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Category: Trauma; Ankle; Sports; Other Introduction/Purpose: Increasing overlap exists between surgical care provided by orthopedic foot and ankle surgeons and podiatrists. Use of either specialty depends on numerous factors including perceived costs. Unfortunately, large scale cost comparisons between the two are lacking. Such data is increasingly important given the current climate of payment reform and cost containment in healthcare. Using national Medicare claims data, we therefore aimed to compare per-case Medicare payments between orthopedic foot and ankle surgeons and podiatrists for ankle fracture fixation. We additionally aimed to describe any differences between groups that may drive differences in payments. Methods: This IRB-exempt retrospective study included patients undergoing either unimalleolar, bimalleolar, or trimalleolar ankle fracture repair as recorded in the national Medicare Limited Data Set (2013-2019). Type of surgeon (orthopedic foot and ankle surgeon or podiatric surgeon) was determined using publicly available healthcare provider taxonomy information available from the Washington Publishing Company ( www.wpc-edi.com ) and maintained by the National Uniform Claim Committee ( www.nucc.org ); crosswalks between Medicare Specialty Code and Provider Taxonomy are publicly available. The primary outcome was total Medicare payments specific to the procedure, as a surrogate for cost (inflation-adjusted to 2019 US dollars). Additionally, patient demographics and hospital characteristics were compared between groups to determine if any specific factors associated with costs may influence group differences. Univariable tests (chi-squared and t-tests; non-parametric tests where appropriate) assessed significance of group differences. Results: Overall, 16,927 unimalleolar; 17,244 bimalleolar; and 11,717 trimalleolar fracture repairs were included. Of these, orthopedic surgeons performed more procedures than podiatrists (86.7% vs 13.3% for uni-; 92.4% and 7.6% for bi-; 92.2% and 7.8% for trimalleolar fracture repairs respectively). The mean and median age (71.6 - 72.7 [70-71] years) as well as the mean and median Charlson-Deyo Comorbidity Index (0.6 - 0.7 [0]) did not significantly differ between patients treated by an orthopedic surgeon or podiatrist (p = 0.157 and p = 0.890 respectively). Regionally, podiatrists saw patients more often in the West and Midwest whereas providers in the South were more often orthopedic surgeons (p < 0.001). Median procedure-specific Medicare payments for all three categories of ankle fracture repairs were significantly lower for orthopedic surgeons compared to podiatrists: $4,156 vs $4,300 for uni-, $4,205 vs $4,379 for bi-, and $4,396 vs $4,525 for trimalleolar, respectively (all p < 0.001). Conclusion: In this analysis comparing Medicare payments between orthopedic foot and ankle surgeons and podiatrists we found that ankle fracture fixation procedures performed by the orthopedic surgeons were less expensive and that cost differences do not appear to be driven by patient characteristics. Additionally, we were able to discern geographic differences regarding practice location of both surgeon types. These data will inform future discussions on how to optimize costs of foot and ankle surgical care.