Medicaid Reimbursement for Common Orthopaedic Foot and Ankle Procedures Is Highly Inconsistent Among States,Ranging from 37% to 324% of Medicare Reimbursement

Abstract

Background:

Medicaid reimbursement to physicians is often perceived to be lower than Medicare, but little is known about orthopaedic foot and ankle reimbursement. This study sought to compare Medicare and Medicaid reimbursement for the 20 most common foot and ankle procedures.

Methods:

Medicare reimbursement rates for common foot and ankle codes were obtained from the online Centers for Medicare & Medicaid fee schedule, while Medicaid rates were found from individual state fee schedule websites. Medicaid rates were compared by state and pooled to obtain national differences. The Medicare Wage Index was used to adjust Medicaid rates by state wages to ensure a more accurate comparison. Variability between states was measured using state percentages of Medicare and coefficient of variation values.

Results:

Medicaid reimbursed physicians higher than Medicare in 31 states overall, with average reimbursement ranging from 37% to 324% of Medicare. Nationally, Medicaid reimbursed 8.8% higher than Medicare, but Medicare reimbursed 3.7% higher when adjusted for the Medicare Wage Index. The Current Procedural Terminology (CPT) codes with the highest ratio of Medicaid to Medicare reimbursement were CPT 28002 for incision and drainage of the foot (176.6%) and CPT 28820 for toe amputation (167.6%). Five codes had lower relative Medicaid reimbursement on average: CPT 27687 for repair procedures on the leg and ankle joint, CPT 28810 for amputation procedures on the foot and toes, CPT 28010 for toe tenotomy, CPT 28005 for incision procedures on the foot and toes, and CPT 28470 for closed treatment of a metatarsal fracture. The coefficient of variation values ranged from 0.34 to 0.84 in the Medicaid group and 0.40 to 0.78 in the adjusted group, indicating high variability between states and between procedures.

Conclusion:

Medicaid reimbursement is highly inconsistent between states, ranging from 37% to 324% of Medicare. Medicaid reimbursed more than Medicare overall, which is in contrast with most published findings that tend to show higher reimbursement for Medicare when compared to Medicaid. When adjusting for wage differences between states, Medicare reimbursed slightly higher than Medicaid.

Level of Evidence:

Level IV, economic analysis.

Keywords

Medicaid reimbursement Medicare foot and ankle

Introduction

Reimbursement for surgical procedures in the United States consists of numerous payers and payment systems, with a constantly evolving landscape in an attempt to contain costs and optimize quality of care. Three groups that represent the largest payers in the United States are private insurers, Medicare (MCR), which primarily covers patients over the age of 65 years and those with certain diseases, and Medicaid (MCD), which primarily covers those with low income or disabilities.¹³ MCR typically reimburses hospitals for its services based on diagnosis-related groups (DRGs), a set fee based on the primary patient diagnosis for a hospitalization, but reimburses physicians on a fee-for-service model for the work they provide.^16,24 MCD reimbursement often involves fee-for-service payments to both hospitals and physicians, though states may contract with managed care plans that reimburse hospitals using other methods.^30,31 Fee-for-service models use Current Procedural Terminology (CPT) codes, unique to each surgical procedure, that correspond to a payment amount based on the number of relative value units (RVUs) attached to that CPT code.³ RVUs combine perceived physician work, costs, and liability to determine the relative value of a service. Modifier codes may be used to adjust reimbursement for fee-for-service rates based on additional work performed.

MCR expenditure has been increasing and is expected to continue to grow in the setting of an aging population.⁸ Perhaps to offset this, reimbursement to physicians has been decreasing over the past 2 decades, as noted in a variety of orthopaedic subspecialties.^{21,22,28,37,38,41} Hospital reimbursement is also decreasing as more than 60% of hospitals in 2019 reported losing money while caring for MCR patients.² MCD similarly is projecting an increase in costs over the coming decade,¹² and nearly 60% of hospitals also lost money in 2019 while treating MCD patients.² For surgeons, studies have demonstrated that MCD, on average, reimburses less than MCR in a variety of specialties, but there is wide variability between states.^7,25,27,39

Reimbursement to surgeons from MCR for orthopaedic foot and ankle procedures have decreased by 30% over the past 2 decades when adjusting for inflation,³⁶ but little is known on MCD reimbursement for this subspecialty. Therefore, the purpose of this study was to collect MCD reimbursement rates for common foot and ankle procedures and compare them to MCR rates. These rates will be important to physicians in a fee-for-service model, but less applicable to ones in an RVU-based system. We predicted a lower average rate than MCR with large variability between states.

Methods

Collection of CPT Codes, RVUs, and localities

The 20 most frequently billed foot and ankle CPT codes from 2017 were used in the MCR reimbursement study by Pollock et al^14,36 and were included in this study after checking with recent Centers for Medicare & Medicaid Services (CMS) use data to ensure they remained highly relevant. Of note, open repair of foot and ankle fracture codes were not included in the analysis as a recent study by Moore et al³⁴ already compared MCD and MCR reimbursement for several such codes. Work RVUs (wRVUs) were collected from the CMS Physician Fee Schedule Look-Up Tool to assess the relative payment among different procedures.¹⁵ For MCR reimbursement, rates vary based on cost of living, which is delineated by Medicare Administrative Contractor (MAC) localities. Many MAC localities represent geographic regions approximating state lines, although some states contain multiple MAC localities. For consistency, the “rest of state” option was used for states with multiple localities, which includes all parts of the state not otherwise defined by specific localities (Table 1).

Table 1.

Twenty Included Foot and Ankle CPT Codes With Their Descriptions and Corresponding Work RVUs.

CPT Code	Procedure Name	RVUs
28296	Correction, hallux valgus (bunionectomy), with sesamoidectomy	8.25
28122	Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	6.76
28299	Correction, hallux valgus (bunionectomy), with sesamoidectomy	9.29
27687	Repair, revision, and/or reconstruction procedures on the leg (tibia and fibula) and ankle joint	6.41
28810	Amputation procedures on the foot and toes	6.64
28308	Osteotomy, with or without lengthening, shortening or angular correction, metatarsal	5.48
28010	Tenotomy, percutaneous, toe	2.97
28124	Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	5.00
28005	Incision procedures on the foot and toes	9.44
28313	Repair, revision, and/or reconstruction procedures on the foot and toes	5.15
28232	Tenotomy, open, tendon flexor	3.51
28272	Capsulotomy	3.92
28285	Repair, revision, and/or reconstruction procedures on the foot and toes	5.62
28270	Capsulotomy	4.93
28001	Incision procedures on the foot and toes	2.00
28002	Incision and drainage below fascia, with or without tendon sheath involvement, foot	2.79
28750	Arthrodesis, great toe	8.57
28234	Repair, revision, and/or reconstruction procedures on the foot and toes	3.54
28820	Amputation, toe	3.51
28470	Closed treatment of metatarsal fracture	2.03

Abbreviations: CPT, Current Procedural Terminology; RVU, relative value units.

Physician Fee Schedules

MCD rates were extracted from each state’s online physician fee schedules. All states were included except Tennessee, which does not use a fee-for-service model for MCD. For some states, rates could vary based on whether the procedure took place inpatient or outpatient and within an MCD facility vs nonfacility. Some states also included modifier codes that could be added to increase reimbursement. For consistency, the highest overall price with no modifiers was obtained from each state wherever possible. MCR rates were collected using the 2023 CMS Medicare Physician Fee Schedule.¹⁶ The facility fee was used for all state-specific MAC localities with no modifier codes.

Medicare Wage Index

To assess the effect that average state wages have on MCD reimbursement rates, the Medicare Wage Index (MWI) was recorded from the Wage Index Files of the CMS website.¹⁸ The MWI represents a ratio of state average wages to the national average. Using methods akin to the MCD reimbursement analysis by Lalezari et al,²⁷ we multiplied the MCD rates by each state’s MWI to produce MWI-adjusted MCD data to more accurately compare disparities between MCD and MCR.

Analyses

Average, median, SD, lower bound, and upper bound values were calculated for MCR, MCD, and MWI-adjusted MCD data sets. MCR was compared to both MCD and MWI-adjusted MCD using dollar differences for each procedure and state. Dollar differences were adjusted by the work RVUs to ascertain differences between procedures. Both the dollar difference and dollar difference per RVU were then averaged to reflect national differences.

To assess variability, state MCD averages were given percentages to MCR to reflect relative reimbursement. The same was done for each individual procedure. Furthermore, coefficient of variation values were calculated by dividing the mean by the SD for each procedure in the MCR, MCD, and MWI-adjusted MCD groups. A coefficient of variation value further from zero represents greater variability within a data set. Coefficient of variation values were also calculated for the dollar differences.

Results

State Averages

For all procedures, 31 states had higher average MCD reimbursement rates than corresponding MCR rates, and Hawaii had identical MCD rates to MCR for all procedures. The average reimbursement across all procedures ranged from 37.2% (Rhode Island) to 323.5% (Idaho) of MCR. Six states had lower reimbursement than MCR for all procedures: Colorado, Connecticut, Michigan, New Hampshire, New Jersey, and Rhode Island. Of note, Washington and Michigan had 1 or more missing values in their MCD data, which were excluded from analysis. Pennsylvania had 5 codes (28296, 28299, 28308, 28002, and 28820) for which the only rates available contained modifier codes within them, and the rates were proportionally higher than the rest of the state’s rates. Figure 1 provides a comparison of state rates in relation to MCR as a heatmap of the United States.

Figure 1.

A heatmap of relative Medicaid reimburse compared to Medicaid by state. Red colors depict states with a Medicaid to Medicare reimbursement ratio less than 1, while blue depicts states with a ratio greater than 1. Tennessee was not included in this study.

National Averages

MCD reimbursed physicians on average 8.8% higher than MCR across all 20 procedures. When adjusting for the MWI, however, MCR reimbursed 3.7% higher. For all states combined, the procedures range from 81.4% (closed treatment of metatarsal fracture) to 176.6% (incision and drainage of the foot below the fascia) of MCR. Overall, 15 procedures were reimbursed higher for MCD. The dollar differences ranged from $91.72 (incision procedures on the foot and toes) less for MCD to $203.14 (bunionectomy with sesamoidectomy) greater for MCD. The dollar difference per wRVU ranged from $18.84 (closed treatment of metatarsal fracture) less for MCD to $38.02 (incision and drainage of the foot below the fascia) greater for MCD (Table 2). The Supplementary Table provides more detailed data by each procedure code.

Table 2.

Analysis of National Medicaid, Wage-Adjusted Medicaid, and Medicare Reimbursement for 20 Orthopaedic Foot and Ankle Codes.

	Insurance Type
National Reimbursement	Medicaid ($)	Wage-Adjusted Medicaid ($)	Medicare ($)
Mean	375.01	331.20	343.55
SD	178.56	166.06	20.01
Median	355.57	299.16	339.47
Lower bound	114.57	112.01	319.09
Upper bound	1215.66	1080.10	442.14
Coefficient of variation	0.48	0.50	0.06

Coefficient of Variation

The coefficient of variation ranged from 0.04 to 0.07 for all MCR procedures, indicating overall low variability between procedures. It ranged from 0.34 to 0.84 for MCD procedures and from 0.40 to 0.78 when adjusting for the MWI, indicating greater variability between states and between procedures. The absolute value coefficient of variation for the dollar difference between MCD and MCR ranged from 1.23 to 47.57. Table 3 depicts the dollar differences for all codes with corresponding coefficient of variation values.

Table 3.

Dollar Difference Alone and per Work RVU Between National MCD and MCR Data.

Descriptor	Mean Difference ($)	Mean Difference per Work RVU ($)	Mean SD ($)	Median Difference ($)	Coefficient of Variation
Correction, hallux valgus (bunionectomy), with sesamoidectomy	153	18	224	148	1.47
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	17	3	180	8	10.55
Correction, hallux valgus (bunionectomy), with sesamoidectomy	203	22	469	145	2.31
Repair, revision, and/or reconstruction procedures on the leg (tibia and fibula) and ankle joint	−50	−8	154	−65	−3.06
Amputation procedures on the foot and toes	−50	−7	159	−57	−3.21
Osteotomy, with or without lengthening, shortening or angular correction, metatarsal	50	9	197	20	3.93
Tenotomy, percutaneous, toe	−28	−10	67	−19	−2.37
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	7	1	110	7	15.02
Incision procedures on the foot and toes	−92	−10	189	−94	−2.06
Repair, revision, and/or reconstruction procedures on the foot and toes	51	10	171	21	3.37
Tenotomy, open, tendon flexor	13	4	104	27	8.03
Capsulotomy	18	4	100	21	5.69
Repair, revision, and/or reconstruction procedures on the foot and toes	10	2	176	−3	16.95
Capsulotomy	33	7	177	12	5.31
Incision procedures on the foot and toes	42	21	59	49	1.39
Incision and drainage below fascia, with or without tendon sheath involvement, foot	106	38	139	73	1.31
Arthrodesis, great toe	48	6	523	−2	10.79
Repair, revision, and/or reconstruction procedures on the foot and toes	10	3	129	17	12.78
Amputation, toe	119	34	184	79	1.55
Closed treatment of metatarsal fracture	−38	−19	57	−36	−1.48

Abbreviations: MCD, Medicaid; MCR, Medicare; RVU, relative value units.

Discussion

The most notable finding from this study was that MCD reimbursement is highly inconsistent between states, ranging from 37% to 324% of MCR reimbursement with substantially higher coefficient of variation values than MCR. By individual procedure code across all states, MCD reimbursement ranged from 81% to 177% of MCR, indicating that MCD procedural rates are not consistently priced. MCD reimbursement on average exceeded MCR by 8.8%, but when adjusting for the cost of living with the MWI, MCR rates were greater than MCD by 3.7%.

Several prior studies have evaluated MCD reimbursement for orthopaedic procedures, including analyses of general orthopaedic procedures, fractures, and hand, spine, and pediatric procedures.^{4,6,7,19,20,27} All of these studies, by contrast, found that MCD reimbursement was lower on average than MCR. This is the first orthopaedic subspecialty identified in which MCD outperforms MCR. Strikingly, however, compared with all these studies that included coefficient of variation values, foot and ankle procedures had the highest average MCD coefficient of variation, indicating very wide variability between states. As Baker et al⁴ summarized in their study on MCD reimbursement in hand procedures, states may set their own MCD rates, allowing that they fall within federal guidelines, but are not transparent in the methods by which they create them. Our data demonstrate that surgeons can be reimbursed from 37% to 324% of MCR for the same procedure based on where they practice. This suggests more objective metrics should potentially be employed nationwide when determining MCD rates in order to establish more uniformity.

The reasoning for higher MCD reimbursement is not apparently clear and is likely multifactorial. One potential theory stems from findings by Meyers et al³³ that median MCR payments for ankle fracture procedures were lower for orthopaedic foot surgeons compared to podiatrists. If these findings are universal within foot and ankle procedures, MCR may compensate orthopaedic foot and ankle surgeons less but MCD may choose to simply offer a single rate for both orthopaedists and podiatrists that is higher overall than orthopaedic MCR rates. Another hypothesis is that foot and ankle procedures are most likely to be interventions for chronic diseases such as diabetes mellitus in which MCD beneficiaries suffer from worse outcomes.⁴² It is known that states may use targeted financial incentives within their MCD programs to achieve better health outcomes,³² and it is possible they have increased reimbursement for some foot and ankle procedures to deal with complications that more often arise in MCD populations.

Indeed, some of the procedures that reimbursed the highest relative to MCR are ones that treat complications of diabetes or skin abscesses, which may be thought to be more common in MCD populations. These codes, though, also have closely-related codes that by contrast reimburse substantially lower for MCD. CPT 28001, 28002, and 28005 code for incision procedures of bursa, sub-fascial layer, and bone, respectively. The first two have average rates well above MCR while CPT 28005 averaged $95 less for MCD. Likewise, CPT 28820 is used for toe amputations at the metatarsophalangeal joint and averaged $119 more for MCD, but the related code 28810, which codes for toe amputation with inclusion of the metatarsal head, averaged $50 less for MCD. It is unclear why there are such discrepancies in seemingly related procedures, but it appears as though MCD programs wish to incentivize physicians to perform certain procedures over others.

Alternatively, the relatively high MCD reimbursement for select procedures may be mainly caused by falling MCR rates. When comparing MCR rates collected in our study to the same 20 procedures used by Pollock et al³⁶ with 2017 data, all 20 procedures have since decreased in reimbursement. This is evident even without adjusting for inflation and is most notable for toe amputation (a $240 decrease) and incision and drainage below the fascia of the foot (a $200 decrease), both of which are reimbursed by MCD on average over $100 more than MCR. The two bunionectomy codes, 28296 and 28122, exhibit the greatest difference between MCD and MCR ($153 and $203, respectively) and were also found to have among the most drastically declining MCR reimbursement by Pollock et al.³⁶ Thus, MCD’s relatively higher reimbursement may in part reflect states not lowering their rates proportionate to MCR over the past few years, though it is unknown if this is intentional or not.

It is important to understand the results of the study within the context of national MCR and MCD payment systems. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law in 2015 and provides two options for physician reimbursement that are affected by quality measures: Merit Based Incentive Payments System (MIPS) and alternative payment models (APMs).¹⁰ MIPS retains a more traditional fee-for-service model in which physicians receive up to 4% bonuses or reductions in their pay for MCR patients based on a composite score of quality measures.⁴⁰ APMs may be optional or mandatory, and include models similar to DRGs, such as the Comprehensive Care for Joint Replacement Model, of which total ankle arthroplasty is included, and the recently announced Transforming Episode Accountability Model, which includes lower extremity joint replacement procedures.^9,17 A number of APMs have also been created and adapted into state MCD programs, representing efforts to change the models by which these health care systems reimburse physicians.¹ These changes reflect pushes to control health care expenditure while increasing the quality of care. Future changes in reimbursement are likely as new systems are established, and it is critical that policy makers have a comprehensive understanding of contemporary reimbursement trends such as those presented in this study.

Despite these efforts and the increase in MCD enrollment under the Patient Protection and Affordable Care Act, MCD patients with foot and ankle complaints continue to suffer from decreased access to care, including longer wait times, more difficulty obtaining appointments, and worse outcomes after surgery.^5,26,29,35 These barriers to access are most prominent in states that maintain unexpanded MCD programs.²³ Although reimbursement alone does not appear to be responsible for decreased access among MCD beneficiaries, this population may face even increased difficulty receiving care in states with poorly funded MCD programs.

Limitations

Comparing MCD and MCR fee schedules is imprecise, as both may contain multiple values for a given procedure. We strove to maintain consistency by using no modifiers for each and using the highest available price for state MCD rates, but it is unclear how accurately this affects actual average rates. There is also a lack of information on how frequently modifier codes are used in procedures, which have the potential to drastically impact reimbursement. Foot and ankle procedures often may encompass multiple CPT codes; as per CMS guidelines, it is important to choose the most comprehensive code for the procedure, which does not bill for more than what is performed.¹¹ Modifier codes are thus very important tools in adjusting reimbursement for extra work performed in a procedure, but could not be accounted for by this study.

Additionally, several codes within 2 states were missing information on reimbursement rates for MCD, whereas 1 state had several codes that only included rates with a modifier that were proportionally higher than its other rates. We hope that these irregularities offset each other to maintain relative accuracy, but they both had the potential to change their states’ relative reimbursement to MCR. The selection of MAC localities designated as “rest of state” when multiple localities applied to a state were intended to fairly represent the state by capturing the greatest percentage of the state possible, but this selection could potentially exclude certain metropolitan areas where wages, and thus Medicare reimbursement, may be higher. Finally, as noted previously, there are many models that can influence rates, such as quality adjustment under MIPS or using APMs, which do not operate using a traditional fee-for-service model. MCD may also be administered through a private managed plan that can use any type of reimbursement model. All of these factors have the potential to change reimbursement for MCD and MCR and are not able to be accounted for within the context of this study.

Conclusion

MCD reimbursement for common orthopaedic foot and ankle procedures was highly inconsistent between states, ranging from 37% to 324% as a proportion of corresponding MCR rates. The extreme variability between states and between procedures suggests that MCD could benefit from more objective metrics to guide reimbursement. Contrary to our hypothesis, MCD did reimburse an overall 8.8% higher rate than MCR, though it reimburses 3.7% less when adjusted for wage differences between states. Orthopaedic surgeons should familiarize themselves with local state rates and advocate for policies that provide fair reimbursement for their services.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251330302 – Supplemental material for Medicaid Reimbursement for Common Orthopaedic Foot and Ankle Procedures Is Highly Inconsistent Among States, Ranging from 37% to 324% of Medicare Reimbursement

Supplemental material, sj-pdf-1-fao-10.1177_24730114251330302 for Medicaid Reimbursement for Common Orthopaedic Foot and Ankle Procedures Is Highly Inconsistent Among States, Ranging from 37% to 324% of Medicare Reimbursement by Adam P. Henderson, M. Lane Moore, Nathan C. Beckett, Paul R. Van Schuyver, Jack M. Haglin, Joseph C. Brinkman and Karan A. Patel in Foot & Ankle Orthopaedics

Footnotes

Appendix

Supplementary Table.

Analysis of National Medicaid, Medicare Wage Index–Adjusted Medicaid, and Medicare Reimbursement for 20 Orthopaedic Foot/Ankle Procedures.

Descriptor	Mean ($)	SD ($)	Median ($)	Lower ($)	Upper ($)	Coefficient of Variation
Medicaid reimbursement
Correction, hallux valgus (bunionectomy), with sesamoidectomy	659	227	640	328	1386	0.34
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	450	181	446	131	1230	0.40
Correction, hallux valgus (bunionectomy), with sesamoidectomy	788	468	718	328	3552	0.59
Repair, revision, and/or reconstruction procedures on the leg (tibia and fibula) and ankle joint	401	153	366	231	1230	0.38
Amputation procedures on the foot and toes	367	158	352	143	1230	0.43
Osteotomy, with or without lengthening, shortening or angular correction, metatarsal	432	198	391	126	1230	0.46
Tenotomy, percutaneous, toe	177	68	178	22	379	0.38
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	337	113	334	99	752	0.34
Incision procedures on the foot and toes	471	185	447	126	1230	0.39
Repair, revision, and/or reconstruction procedures on the foot and toes	407	173	386	143	1230	0.42
Tenotomy, open, tendon flexor	252	105	256	38	589	0.42
Capsulotomy	267	99	265	39	604	0.37
Repair, revision, and/or reconstruction procedures on the foot and toes	391	178	370	151	1230	0.46
Capsulotomy	364	177	335	16	1230	0.49
Incision procedures on the foot and toes	138	60	141	17	275	0.43
Incision and drainage below fascia, with or without tendon sheath involvement, foot	245	138	213	25	776	0.56
Arthrodesis, great toe	619	521	579	197	3930	0.84
Repair, revision, and/or reconstruction procedures on the foot and toes	275	130	276	27	651	0.47
Amputation, toe	294	183	254	82	1230	0.62
Closed treatment of metatarsal fracture	167	57	166	23	346	0.34
Medicare Wage Index–adjusted Medicaid reimbursement
Correction, hallux valgus (bunionectomy), with sesamoidectomy	582	233	537	273	1671	0.40
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	398	176	361	135	1136	0.44
Correction, hallux valgus (bunionectomy), with sesamoidectomy	692	397	611	317	2748	0.57
Repair, revision, and/or reconstruction procedures on the leg (tibia and fibula) and ankle joint	355	145	316	203	952	0.41
Amputation procedures on the foot and toes	324	144	291	147	952	0.45
Osteotomy, with or without lengthening, shortening or angular correction, metatarsal	381	182	333	130	1076	0.48
Tenotomy, percutaneous, toe	156	72	152	23	456	0.46
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	300	126	279	101	907	0.42
Incision procedures on the foot and toes	419	190	375	130	1154	0.45
Repair, revision, and/or reconstruction procedures on the foot and toes	363	166	324	141	998	0.46
Tenotomy, open, tendon flexor	224	111	214	39	711	0.50
Capsulotomy	237	107	224	42	728	0.45
Repair, revision, and/or reconstruction procedures on the foot and toes	346	170	299	156	1024	0.49
Capsulotomy	321	163	288	17	952	0.51
Incision procedures on the foot and toes	121	57	117	19	331	0.47
Incision and drainage below fascia, with or without tendon sheath involvement, foot	212	117	194	27	629	0.55
Arthrodesis, great toe	543	423	470	203	3041	0.78
Repair, revision, and/or reconstruction procedures on the foot and toes	244	130	231	28	766	0.53
Amputation, toe	256	149	228	85	952	0.58
Closed treatment of metatarsal fracture	148	63	139	25	417	0.43
Medicare reimbursement
Correction, hallux valgus (bunionectomy), with sesamoidectomy	507	30	500	473	668	0.06
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	433	26	428	402	566	0.06
Correction, hallux valgus (bunionectomy), with sesamoidectomy	584	34	578	543	766	0.06
Repair, revision, and/or reconstruction procedures on the leg (tibia and fibula) and ankle joint	450	27	445	415	580	0.06
Amputation procedures on the foot and toes	416	25	411	385	543	0.06
Osteotomy, with or without lengthening, shortening or angular correction, metatarsal	381	23	377	353	494	0.06
Tenotomy, percutaneous, toe	205	12	203	191	267	0.06
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing)	329	19	325	307	431	0.06
Incision procedures on the foot and toes	562	21	558	528	617	0.04
Repair, revision, and/or reconstruction procedures on the foot and toes	356	21	352	329	461	0.06
Tenotomy, open, tendon flexor	238	16	235	221	309	0.07
Capsulotomy	249	18	245	231	326	0.07
Repair, revision, and/or reconstruction procedures on the foot and toes	380	22	375	353	494	0.06
Capsulotomy	330	20	326	306	430	0.06
Incision procedures on the foot and toes	95	6	94	90	130	0.06
Incision and drainage below fascia, with or without tendon sheath involvement, foot	139	8	137	131	188	0.06
Arthrodesis, great toe	570	34	564	528	741	0.06
Repair, revision, and/or reconstruction procedures on the foot and toes	265	16	262	245	341	0.06
Amputation, toe	176	11	174	165	237	0.06
Closed treatment of metatarsal fracture	205	13	202	187	255	0.06

Ethical Approval

Ethical approval was not sought for the present study because no patient information was used and no human or animal testing was performed.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Adam P. Henderson, BS,

M. Lane Moore, MD, MBA,

Jack M. Haglin, MD, MS,

References

Alternative Payment Models in the Quality Payment Program as of December 2023. Centers for Medicare & Medicaid Services—Quality Payment Program. 2023. Accessed June 19, 2024. https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2647/2023and2024CompListofAPMs.pdf?linkId=277175263

American Hospital Association. Fact Sheet: Hospital Costs Explained. May 2021. Accessed June 19, 2024. https://www.aha.org/aha-search?search_api_fulltext=Fact+Sheet%3A+Hospital+Costs+Explained

American Medical Association. Relative value units. 2025. Accessed June 19, 2024. https://cpt-international.ama-assn.org/relative-value-units

Baker

Rivlin

Sodha

, et al. Variability in Medicaid reimbursement in hand surgery may lead to inequality in access to patient care. Hand (N Y). 2022;17(5):983-987. doi:10.1177/1558944720964966

Bakhsh

Childs

Flemister

Baumhauer

Ketz

Evaluating patients for elective outpatient foot and ankle surgery: insurance as a predictor of patient outcomes. Foot Ankle Spec. 2019;12(6):522-529. doi:10.1177/1938640018823070

Casper

Schroeder

McKenzie

, et al. Medicaid reimbursement for common spine procedures: are compensation rates consistent? Spine (Phila Pa 1976). 2019;44(22):1585-1590. doi:10.1097/BRS.0000000000003241

Casper

Schroeder

Zmistowski

, et al. Medicaid reimbursement for common orthopedic procedures is not consistent. Orthopedics. 2019;42(2):e193-e196. doi:10.3928/01477447-20181227-06

Centers for Medicare & Medicaid Services. CMS Releases 2023-2032 National Health Expenditure Projections. June 12, 2024. Accessed June 19, 2024. https://www.cms.gov/newsroom/press-releases/cms-releases-2023-2032-national-health-expenditure-projections#:~:text=Medicare:%20Average%20annual%20Medicare%20expenditure,and%201964)%20enroll%20in%202029

Centers for Medicare & Medicaid Services. Comprehensive Care for Joint Replacement Model. 2021. Accessed June 19, 2024. https://www.cms.gov/priorities/innovation/innovation-models/cjr

10.

Centers for Medicare & Medicaid Services. MACRA. 2024. Accessed June 19, 2024. https://www.cms.gov/medicare/quality/value-based-programs/chip-reauthorization-act

11.

Centers for Medicare & Medicaid Services. Medicare NCCI 2022 Coding Policy Manual- Chapter 1: General correct coding policies for national correct coding initiative policy manual for Medicare services. CMS. January 1, 2022. Accessed March 3, 2025. https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf

12.

Centers for Medicare & Medicaid Services. National health expenditure data: Projected. 2024. Accessed June 19, 2024. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/projected

13.

Centers for Medicare & Medicaid Services. NHE fact sheet. 2024. Accessed June 19, 2024. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet

14.

Centers for Medicare & Medicaid Services. Part B National Summary Data File. 2024. Accessed February 22, 2025. https://www.cms.gov/data-research/statistics-trends-and-reports/part-b-national-summary-data-file

15.

Centers for Medicare & Medicaid Services. Physician Fee Schedule Look-Up Tool. 2024. Accessed June 16, 2024. https://www.cms.gov/medicare/physician-fee-schedule/search/overview

16.

Centers for Medicare & Medicaid Services. Physician Fee Schedule. 2024. Accessed June 15, 2024. https://www.cms.gov/medicare/payment/fee-schedules/physician

17.

Centers for Medicare & Medicaid Services. Transforming Episode Accountability Model (TEAM). 2024. Accessed June 19, 2024. https://www.cms.gov/priorities/innovation/innovation-models/team-model

18.

Centers for Medicare & Medicaid Services. Wage index files. 2024. Accessed June 16, 2024. https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/wage-index-files

19.

Eckhoff

Tadlock

Medicaid reimbursement of pediatric surgeries. J Orthop Bus. 2022;2(1):1-3. doi:10.55576/job.v2i1.10

20.

Green

Scanaliato

Polmear

, et al. Variation in state and federal reimbursement in the United States in the treatment of upper extremity fractures. J Shoulder Elbow Surg. 2021;30(11):2543-2548. doi:10.1016/j.jse.2021.04.016

21.

Haglin

Lott

Kugelman

Konda

Egol

KA.

Declining Medicare reimbursement in orthopaedic trauma surgery: 2000-2020. J Orthop Trauma. 2021;35(2):79-85. doi:10.1097/BOT.0000000000001947

22.

Haglin

Zabat

Richter

, et al. Over 20 years of declining Medicare reimbursement for spine surgeons: a temporal and geographic analysis from 2000 to 2021. J Neurosurg Spine. 2022;37(3):452-459. doi:10.3171/2022.2.SPINE211368

23.

Hoch

Scott

Gross

CE.

Medicaid patients face limited access to care for ankle sprains in unexpanded states. Foot Ankle Spec. 2025;18(1):74-79. doi:10.1177/19386400221125375

24.

How does Medicare reimburse hospitals? Medicare.org. 2020. Accessed June 19, 2024. https://www.medicare.org/articles/how-does-medicare-reimburse-hospitals/

25.

Kaura

Berlin

Momoh

Kozlow

JH.

State variations in public payer reimbursement for common plastic surgery procedures. Plast Reconstr Surg. 2018;142(6):1653-1661. doi:10.1097/PRS.0000000000005013

26.

Kim

Wiznia

Roth

Walls

Pelker

RR.

Survey of patient insurance status on access to specialty foot and ankle care under the Affordable Care Act. Foot Ankle Int. 2016;37(7):776-781. doi:10.1177/1071100716642015

27.

Lalezari

Pozen

CJ.

State variation in Medicaid reimbursements for orthopaedic surgery [published correction appears in J Bone Joint Surg Am. 2019 Oct 16;101(20):e112. doi: 10.2106/JBJS.ER.17.00279]. J Bone Joint Surg Am. 2018;100(3):236-242. doi:10.2106/JBJS.17.00279

28.

Mayfield

Haglin

Levine

Della Valle

Lieberman

Heckmann

Medicare reimbursement for hip and knee arthroplasty from 2000 to 2019: an unsustainable trend. J Arthroplasty. 2020;35(5):1174-1178. doi:10.1016/j.arth.2019.12.008

29.

McKissack

Viner

McMurtrie

, et al. Does insurance status affect access to care among ankle fracture patients? An institutional retrospective study. J Foot Ankle Surg. 2021;60(3):520-522. doi:10.1053/j.jfas.2020.10.006

30.

Medicaid and CHIP Payment and Access Commission (MACPAC). Medicaid base and supplemental payments to hospitals. June 2021. Accessed June 19, 2024. https://www.macpac.gov/publication/medicaid-base-and-supplemental-payments-to-hospitals/

31.

Medicaid and CHIP Payment and Access Commission (MACPAC). Provider payment and delivery systems. Accessed June 19, 2024. https://www.macpac.gov/medicaid-101/provider-payment-and-delivery-systems/

32.

Medicaid and CHIP Payment and Access Commission (MACPAC). The use of healthy behavior incentives in Medicaid. August 2016. Accessed June 19, 2024. https://www.macpac.gov/publication/the-use-of-healthy-behavior-incentives-in-medicaid/

33.

Meyers

Gokcen

Kelly

, et al. National cost comparisons between orthopaedics and podiatry in ankle fracture fixation. Foot Ankle Orthop. 2022;7(4):2473011421S00807. doi:10.1177/2473011421S00807

34.

Moore

Henderson

Haglin

, et al. Medicaid reimbursement for common orthopaedic trauma procedures is 16.0% less compared with Medicare with substantial variability between states. J Orthop Trauma. 2024;38(11):e362-e370. doi:10.1097/BOT.0000000000002901

35.

Pitts

McKissack

Alexander

, et al. Do geographic region, pathologic chronicity, and hospital affiliation affect access to care among Medicaid- and privately insured foot and ankle surgery patients? South Med J. 2021;114(1):35-40. doi:10.14423/SMJ.0000000000001198

36.

Pollock

Moore

Haglin

, et al. Between 2000 and 2020, reimbursement for orthopaedic foot and ankle surgery decreased by 30. Arthrosc Sports Med Rehabil. 2021;4(2):e553-e558. doi:10.1016/j.asmr.2021.11.016

37.

Pollock

Richman

Estipona

, et al. Inflation-adjusted Medicare reimbursement has decreased for orthopaedic sports medicine procedures: analysis from 2000 to 2020. Orthop J Sports Med. 2022;10(2):23259671211073722. doi:10.1177/23259671211073722

38.

Pollock

Richman

Kuttner

, et al. Medicare payment for orthopaedic oncology procedures over the past 20 years. J Am Acad Orthop Surg Glob Res Rev. 2022;6(8):e22.00132. doi:10.5435/JAAOSGlobal-D-22-00132

39.

Rallo

Berke

Shaw

Bunch

Menger

RP.

State-to-state variation in Medicaid reimbursement for neurosurgical procedures: implications for healthcare access in vulnerable populations. Neurosurgery. Published online January 19, 2024. doi:10.1227/neu.0000000000002823

40.

Saleh

Shaffer

WO.

Understanding value-based reimbursement models and trends in orthopaedic health policy: an introduction to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. J Am Acad Orthop Surg. 2016;24(11):e136-e147. doi:10.5435/JAAOS-D-16-00283

41.

Thornburg

Gupta

Chow

Haglin

Noland

An analysis of procedural Medicare reimbursement rates in hand surgery: 2000 to 2019. Hand (N Y). 2022;17(6):1207-1213. doi:10.1177/1558944721990807

42.

Zhang

Huang

Drum

, et al. Insurance status and quality of diabetes care in community health centers. Am J Public Health. 2009;99(4):742-747. doi:10.2105/AJPH.2007.125534

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