Reimbursement for Hip Fractures: The Impact of Varied CPT Coding Using RVUs

Abstract Background Many orthopedic practices routinely code hip fracture hemiarthroplasty as Current Procedural Terminology (CPT) 27125 even though 27236 is the correct CPT code. Our objective is to determine the financial impact this simple mistake has on surgeon reimbursement. Methods Our data comprised cases assigned ICD-10 code S72.001A thru S72.035A and CPT codes 27125 or 27236 within the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2016-2017 database. Relative Value Units (RVU) per CPT code and the Centers for Medicare and Medicaid Services reported RVU conversion factor of $36.0896 per 1 RVU was used to calculate reimbursement per case. The dollar difference and percent difference per case was then calculated between cases assigned CPT code 27125 and those assigned 27236. Results Our total sample consisted of 12,287 NSQIP cases. Of those, 4,185 (34%) were cases of a hip fracture treated with hemiarthroplasty that were incorrectly coded as CPT code 27125. That error in coding results in a decrease in reimbursement of $35.01 per case, a 5.51% difference. Conclusion Since the current healthcare reimbursement model relies solely on CPT codes to determine RVUs, it is imperative that orthopedic surgeons understand the financial impact of incorrect coding. Although correct coding of hemiarthroplasty procedures for hip fractures is an easy task to fix in the future, we hope that through this study a greater emphasis is placed on coding in orthopedic surgery.