When the Survey Doesn’t Have Your Specialty: Benchmarking an HPB Surgeon’s Outlier Practice

A surgeon producing more than 20,000 wRVUs a year that doesn’t fit cleanly into any national compensation survey specialty. That was the challenge in a recent BFMV engagement involving a high-volume hepato-pancreato-biliary (HPB) surgeon: no major survey reports HPB as its own specialty line, so work was needed to determine which existing specialty, or blend of specialties, could support a defensible number.

A Subspecialty the Surveys Don't Recognize

HPB physicians specialize in the surgical treatment of the liver, pancreas, gallbladder, and bile ducts, managing both complex benign conditions—cysts, chronic pancreatitis, biliary obstruction—and malignant tumors, often using advanced minimally invasive and robotic techniques. There are an estimated 900 to 1,200 practicing HPB surgeons in the United States, a small enough population that none of the major physician compensation surveys report HPB as a separate specialty line.

Training pathways compound the ambiguity. Physicians reach HPB practice through several different routes: a Complex General Surgical Oncology fellowship, an American Society of Transplant Surgeons–accredited fellowship, or a Fellowship Council–accredited program sponsored by the Americas Hepato-Pancreato-Biliary Association. Depending on which path a given surgeon took and the needs of the health system employing them, their day-to-day practice can resemble general surgery, surgical oncology, transplant surgery, or some blend of all three. Most HPB surgeons also don't have the patient volume to sustain an exclusively HPB practice, so they maintain a broader footprint that typically includes acute care and emergency general surgery call coverage.

Without a dedicated HPB benchmark, the practical question becomes: which existing specialty—or combination of specialties—provides the most defensible comparison?

Five Candidate Specialties, Five Different Profiles

We compared HPB with five specialties that HPB physicians most plausibly resemble: general surgery, surgical oncology, transplant (liver), hepatology, and gastroenterology. The differences among them are substantial.

Based on BFMV research, for the median physician, evaluation and management (E&M) volume as a share of total CPT volume ranges from 16% in gastroenterology to 40% in hepatology, with general surgery and transplant liver at around 31% each, and surgical oncology at 37%. Use of the G2211 add-on code—a marker of complex, longitudinal care management—varies even more sharply. Hepatology reports it in 6.4% of visits, surgical oncology in 2.6%, gastroenterology in under 1%, and transplant liver essentially never.

The procedural mix diverges just as much. Representative top procedures for general surgery (laparoscopic cholecystectomy, hernia repair, appendectomy) fall in the 6–10 wRVU range. Gastroenterology and hepatology procedures (endoscopies, biopsies, colonoscopies) cluster even lower, at 2–4.5 wRVUs. Surgical oncology's representative procedures generally run up to 15 wRVUs. Transplant liver surgery falls in a substantially higher wRVU range: liver transplantation alone carries an 87.75 wRVU value.

That spread matters when determining fair market value compensation using a wRVU conversion factor. Applying a conversion factor calibrated to gastroenterology's procedure mix to a surgeon doing transplant-tier cases—or vice versa—may produce a distorted number.

A Practice That Doesn't Fit Any Single Box

The physician at the center of this analysis makes the problem concrete. He is a fellowship-trained HPB surgeon with a leadership role directing GI surgical services and an HPB fellowship program. This academic background included a liver transplant fellowship, an academic faculty appointment, and a substantial publication record. His practice is built around complex pancreatic, hepatic, and gastrointestinal surgery—but his production data show a physician whose activity extends well beyond a narrow HPB scope.

His annual production exceeded 20,000 wRVUs, significantly higher than the 90th-percentile benchmark for each of the five comparison specialties. His CPT volume was broken down into 41% E&M, 44% surgical, 12% medicine, and 2% radiology, and he took substantial inpatient calls, picking up general surgery and other non-HPB cases along the way. His three highest-volume procedures were partial pancreatectomy (48150, 51.52 wRVUs), laparoscopic paraoesophageal hernia repair (43281, 25.94 wRVUs), and partial hepatectomy (47120, 38.03 wRVUs)—a case mix that sits closer to transplant surgery than to general surgery, surgical oncology, hepatology, or gastroenterology. Notably, his numbers didn’t show meaningful use of Medicare add-on codes for complexity and extended time, reinforcing that his practice is procedurally driven rather than centered on longitudinal complex care management, as in specialties such as hepatology.

Taken together, the data point to liver transplant surgery as the closest available comparator in terms of case complexity and wRVU intensity per procedure. However, transplant surgeons' compensation models and conversion factors are typically built around a transplant-focused scope of practice. However, the answer wasn’t as simple as applying a transplant conversion factor to a physician whose wRVU total also reflects a heavy E&M load, general surgery call coverage, and roughly twice the volume of any single benchmark specialty.   

A Defensible Approach

This case illustrates a structural limitation in specialty-based benchmarking: national surveys benchmark specialties, not practices. When a physician's actual scope of work spans several specialty definitions—as is common for HPB surgeons, and increasingly common across other hybrid subspecialties—a single conversion factor borrowed from the “closest” specialty can produce a defensible-looking number that is nonetheless disconnected from what the physician is actually doing. Our approach in this case was to use a more defensible approach of decomposing the physician's production by CPT code and clinical activity type, comparing that mix against multiple candidate specialties rather than picking one, and building a blended or practice-specific benchmark that reflects the physician's actual case mix, volume, and site of service.

BFMV works with physicians and physician employers to benchmark production and compensation when a cookie-cutter analysis won't do the job. For more information, reach out to one of our consultants (see our Teams page) or call us at 678-987-8765 to set up a consultation.