News From ACFAS

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We have the answers! The Practice Management Committee is hosting an Ask the Coder program at the Annual Scientific Conference in San Antonio. If you have a surgical coding question, you can sign up for a free half-hour consultation with our coding consultant, Jacqueline Kravitz, CPC, AAPC Fellow. Sessions will be offered on a first-come, first-serve basis and will meet in the ACFAS Membership Booth. Times available, include:

Wednesday, February 19
10am–4pm

Thursday, February 20
9:30am–4pm

Friday, February 21
9:30am–1:30pm

To reserve your time slot, email Melissa Matusek, director of Marketing and Communications. Whether you are a novice speaker or keynoter, this in-person speaking coaching at ACFAS 2020, will benefit anyone who addresses an audience. Take advantage of this resource – even the most effective, powerful presenters can benefit from coaching. Group or individual sessions will help you feel great and sound spectacular.

Sign up today to get the tips and tools to perfect your speaking skills. Contact Michelle Majewski or Mary Meyers for more information. ACFAS has partnered up once again with Call4Posters™ for your ACFAS 2020 poster printing needs. Call4Posters™ is the simple and convenient way to have your poster printed and shipped for pickup on site at the meeting. Visit the Call4Posters™ site for more information and fees.

Foot and Ankle Surgery

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Skin-related complications of ankle fractures are difficult to reconstruct due to the inadequacy of soft tissue in the region. Although free flaps are generally considered first choice in reconstruction of this area, they may not be a suitable option in all cases, especially in patients with advanced age and comorbidities. Perforator flaps offer a fast and safe alternative in lower extremity reconstruction. The study reports the researchers' experience with reconstructing soft-tissue defects of the medial malleolar region using a posterior tibial artery perforator flap for postoperative complications of ankle fracture-related surgeries.


The purpose of the study was to identify the extent to which a dissection of the syndesmosis and an avulsed posterior edge of the tibia can change the tibiofibular diastasis and fibular rotation. Three-dimensional scans with a mobile C-arm of 22 cadaver legs were taken of the intact fibula, after dissection of the anterior part of the syndesmosis and the interosseus membrane, ostetomy of the posterior malleolus and osteosynthesis. The distinction between the intact fibula and the osteotomy of the posterior tibia was about 0.082 millimeters for the tibiofibular distance in the incisura tibiofibularis and about 0.046 degrees for the angle of the fibular rotation.

The study concludes that neither the dissection of the syndesmosis nor the osteotomy of the posterior malleolus significantly influenced the position of the tibula in the incisura tibiofibularis in the cadaveric model. However, in the non-weightbearing situation, a lesion of the syndesmotic complex might not be evident in intraoperative three-dimensional imaging.


The study used the 5 percent Medicare Standard Analytical Files data set for 2005–2014 to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar and trimalleolar ankle fractures. Ninety-day costs were calculated based on all acute care and post-acute care payments starting from day zero of surgery to day 90 post-operatively, and linear regression was used to derive the marginal cost impact of patient-level, procedure-level and state-level factors.

Procedure-level factors associated with significant marginal cost increases were inpatient surgery, trimalleolar fracture and syndesmotic fixation. For comorbidites, the largest increases in marginal cost were seen for chronic kidney disease, malnutrition, obesity, cerebrovascular disease/stroke and anemia. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to overtake the current fee-for-service model in patients with fractures.

Practice Management

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Patient collections can be difficult and unpleasant, especially given high-deductible plans that have made patients responsible for more of the cost of their care. While there is no cure-all for patient collection problems, taking the right steps to collect better can actually help forge better patient relationships. Surprise medical bills cause ill will that can undermine those relationships.

In many cases, the "surprise" is caused mainly by patients' misunderstanding of health plan rules, which are often arcane and poorly explained. This means that the task of explaining insurance will frequently fall to providers, who should be proactive instead of waiting for a patient to be confused about something.


The article provides some strategies that physicians can adopt before and after signing an employment contract to avoid problems with non-compete clauses. One strategy is negotiating the contract to remove or reduce the impact of the non-compete clause, which some doctors are hesitant to do. Dealing with these types of negotiation is a skill, much like developing a good bedside manner, and physicians can be creative with the requests they make of an employer.

Sometimes a physician cannot avoid being penalized for breaking a non-compete agreement, often with a monetary fine. When the financial implications of taking a new job are too costly, doctors still need to earn an income before the non-compete restrictions expire. Telemedicine and locum tenens work, often in different states, can provide temporary employment during this period to get around location restrictions.


A new study from the University of Michigan found that out of 2,000 people between the ages of 50 and 80 it surveyed, 43 percent have looked online to see how patients rated a doctor. Two-thirds of older Americans who had looked online said they chose a doctor because of good online ratings and reviews. Online reviews were given as much weight as what these older adults heard from family and friends. Seven percent of surveyed respondents said they had posted a review or rating of a doctor online. Among older adults who looked at reviews, 69 percent said they would not choose a doctor who had mostly negative reviews and 71 percent said that some bad reviews among many positive reviews would not stop them from choosing a doctor.

Health Policy and Reimbursement

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The US Centers for Medicare and Medicaid Services (CMS) has proposed changes to Medicare Advantage payments for 2021 that include an increase in the percentage of patient "encounter data" used to calculate payments. CMS plans to continue phasing in the use of diagnoses from encounter data to determine patient risk scores, which are used to adjust insurer payments from the federal government despite complaints about its accuracy from the insurance industry.

CMS has used encounter data to calculate payments since 2016 and wants to use more of it, proposing a blend of 75 percent encounter data and 25 percent data from the less-detailed Risk Adjustment Processing System (RAPS), which was historically used to calculate risk scores. In 2020, CMS is using an equal mix of encounter data and RAPS data. The proposed change is included in the first of two parts of the 2021 Medicare Advantage advance notice, which will be finalized no later than April 6. Comments are due to the agency by March 6.


A study published in Health Affairs found that Medicaid expansion made declines in health status 1.8 percentage points less likely in states that expanded the medical coverage. The study examined 12 Southern states, including those that have accepted the expansion of Medicaid under the Affordable Care Act. A majority of the 14 states that have rejected the expansion of Medicaid are in the South, including Texas and Florida, which have the highest populations of the holdout states.


The US Supreme Court has ordered the Trump administration and states challenging the Affordable Care Act (ACA) to respond by Friday to an appeal filed by defenders of the health care law. This abbreviated timeline gives the court the option to take up the case in its current term, which would mean ruling on a contentious issue this spring as the presidential campaign heats up. Nineteen states led by California asked the Supreme Court last week for a quick decision on whether to take the case. They are appealing last month's ruling by a federal appeals court that said the ACA's individual mandate is unconstitutional and that the rest of the law cannot survive without it.

The states asked the court to hear the case on April 26 or add an extra argument day in May. The law was challenged by 17 states led by Texas, which argued that the individual mandate, which requires all Americans to buy insurance or pay a penalty on their income tax, was unconstitutional.


The Camden Coalition of Healthcare Providers was founded by Dr. Jeffrey Brenner in 2002 to address the medical and social needs of the most expensive patients and keep them out of the hospital by providing them with coordinated care. However, a recent study in the New England Journal of Medicine found that the program did not result in fewer hospital readmissions in the six months after a patient left the hospital. The study involved 800 patients, each with at least two chronic conditions and compared hospital admissions for patients whose care was coordinated by the Camden Coalition with those whose care was not.

Medicine, Drugs and Devices

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A new study in the Annals of Internal Medicine finds that less than 10 percent of primary care providers in the United States can prescribe the opioid-addiction medication buprenorphine. Access is even more scarce in the rural counties that have been hit the hardest by opioid-related overdoses. From 2007–17, the number of providers with waivers to prescribe buprenorphine climbed from 3.8 for every 100,000 people to 17.3. Over the same period, opioid-related deaths rose from about 16,500 per year to 46,000 per year.


Medical applications of genome editing tool CRISPR-Cas9 had a landmark in 2019 as the first results came in from trials testing the tool in people and more trials were launched. Seven years after researchers discovered that CRISPR-Cas9, a molecular defense system, could be harnessed to rewrite human genes, the US government's clinicaltrials.gov database lists more than a dozen active studies that are testing CRISPR as a treatment for a range of diseases. Right now these trials are too small to provide any hard conclusions about the safety and efficacy of CRISPR-Cas9 therapies, and preliminary results have been mixed.