News From ACFAS

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Make sure you have your first choice of hotel rooms for ACFAS 2015 in Phoenix by booking your hotel reservations online today with our official housing partner, onPeak. Rooms are available on a first-come, first-served basis, so sign up now to get your first choice of exclusive hotels.

Visit acfas.org/phoenix for full details and to get the lowest rates for your stay in Phoenix. Online registration for ACFAS 2015 will be available soon -- check the conference website regularly for updates. The Coalition for Patients’ Rights (CPR) has urged the federal government to take action on a provision that is preventing patients from accessing the care provider of their choice. ACFAS is a member of the coalition.

Under the Affordable Care Act, private health insurers must include and reimburse licensed or certified healthcare providers in insurance plans. The provision specifies that insurers “shall not discriminate with respect to participation under the plan or coverage against any healthcare provider who is acting within the scope of that provider’s license or certification under applicable state law.” However, many insurers are excluding such licensed providers entirely from participation in health insurance plans or are not allowing them to participate to the full extent permitted under applicable state law.

CPR called for the federal government to rescind an April 2013 Frequently Asked Questions document, that ignores the congressional intent of Section 2707(a) and has allowed insurers to exclude entire classes of licensed healthcare providers. CPR wants corrective action that will clearly instruct insurers of their obligation to follow the law based on congressional intent in crafting it.

For more information on this issue, visit CPR’s website. Are you and your office staff using modifiers correctly to ensure you’re getting paid appropriately for services provided? Are you aware of the four new Healthcare Common Procedure Coding System modifiers that define subsets of Modifier -59 for Distinct Procedural Service take effect January 1, 2015?

If not, plan to attend ACFAS’ webinar, Understanding Modifiers: Including the New Subsets for Modifier -59, set for Wednesday, November 12, 2014, from 7:30–8:30 pm (CST). Jacqueline Reiss-Kravitz, CPC, will walk participants through the correct use of all Current Procedural Terminology modifiers for foot and ankle procedures, help untangle the web and show how to properly bill services to third-party payers, Medicare and Medicaid.

Visit acfas.org/practicemanagement to register now! No matter if you’re looking to strengthen your surgical skills in forefoot and rearfoot reconstruction or to learn the latest in coding and practice management, ACFAS’ education programs have just what you need. This fall’s lineup of courses, workshops and seminars—led by expert faculty—promises to deliver the superior in-depth instruction you have come to count on from ACFAS.

Through focused lectures, engaging panel discussions and hands-on lab work, these conveniently located two-day programs broaden your knowledge of the most up-to-date techniques, procedures and policies and also give you the chance to earn CPME CE credits.

View our Education Calendar for the full listing of in-person educational opportunities this fall and to register. See you in class!

Foot and Ankle Surgery

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Several members of Northwestern University's Department of Orthopaedic Surgery have performed a study they say provides the first 3D imaging-based description of the anatomy of the fifth metatarsal. The study's authors believe providing such a description is important because it will aid orthopaedic surgeons in the pre-operative planning for surgical treatment of Jones fractures using intramedullary (IM) screw fixation. Selecting the correct screw for such procedures is important because failing to do so can result in refractures, non-union and cortical blowout fractures. The authors used foot computed tomography (CT) scans of 119 patients and used 3D models to make a number of measurements of the fifth metatarsal. They found that the average straight segment length of the fifth metatarsal was 52 mm and that this comprised 68 percent of the total length of the metatarsal from its proximal end. The measurements also showed that the widest part of the medullary canal cross-section was in the sagittal plane, while the narrowest part was the coronal plane. These and other findings led the study's authors to conclude that screws used during surgery should be less than 68 percent of the length of the fifth metatarsal. The study also noted that a screw with a diameter of more than 4.5 mm may be needed to provide adequate fixation since the isthmus of the medullary canal for most of the fifth metatarsals examined were larger than 4.5 mm.


A new study sought to shed some light on the comparative advantages and disadvantages of two recently developed ligament reattachment techniques for the modified Brostrom procedure, a topic that has been the subject of few studies. The study involved 45 amateur athletes under the age of 30, 24 of whom were treated with the suture anchor technique while the remaining 21 were treated with the suture bridge technique. Similar functional outcomes were seen in both groups of patients. No significant differences were seen between the two groups in terms of the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Foot and Ankle Outcome Score (FAOS), the Karlsson score, Sefton grade and stress radiographs used to evaluate mechanical stability. No significant differences were seen between the time it took patients in both groups to resume several exercises, including jogging, spurt running and standing on one leg for more than one minute. The study found that three patients in the suture anchor group experienced skin irritation caused by the suture materials while two cases of intraoperative breakage of the suture anchor were observed in the suture bridge group.


A new study has found that primary cement arthroplasty could be a good treatment option for elderly and less active individuals suffering from various types of advanced ankle destruction, such as intractable infection or bone tumor. The study involved 16 patients between the ages of 23 and 74 who underwent the procedure and were followed up with after an average of 39 months. At final follow-up, patients were asked to report their level of athletic activity, the length of time they could walk continuously, whether or not they needed walking aids, and whether or not they required pain medications. None of the cement spacers used in the study broke during the study period. The average American Orthopaedic Foot and Ankle Society (AOFAS) score improved from 39 pre-operatively to 70 post-operatively, while the average visual analogue scale (VAS) score improved from 8 to 3 during the same period of time. In addition, nine patients reported not needing walking aids, while 10 said they did not need pain medications. Nine patients were also able to walk continuously for an hour. One patient experienced a failure of the procedure, as he or she was in constant pain at final follow-up.

Practice Management

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Debt collection is becoming an increasingly important issue for physicians' practices as patients face higher out-of-pocket costs for healthcare and as managed care companies increasingly look for ways to deny claims. Healthcare industry organizations and experts say practices can follow several guidelines to ensure they are paid the money they are owed. The Healthcare Financial Management Association and the Association for Credit and Collection Professionals, for example, has worked with healthcare providers and others to develop a set of best practices for medical debt collection that includes a recommendation for practices to educate patients about payments and debt collection as soon as possible. Doing this is necessary because a lack of effective communication with patients leaves them confused about whether they are required to pay what the practice tells them they owe and follow their debt collection policies or follow the directions provided by debt collectors. This confusion exists because practices and debt collectors are failing to properly communicate with one another, the organizations found. Experts also say practices that outsource their debt collection activities should ensure that vendors follow industry best practices. As for ensuring claims are paid by managed care companies, practices should ensure their bills are "clean" and "well-documented" to make it as difficult as possible for the payer to deny a claim, says attorney Bradley M. Seldin.


Hospitals may be able to improve the experiences of their patients and boost their Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) scores by striving for higher levels of employee engagement, experts say. One such expert is Kevin Gwin of Ardent Health Services, who notes that hospitals cannot expect loyalty from their patients unless they first gain the loyalty of their employees. Gwin and other experts say hospitals can take a number of steps to improve employee engagement, including holding social events that allow rank-and-file employees to interact with members of management. Such events are important because they build trust and make it more likely that employees will confide in management about compliance issues or any other matters they may need help with to perform their jobs. In addition, Gwin says it is important to ensure the pay and benefits given to employees are competitive and that they have paid time off and opportunities to grow in their careers. Management should also be sure to listen to the concerns of staffers by surveying them about the issues they face on a daily basis, Gwin says, including whether equipment is current and in good working order.


Physicians' practices that directly employ physician assistants (PAs) or nurse practitioners (NPs), or hire these individuals as independent contractors, should take several steps to protect themselves from malpractice suits that result from mistakes these providers make, writes Jeffrey D. Brunken, RPLU, CPCU, GEBS, GBDS, of the physician insurance provider The MGIS Companies Inc. For example, practices should ensure that contracts with independent PAs or NPs include bilateral hold-harmless language, as this will protect physicians from any mistakes made by the non-physician provider unless the errors are the result of actions taken under their explicit direction. Brunken notes this is important because a physician's liability insurance will not cover them for liability they assume through a contract. Independent contractors should also be required to provide proof that they carry professional liability insurance with liability limits similar to those the physician has, Brunken says. Practices that directly employ non-physician providers, on the other hand, will want to have the provider covered under the practice's policy. However, the provider should be named separately on the policy with his or her own limits of liability. Practices that share liability limits with non-physician providers may not be sufficiently covered in the event both they and a non-physician provider are sued together.

Health Policy and Reimbursement

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The medical device industry trade group AdvaMed held a news conference on Oct. 6 to discuss what it believes are the negative effects of pay-for-performance and risk-based reimbursement models on the ability of patients to access medical technologies. The news conference came after AdvaMed released a white paper that found that some insurers considering moving to new reimbursement models are becoming more hesitant to cover new medical technologies or want to see more proof that these devices are effective. Several AdvaMed executives said Oct. 6 that insurers are putting too much emphasis on meeting cost targets instead of quality benchmarks, and added pay-for-performance and risk-based reimbursement models need to modified to protect patients from "unintended consequences," namely encouraging physicians not to use technologies that will benefit those under their care. Representatives from Cigna and Aetna responded to AdvaMed's white paper by saying they are willing to pay for medical technologies that have proven benefits for patients.


The issue of whether the Internal Revenue Service (IRS) can subsidize health insurance for consumers living in states that chose not to build their own exchanges grew less clear on Sept. 30 when a U.S. district court judge in Oklahoma ruled that the agency could not provide such subsidies. Judge Ronald White noted in his ruling that the IRS's decision to provide susbidies to these consumers was "arbitrary, capricious, an abuse of discretion or otherwise not in accordance with the law." He added that the Affordable Care Act as currently written does not allow for subsidies to be given to consumers living in states that have opted to rely on the federal government's Healthcare.gov and said Congress will need to revisit the law if it wants to provide financial help for these consumers to purchase insurance coverage. White's ruling, which the Obama administration is likely to appeal to the 10th U.S. Circuit Court of Appeals, comes roughly two months after two federal appeals courts came to two separate conclusions about the IRS rule. The case that was decided in favor of the administration has been appealed to the U.S. Supreme Court, although it is uncertain whether justices will take the case. Conflicting rulings on the issue from circuit courts, however, could increase the likelihood that the Supreme Court will consider the issue.


The Obama administration recently released two reports touting the Affordable Care Act's successes in driving down the cost of uncompensated care at hospitals and increasing the number of insurance companies offering plans through the new health insurance exchange. The first report found that the number of uninsured patients admitted to hospitals in states that expanded Medicaid dropped by roughly one-third on average in 2014 compared to the previous year. The number of uninsured patients admitted to hospitals did not fall in states that did not expand Medicaid, however. The decline in the number of such patients is expected to result in a $5.7 billion decline in the cost of uncompensated care by the end of the year. Nearly three-quarters of those savings will come from states that expanded Medicaid. The American Hospital Association is striking a cautiously optimistic tone regarding the findings, while America's Essential Hospitals is saying the cost of uncompensated care is still a problem, particularly for the public hospitals it represents. Meanwhile, a separate report found that the number of insurance companies participating in the healthcare exchange will increase by 25 percent next year. It remains unclear whether the increase in the number of insurers will result in lower costs for consumers, although greater competition is expected to drive down prices over time.

Medicine, Drugs and Devices

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Clinicians who need to measure the calcaneal pitch angle (CPA) or the talonavicular coverage angle (TNCA) of a foot should strictly adhere to best practices for obtaining medial-lateral (ML) and anterior-posterior (AP) foot radiographs, since misalignment of an X-ray source can result in mistakes in the measurement of these two parameters, a new study has found. The study determined that CPA measurements taken from ML radiographs were sensitive to transverse plane misalignment from -10 to -25 degrees and from 15 to 25 degrees. In addition, the study found no effect on TNCA measurements taken from AP images that only had sagittal plane misalignment. However, TNCA measurements were affected by transverse plane alignment of AP images when there was also zero, 10 and 15 degrees sagittal misalignment in these images. Two other measurements, the lateral talometatarsal angle (LTMA) and talometatarsal angle (TMA), were not affected even when significant misalignment was present in ML and AP radiographs, respectively.


Bisphosphonates, denosumab and teriparatide are effective at reducing the risk of non-vertebral fractures, a recent systematic review of 294 articles found, although raloxifene is not. The review found that bisphosphonates, denosumab and teriparatide brought about relative risk reductions from 0.60 to 0.80 for non-vertebral fractures compared to placebo. A review of placebo-controlled trials involving raloxifene, however, showed that this drug is effective at reducing the risk of vertebral but not non-vertebral fractures. The review's authors examined the side effects of these drugs as reported in the articles, and found gastrointestinal side effects, hot flashes, thromboembolic events and infections varied among the different drugs. The authors reported several limitations of their review, including a small number of studies that directly compared osteoporosis drugs, which they said made it difficult to determine the comparative effectiveness of the drugs. Another limitation was the scarcity of data regarding the use of these drugs in men.