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Quality Improvement/Clinical Outcomes

E381: Impact of 2021 & 2023 Evaluation & Management (E&M) Code Updates on Surgical Oncologists

Introduction: Most surgical procedures include a 10 or 90-day global period. The number of relative value units (RVUs) assigned to a procedure therefore reflects not just the procedure itself, but also assumes a fixed number of postoperative visits in the hospital and clinic. A list of these assumed visits is available online and adopts the same structure as E&M codes used throughout healthcare (eg, level 2 established visit). Historically, when the RVUs assigned to E&M codes were changed, surgical procedures with global periods were also updated.  In 2021 and 2023, E&M codes underwent a major overhaul, however, the associated RVU increases were not incorporated into surgical RVUs. We aimed to assess the impact of this on common surgical oncology procedures.

Methods:

Ten procedures were identified accounting for the breadth (soft tissue, colorectal, HPB) and complexity (port placement to Whipple) of procedures performed by surgical oncologists. Work RVU files were retrieved from the Centers for Medicare & Medicaid Services (CMS) along with work time files to ascertain the number of assumed E&M visits incorporated into RVU valuations. Actual and expected RVUs were generated for each procedure at 3 times points – 2019 (prior to any E&M changes), 2021 (office-visit updates), and 2023 (hospital-visit updates).

Results:

Work RVUs ranged from 5.02 (excision of malignant lesion > 4cm) to 52.84 (Whipple procedure). Actual RVUs did not change for any of the 10 procedures between 2019 and 2023. The difference between expected and actual RVUs is plotted in the Figure. In 2021, the lack of RVU adjustment for office-based visits lead to an effective reduction ranging from 2.4% (Whipple) to 8.0% (partial mastectomy). In 2023, the lack of RVU adjustment for hospital-based visits effectively reduced RVUs a further 0% (partial mastectomy) to 5.5% (laparoscopic partial colectomy with ileocolostomy). Overall, RVUs were effectively reduced by 4.9% (total thyroidectomy) to 9.3% (biopsy/removal of lymph nodes).

Conclusions:

This study demonstrates the direct effect of CMS neglecting to update surgical RVUs as part of the 2021 and 2023 E&M updates. This led to an effective reduction of RVUs for common surgical oncology procedures of ~ 5 to 10%.  The downstream consequences of these financial changes are too early to ascertain but may place patients at risk of reduced quality and access.

Learning Objectives:

  • Upon completion, participant will be able to describe the structure of an RVU valuation, specifically as it relates to 10 and 90-day global periods
  • Upon completion, participant will be able to describe the 2021 and 2023 E&M code updates
  • Upon completion, participant will be able to describe the impact of 2021 and 2023 E&M code updates on surgical oncologist RVU valuations