News From ACFAS

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If you haven’t yet sent us your ACFAS 2016 manuscript, the clock is ticking. Manuscript submissions are due August 14, 2015.

Scheduled for February 11–14 in Austin, Texas, ACFAS’ annual manuscript competition brings together the very best in advanced podiatric medical research. All manuscripts submitted for consideration are blind-reviewed and judged on established criteria. Winners divide $10,000 in prize money.

Don’t delay—refer to our manuscript requirements and instructions for authors for your chance to be a contender in one of the conference’s main events.
If you're undecided about continuing your training after residency, check out ACFAS' newly released podcast, Investing in My Future: Is It Worth Another Year?

A panel of former post-graduate fellows review the pros and cons of pursuing a fellowship and discuss the investments they made financially, intellectually and socially. They also describe characteristics of the "Ideal Fellow," explain potential return on investment and outline a fellow's responsibilities to give back to the profession after fellowship.

ACFAS' podcast library includes What Is Fellowship Like: By Fellows, For Fellows, Foot and Ankle Fellowships...Why They Might Be Right for You and other releases to help guide you before, during and after residency. New podcasts are added each month, so visit the library often to listen to the latest releases.
Your unpublished research deserves an attentive and targeted audience. Submit your article to the Journal of Foot & Ankle Surgery (JFAS) and reach foot and ankle surgeons, podiatrists, orthopaedic surgeons and sports medicine physicians who value your insights on foot and ankle surgery.

Visit the Author’s Corner on jfas.org to learn how to send us your article for consideration. The Author’s Corner also includes info on copyright transfer, conflict of interest, artwork guidelines and more to make the submission process as easy and painless as possible.

Published bimonthly and peer-reviewed, JFAS is considered the leading source for original, clinically focused articles on surgical and medical management of the foot and ankle. JFAS is also indexed through Index Medicus, Excerpta Medica, BioSciences Information Service of Biological Abstracts and CINAHL, which gives your article even more exposure.

Writing for JFAS is more than just another line item on your resume—it’s your opportunity to share your research with your colleagues and to advance the profession. Submit your article today!

Foot and Ankle Surgery

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Researchers investigated the clinical effects of anatomical reconstruction of the lateral ankle ligaments to treat chronic lateral ankle instability (CAI). Fifteen patients with CAI were treated by creating fibular channels with a patient-specific navigational template. The patients were followed up for nine to 24 months after the operation. No recurrent CAI was observed, and 14 of the patients were rated as "excellent." No severe complications were found. The researchers built a digital navigation template for creating fibular channels to reconstruct the ankle ligament. Using the template was important to physically building the channels. The experiment successfully facilitated the treatment of CAI.


A recent study analyzed the incidence and functional outcome of a distal tibiofibular synostosis. Researchers observed 274 patients with isolated AO type 44-B or C fractures of the ankle who underwent surgical treatment. Patients were divided into three groups based on radiograph results: 222 showed no or minor calcifications, 37 displayed severe calcification and 15 had complete synostosis. There was no significant difference in incidence of synostosis between AO type 44-B and type 44-C fractures. Severe calcification or synostosis occurred in 21 patients in whom a syndesmotic screw was used and in 31 in whom a syndesmotic screw was not used. No other significant differences were found. The researchers determined their findings suggest that synostosis of the distal tibiofibular syndesmosis in general does not warrant treatment.


A recent study investigated whether including quantitative data on blood flow distribution compared with visual qualitative evaluation could improve the performance and reliability of mTc-hydroxymethylene diphosphate three-phase bone scintigraphy (TPBS) in patients who may have charcot neuropathic osteoarthropathy (CNO). Ninety patients with confirmed diagnosis of CNO were observed. The three-phase bone scintigraphy was tested for sensitivity, specificity and accuracy. With/without quantitative data, the respective results were 89 percent/88 percent, 58 percent/62 percent and 77 percent/78 percent. Researchers concluded that adding quantitative data on blood flow distribution in the interpretation of TPBS improved intra-observer variation. No difference in interobserver variation was found, and diagnostic performance did not improve using quantitative data in the evaluation.

Practice Management

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You may think that keeping billing in-house is important, but outsourcing billing can:

1. Free up office space. The biller will not need a workstation and the records are stored somewhere else.
2. Make some employee turnover irrelevant. Unless your practice is big enough to justify a billing department, let someone else handle turnover.
3. Cut down on incoming phone calls. Your office staff will have an easier time if billing calls go directly to the billing service.
4. Turn a fixed expense into a variable one. Staff and office space are fixed expenses; if your practice pays a percentage of collections for the billing service, a perfect correlation exists between collections and cost.
5. Know what is going on in the marketplace. Outsourcing billing provides a broader perspective that an in-house biller otherwise would not know.
6. Anticipate payer rule changes. A good billing service is always aware of proposed changes.
7. Access solid data analytics. The service can share data and help identify what your practice is doing well and poorly.
8. Know your accounts receivables. A good billing service will provide all information necessary, something an in-house billing person has no time to provide.
9. Have a resource at payer offices. Billing services can often develop more personal relationships that expedite problem resolution.
10. Be prepared for a payer audit. A good billing service is an expert advocate in case of a payer's audit. They know the process and jargon and have the documentation on hand.

The deadline for ICD-10 implementation is fast approaching, so it is important to become as well-educated in the new coding increases as possible. One important thing to consider is location. ICD-10 has almost 70,000 codes, but that number seems less frightening when you realize that many of the codes are location-based. While the number is still quite high, knowing that ailments will be compartmentalized by location is a positive. To best prepare, run a list of the most frequently used conditions that affect bilateral anatomic parts of the body. Codes in the musculoskeletal chapter have increased greatly due to increased specificity of location and laterality. Pain, arthritis, gout—all of these conditions have more code options than in ICD-9. Gout is a good example, going from less than a dozen codes in ICD-9 to more than 100 codes in ICD-10. The largest increase in codes is in Chapter 19, "Injury, Poisoning and Certain Other Consequences of External Causes" because the locations become more specific, and laterality is added to the description of many injuries. Also, many more codes describe complications of an injury. Most electronic health records have a built-in translation program that will map codes from ICD-9 to ICD-10, and many medical providers are seeing these ICD-10 codes in their problem lists. Mapping or translation programs between ICD-9 and ICD-10 will be of great help. However, any code that has increased location specificity or laterality will map to an unspecified code in ICD-10.


Telehealth services are becoming a rapidly growing industry, emerging so quickly that many physicians may not have noticed it yet. Virtual visits are viewed either as competition or as a revenue source for physicians. But should physicians stay away from this revolution or join in? Virtual visits could ultimately save much money. For example, the Bon Secours Virginia Medical Group says that telehealth could reduce health costs for the 13,000 employees in its self-insured plan, while capturing additional shared savings for the 27,000 Medicare patients in its accountable care organization. Some organizations believe that virtual visits will help with continuity of care. If patients pay monthly fees for online messaging, continuity could rise and deeper relationships could form. But there are downsides. Patients will want to be able to access their physicians outside office hours, and a new business model will need to be drawn up to accommodate rapidly changing expectations. In addition, many physicians could earn less with virtual visits than in-person visits. As of now, 49 state boards require that physicians engaging in telemedicine are licensed in the state where the patient is located.

Health Policy and Reimbursement

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A new calculation called the "Adjusted Complication Rate" is now being used to score surgeons against their peers. The statistic, developed by non-profit news outlet ProPublica, analyzes nearly 17,000 doctors performing low-risk, common elective procedures. It is causing debate among the surgical community because it could have long-ranging effects on surgeons across the country. If a surgeon appears on the list with a higher-than-average complication rate, it could impact payments and reputation. A preliminary analysis found that half of the 3,575 hospitals observed had a surgeon performing a procedure at which they are high risk. Many doctors are skeptical about whether or not the statistic can properly capture the vast array of risks involved with the patient population, and the model could even lead to doctors choosing lower-risk patients to boost their scores. Charles Mick, a spine surgeon in Massachusetts who helped develop the formula, said that the statistic shouldn't be viewed as a scorecard but as a tool to improve care. "I'm hopeful hospitals will look at the data and look for other systems that could work for them," Mick said. "And if you're below average, you can demonstrate how they've improved."


The Centers for Medicare and Medicaid Services (CMS) announced July 8 that physicians will see a 0.5 percent overall increase in Medicare reimbursement next year under a new proposed physician fee schedule. The fee schedule is expected to be finalized this fall and is the first to be issued since Congress repealed the controversial sustainable growth rate (SGR) formula in April. "Today's release of the proposed 2016 Medicare Physician Fee Schedule marks the beginning of health security for millions of elderly and disabled Americans who depend on Medicare," Robert Wergin, MD, president of the American Academy of Family Physicians. The rule will also reimburse physicians for discussion of patients' wishes regarding end-of-life care. The American Medical Association (AMA) supported the proposal, stating that it "affirms the need to support conversations between patients and physicians to establish and communicate the patients' wishes in responding to various medical situations."  


The Centers for Medicare and Medicaid Services (CMS) has released a plan for reimbursing hospitals and ambulatory surgical centers starting in 2016. Proposed changes include a reduction in outpatient payment rates as well as updating Medicare's conversion rate in the physician payment schedule. Under the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System, CMS proposed changes in payment rates for hospital outpatient departments, ASCs and partial hospitalization services conducted in community mental health centers. CMS suggested a decrease of 0.1 percent for outpatient payment rates. An additional two percentage-point increase will be included to account for inflation in OPPS payments due to an increase in payments for laboratory tests. CMS also suggested updates to the conversion factor by two percent. According to the agency, CMS last year overestimated the use of laboratory test packaging by about $1 billion. Consequently, the agency decided to reduce the conversion factor. The proposed rule also includes important proposed changes to the Two Midnight Rule 2016.  See a related fact sheet for detailed information.


Only a few months remain before the Oct. 1 deadline mandating ICD-10 implementation, and the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) are stepping forward to assist physicians in their transition to the new diagnostic coding system. CMS and AMA will educate providers via webinars, on-site training, educational articles and national provider calls. CMS will also set up an ICD-10 communications and coordination center that will send letters to providers encouraging ICD-10 readiness, provide additional training and host provider calls. CMS’ free help includes the “Road to 10” aimed specifically at smaller physician practices with primers for clinical documentation, clinical scenarios and other specialty-specific resources to help with implementation. AMA also has a broad range of materials available to help physicians prepare for the deadline.  


U.S. Rep. Mike Thompson (D-Calif.) has introduced the Medicare Health Parity Act of 2015, which would phase in telemedicine for Medicare beneficiaries and put the practice of telemedicine on a path toward parity with in-person healthcare visits. A previous version of the bill called for a four-year, phased-in approach, while the new bill calls for a three-phase approach. The legislation is supported by several groups, including the American Telemedicine Associate, Telecommunications Industry Association, American Heart Association and the American Stroke Association.

Medicine, Drugs and Devices

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The Supreme Court ruled in June that the Affordable Care Act (ACA) could continue subsidizing millions of Americans, and now Republican lawmakers are turning to the medical device tax to attempt to chip away at the law. The House has already voted to repeal the tax, although it is expected that President Barack Obama will veto a standalone repeal. The tax itself is a 2.3 percent levy imposed on manufacturers or importers of devices, designed to yield nearly $30 billion over the course of a decade. Advocates of the repeal argue that lifting the tax would make it cheaper to produce medical devices. Proponents of the tax claim it is a fair fee for manufacturers who have seen profits rise as more Americans have signed up for coverage. The Obama administration has continually upheld the tax as a key component of funding, one that does not put undue strain on the industry.


Nurse practitioners and physician assistants are playing an increasingly large role in the healthcare system, but the federal Physician Payment Sunshine Act does not require companies to publicly report payments to these professionals, even though they are often allowed to write prescriptions in most states.  In June, a nurse practitioner in Connecticut pleaded guilty to taking $83,000 in kickbacks from a drug company in exchange for prescribing its high-priced drug to treat cancer pain, but this payment does not appear on federal government data on payments by drug and device companies.  For some drugs, including narcotic controlled substances, nurse practitioners and physician assistants are some of the top prescribers.


Two senators have introduced a measure to make Food and Drug Administration (FDA) device reviews more efficient. The bill includes three main elements. First, it seeks to consistently apply a "least burdensome" approach across the entirety of the review process. Second, it allows medical device sponsors to secure a central Institutional Review Board (IRB) approval instead of receiving study approvals from local IRBs. This allows for quicker and cheaper multi-center trials. Finally, the bill asks that FDA publish updated guidance on the criteria for CLIA waivers, especially for point-of-care and rapid diagnostic tests. This guidance should make it apparent that "if a test performs the same in the hands of untrained users as it does in the hands of laboratory professionals, then it may be administered in CLIA-waived labs." Medtech industry group AdvaMed applauded the proposal, saying that the law will "greatly improve the efficiency of FDA's medical technology review process."