Getting paid less for more: shoulder arthroplasty incidence and reimbursement within Medicare from 2000 to 2019

Rate of reimbursement for 22-modifier in shoulder surgery

Background

The 22-modifier is a reimbursement amendment designed by the Current Procedural Terminology (CPT) to reflect increased case complexity. When a CPT code is shared between more than 1 procedure or is used to capture a breadth of procedures, a 22-modifier can be used to acknowledge the increased workload in a particular procedure when compared to the standard procedure. We hypothesize that discrepancies exist among 22-modifier reimbursement rates in shoulder surgery, and that payers, particularly commercial, are reimbursing at lower rates for extensive surgical efforts. Identifying potential reimbursement shortcomings can open dialog between payers and surgeons to ensure transparency and fairness.

Methods

22-modifier amendments for total shoulder arthroplasty (TSA) (CPT code 23472), revision of TSA (23474), and arthroscopic rotator cuff repair (29827) occurring from October 31, 2018 to March 23, 2022 were queried, resulting in 566 instances from 11 surgeons at a single site. Financial data were collected from the billing department, while patient demographics and operative reports were collected from medical records. The billing staff requested reimbursement identically on all claims, excluding 1 surgeon, who also sent a reimbursement cover sheet detailing case complexity. Request for reimbursement was submitted for some cases without an operative report. Complexity justifications included obesity (body mass index >30 or >35), reverse TSA, revision procedures, massive repair, surgeon-determined prolonged length of procedure, no justification for 22-modifier listed, and undiagnosed hypertension which created a medical emergency.

Results

In total, 150 (26.5%) of 22-modifier cases were successfully reimbursed. TSA, revision of TSA, and arthroscopic rotator cuff repair had a reimbursement rate of 40.7%, 35.3%, and 13.0%, respectively. Of successful claims, Medicare reimbursed 75.3% and commercial only 26.7%. The highest rates of reimbursement justifications were length of procedure (41.7%), reverse shoulder arthroplasty (40.6%), and revision procedure (32.4%). The surgeon who included the cover sheet was successfully reimbursed (41.6%) more frequently than 2 surgeons with similar case volume (18.3% and 19.5%).

Conclusion

Criteria for successful reimbursement of the 22-modifier are ambiguous, complicating reimbursement efforts. Clinicians should consider concentrating efforts on obtaining 22-modifier reimbursement from Medicare in cases with increased length of procedure, as well as revision procedures and reverse shoulder arthroplasties. Surgeons may receive higher reimbursement rates with the addition of a cover sheet detailing the complexity of the procedure and any associated increases in complication rates or costs. Clarification from insurance carriers is needed to determine what constitutes a 22-modifier.

Disparate financial incentives for hospitals and surgeons to perform total shoulder arthroplasty in higher-risk patients

BACKGROUND

Despite heightened focus on delivering high-value, cost-conscious healthcare, existing reimbursement practices differ for hospital systems and surgeons. This study aimed to investigate the relationship between patient risk and reimbursement for hospitals and surgeons among US Medicare patients undergoing primary total shoulder arthroplasty (TSA).

METHODS

A retrospective analysis of clinical and financial data was performed using the publicly available "2022 Medicare Physician and Other Practitioner" and "2022 Medicare Inpatient Hospitals" files. Patients were dichotomized into a sicker cohort, defined as a Hierarchical Condition Category (HCC) risk score of 1.5 or greater, and a healthier cohort with HCC risk scores less than 1.5. Surgeon and hospital reimbursement data were collected and compared across patient cohorts.

RESULTS

In 2022, 79,668 TSA procedures were billed to US Medicare, with an overall mean surgeon reimbursement of $798.04. Among these patients, 1065 had an HCC risk score greater than 1.5 and were categorized as high-risk, while the remaining 78,603 patients had lower scores and were categorized as standard-risk. Mean surgeon reimbursement for the high-risk cohort trended to be less than the standard-risk cohort ($787.78 vs. $798.19). Among patients in the high-risk cohort, HCC risk score had a significant negative effect on mean surgeon reimbursement (P < .001). Among 16,734 Medicare patients who were admitted as inpatients for primary shoulder arthroplasty in 2022, the mean hospital reimbursement was $18,586.60. In contrast to surgeon reimbursement, hospital reimbursement was significantly greater for the high-risk cohort, with a mean payment of $19,063.27 compared to $15,239.36 for the standard-risk cohort (P < .001).

CONCLUSIONS

Although US hospital reimbursement for TSA increased among higher-risk patients with greater medical comorbidities, surgeon reimbursement among higher-risk patients was relatively unchanged, with a trend toward a small decrease. Such a discrepancy may create disparate incentives for hospitals and surgeons to take on extra risk in caring for complex patients. These data may inform future healthcare policies that promote continued access to shoulder arthroplasty care among higher-risk patients.

Utilization trends of the ExactechGPS® computer-assisted navigation system in total shoulder arthroplasty

BACKGROUND

Guidance technology in total joint arthroplasty has gained popularity over the last few decades. Computer-assisted navigation (CAN) was recently introduced for glenoid implantation in total shoulder arthroplasty (TSA). However, utilization trends of CAN TSA are not currently known. This study aims to determine the prevalence and trends of CAN usage in TSA from its introduction in 2017 until 2023.

METHODS

A retrospective review was performed of all TSAs (anatomic TSA [aTSA] or reverse TSA [rTSA]) implanted using a single computer navigation shoulder system (ExactechGPS®; Gainesville, FL). Intraoperative navigation was performed for the glenoid component only. Use of CAN was reported per year to determine trends in the prevalence of CAN cases, number of users, new users, dropped users, high-volume users (>50 CAN cases/year), and the number of cases completed by high-volume users. The data were also stratified by type of TSA (aTSA vs. rTSA) and type of glenoid component used (augmented or nonaugmented).

RESULTS

From 2017 to 2023, navigated TSAs increased from 654 to 9777 cases per year, with a greater increase in navigated rTSA than aTSA volume. The number of CAN cases using augmented implants grew 1435% whereas nonaugmented implants grew 1352%. By 2023, the overall number of CAN users increased from 79 to 667 users. High-volume CAN surgeons increased to 50 users by 2023. Over this period, the number of CAN TSA performed by high-volume surgeons increased more rapidly than the actual number of high-volume surgeons per year.

CONCLUSIONS

This study demonstrates an exponential increase in the use of CAN for TSA in the last 8 years. This increase is driven by progressive growth in both the volume of new users and CAN TSAs performed by existing users by several hundred folds. These upward trends in use of guidance technology for TSA are likely to continue in future.

Health Policy Challenges and Reforms: Critical Updates for Orthopaedic Surgeons

» Medicare reimbursement: Physician payments have declined 29% since 2001, straining practice sustainability. Proposed legislation (H.R. 2474) could align payments with inflation, although concerns persist about its fiscal impact on Medicare.» Medicare advantage: These plans provide benefits such as cost caps and premium-free options for patients, but increase administrative burdens, delay care, and restrict provider networks for physicians.» Prior authorization: Intended to ensure appropriate care and control costs, prior authorization frequently delays treatment, raises administrative workloads, and contributes to physician burnout. Proposed reforms aim to balance efficiency and oversight.» Noncompete clauses: Advocates argue noncompete clauses protect healthcare investments, but critics highlight their role in limiting physician mobility, disrupting patient care, and reducing competition. Legal challenges to a federal ban add uncertainty.» Physician-owned hospitals: Supporters emphasize physician-owned hospitals' high-quality care and competitive benefits, whereas detractors warn of risks such as conflicts of interest, inequities in patient access, and strain on community hospitals.» Advancing nonopioid pain management: Nonopioid strategies reduce dependency risks and improve recovery but may require additional resources and upfront costs. Policies such as the Non-Opioids Prevent Addiction in the Nation Act aim to incentivize their use.

Delayed elective total shoulder arthroplasty: causes and eventual outcomes

PURPOSE

The purpose of this study is to identify risk factors for delays in planned total shoulder arthroplasty (TSA) and determine the perioperative outcomes of TSAs that experienced a delay.

METHODS

The American College of Surgeons National Quality Improvement Program (NSQIP) database was queried from 2006 to 2019 for primary TSA. Delayed TSA was defined as surgery that occurred greater than one day after hospital admission. Patient demographics, comorbidities, and post-operative complications were collected and compared; the incidence of delayed TSA was analyzed.

RESULTS

The delayed patients were older, had a higher BMI, a higher rate of recent prior major surgery, and more comorbidities. Delayed patients had higher rates of postoperative complications, return to the OR, and 30-day readmission. Between 2006 and 2019, the rate of delayed TSA decreased.

CONCLUSION

Surgeons should take care to ensure that patients with comorbidities undergo thorough preoperative clearance to prevent same-day cancellations and postoperative complications.

Do preoperative scapular fractures affect long-term outcomes after reverse shoulder arthroplasty?

BACKGROUND

Postoperative scapular stress fractures (SSFs) are a formidable problem after reverse shoulder arthroplasty (RSA). Less is known about patients who have these fractures preoperatively. The primary aim of this study was to examine postoperative satisfaction in patients undergoing primary RSA who have preoperative SSF and compared to a matched cohort without preoperative fracture. The secondary aim was to examine the differences in patient-reported outcomes between and within study cohorts.

METHODS

A retrospective chart review of primary RSAs performed by a single surgeon from 2000 to 2020 was conducted. Patients diagnosed with cuff tear arthropathy (CTA), massive cuff tear (MCT), or rheumatoid arthritis (RA) were included. Five hundred twenty-five shoulders met inclusion criteria. Fractures identified on preoperative computed tomography scans were divided into 3 groups: (1) os acromiale, (2) multifragments (MFs), and (3) Levy types. Seventy-two shoulders had an occurrence of SSF. The remaining 453 shoulders were separated into a nonfractured cohort. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and visual analog scale (VAS) scores were compared pre- and postoperatively in the total fracture group and the nonfractured group cohort. The multifragment subgroup was also compared to the pooled Os/Levy subgroup.

RESULTS

The total incidence of SSF in all shoulders was 13.7%. There was a difference in satisfaction scores at all time points between the nonfracture (7.9 ± 2.8) and total fracture group (5.4 ± 3.6, P < .001, at last visit). There was also a greater ASES total score in the nonfractured group vs the total fracture group at the final visit (69.4 ± 23.4 and 62.1 ± 24.2; P = .02). The MF group had worse ASES functional or VAS functional scores than the Os/Levy group at all time points: at 1 year, ASES function: MF 24.2 ± 14.5 and Os/Levy 30.7 ± 14.2 (P = .045); at 2 years, ASES function: MF 21.4 ± 14.4 and Os/Levy 35.5 ± 10.6 (P < .001); and at last follow-up, VAS function: MF 4.8 ± 2.8 and Os/Levy 6.4 ± 3.2 (P = .023).

DISCUSSION

Scapular fractures were proportionally most common in patients diagnosed with CTA (16.3%) compared with a 9.2% and 8.6% incidence in patients diagnosed with MCT and RA, respectively. Patients with preoperative SSF still see an improvement in ASES scores after RSA but do have lower satisfaction scores compared with the nonfractured cohort. The multifragment fracture group has lower functional and satisfaction scores at all postoperative time points compared with both the nonfracture and the Os/Levy fracture group.

Patient-related risk factors for early unplanned reoperation following revision total shoulder arthroplasty

Purpose

There has been an increase in the number of total shoulder arthroplasty (TSA) revisions performed as the number of primary surgeries increases rapidly. Revision procedures have a higher failure rate and there is a lack of understanding of patient risk factors for needing another repeat surgery following revision TSA.

Methods

Revision patients were separated into two cohorts: those needing an unplanned reoperation and those that did not within 30 days following revision TSA. Multivariate logistic regression was performed to identify independent risk factors for an unplanned reoperation.

Results

1909 revision TSA patients were included in the final analysis. Sixty-nine of these patients underwent an unplanned reoperation within 30 days and 1840 did not. Multivariate logistic regression analyses found an ASA class of III or IV, male sex, congestive heart failure, and inpatient setting to be independent risk factors.

Conclusion

3.6% of revision TSA patients require an unplanned reoperation within 30 days postoperatively. An ASA class of III or IV, male sex, congestive heart failure, and inpatient setting were found to be independent risk factors for early reoperation. Surgeons should be aware of these risks to improve preoperative patient optimization and guide shared decision making with patients considering revision.

Treatment of Glenoid Wear with the Use of Augmented Glenoid Components in Total Shoulder Arthroplasty: A Scoping Review

» Treatment of glenoid bone loss continues to be a challenge in total shoulder arthroplasty (TSA). Although correcting glenoid wear to patient's native anatomy is desirable in TSA, there is lack of consensus regarding how much glenoid wear correction is acceptable and necessary in both anatomic and reverse TSA.» Use of augmented glenoid components is a relatively new treatment strategy for addressing moderate-to-severe glenoid wear in TSA. Augmented glenoid components allow for predictable and easy correction of glenoid wear in the coronal and/or axial planes while at the same time maximizing implant seating, improving rotator cuff biomechanics, and preserving glenoid bone stock because of off-axis glenoid reaming.» Augmented glenoid components have distinct advantages over glenoid bone grafting. Glenoid bone grafting is technically demanding, adds to the surgical time, and carries a risk of nonunion and graft resorption with subsequent failure of the glenoid component.» The use of augmented glenoid components in TSA is steadily increasing with easy availability of computed tomography-based preoperative planning software and guidance technology (patient-specific instrumentation and computer navigation).» Although different augment designs (full wedge, half wedge, and step cut) are available and a particular design may provide advantages in specific glenoid wear patterns to minimize bone removal (i.e. a half wedge in B2 glenoids), there is no evidence to demonstrate the superiority of 1 design over others.

Increased preoperative aspartate aminotransferase-to-platelet ratio index predicts complications following total shoulder arthroplasty

Background

This study investigates the association between aspartate aminotransferase-to-platelet ratio index (APRI), a noninvasive measure of liver function, and 30-day postoperative complications following total shoulder arthroplasty (TSA).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2021. The study population was divided into 4 groups based on preoperative APRI: normal/reference (APRI ≤ 0.5), mild fibrosis (0.5 < APRI ≤ 0.7), significant fibrosis (0.7 < APRI ≤ 1), and cirrhosis (APRI > 1). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative APRI and postoperative complications.

Results

Compared to the reference group, significant fibrosis was independently associated with a greater likelihood of major complications (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.11-2.99; P = .017), minor complications (OR: 2.70, 95% CI: 1.67-4.37; P < .001), pneumonia (OR: 5.78, 95% CI: 2.58-12.95; P < .001), blood transfusions (OR: 2.89, 95% CI: 1.57-5.32; P < .001), readmission (OR: 1.88, 95% CI: 1.10-3.21; P = .022), and non-home discharge (OR: 1.83, 95% CI: 1.23-2.73; P = .003). Cirrhosis was independently associated with a greater likelihood of minor complications (OR: 3.96, 95% CI: 2.67-5.88; P < .001), blood transfusions (OR: 5.85, 95% CI: 3.79-9.03; P < .001), failure to wean off a ventilator (OR: 9.10, 95% CI: 1.98-41.82; P = .005), and non-home discharge (OR: 2.06, 95% CI: 1.43-2.96; P < .001).

Conclusion

Increasing preoperative APRI was associated with an increasing rate of postoperative complications following TSA.

Prediction of total healthcare cost following total shoulder arthroplasty utilizing machine learning

BACKGROUND

Given the increase in demand in treatment of glenohumeral arthritis with anatomic total (aTSA) and reverse shoulder arthroplasty (RTSA), it is imperative to improve quality of patient care while controlling costs as private and federal insurers continue its gradual transition toward bundled payment models. Big data analytics with machine learning shows promise in predicting health care costs. This is significant as cost prediction may help control cost by enabling health care systems to appropriately allocate resources that help mitigate the cause of increased cost.

METHODS

The Nationwide Readmissions Database (NRD) was accessed in 2018. The database was queried for all primary aTSA and RTSA by International Classification of Diseases, Tenth Revision (ICD-10) procedure codes: 0RRJ0JZ and 0RRK0JZ for aTSA and 0RRK00Z and 0RRJ00Z for RTSA. Procedures were categorized by diagnoses: osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN), fracture, and rotator cuff arthropathy (RCA). Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics were included, such as volume of procedures performed by the respective hospital for the calendar year and wage index, which represents the relative average hospital wage for the respective geographic area. Unplanned readmissions within 90 days were calculated using unique patient identifiers, and cost of readmissions was added to the total admission cost to represent the short-term perioperative health care cost. Machine learning algorithms were used to predict patients with immediate postoperative admission costs greater than 1 standard deviation from the mean, and readmissions.

RESULTS

A total of 49,354 patients were isolated for analysis, with an average patient age of 69.9 ± 9.6 years. The average perioperative cost of care was $18,843 ± $10,165. In total, there were 4279 all-cause readmissions, resulting in an average cost of $13,871.00 ± $14,301.06 per readmission. Wage index, hospital volume, patient age, readmissions, and diagnosis-related group severity were the factors most correlated with the total cost of care. The logistic regression and random forest algorithms were equivalent in predicting the total cost of care (area under the receiver operating characteristic curve = 0.83).

CONCLUSION

After shoulder arthroplasty, there is significant variability in cumulative hospital costs, and this is largely affected by readmissions. Hospital characteristics, such as geographic area and volume, are key determinants of overall health care cost. When accounting for this, machine learning algorithms may predict cases with high likelihood of increased resource utilization and/or readmission.