. These differences varied by specialty, with the largest discrepancy in neurosurgery. Procedures in this sample were last reviewed, on average, in 2000, with procedures reviewed more recently having more accurate valuations with respect to LOS. CONCLUSIONS: The number of postoperative visits assumed in the valuation of surgical RVUs is grossly inaccurate. Holding all else equal, removing global periods from surgical RVUs would dramatically reduce surgeon compensation.

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures.

OBJECTIVE: The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures. SUMMARY BACKGROUND DATA: Reducing surgical costs is paramount to the viability of hospitals. METHODS: Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons. RESULTS: The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy. CONCLUSIONS: Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

Cost Saving of Short Hospitalization Nonoperative Management for Acute Uncomplicated Appendicitis.

BACKGROUND: Nonoperative management (NOM) of uncomplicated appendicitis has gained recognition as an alternative to surgery. In the largest published randomized trial (Appendicitis Acuta), patients received a 3-d hospital stay for intravenous antibiotics; however, cost implications for health care systems remain unknown. We hypothesized short stay protocols would be cost saving compared with a long stay protocol. MATERIALS AND METHODS: We constructed a Markov model comparing the cost of three protocols for NOM of acute uncomplicated appendicitis: (1) long stay (3-d hospitalization), (2) short stay (1-d hospitalization), and (3) emergency department (ED) discharge. The long stay protocol was modeled on data from the APPAC trial. Model variables were abstracted from national database and literature review. One-way and two-way sensitivity analyses were performed to determine the impact of uncertainty on the model. RESULTS: The long stay treatment protocol had a total 5-y projected cost of $10,735 per patient. The short stay treatment protocol costs $8026 per patient, and the ED discharge protocol costs $6,825, which was $2709 and $3910 less than the long stay protocol, respectively. One-way sensitivity analysis demonstrated that the relative risk of treatment failure with the short stay protocol needed to exceed 6.3 (absolute risk increase of 31%) and with the ED discharge protocol needed to exceed 8.75 (absolute risk increase of 45%) in order for the long stay protocol to become cost saving. CONCLUSIONS: Short duration hospitalization protocols to treat appendicitis nonoperatively with antibiotics are cost saving under almost all model scenarios. Future consideration of patient preferences and health-related quality of life will need to be made to determine if short stay treatment protocols are cost-effective.

Assessment of the Contribution of the Work Relative Value Unit Scale to Differences in Physician Compensation Across Medical and Surgical Specialties.

Importance: The work relative value units (wRVUs) for a physician service can be conceptualized as the amount of time spent by the physician multiplied by a compensation rate (wRVUs/min). Disproportionately high compensation rates assigned to procedures have been blamed for pay differences across specialties, but to our knowledge, a comprehensive assessment is lacking. Objective: To assess how compensation rates built into work RVUs contribute to differences in physician compensation across specialties. Design, Setting, and Participants: This cross-sectional analysis examined 2017 Part B fee-for-service Medicare data. The data were analyzed from May 1 to May 30, 2019. Main Outcomes and Measures: A specialty-wide compensation rate (wRVUs/min) was generated for 42 medical and surgical specialties defined as the sum of wRVUs for all billed current procedural terminology codes divided by the presumed time to perform those services. This measure accounted for the volume and diversity of services each specialty provides. Sensitivity analyses were performed to assess the association of errors in wRVU time estimates with average compensation rates. Results: The final sample included 42 specialties and 6587 distinct Current Procedual Terminology (CPT) codes. The number of CPT codes attributed to a specialty ranged from 575 (medical oncology) to 4346 (general surgery). Compensation rates ranged from 0.029 wRVUs/min (pathology) to 0.057 wRVUs/min (emergency medicine). Most specialties (34/42 [81.0%]) had compensation rates between 0.035 and 0.045 wRVUs/min. The mean compensation rate for surgical specialties was 7.2% higher than for medical specialties, a difference that was not statistically significant. This narrow range reflects the fact that most specialties had more than 60% of time allocated to activities outside the intraservice period. Assuming that time values for surgical procedures are significantly overestimated increased the difference in average compensation between surgical and medical specialties to 23.4%. Conclusions and Relevance: Compensation rates assumed in wRVU valuations are small contributors to differences in physician compensation. Factors outside of the wRVU system, such as payer mix and work hours, could be targeted if narrowing the difference in compensation across specialties is desired.

All-payer Spending on Common Hospital-based Services in California.

BACKGROUND: Hospital-based care accounts for one third of US health spending or over $1 trillion annually, yet a detailed all-payer assessment of what services contribute to this spending is not available. STUDY DESIGN: Cross-sectional and longitudinal evaluation of hospital financial statements from acute-care general hospitals in California between fiscal years 2007 and 2016. The amounts spent on 41 different revenue centers were included. The primary outcome was state-level and hospital-level spending for each revenue center including decomposing growth trends into changes in volume and prices. RESULTS: The analysis included 2941 annual financial statements from 331 hospitals. Between 2007 and 2016, total spending across all centers increased 66.6% from $43.7B to $72.9B. Five centers-surgery and recovery, drugs sold to patients, acute medical/surgical floor, the clinical laboratory, and emergency services-accounted for over 50% of total spending in 2016. Overall spending growths ranged from 1.1%/y (acute pediatrics) to 17.9%/y (observation). Other revenue centers with large increases in spending included emergency services (164.7%), clinics (on-site 114.5%, satellite 129.7%), anesthesia (119.6%), echocardiography (114.4%), and computed tomography (100.8%). Most services had volume growths within ±2%/y, although there were exceptions (eg, observation hours increased 10.0%/y). Prices grew fastest for echocardiograms (10.5%/y), cardiac catheterization (9.7%/y), therapeutic radiology (8.0%/y), and emergency visits (7.5%/y). In general, median prices for services in 2016 were larger than Medicare allowed amounts. CONCLUSIONS: Overall hospital-based spending increased 66.6% between 2007 and 2016 in California, but there was wide variation in spending growth across revenue centers. Understanding this variation-including the relative contributions of volumes and prices-can guide efforts to curb excessive health care spending and optimize resource dedication to current and future patient care needs.

Differences in Outcomes Based on Sex for Pediatric Patients Undergoing Pyloromyotomy.

BACKGROUND: Males and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy. MATERIALS AND METHODS: Using the Kids' Inpatient Database for the years 2003-2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged <1 y who underwent pyloromyotomy for hypertrophic pyloric stenosis. The primary predictor of interest was sex. Outcomes included mortality, in-hospital complications, cost, and length of stay. Regression models were adjusted by race, age group, comorbidity, complications, and whether operation was performed on the day of admission with region and year fixed effects. RESULTS: Of 48,834 weighted operations, 81.8% were in males and 18.2% were in females. The most common reported race was white (47.3%) and most of the patients were ≥29 days old (72.5%). There was no difference in the odds of postoperative complications, but females had a significantly longer length of stay (incidence rate ratio, 1.28; 95% confidence interval [95% CI], 1.18-1.39; P ≤ 0.01), higher cost (5%, 95% CI, 1.02-1.08; P ≤ 0.01), and higher odds of mortality (odds ratio, 3.26; 95% CI, 1.52-6.98; P ≤ 0.01). CONCLUSIONS: Our study demonstrated that females had worse outcomes after pyloromyotomy compared with males. These findings are striking and are important to consider when treating either sex to help set physician and family expectations perioperatively. Further studies are needed to determine why such differences exist and to develop targeted treatment strategies for both females and males with pyloric stenosis.

Association of implicit intensity values incorporated into work RVUs with objective measures.

BACKGROUND: The "intensity" of a surgical procedure is supposed to be incorporated into work RVUs to allow higher compensation rates for more complex procedures. However, updates to work RVUs are subjective and it is unclear if these intensity values correlate to objective measures of a procedure's complexity. METHODS: Centers for Medicare and Medicaid Services (CMS) data were used to calculate intraservice intensity values for CPT codes in 2017 ("CMS intensity values"). Twenty-six objective measures- spanning patient, case, and risk characteristics - were generated using the 2017 participant use file from NSQIP. CMS intensity values were compared to objective measures using scatterplots and correlations. RESULTS: Among 473 CPT codes, CMS intensity values ranged from 0.0031 to 0.142 work RVUs/minute. CMS intensity values were positively associated with 3 objective measures, negatively associated with 5 measures, and not associated with the remaining 18 measures. CONCLUSIONS: Despite intensity values - and therefore compensation rates - varying over 40-fold in the wRVU scale, there was generally no association between their magnitude and objective measures of surgical intensity.

Surgeon work captured by the National Surgical Quality Improvement Program across specialties.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) database is increasingly used for surgical research. However, it is unclear how well this database represents the breadth of work performed by different specialties. METHODS: Using the 2017 NSQIP participant use file and the 2017 Medicare Physician/Supplier Procedure Summary file, we evaluated (1) what proportion of surgical work is captured by NSQIP, (2) what procedures and disciplines are undersampled, and (3) the overall concordance between the NSQIP sample and a national sample. RESULTS: The NSQIP database reported at least one case for 4,463 out of the 5,272 Current Procedures Terminology codes in the Medicare file, potentially capturing 97.8% of surgical work across all 10 specialties. However, this proportion decreased to 72.1% when only procedures with at least 100 cases in NSQIP were considered. Limiting our analysis to only those procedures with 100 cases had markedly different effects by specialty. In part, this was owing to undersampling of minor procedures, which are more common in disciplines such as otolaryngology and urology. The overall association between the size of the NSQIP sample and the Medicare sample was 0.08. CONCLUSION: Although NSQIP has the potential to capture a diverse surgical caseload, some specialties and procedures are undersampled, limiting the ability for NSQIP to generate valid benchmarks. There was little correlation between the sample sizes in NSQIP and a national sample. Increasing sampling of underrepresented procedures and developing weights to scale NSQIP to a national sample would strengthen the program's ability to inform health outcomes research and provide valid comparisons across procedures and specialties.

A Comparison of Costs: How California Teaching Hospitals Achieved Slower Growth Than Nonteaching Hospitals in Operating Room Costs From 2005 to 2014.

PURPOSE: Historically, teaching hospitals have had higher costs than nonteaching hospitals, introducing potential financial risk in value-based payment models. This study compared risk-adjusted operating room (OR) costs between California teaching and nonteaching hospitals. METHOD: Using 2,992 financial statements from fiscal years (FYs) 2005-2014, the authors extracted data for OR total costs, components of direct costs, and indirect costs. Cross-sectional and longitudinal models estimated OR costs per minute of surgery by teaching status, ownership, case mix index, and geographic area. RESULTS: Risk-adjusted cost was $9.44 per minute less in teaching than nonteaching hospitals in FY 2014 (95% CI, 3.03-15.85, P = .004). Between FY 2005 and FY 2014, OR costs grew more slowly at teaching hospitals because of slower wage growth and indirect costs per minute (-$0.13 and -$0.77 per minute per year, respectively, P = .005 and P < .001). Hourly pay rose more at teaching hospitals ($0.26 per hour per year, P = .008) but was offset by slower full-time equivalents growth (-0.002 per 10,000 OR minutes per year, P = .001). Between FY 2005 and FY 2014, operative volume increased at teaching hospitals and decreased at nonteaching hospitals. CONCLUSIONS: By 2014, California teaching hospitals had lower OR costs per minute than nonteaching hospitals because of relative labor productivity gains and slower indirect cost growth. The latter likely resulted from a volume shift from nonteaching to teaching facilities. These trends will help teaching hospitals compete under value-based models. Implications for patients and nonteaching hospitals warrant evaluation.

Association of Work Measures and Specialty With Assigned Work Relative Value Units Among Surgeons.

Importance: The primary data sources used to generate and update work relative value units (RVUs) are surveys of small groups of specialists who are asked to estimate the time and intensity needed to perform surgical procedures. Because these surveys are conducted by specialty societies and rely on subjective data, these sources have been challenged as potentially biased. Objective: To assess whether objective work measures are associated with a surgical procedure's assigned work RVUs and whether differences exist by surgical specialty. Design, Setting, and Participants: This cross-sectional study obtained data from the 2016 and 2017 participant use files of the American College of Surgeons National Surgical Quality Improvement Program. The 2017 physician fee schedule of the Centers for Medicare & Medicaid Services was a secondary data source. Procedures were included if they had at least 100 patient-level observations over the 2-year period. Data were analyzed from August 29, 2018, to April 2, 2019. Main Outcomes and Measures: The dependent variable was a procedure's assigned work RVU. Independent variables of work RVUs were 4 procedure-level work measures (median operative time, median postoperative length of stay, all-cause 30-day readmission rate, and all-cause 30-day reoperation rate) and surgeon specialty (10-level category using general surgery as the reference). Results: The data set included 628 unique Current Procedural Terminology (CPT) codes and 726 CPT-specialty combinations from 1 239 991 patient observations. Statistically significant associations were found between each work measure and assigned work RVU, as follows: median operative time (R2 = 0.74; 95% CI, 0.71-0.78), postoperative length of stay (R2 = 0.42; 95% CI, 0.36-0.48), rate of readmission (R2 = 0.18; 95% CI, 0.13-0.23), and rate of reoperation (R2 = 0.15; 95% CI, 0.10-0.20). Including all 4 measures explained 80.2% (95% CI, 77.3%-83.1%) of the variation. Adding the surgical specialty improved the overall fit of the model (likelihood ratio test χ2 = 231.27; P < .001). Cardiac (7.78; 95% CI, 4.25-11.31; P < .001) and neurosurgery (2.46; 95% CI, 1.08-3.83; P < .001) had higher work RVUs compared with general surgery, whereas orthopedics (-1.53; 95% CI, -2.48 to -0.59; P = .002), urology (-1.58; 95% CI, -2.88 to -0.29; P = .02), plastics (-2.70; 95% CI, -4.39 to -1.01; P = .002), and otolaryngology (-3.05; 95% CI, -4.69 to -1.42; P < .001) had lower work RVUs compared with general surgery. Conclusions and Relevance: Objective work measures appeared to be associated with assigned work RVUs, predominantly with operative time; registry data can be used to augment and inform the generation and updating processes of the work RVUs.