News From ACFAS

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In online balloting that ended on December 22, ACFAS members approved recommended bylaw amendments by a 91 percent majority and elected three new board members:

• Christopher D. Lotufo, DPM, FACFAS
• Alan Ng, DPM, FACFAS
• Matthew E. Williams, DPM, FACFAS

Previously elected to serve as chair of the Region Presidents Council and ex-officio board member:

• Alan A. MacGill, DPM, FACFAS

Drs. Williams and Ng will serve three-year terms (2020-2023). Drs. Lotufo and MacGill will serve two-year terms (2020-2022).

Also serving on the 2020-2021 Board of Directors are Scott C. Nelson, DPM, FACFAS, President; Thanh Dinh, DPM, FACFAS, President-Elect; Michael J. Cornelison, DPM, FACFAS, Secretary-Treasurer; Christopher L. Reeves, DPM, MS, FACFAS, Immediate Past President; Eric A. Barp, DPM, FACFAS and George T. Liu, DPM, FACFAS. The board will appoint one additional director to fill a vacancy created by the resignation of Brian B. Carpenter, DPM, FACFAS.

The new board will be installed on February 20 during the ACFAS 2020 Scientific Conference in San Antonio. Get the tools you need to properly code surgical procedures and evaluation and management services. Join us in San Antonio Tuesday, February 18 for the Coding and Billing for the Foot and Ankle Surgeon preconference workshop the day before ACFAS 2020.

This comprehensive workshop will leave you with helpful tools to understand trends in surgical coding, including how to code for new advances in foot and ankle surgery, appropriately select modifiers for complex, staged and multiple procedures cases and understand where higher level E&M codes fit into your surgical practice. This course will give you the skills to code effectively in turn increasing reimbursements and showing an immediate return on investment in your practice.

Visit acfas.org/sanantonio to register and reserve your spot for this comprehensive workshop today. The ACFAS Marketing Toolbox has two new ways to educate patients and promote your practice! Two new PowerPoints are now available—Weekend Warrior and CrossFit. The CrossFit presentation covers various injury risks that come with high-intensity workouts and treatment, and Weekend Warrior covers spreading out your workouts throughout the week to avoid injury risk associated with cramming them into the weekend.

These presentations can be used to educate patients whether in your office or in the community. Use them as slideshows in your practice waiting room, post to your social media accounts or take it with you to present at a community health event. The possibilities are endless!

Visit the Marketing Toolbox at acfas.org/marketing to access the full PowerPoint library and countless other resources available to promote your practice and educate patients any time.

Foot and Ankle Surgery

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Percutaneous Achilles tenotomy (PAT) is performed in most patients as part of the Ponseti method, but there is a lack of objective data assessing early radiographic changes in children undergoing PAT. Forty-nine patients with idiopathic clubfoot treated by Ponseti casting were prospectively enrolled between October 2017 and October 2018. Preoperative and postoperative ankle dorsiflexion (ADF) and lateral talocalcaneal angle (LTCA) values with the ankle in maximal dorsiflexion as well as postoperative LTCA values with the ankle in the neutral position (post-LTCAneutral) were measured. Post-LTCA improved significantly from 18.6 ± 9.2 degrees to 25.1 ± 10.5 degrees, while pre-ADF and pre-LTCA showed a positive correlation in both the less than 28-day group and the Dimeglio III group.

However, post-ADF and post-LTCA showed a positive correlation in the Dimeglio III group. Improvement in post-LCTA in the Dimeglio III group was similar to that in the Dimeglio IV group. Thus, the LTCA increased immediately after PAT in clubfoot, but the improvement seemed to be unrelated to the severity of the disease. Researchers conclude that PAT led to an increase in both ADF and the LTCA, and it contributed to the improvements in subtalar joint motion and alignment.


Researchers devised a novel syndesmotic plate (NSP) for simultaneous fixation of lateral malleolus fractures and distal tibiofibular injuries. The study compares the biomechanical characteristics of the NSP to syndesmotic screw and suture-button fixations. Using 12 cadaveric specimens, axial loading as well as rotation torque were applied in three different ankle questions: neutral, dorsiflexion and plantarflexion. After the specimens were tested, they were made into a pronation-abduction III fracture model, then fixed sequentially with a distal fibular anatomic locking plate (DFALP) combined with syndesmotic screws, DFALP combined with suture button and NSP. The syndemsmotic dispalcement and the strain of the tibia and fibular were recorded during the experiment.

In most cases, the displacements and strains of the NSP group and the screw group were smaller than the suture button groups and the native. The displacements and strains of the NSP group were also slightly smaller than the screw group in most cases, and there was no significant different between the two groups. Researchers conclude the NSP they developed has a fixed strength no less than the traditional syndesmotic screw fixation.


The study investigated whether children with ostechondral lesion of the talus (OLT) are at risk to develop any radiographic evidence of early joint degeneration despite treatment efforts. Fifty-six ankles were identified over six years with stable OLT that underwent operative treatment. Radiographs were evaluated for physeal status, OLT characteristics and signs of osteoarthritis according to the Kellgren-Lawrence Scale. Despite incomplete treatment to radiographic resolution, the Kellgren-Lawrence scores still worsened in 23 percent of the children. No risk factors (preoperative classification, age, physeal patency) were associated with advancing radiographic evidence of articular degeneration.

However, a classification and regression tree analysis revealed that a patient age of 11.5 years old could be predictive of advancing Kellgren–Lawrence scores with one-third of older children worsening. Despite active treatment of OLT, the ultimate prognosis is guarded with approximately one out of four children advancing their Kellgren and Lawrence score during treatment. The short-term advancement of degenerative disease in childhood OLT warrants further investigation into better treatment methods to preserve ankle health in these young patients.

Practice Management

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Experian Health estimates that 15 million patient records were compromised in 2018, highlighting the need for health care organizations to take steps to safeguard patient data. This includes deploying secure log-in monitoring and device intelligence to verify a person is who they say they are when trying to access medical records. Organizations should also automate patient portal enrollment, use fraud management tools and educate employees on security threats and warning signs.


The article outlines some of the challenges physician practices will face going into 2020. One of these is hiring quality clinical staff as smaller practices may not be able to match the pay and benefits of larger organizations. Practices can lure talent by focusing on flexibility, work-life balance, professional growth through education and having more say in a practice's operations. When it comes to negotiating better payer contracts, practices should focus on payers that pay less than the Medicare fee schedule amount, then create a value proposition based on patient volume, extended office hours to reduce emergency department visits and practice location. Practice should ask for a cost-of-doing business increase at a minimum and look to get more revenue from ancillary services by negotiating for 100 percent of Medicare rates. Practices will also need to combat growing cybersecurity threats, which they can do by leveraging security best practices such as keeping all software up-to-date and enforcing automatic logoffs. Reaching patients with chronic conditions will continue to be a challenge, one that practices can fight by practicing compassion, acceptance and partnership with the patient, respecting their autonomy and experiences. Physicians should remain careful about possible lawsuits and avoid them by practicing thorough documentation, reviewing medications, and following up on tests and persistent symptoms. Physicians themselves should practice self-care to avoid burnout, which is a growing problem for health care providers. Increased competition from urgent care centers and retail clinics will continue to challenge practices in 2020. As always, accurate documentation and coding are necessary to avoid denials and ensure proper reimbursement levels. Physicians say administrative hassles and regulatory requirements, such as the need for prior authorizations, are their biggest challenge.


The article reviews potential paths for physician groups that are considering a whole or partial sale. One structure is an asset purchase, which generally works best when the buyers are interested in select assets of the target practice. If the buyer is not concerned about the practice continuing as a going concern, an asset purchase is likely the best approach. The seller in an asset purchase transaction must make sure it receives sufficient consideration to cover any future liabilities, and because the taxable income the corporation receives may be subject to double taxation in a C-corporation, physicians should discuss the proposed approach with their accountant. Buyers sometimes choose an asset purchase structure even when looking to continue the practice as a going concern if they are especially concerned about acquiring unknown or contingent liabilities. Another path is a stock purchase, which generally works best when the buyer wants to acquire the target practice as a going concern and there are few shareholders. Sellers will generally prefer the tax treatment of a stock purchase, while buyers will prefer the transaction be taxed as an asset purchase. A merger works well when there are multiple shareholders in a target practice that a buyer wishes to acquire as a going concern, as once a majority of shareholders consent to the transaction, the buyer can have control of the business going forward. Mergers and acquisitions vary according to the laws of the state in which the practice is formed, including state and federal tax laws.

Health Policy and Reimbursement

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The US House Committee on Energy and Commerce is questioning eight major insurers and physician staffing firms about their role in surprise billing. Legislators have been focusing on ways to end surprise bills which often result in consumers paying thousands of dollars for out-of-network care. The committee sent letters to Envision Healthcare, Team Health, Anthem, Cigna, CVS Health, Health Care Service Corporation, Highmark and UnitedHealth Group, requesting information on billing policies when a patient receives out-of-network care.

The US House Ways and Means Committee, meanwhile, cited research from experts at the American Enterprise Institute and the Brookings Institution, showing that surprise bills are frequently associated with services provided by an out-of-network emergency physician or ancillary clinician at an in-network health facility. Many of the services that are often associated with surprise bills are also areas where hospitals have increasingly outsourced patient care, committee members said. This occurs because physician staffing companies and hospitals independently negotiate contracts with insurers. A study by researchers at Yale found that hospitals that contract with physician staffing companies have higher rates of out-of-network billing. Evidence indicates that physician staffing firms charge significantly higher in-network rates than their counterparts, thereby driving reimbursement upwards as they enter into staffing arrangements with hospitals, the committee said.


Lawmakers and the Trump administration were unable to enact significant legislation in 2019 to curb consumer drug spending. White House policy chief Joe Grogan and Wendell Primus, a top Pelosi aide, unsuccessfully tried to overhaul Medicare and cap out-of-pocket costs for seniors. Democrats proposed the Lower Drug Costs Now Act, but more progressive lawmakers disagreed over its proposed arbitration mechanism, the number of drugs Medicare could negotiate, and whether discounts would extend to uninsured patients. Meanwhile, Congress passed the CREATES Act and a ban on "pay-for-delay" practices, each intended to facilitate generic drug development. The CREATE Act guarantees generic drugmakers' access to samples of brand-name medicines, and is predicted to save taxpayers more than $3 billion.

The White House failed to enact initiatives backed by HHS Secretary Alex Azar, including the "rebate rule" that bars certain rebates paid by drug manufacturers to insurers and PBMs, as well as a proposed change to Medicare's "protected classes." That change would allow private insurers under Medicare to deny coverage for drugs whose price increases exceeded the inflation rate. The Trump administration also lost in court on a proposal to require drug makers to include list prices in television commercials. In addition, GOP lawmakers were unable to agree on an "international price index" that would cap Medicare payments for certain drugs based on foreign price levels.


Medicare faces a turbulent 2020 as the program moves to shore up its finances and expand opportunities for providers to coordinate patient care. The US Centers for Medicare & Medicaid Services will try once again next year to cut Medicare payments to off-campus, hospital-based clinics. The US Health and Human Services Department, meanwhile, expects to complete its first-ever overhaul of two major health-care anti-corruption laws in 2020, including revamping the Stark law, which prohibits physician self-referrals. The upcoming initiatives aim to reduce program expenditures before millions of aging baby boomers are expected to double Medicare spending to more than $1.5 trillion by 2028.


Approximately 8.3 million people signed up for health coverage this fall under the Affordable Care Act (ACA) in the 38 states that use the HealthCare.gov enrollment system, according to federal figures, reflecting a decline of less than 2 percent from a year ago. There was a slight increase in the number of first-time applicants, whose total was slightly more than 2 million. Tax changes made by lawmakers in late 2017 blocked an IRS penalty on Americans who did not fulfill the law's insurance mandate. This is the first year the penalty is absent. Federal government data indicates that the removal of the penalty had little effect on enrollment.

Dan Mendelson, founder of Avalere Health, observes that the number of Americans who gained coverage via marketplace plans or an expansion of Medicaid is roughly half of the 40 million predicted when the ACA passed nearly 10 years ago. The new total is for the seventh year the ACA marketplaces are providing a way for people to purchase coverage if they cannot get health benefits via their workplace. The Trump administration has reduced the ACA sign-up period by half and nearly eliminated federal aid for publicizing enrollment and providing assistance through nonprofit groups. It also allowed consumers for this first time this year to buy ACA health plans directly from insurers. CMS gave consumers an extra two days to enroll following the December 15 deadline after some people were unable to access the website.

Legal Briefs

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In 2018, Derek Lewis and another former employee of Community Health Systems (CHS) filed a whistleblower lawsuit against the Tennessee-based hospital chain, citing a problem with software that failed to track certain drug prescriptions or dosages properly. Lewis, who worked as an electronic health records (EHR) specialist, alleges in the suit that CHS obtained millions of dollars in federal subsidies fraudulently by covering up flaws in these systems at the more than 120 hospitals it owned or operated. The whistleblowers also alleged that Medhost, the Tennessee company that developed the software, concealed defects during government-mandated reviews intended to ensure safety.

Both CHS and Medhost denied the allegations and moved to dismiss the suit; the motions are pending. The lawsuit is one of dozens of other suits filed by whistleblowers, hospitals, and physicians nationwide alleging flaws in EHR software that may pose a danger to patients. A major portion of the $38 billion in federal subsidies went to companies that misled the government about the quality of their products, according to an ongoing probe by Fortune and Kaiser Health News. Their investigation revealed in March that thousands of injuries, deaths or near misses linked to software defects, user errors and other problems have been gathering in various government-sponsored and private repositories.