Presented by: Victoria S. Edmonds MD
Mayo Clinic Arizona

Introduction

Ureteroscopy for stone treatment carries higher risk of complication in comorbid patients. In the United States, hospital and facility payments for stone treatment episodes are now risk-adjusted to account for patient complexity. However, this is not reflected in surgeon payment. We compared surgeon reimbursement among patients with differing risk profiles undergoing ureteroscopy with laser lithotripsy stones.

Materials

The publicly available “2021 Medicare Physician and Other Provider” file was used to collect demographics and comorbidities for the patient panels of US urologists, including mean age and rates of atrial fibrillation (AF), chronic kidney disease (CKD), diabetes (DM), and congestive heart failure (CHF). The mean patient hierarchal condition category (HCC) risk score was collected, which is a standardized metric with score of 1.0 representing an average patient. This data was linked to all procedures billed to Medicare in 2021 under CPT code 52356 and Medicare surgeon reimbursement for all episodes. Student T-tests and Chi-squared analysis were used to compare variables in patients with HCC risk score of less than and greater than 1.5. 

Results

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In 2021, 52,816 procedures under CPT code 52356 were billed to Medicare. Mean physician reimbursement was $338.24. Patients with HCC risk scores greater than 1.5 had higher rates of comorbidities compared to patients with HCC less than 1.5 (Table 1). The mean payment for patients with HCC greater than 1.5 was $329.77, which was significantly lower than the mean payment of $340.47 for patients with HCC less than 1.5 (p < 0.001).

Conclusion

Although risk-adjustment exists for hospital reimbursement in the US, there is currently no risk-adjustment for surgeon fees. We demonstrate that mean surgeon reimbursement for ureteroscopy for stone treatment is lower for more comorbid patients. Risk-adjustment for surgeon reimbursement should be considered to incentivize surgeons to treat complex patients who will likely require increased surgeon time and resources.

Funding

None.

Co-Authors

Kevin M. Wymer, MD
Mayo Clinic Arizona

Mitchell R. Humphreys, MD
Mayo Clinic Arizona

Karen L. Stern, MD
Mayo Clinic Arizona