TJA Work Load Increased, But CMS Cut wRVUs 5%!?

With the push toward rapid recovery following total joint arthroplasty (TJA), clinicians are having to “front load” a significant amount of work, says new research from the University of Arkansas for Medical Sciences in Little Rock. Their study, “Electronic Medical Record Audit Time Logs as a Measure of Preoperative Work Before Total Joint Arthroplasty,” appears in the July 1, 2021 edition of The Journal of Arthoroplasty.

Jeffrey Stambough, M.D., study co-author and assistant professor in the Department of Orthopaedic Surgery at the University of Arkansas for Medical Sciences explained to OTW the genesis of this study. “This work is vital as a response to CMS [Centers for Medicare & Medicaid Services] and their devaluation of our CPT codes for hip and knee arthroplasty. Although multiple studies have shown that as we try to better ‘optimize’ our patients leading up to surgery, CMS has decreased the relative wRVU [work relative value units] for hip and knee arthroplasty in 2021 by 5.3% from 20.72 to 19.6.”

“However, current THA and TKA [total hip arthroplasty and total knee arthroplasty] valuations do not account for any of this pre-op work,” added Dr. Stambough. “Prior studies have estimated pre-arthroplasty work using surveys, retrospective chart reviews, and self-reported time logs. These methods are faulty to the extent that they rely on report bias or general estimates. Therefore, a more objective approach was warranted and may serve to support these previous findings. Our aims were to objectively quantify pre-operative work with THA and TKA using electronic medical record audit logs.”

Using EMR data from 100 elective knee and 100 elective hip arthroplasties, the researchers recorded every mouse click and action in the EMR. For each member of the clinical team, the investigators calculated and summed the time between mouse clicks. They then quantified and compared total preoperative work between groups defined by gender, procedure, age, insurance type, or health literacy.

“The mean time spent in each patient’s chart in the pre-arthroplasty period was 76.8 (SD 47.8) minutes,” explained Dr. Stambough to OTW. “Individuals <65 years of age required significantly increased duration of pre-arthroplasty work when compared to their older cohort (P = .04). The total pre-operative work for individuals <65 averaged an additional 14 minutes when compared to adults ≥65 years of age. Surgeon clinical nurses accounted for more than 50% of the overall pre-operative work (46.7 minutes, SD 39.1).”

“The results from our study suggest that a significant amount of pre-arthroplasty work is unaccounted for in the current reimbursement schedule. Compensation for pre-TJA work is warranted and should not be minimized. Furthermore, fair compensation for pre-TJA work that serves to maximize postoperative recovery is essential to encourage surgeons and their teams to optimize surgical protocols.”