Longitudinal Trends in wRVU and Reimbursement for Free Flap and Implant-Based Breast Reconstruction: A 13-Year Valuation Analysis

Background: The work relative value unit (wRVU) system influences Medicare reimbursement by quantifying procedural complexity and physician effort. There are known disparities in wRVU and reimbursement per hour between implant and autologous breast reconstruction, however studies analyzing temporal changes in this relationship are limited. This study evaluates 13-year trends in wRVU/hour, reimbursement/hour, and complexity measures between implant-based and free flap breast reconstruction. We hypothesize that implant-based reconstruction maintains higher wRVUs and reimbursement per hour, but valuation for free flap reconstruction has improved. Methods: A retrospective study was conducted using the NSQIP database (2009–2021) to analyze operative times and complication rates for unilateral breast reconstruction procedures: implant-based (CPT 19340, 19342, 19357) and free flap (CPT 19364). Annual wRVU and Medicare reimbursement were sourced from the CMS. Temporal trends in wRVU/hour and reimbursement/hour were analyzed and compound annual growth rates were calculated. Results: Among 27,106 cases, implant-based reconstruction had significantly shorter median operative times (1.4 hours) and higher median wRVUs per hour (11.94) compared to free flap reconstruction (6.77 hours, 6.29 wRVUs/hour; p < 0.001). Over time, immediate reconstruction CPT 19357 demonstrated increasing operative times alongside declining wRVUs/hour and reimbursement/hour ( p <0.01). In contrast, immediate and delayed CPT 19364 showed a significant increase in reimbursement/hour, largely driven by decreased operative time ( p <0.01). Conclusions: Although wRVU and reimbursement per hour has increased for free flap reconstruction and declined for immediate tissue expander reconstruction, free flap breast reconstruction remains undervalued. This disparity in valuation may disincentivize microsurgical reconstruction, affecting institutional support and patient access.