1164143

research-article2023
FAOXXX10.1177/24730114231164143Foot & Ankle OrthopaedicsAlexander et al

Article

Foot & Ankle Orthopaedics

Cost Analysis and Reimbursement of

2023, Vol. 8(1) 1­–6
© The Author(s) 2023
DOI: 10.1177/24730114231164143
https://doi.org/10.1177/24730114231164143

Weightbearing Computed Tomography journals.sagepub.com/home/fao

Nathaniel B. Alexander, MD1, Shumaila Sarfani, MD2 ,

Carson D. Strickland, MD3, David R. Richardson, MD1 , G. Andrew Murphy, MD1 ,
Benjamin J. Grear, MD1, and Clayton C. Bettin, MD1

Abstract
Background: Weightbearing computed tomography (WBCT) is becoming a valuable tool in the evaluation of foot and
ankle pathology. Currently, cost analyses of WBCT scanners in private practice are lacking in the literature. This study
evaluated the costs of acquisition, utilization, and reimbursements for a WBCT at a tertiary referral center, information of
particular interest to practices considering obtaining such equipment.
Methods: All WBCT scans performed at a tertiary referral center over the 55-month period (August 2016 to February
2021) were retrospectively evaluated. Patient demographics, pathology location, etiology, subspecialty of the ordering
provider, and whether the study was unilateral or bilateral were collected. Reimbursement was calculated based on payor
source as a percentage of Medicare reimbursement for lower extremity CT. The number of total scans performed per
month was evaluated to determine revenue generated per month.
Results: Over the study period, 1903 scans were performed. An average of 34.6 scans were performed each month. Forty-
one providers ordered WBCT scans over the study period. Foot and ankle fellowship-trained orthopaedic surgeons ordered
75.5% of all scans. The most common location of pathology was the ankle, and the most common etiology was trauma. The
device was cost neutral at 44.2 months, assuming reimbursement for each study was commensurate with Medicare rates. The
device became cost neutral at approximately 29.9 months when calculating reimbursement according to mixed-payor source.
Conclusion: As WBCT scan becomes more widely used for evaluation of foot and ankle pathology, practices may be
interested in understanding the financial implications of such an investment. To the authors’ knowledge, this study is the
only cost-effectiveness analysis of WBCT based in the United States. We found that in a large, multispecialty orthopaedic
group, WBCT can be a financially viable asset and a valuable diagnostic tool for a variety of pathologies.
Level of Evidence: Level III, diagnostic.

Keywords: weightbearing computed tomography (CT), foot and ankle, cost analysis, reimbursement, acquisition and
utilization, CT scanner, Medicare

Introduction
Weightbearing CT (WBCT) is a technology that has shown
utility in the evaluation and treatment of foot and ankle
pathologies. Initially used commercially in maxillofacial
imaging in the 1990s, cone-beam imaging involves a coni-
cal X-ray beam and a flat image intensifier that rotates
around an anatomic region of interest. Algorithms are used
to translate data into 3-dimensional (3D) models from
which reconstructions of orthogonal planes can be made.
The data collected from a cone beam CT scanner can also
1
Department of Orthopaedic Surgery and Biomedical Engineering,
University of Tennessee Health Science Center—Campbell Clinic,
Memphis, TN, USA
2
Ortho San Antonio, San Antonio, TX, USA
3
Mid Tennessee Bone and Joint, Columbia, TN, USA
Corresponding Author:
Clayton C. Bettin, MD, Campbell Clinic Department of Orthopaedic
Surgery and Biomedical Engineering, University of Tennessee Health
Science Center, Memphis, Tennessee, Campbell Foundation, 1211 Union
Ave, Suite 510, Memphis, TN 38104, USA.
Email. cbettin@campbellclinic.com

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-
NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction
and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages
(https://us.sagepub.com/en-us/nam/open-access-at-sage).
2 Foot & Ankle Orthopaedics
be used to create traditional radiographic projections with-
out having to take multiple images. Recent studies have
demonstrated that WBCT can provide more accurate infor-
mation on the 3D relationships of osseous structures of the
foot and ankle than radiographs or conventional CT scans
and require less time for image aquisition.21 WBCT also
exposes patients to significantly lower doses of radiation
than conventional CT scans, although estimates of true radi-
ation exposure vary.4,15,20 The smaller footprint of WBCT
and decreased need for shielding make it a convenient tech-
nology to incorporate into in-office radiology departments.
As WBCT becomes more widely used in orthopaedic prac-
tice, understanding the costs related to its acquisition and
reimbursements will be of increasing interest.
To the authors’ knowledge, no cost analyses of WBCT
in the United States have been reported in the literature.
The primary purpose of this study was to evaluate the cost
of utilization of a WBCT in a tertiary referral, physician-
owned practice. Secondarily, the utilization of WBCT
based on orthopaedic subspecialty, location, and etiology
of pathology was investigated.
Materials and Methods
After obtaining institutional review board approval, all
WBCT scans performed from the time of initial acquisition
of the device on August 16, 2016, through February 19,
2021, were retrospectively analyzed. Age, patient gender,
pathology location and etiology, unilateral vs bilateral
imaging, subspecialty of the ordering provider, and payor
source were collected. The location of the primary pathol-
ogy was categorized into ankle (tibiotalar joint), hindfoot
(transverse tarsal joint to subtalar joint), midfoot (tarso-
metatarsal to transverse tarsal joint), and forefoot (distal to
tarsometatarsal joints). The pathology was further catego-
rized as trauma, developmental, degenerative (including
Charcot), tumor, fusion/healing, ulcer, or hardware evalua-
tion. Sprains and stress fractures were categorized under
trauma for evaluation purposes. If multiple sites of signifi-
cant pathology were noted, both locations and pathologies
were counted. The payor source was categorized as private
insurance, self-pay, worker’s compensation insurance,
Medicare, or Medicaid. Costs associated with device acqui-
sition and maintenance were obtained from a pro forma
analysis performed prior to purchase. The device used in
this practice was a PedCat WBCT scanner, with a cost of
$179000 including in the extended warranty, which cost
$30000.
Results
This study included 1704 unique patients. Fifty-four per-
cent (920 patients) were female, and 46% (784 patients)
were male. Ages ranged from 6 to 92 years (average age 44
years), with 206 patients being under the age 18 years. The
average number of scans performed per patient was 1.12
(range of 1-5). During the 55-month collection period, 1903
WBCTs were performed, of which 101 were bilateral stud-
ies. An average of 34.6 scans were performed each month
(range 18-50 scans). Forty-one providers from 9 subspecial-
ties used the device. Five foot and ankle fellowship-trained
surgeons ordered 1438 studies over the collection period,
yielding an average of 26.6 scans per month. Other special-
ties that significantly used the device were physical medi-
cine and rehabilitation/physiatry (126 studies) and pediatric
orthopaedics (86 studies). The provider who ordered each
study would follow the patient unless they had pathology
that necessitated evaluation by a fellowship-trained foot
and ankle surgeon. A breakdown of WBCT ordered by spe-
cialty can be seen in Figure 1. Physician assistants (PAs)
were not broken down by subspecialty for the purposes of
this study.
When WBCT use was evaluated based on location of
pathology, 8.5% (152/1898) was for forefoot pathology,
25.7% (488/1898) for midfoot pathology, 27.6 (525/1898)
for hindfoot pathology, and 38.1 (723/1898) for ankle
pathology. The most common disease processes evaluated
by WBCT in this cohort were trauma (54%, 981/1816),
degenerative diseases (30%, 546/1816), fusion/healing
assessment (10%, 179/1816), congenital/developmental
anomalies (4%, 67/1816). Tumors, hardware evaluation,
arthroplasty evaluation, and ulcers accounted for <1% each.
(11/1816, 9/1816, 9/1816, and 14/1816, respectively).
The procurement cost was $179000 for the device,
$30000 for the extended warranty, and $995 for 1-time
licensing fees, giving a total of $209995. Staffing costs
were negligible as the device is run by already employed
radiology technicians during normal business hours; thus,
there is minimal to no additional cost in salary or employee
hours. The daily number of scans is low; thus, we surmise
that most groups with in-house radiology would be able to
use this technology without having to increase staffing.
To allow for ease of analysis and applicability of infor-
mation across orthopaedic practices, Medicare reimburse-
ment of $163.50 for Current Procedural Terminology
(CPT) code 73700, Diagnostic Radiology (Diagnostic
Imaging) Procedures of the Lower Extremities, was used as
a baseline for compensation. Private insurance, workers’
compensation insurance, and self-pay reimbursements were
estimated to be 180% of Medicare, yielding $294.30 in
reimbursement per scan. Medicaid was calculated to be
61% of Medicare reimbursement, resulting in $99.74 per
scan. These values were calculated after a review of the lit-
erature comparing reimbursement of Medicare vs private
insurance and Medicare vs Medicaid for in-hospital and
out-of-hospital services.1,14 These values do have heteroge-
neity based on geographic area and a health system’s nego-
tiated prices with insurance providers; however, the authors
Alexander et al 3

Figure 1. Utilization of weightbearing CT scanner by provider specialty. Foot and ankle–trained providers used the device most
commonly, followed by nonoperative sports, physical medicine and rehabilitation/physiatry (PM&R), and pediatric orthopaedic surgery.

Payor source:

% 0% 1
15% 19% Medicare
5% Private Insurance
Worker's Compensaon
Medicaid
Self Pay
61%

Figure 2. Payor source. The majority of patients in our study were privately insured (1101/2802), followed by Medicare (340/1802),
Medicaid (262/1802), worker’s compensation (95/1802), and self-pay (4/1802).

thought that these multipliers were conservative enough to fee was then paid to the radiology group interpreting the
be widely applicable.1,14 Each CPT code was billed for the images. Thus, the technical component of a CT scan per-
global fee; a contracted fee consisting of 16% of the global formed on a Medicare-insured patient would net $137.34, a
4 Foot & Ankle Orthopaedics
privately insured, workers’ compensation, or self-pay
patient would net $247.2, and a Medicaid insured patient
would net $83.79.
Regarding payor source, 61% (1101/1802) of patients
were privately insured, 19% (340/1802) were Medicare
insured, 15% (262/1802) were Medicaid insured, and 5%
(95/1902) were under worker’s compensation (Figure 2).
Based on an average number of 34.6 scans per month, the
WBCT scan generated $4751.96 in gross revenue, assum-
ing Medicare-only reimbursement rates for all scans, and
$7014.08 per month gross revenue based on mixed-payor
source reimbursement specific to the authors’ institution.
Based on these amounts, it would take 44.2 months to
pay off the device at Medicare reimbursement rates and
29.9 months to pay off the device on mixed-payor reim-
bursements. It should be noted that this time frame will vary
significantly based on each institution’s payor mix distribu-
tion and the total number of scans ordered.
To earn back the total cost of the device, 1529.0 scans
would have to be performed at Medicare-only reimburse-
ment rates, and 1035.9 scans would have to be performed
at mixed-payor rates. For the purposes of this study, we
amortized the initial and ongoing costs over a 60-month
period and found that 25.48 scans were needed per month
to break even, assuming all-Medicare reimbursement or
17.26 scans using our institution’s payor mix. If the repay-
ment were amortized over a 120-month period, 12.74 scans
per month for all Medicare reimbursement and 8.63 scans
for mixed payors would be required for the device to
become cost neutral. Assuming an average life span of
10 years for the machine, that leaves a profit of $360240.68
to $631694.29. These figures disregard some benefits and
potential cost savings, including the ability to more accu-
rately template and plan for procedures, decreased time to
accurate diagnosis, and personnel savings associated with
reduction in time required to obtain imaging compared
with standard foot and ankle radiographs.2,3 This calcula-
tion may also underestimate the increased costs associated
with operating the machine over years 6 to 10. The device
at this institution has been in use for 7 years without sig-
nificant issue.
Discussion
To the authors’ knowledge, no studies exist evaluating the
cost effectiveness of WBCT in a US-based orthopaedic
practice. Several studies based on a large patient cohort in
Europe have been published; however, these results have
limited applicability in the United States because of the sig-
nificant differences in reimbursements and health care
expenditures between the European Union (EU) and US
health care systems. Richter et al2,17-19 demonstrated that
WBCT decreased the time to image acquisition by 12 min-
utes per patient, decreased average radiation exposure, and
increased income from 19 to 58 euros per patient. The
increased income per patient in these studies was primarily
the result of decreased staffing costs for image acquisition as
only 15.1% of their cohort was not insured by a single payor
system and generated income directly from the imaging ser-
vices. WBCT was also used as the primary imaging modal-
ity at this institution during the study period, leading to
comparatively high volumes of WBCT’s being performed.
The authors believe that WBCT is a useful adjunct to plain
radiographs of the foot and ankle, but it has not become the
primary imaging modality at this institution.
Limitations of this study include a lack of a standard
protocol for imaging of foot and ankle injuries in our
group. Additionally, our study primarily serves as a case
example of one institution’s experience with WBCT from
primarily a reimbursement perspective. Differences in
personnel cost were not evaluated. Many factors vary
across the country and individual institutions that should
be considered, including number of providers in the area
or group that would contribute to the number of scans per
month, payor mix, and insurance contracts for reimburse-
ments, to name a few. This study was performed at a ter-
tiary referral center with 5 foot and ankle–trained surgeons;
smaller practices may have issues using the technology
enough for it to be financially viable. To allow for wide
applicability across practice settings, the multiplier for the
reimbursement paid by private insurance in comparison to
Medicare was set at 180% for this study. A review of the
literature showed that this value ranges from 161% to
358%, so this value may vary widely based on contract
negotiations between practices and insurers; however, we
thought that 180% would provide a broadly applicable and
appropriately conservative estimate.1,14 When evaluating
the financial viability of using a similar device, readers
would be encouraged to base it on the regional or group-
specific reimbursement rates.
Future areas of study include further evaluation of cost
efficacy, more accurate assessment of reimbursement for
non-Medicare carriers, evaluation of costs associated with
operating the device. Evaluating the effect of WBCT on
length of patient encounters and time between imaging
being ordered and the study being performed, as well as,
patient perception of WBCT vs traditional imaging modali-
ties could be future areas of study. Comparison of the num-
ber of CT’s ordered prior to implementation of WBCT in
this center vs after would be another area of interest. WBCT
has shown to be a cost-effective tool for the evaluation of
lower extremities at this institution. The technology has
benefits over traditional helical CT scans in evaluating the
foot and ankle under physiologic loads, the primary benefit,
however, likely stems from the convenience of having this
technology available in office for use instead of traditional
CT for nonweightbearing studies. The lower radiation dose
and ease of image acquisition may lead to more studies
Alexander et al
being performed; however, the literature has yet to bear out
whether this leads to more accurate diagnosis. This modal-
ity has not replaced standard radiographs but has proven to
be a valuable addition to diagnostic imaging at this tertiary
referral center.
Conclusion
Based on the authors’ experience, WBCT appears to be a
potentially financially profitable technology for evaluat-
ing a variety of foot and ankle pathologies in a private
orthopaedic practice. Some authors have transitioned to
using WBCT as the primary modality for foot and ankle
imaging, stating a savings in image acquisition time com-
pared to traditional imaging modalities, with an accept-
able radiation dose.4,20 WBCT was used in this practice for
a variety of pathologies but was most used for evaluating
traumatic injuries and degenerative processes about the
foot and ankle. WBCT has not replaced traditional radio-
graphs in this practice for initial imaging of lower extrem-
ity complaints. Because of this, we do not believe that
there is any revenue lost on plain radiographs by using this
technology in appropriately indicated patients. The most
evaluated location in our cohort was the ankle, which dif-
fers from the experience of some other authors.5,6,9 WBCT
has been demonstrated to be a useful modality for assess-
ing the complex 3-dimensional relationships of the osse-
ous anatomy of the foot and ankle under physiologic
load.2,11,12 This is partly due to the lack of rotational and
projection bias.1 Recent studies have investigated acquired
flatfoot deformity, hallux valgus, syndesmotic injury, ses-
amoid position, lateral ankle instability, and first metatar-
sal position7,8,10; however, there is still debate on the most
accurate method of deformity measurement and what con-
stitutes a clinically significant abnormality or a subclinical
deformity.13,22 The effect of weightbearing on specific
radiographic measurements also remains a topic of study
because some measurements demonstrate statistically sig-
nificant differences between weightbearing and non-
weightbearing imaging modalities.3,16,22
Ethical Approval
Institutional Review Approval: University of Tennessee Health
Science Center (Approval #21-08141-XP)
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this arti-
cle. ICMJE 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.
5
ORCID iDs
Shumaila Sarfani, MD, https://orcid.org/0000-0003-3861-4481
David R. Richardson, MD, https://orcid.org/0000-0002-7184-
5233
G. Andrew Murphy, MD, https://orcid.org/0000-0001-8914-
9992
Clayton C. Bettin, MD, https://orcid.org/0000-0003-1540-3526
References
1. Bai G, Anderson GF. Market power: price variation among com-
mercial insurers for hospital services. Health Aff (Millwood).
2018;37(10):1615-1622. doi:10.1377/hlthaff.2018.0567
2. Barg A, Bailey T, Richter M, et al. Weightbearing com-
puted tomography of the foot and ankle: emerging technol-
ogy topical review. Foot Ankle Int. 2018;39(3):376-386.
doi:10.1177/1071100717740330
3. Carrino JA, Al Muhit A, Zbijewski W, et al. Dedicated
cone-beam CT system for extremity imaging. Radiology.
2014;270(3):816-824. doi:10.1148/radiol.13130225
4. Conti MS, Ellis SJ. Weight-bearing CT scans in foot and
ankle surgery. J Am Acad Orthop Surg. 2020;28(14):e595
-e603. doi:10.5435/JAAOS-D-19-00700
5. de Cesar Netto C, Saito GH, Roney A, et al. Combined weight-
bearing CT and MRI assessment of flexible progressive col-
lapsing foot deformity. Foot Ankle Surg. 2021;27(8):884-891.
doi:10.1016/j.fas.2020.12.003
6. de Cesar Netto C, Shakoor D, Dein EJ, et al. Influence of
investigator experience on reliability of adult acquired flat-
foot deformity measurements using weightbearing com-
puted tomography. Foot Ankle Surg. 2019;25(4):495-502.
doi:10.1016/j.fas.2018.03.001
7. de Cesar Netto C, Shakoor D, Roberts L, et al; Weight
Bearing CT International Study Group. Hindfoot alignment
of adult acquired flatfoot deformity: a comparison of clini-
cal assessment and weightbearing cone beam CT examina-
tions. Foot Ankle Surg. 2019; 25(6):790-797. doi:10.1016/j.
fas.2018.10.008
8. de Cesar Netto C, Schon LC, Thawait GK, et al. Flexible
adult acquired flatfoot deformity: comparison between
weight-bearing and non-weight-bearing measurements using
cone-beam computed tomography. J Bone Joint Surg Am.
2017;99(18):e98. doi:10.2106/JBJS.16.01366
9. Haldar A, Bernasconi A, Junaid SE, Lee KHB, Welck M,
Saifuddin A. 3D imaging for hindfoot alignment assessment:
a comparative study between non-weight-bearing MRI and
weight-bearing CT. Skeletal Radiol. 2021;50(1):179-188.
doi:10.1007/s00256-020-03532-7
10. Hamard M, Neroladaki A, Bagetakos I, Dubois-Ferrière V,
Montet X, Boudabbous S. Accuracy of cone-beam computed
tomography for syndesmosis injury diagnosis compared
to conventional computed tomography. Foot Ankle Surg.
2020;26(3):265-272. doi:10.1016/j.fas.2019.03.006
11. Kimura T, Kubota M, Taguchi T, Suzuki N, Hattori A,
Marumo K. Evaluation of first-ray mobility in patients with
hallux valgus using weight-bearing CT and a 3-D analysis
system: a comparison with normal feet. J Bone Joint Surg Am.
2017;99(3):247-255. doi:10.2106/JBJS.16.00542
6 Foot & Ankle Orthopaedics
12. Lepojärvi S, Niinimäki J, Pakarinen H, Koskela L, Leskelä
HV. Rotational dynamics of the talus in a normal tibiotalar
joint as shown by weight-bearing computed tomography.
J Bone Joint Surg Am. 2016;98(7):568-575. doi:10.2106/
JBJS.15.00470
13. Lintz F, Beaudet P, Richardi G, Brilhault J. Weight-bearing
CT in foot and ankle pathology. Orthop Traumatol Surg Res.
2021;107(1S):102772. doi:10.1016/j.otsr.2-020.102772
14. Lopez E, Neurman T, Jacobson G, Levitt L. How much more
than Medicare do private insurers pay? A review of the litera-
ture. KFF. May 28, 2020. Accessed April 28, 2022. https://
www.kff.org/medicare/issue-brief/how-much-more-than-
medicare-do-private-insurers-pay-a-review-of-the-literature/
15. Ludlow JB, Johnson BK, Ivanovic M. Estimation of effec-
tive doses from MDCT and CBCT imaging of extremities.
J Radiol Prot. 2018;38(4):1371-1383. doi:10.1088/1361-
6498/aae44b
16. Malhotra K, Welck M, Cullen N, Singh D, Goldberg AJ. The
effects of weight bearing on the distal tibiofibular syndesmo-
sis: a study comparing weight-bearing CT with conventional
CT. Foot Ankle Surg. 2019;25(4):511-516. doi:10.1016/j.
fas.2018.03.006
17. Richter M, Lintz F, Barg A, Bursses A. Benefit of weight-
bearing CT - what have we learned from more than 8,000
scans at a foot and ankle center [Abstract]. Foot Ankle
Orthop. 2018;3(3):2473011418S00401. doi:10.1177/247301
1418S00401
18. Richter M, Lintz F, de Cesar Netto C, Barg A, Burssens A.
Results of a 5-year, 10,000 scans experience with weight-bear-
ing CT. Impact on costs, radiation exposure and time spent
[Abstract]. Foot Ankle Orthop. 2019;4:2473011419S00358.
doi:10.1177/2473011419S00358
19. Richter M, Lintz F, de Cesar Netto C, Barg A, Burssens
A. Results of more than 11,000 scans with weightbearing
CT – impact on costs, radiation exposure, and procedure
time. Foot Ankle Surg. 2020;26(5):518-522. doi:10.1016/j.
fas.2019.05.019
20. Richter M, Lintz F, de Cesar Netto C, Barg A, Burssens A,
Ellis S. Results from more than 13,000 weight-bearing CT
scans over 6.8 years. Impact on costs, radiation exposure
and time spent. Fuß Sprunggelenk. 2020;18(3):185-192.
doi:10.1016/j.fuspru.2020.05.001
21. Richter M, Seidl B, Zech S, Hahn S. PedCAT for 3D-imaging
in standing position allows for more accurate bone position
(angle) measurement than radiographs or CT. Foot Ankle
Surg. 2014;20(3):201-207. doi:10.1016/j.fas.2014.04.004
22. Shakoor D, de Cesar Netto C, Thawait GK, et al. Weight-
bearing radiographs and cone-beam computed tomography
examinations in adult acquired flatfoot deformity. Foot Ankle
Surg. 2021;27(2):201-206. doi:10.1016/j.fas.2020.04.011