Session VIII - Polytrauma

The Accuracy of Multiple-Procedure Reimbursement in Orthopaedic Trauma

William R. Creevy, MD; Paul Tornetta, III, MD; Scott Dhupar, MD, Boston University Medical Center, Boston, MA

Introduction: The health care delivery system in the United States is being challenged to control the cost of medical care; an increasingly common method for doing so is to reduce payments to hospitals and physicians. This unfavorable trend is a particular concern for physicians providing care to trauma patients. Adequate reimbursement from insured patients is often necessary to subsidize the charity care provided to patients who are uninsured. Moreover, clinical revenue is an increasingly important source of financing for educational and research activities. Orthopaedic trauma surgeons frequently provide surgical services that involve multiple procedures during the same operation. Management of isolated or combined injuries may also entail several subsequent procedures in the postoperative period after the initial operation. Reimbursement in this situation is complicated and involves the application of variable discounts to contractual rates based upon complex formulas.

Purpose: The purpose of this study was to evaluate the accuracy of third-party reimbursement for orthopaedic trauma when multiple surgical procedures were performed, either during a single operative session or during subsequent sessions in the operating room.

Methods: The clinical and billing data for 200 consecutive operations performed by two attending orthopaedic trauma surgeons at an urban academic level-1 trauma center during the period from July 1998 to June 2000 were retrospectively reviewed. All operative sessions involved three or more separate and distinct surgical procedures for which unique common procedure terminology (CPT) codes were used. HCFA-1500 billing forms and explanation of benefit forms (payment) were obtained for all claims in which at least one payment had been made. The actual payment for each procedure was compared to the expected payment based upon the contracted fee schedule. Payor-specific discounts for multiple procedures and/or subsequent sessions performed after the initial surgery were applied. All cases had been coded by the attending surgeon, including CPT codes, ICD-9 diagnosis codes, and the appropriate modifiers. Prior to submission, a certified coding and reimbursement specialist reviewed this information, and corrections or additions were made with the surgeon's approval.

Results: The 200 operative sessions included 721 distinct procedures for which individual CPT codes were used. In total, only 68% of the claims were initially paid correctly; the payment was less than expected for 29%, and was more than expected for 3%.

Discussion: Reimbursement for surgical procedures in orthopaedic trauma is a complex financial transaction that requires careful attention to detail in order to obtain the maximum expected revenue. Payment for these procedures is often incorrect and usually less than what should have been paid based upon contractual agreements. Despite accurate coding and claims submission, underpayment is common. Orthopaedic trauma surgeons and their billing staff need to become more knowledgeable regarding this subject.

Conclusion: Although accurate coding by the surgeon is important, this alone is not sufficient to insure correct payment. An organized method is necessary that allows for timely analysis of payments for individual procedures.