News From ACFAS

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The official hotel block for ACFAS 2016 in Austin is now open. Visit acfas.org/austin today to make your reservations through ACFAS’ housing partner, onPeak, and take advantage of exclusive discounted rates and complimentary amenities at these choice hotels:

• Hilton Austin (headquarters hotel): $229/night
• Courtyard Austin Downtown: $199/night
• Hilton Garden Inn Austin Downtown: $189/night
• Hyatt Place Austin Downtown: $209/night
• JW Marriott Austin: $229/night
• Residence Inn Austin Downtown: $209/night

Booking in ACFAS’ hotel block not only helps ensure you get the best deal, it also protects you from unauthorized third parties claiming to be our official housing partner.

These special limited-time rates won’t last long—head to acfas.org/austin now and get one step closer to ACFAS 2016! Congratulations to the following officers for the 2016–2017 term:

President: Sean T. Grambart, DPM, FACFAS
President-Elect: Laurence G. Rubin, DPM, FACFAS
Secretary-Treasurer: John S. Steinberg, DPM, FACFAS
Immediate Past President: Richard Derner, DPM, FACFAS

These new Board officers will be installed during ACFAS 2016 set for February 11–14 in Austin, Texas.
JFAS just got even more accessible! The Journal of Foot & Ankle Surgery (JFAS) is now available through your iPhone and Android devices, as well as your iPad, through the JFAS mobile app. Now it’s easier than ever to take JFAS with you wherever you go. No matter if you’re at work, home or on the road, you can stay informed of the latest advances in foot and ankle surgery with just a tap of your finger.

Convenient mobile access to JFAS means you can also:

• browse new or past issues or get a preview of issues in press
• find the content you want more quickly with streamlined layouts and navigation
• interact with figures, tables, multimedia and supplementary content
• personalize your experience with My Reading List and Notes
• save articles for offline reading or share them via social media

Visit your app store today for your free download and put the power of JFAS at your fingertips! The new ICD-10 implementation will change the number of potential characters in a code set from five to seven. However, since not all codes require seven characters, it is important to know when the seventh character is needed.

The seventh character, which is based on the care the patient received and type of encounter (initial, subsequent or sequela), does not depend on whether the patient is seeing a new or different physician.

If a code requires a seventh character, it will be listed with an underscore in the last column of the ICD-10 code. Seventh character codes will most likely be needed in injury and poisoning cases and diseases of the musculoskeletal system.

For more information on the ICD-10 implementation, visit ACFAS’ ICD-10 resource page.
The following foot and ankle reconstruction fellowship meets the minimal requirements to be granted Conditional Status with ACFAS:

Penn Lower Extremity Plastic & Reconstructive Surgery Fellowship
Philadelphia, Pennsylvania
Program Director: Albert D’Angelantonio, III, DPM, FACFAS
acfas.org/fellowshipdangelantonio/

All Conditional Status programs are considered for "Recognized Status" with ACFAS by the Fellowship Committee after the first fellow completes the program.

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/fellowshipinitiative for a complete listing of programs and minimal requirements.

Foot and Ankle Surgery

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A recent study was conducted to assess and compare long-term clinical and radiographic outcomes using osteochondral autograft and allograft to manage either recurrent or large osteochondral lesions of the talar dome (OLT). Thirty-six patients were observed: 20 were administered osteochondral autograft plugs and 16 received osteochondral allograft plugs. Pre- and postoperative function and pain were graded with the Foot and Ankle Ability Measures (FAAM) scoring system and a Visual Analog Scale (VAS) of pain. The 20 patients who received osteochondral autograft saw their mean FAAM scores increase from 54.4 preoperatively to 85.5 after final follow-up. The mean VAS pain score decreased from 7.9 out of 10 preoperatively to 2.2 out of 10 after final follow-up. The 16 patients who received osteochondral allograft experienced increases in FAAM scores from 55.2 to 80.7; the VAS pain score in this group decreased from 7.8 out of 10 to  2.7 out of 10. The researchers concluded osteochondral allograft achieved results comparable to osteochondral autograft for treating recurrent or large OLTs.


Up to 50 percent of patients with a diabetic foot ulcer show symptoms of peripheral artery disease (PAD). Researchers used a 2012 systematic review to conduct an updated study on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. Fifty-six patients were eligible for review. The major outcomes following endovascular or open bypass surgery were similar among the four selected randomized studies with a control group. The one-year limb salvage rates after open surgery were 85 percent and after endovascular revascularization, the rate was 78 percent. After one year, 60 percent of ulcers had healed following either type of surgery. There was insufficient data to suggest that one surgery was superior to the other. The researchers concluded by citing a need for standardized reporting of baseline demographic data, disease severity and outcome reporting.


Plantar faciitis is thought to be best treated by conservative methods, but many patients still experience prolonged duration of symptoms that often results in surgery. One study analyzed the long-term outcomes of partial plantar fascial release, which is reported to have a short-term success rate of up to 80 percent. Twenty-four patients were assessed and received two outcome score questionnaires: Visual Analog Scale—Foot and Ankle and Manchester Oxford Foot Questionnaire (MOXFQ). All patients were reviewed postoperatively. Patients who had received preoperative steroid injections achieved worse outcomes than patients who did not. The mean MOXFQ score was 33.6 ± 3.9 (0–64). Mean VAS-FA score was 57.8 ± 4.9 (24–100). The study found a negative correlation between duration of follow-up and outcome in both scores. This indicated that patients continued to improve many years following the operation. The authors suggested that open plantar fascia release is a questionable clinical method and that patients can often improve over the natural course of the disease.

Practice Management

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When ICD-10 becomes official in October, some practices will transition smoothly. Claims denials in many cases will be forgiven if the submitted code is in the right family of codes. That said, providers are still bracing for an increase in denials. Whether or not payers go easy on coding mistakes, those increases will occur. It is a good idea to handle this by having a system in place for managing claims that bounce back. If ICD-10 training is finished, or if you have some extra time, it is important to put this plan in action. Coding will be slower and time will be in a crunch at the beginning of implementation, so it is worth the effort to make sure refused claims are worked promptly. "Practices should implement a denials process, in which denials and rejections are worked every day and one that has a 24-hour turnaround time," said Asia Blunt, an AAPC-certified coder and trainer. Blunt also noted that setting up a tracking system is important so that you can monitor the reason for denials and rejections.


Fewer than half of physician leaders have access to formal physician leadership training at their organization, according to a new survey from the Navigant Center for Healthcare Research and Policy Analysis. The survey also indicated that support for leadership programs is growing, although opinions differ on how those programs should be structured. The survey, which polled 2,398 members of the American Association of Physician Leadership, found that hospitals often recruit leaders from outside the healthcare sector, particularly when seeking financial expertise. "The survey results demonstrate the timely need to educate and empower physicians as leaders within healthcare organizations," Paul Keckley, Ph.D., managing director at Navigant, said.

Health Policy and Reimbursement

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The American Medical Association (AMA) issued a 12-page analysis Sept. 8 expressing discontent with the proposed Anthem-Cigna and Aetna-Humana mergers. The report claimed the consolidations would lead to an “unprecedented lack of competition” in the market. “A lack of competition in health insurer markets is not in the best interests of patients or physicians,” AMA President Steven J. Stack wrote in a statement. Aetna, Humana, Cigna and Anthem are four of the five biggest health insurers in the country. The report found that as many as 154 cities would experience decreased competition. Seven in 10 cities already experience a “significant absence” of competition, and 46 states have two insurers with at least a 50 percent share of the market. The U.S. Department of Jusice must approve the mergers before they are finalized.


The entire country is gearing up for the Oct. 1 ICD-10 deadline, but Medicaid programs in California, Louisiana, Maryland and Montana will not be fully converting despite the federal mandate. They have instead received approval from the Centers for Medicare and Medicaid Services to take incoming claims coded in the ICD-10 system, convert them to ICD-9 codes and use the older systems to calculate payments. This is because the claims processing systems in those four states are unable to perform payment calculations using the new ICD-10 codes. Experts warn risks are involved with this approach, and many believe that it could be a large burden on healthcare organizations. Risks include compromised data quality from “convoluted codes” that do not map to similar concepts in moving from one code set to another, as well as hits to providers' bottom lines from delayed or rejected claims due to cross-coding issues. In addition, the four Medicaid programs may not be the only payers using the technique. Holley Louie, president-elect of the Healthcare Billing and Management Association, said, “We've heard from some of the smaller commercial plans that they will do the same thing.” The method, known as a crosswalk technique, is not permanent or long-term. Once the systems are completely ready, full implementation will be required.


The Centers for Medicare and Medicaid Services (CMS) came to an agreement in July with the American Medical Association that allowed for a one-year Medicare payment accommodation period following ICD-10 implementation in which incorrectly coded claims would still be paid. This was a big step for CMS, but there have been no other announcements concerning other insurers. According to Pat Kennedy, president of PJ Consulting Inc., this is because insurers want to keep the pressure on providers and vendors to be ready. Kennedy noted that within a month, payers should issue announcements of reassurance. Not all providers will be happy, especially those who have done little to prepare for ICD-10. Providers who have given a solid effort will be helped, but Kennedy is not so sure about those who have done nothing. Small regional payers, on the other hand, will not be providing sufficient help since they do not have the same resources as larger payers. Kennedy said no matter how ready and able you are, there will be pains. ICD-10 is the biggest change in years, and everyone is aware of how critical it is to be as prepared as possible.

Medicine, Drugs and Devices

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Crowdfunding sites are typically used to raise money for creative projects, but a growing number of entrepreneurs are turning to the online community to raise money for experimental medical devices. Companies like Airing, which is raising money on Indiegogo to fund a disposable medical device to treat sleep apnea, are lining up hundreds of customers and taking in hundreds of thousands of dollars despite the fact that their products are years away from being approved by the U.S. Food and Drug Administration (FDA). Entrepreneurs turn to crowdfunding in this situation because it allows them to raise the money more quickly. This is because the community donating has a stake—they desperately care about the product. Airing has raised more than $1 million from 10,000 donors, which CEO Stephen Marsh attributes to "how badly people want to try these." Funding devices online falls into a legal gray area, but regulators have taken no action to halt the practice. Lawyers and agency observers say it is unlikely FDA will devote its limited resources to regulating the practice unless it appears patients are being harmed.


The U.S. Food and Drug Administration (FDA) has issued a warning that medical devices are at increased risk of being hacked. The problem was discovered by cybersecurity expert Billy Rios, who noted that IV pumps and other devices are connected to a centralized computer network, making them easier to access. Rios' research has prompted FDA to warn hospitals to stop using certain types of pumps. But the threat goes beyond pumps alone. Pacemakers have been hacked, and devices like insulin pumps and EKG machines are also at risk. Rios believes there is a simple reason why manufacturers have not fixed the issues. "Normally, what has to happen is we have to wait for someone to be killed. And that’s not a good point,” he said. “We don’t want someone to have to die in order to become a data point for them to make a decision." While the chance of any specific medical device getting hacked is low, a very real threat still exists.


A new, inexpensive drug being used during surgeries at St. Michael's Hospital in Toronto can reduce the number of red blood cell transfusions by more than 40 percent without negatively affecting patients. A recent study showed that tranexamic acid (TXA) prevents excessive blood loss and can be effective in orthopedic, trauma and cardiac patients. Patients who received TXA at St. Michael's Hospital did not experience any increase in adverse effects or mortality rates. "Other hospitals and surgical centres should consider making TXA mandatory for similar surgeries because it can improve quality of care, decrease the need for blood transfusions and even save money," said Dr. Greg Hare, an anesthesiologist at St. Michael's. The drug costs just $10 per patient, which stands in stark contrast to the $1,200 price tag associated with transfusing one unit of blood.