Why do female plastic surgeons earn less than their male colleagues? Differences in billing and coding for procedures performed may partially explain this income gap, according to a study in the November issue of Plastic and Reconstructive Surgerythe official medical journal of the American Society of Plastic Surgeons (ASPS). 

Gender-related differences in income may also be related to a lower overall volume of procedures and fewer major surgeries, reports the special Plastic Surgery Focus article by ASPS Member Surgeon Loree K. Kalliainen, MD, of Brown University, Providence, R.I., and colleagues. “This study should encourage acknowledgement of gender disparities in surgical practice types, as well as in billing and coding practices,” the researchers write.

Gender Gap in Plastic Surgery Income Linked to Differences in Work RVUs

Previous reports have shown that female physicians have lower incomes than their male colleagues across specialties, including plastic surgery. In one recent survey, average income was $49,000 lower for women plastic surgeons: an 11% income gap.

To explore possible explanations for the gender discrepancy, the researchers analyzed surgical cases submitted to the American Board of Plastic Surgeons (ABPS) by 1,036 candidate surgeons from 2014 to 2018. Case lists are a key step for surgeons seeking to become board-certified plastic surgeons.

The analysis focused on gender differences in the way the procedures were coded for billing purposes, as well as the numbers and types of surgeries performed. Coding using the relative value system (RVU) is a standardized method to account for a wide range of factors affecting the value of physicians’ work, such as the time, effort, and risks of specific procedures and services. Each surgical procedure (or component of a complex procedure) has a specified RVU. Surgeons may be paid a negotiated rate per RVU.

Of the 1,036 plastic surgeons included in the analysis, 277 were women. Female surgeons were more likely to work in academic or independent academic settings, while male surgeons were more likely to be in private practice.

Analysis of case lists found significant differences in coding between male and female surgeons. Average total RVUs were about 19% lower for women surgeons compared to men, with an overall difference of 818 work RVUs. Average work RVUs billed per case were about 11% lower for female surgeons.

Female plastic surgeons also performed fewer major surgeries, compared to men: 77.6 versus 90.5 major cases, a difference of about 14%. Overall number of cases was about 10% lower for women surgeons, just under the cutoff for significance. Numbers of minor cases were similar between gender groups.

Male surgeons billed more work RVUs than female surgeons in academic, independent, and private practice settings. However, practice type did not seem to be a major determinant of the number of cases performed.

Improvement in Coding Practices Needed to Reduce Gender Wage Gap

“This study supports the hypothesis that differences in earnings between male and female plastic surgeons are related to the number of major operative cases performed and how they are coded,” Kalliainen and coauthors write. They estimate that, over a year, the female surgeons in their study would have earned about $55,000 less than their male colleagues—a difference of about 19%. The gender differences in work RVUs and income are comparable to those reported in other specialties, including cardiology and plastic surgery.

“This work provides new insight into and compelling evidence explaining some of the gender wage gap in plastic surgical practice,” the researchers write. “It is not simply the volume of surgery that affects annual income, but the types of cases performed.”

Kalliainen and colleagues highlight the need for initiatives to improve coding practice among plastic surgeons, as well as further studies devoted to understanding the gender-related differences in billing and coding. The authors conclude: “It’s important to code accurately, not only for oneself, but for appropriate reimbursement and documentation of patient illness severity for the medical system to ensure that reimbursement is dispersed equitably.”