Discrepancies in Assigned vs. Observed Operative Times: Consequences for RVU-Based Reimbursement in Plastic Surgery

BACKGROUND: Discrepancies between assigned and actual operative durations may distort time-based valuation of surgical procedures. This study evaluated the impact of operative time source on wRVU per minute and reimbursement per minute across commonly reimbursed reconstructive plastic surgery operations. METHODS: Using 2023 National Surgical Quality Improvement Program (NSQIP) data, we compared actual operative times for 11 commonly reimbursed plastic surgery procedures to CMS-assigned times from the Physician Fee Schedule. Each CPT (15830, 19316, 19318, 19325, 19340, 19342, 19357, 19364, 19370, 19371, 19380) was linked to its CMS-assigned wRVU. wRVU per minute and reimbursement per minute were calculated using both NSQIP-observed and CMS-assigned operative times. Statistical analyses included Wilcoxon signed-rank tests, Kruskal-Wallis tests, Spearman correlations, and multivariable linear regression. RESULTS: Among 6,537 single-CPT cases, CMS underestimated operative time in 5 of 11 procedures. The largest discrepancies were observed in immediate implant insertion (+93.5 min), free flap breast reconstruction (+60.5 min), and breast augmentation (+18.5 min), resulting in reduced wRVU/min and $/min. Time discrepancy correlated strongly with reduced wRVU/min (ρ=-0.84). NSQIP-modeled reimbursement showed 2,637 single-CPT cases (40.3%) as underpaid, totaling $751,149.18. Among 15,570 multi-CPT cases, 5,099 (32.7%) were under-reimbursed, with a cumulative modeled underpayment of $2,002,956.29. CONCLUSIONS: CMS operative times frequently underestimated the duration of plastic surgery procedures. Time discrepancies were associated with substantial reductions in wRVU/min and $/min, particularly for complex or implant-based operations. These findings suggest that current CMS time assignments do not adequately capture operative complexity and may contribute to systematic underpayment in reconstructive surgery.