News From ACFAS

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Join us for the preconference workshop Coding and Billing for the Foot and Ankle Surgeon on Wednesday, March 21 from 7:30am–5:30pm at the Gaylord Opryland Hotel in Nashville, and learn how a few simple changes to your coding and billing process can help you realize maximum reimbursement for the care you provide. Speakers will cover:

• What’s new in coding for 2018
• Evaluation and management coding, including where higher-level office visits fit into your surgical practice
• Decoding the mystery of modifiers
• Surgical coding scenarios, including forefoot reconstruction, arthrodesis, office procedures and more

The link between accurate coding and proper reimbursement is clear, and it can make all the difference in how smoothly your practice operates this year. Register now at acfas.org/nashville. The U.S. Bone and Joint Initiative (USBJI) has released new chapters called “Big Picture,” “Economic Cost” and “Neuromuscular Diseases” in the fourth edition of The Burden of Musculoskeletal Diseases in the United Status (BMUS).

Fourth edition chapters will be released under advance publication until all are complete. Until that time, the third edition remains the latest complete edition. ACFAS members should use the burden of disease data included in BMUS as necessary to develop value propositions and other communications about musculoskeletal care and to develop research proposals.

For more information, visit boneandjointburden.org. Energize your mornings during ACFAS 2018 by attending satellite breakfasts on Friday, March 23 and Saturday, March 24 at the Gaylord Opryland Hotel. Enjoy a delicious meal while learning what’s new in surgical approaches and technologies.

FH Ortho Satellite Breakfast
CALCAnail—A Reproducible Intraosseous Approach to Calcaneal Fractures and Primary Subtalar Arthrodesis: Six-Year International Outcome
Friday, March 23
6:30–7:30am
Governor’s Room C
RSVP to sedlacek@fhortho.com

Osiris Satellite Breakfast
Friday, March 23
6:30–7:30am
Surgical Reconstruction of the At-Risk Foot and Ankle: The Application of Umbilical Grafts for Foot and Ankle Salvage Procedures
Governor’s Room E
RSVP to acfaslecture@osiris.com

Amniox Medical Satellite Breakfast
Saturday, March 24
6:30–7:30am
Bringing Clarity to Biologics: Understanding the Role of Regenerative Medicine in Podiatric Surgery
Governor’s Room C

Foot and Ankle Surgery

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Researchers conducted a study to assess the inter-observer agreement of three diabetic foot classification systems: the Wagner, the University of Texas and the PEDIS. The study included 250 consecutive patients diagnosed with diabetic foot syndrome in 2009–2013. Wound scores were recorded at admission and a reevaluation was performed simultaneously or 24 hours later by a different evaluator. The research revealed moderate inter-observer agreement between the first evaluation and the reevaluation for Wagner scale, University of Texas scale and for PEDIS scale. In conclusion, this moderate agreement shows that these scales should not be used alone for management decisions regarding diabetic foot syndrome and should, therefore, be integrated with other clinical data.


New research evaluates the midterm outcomes of Lisfranc injuries in adolescents operatively treated with Kirschner wire or screw fixation. Researchers included eight adolescent patients with Lisfranc injuries operatively treated in a single institution in the study. The mean duration of follow-up was 3.8 years. Analysis was carried out of the intermetatarsal distance on radiographs at initial displacement and final reduction. All cases were scored functionally using the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale. Researchers conclude that most operatively treated cases of adolescent Lisfranc injuries will do well at the midterm follow-up, with a mean AOFAS Midfoot score of 93.4.


A new study describes distal tibial oblique osteotomy (DTOO) and the surgical technique's applicability for ankle osteoarthritis with varus deformity. The researchers devised DTOO and have used the technique since 1994 for ankle osteoarthritis of advanced and late stages associated with varus inclination. DTOO can be used for cases of varus ankle osteoarthritis with a range of the ankle joint movement of at least 10 degrees or more. The osteotomy is obliquely directed across the distal tibia from proximal-medial to distal lateral and is of an opening-wedge type with the center of rotation coincident with the center of the tibiofibular joint. A laminar spreader instrument is inserted in the osteotomy to open the wedge until the lateral surface of the talar body is seen on X-ray to be in contact and congruent with the medial articular surface of the lateral malleolus. DTOO is a procedure designed for ankle osteoarthritis, and it improves the contact area of the ankle joint and decreases the load pressure per unit area. This is accomplished with an improvement in ankle stability and a restoration of the hindfoot valgus. Clinical results confirm a reduction in ankle pain and an ability to perform hard manual work or return to sports activities.

Practice Management

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According to the 2017 Patient-Provider Relationship Study, which is based on a survey of nearly 2,100 patients ages 21 to 70, all patients want four key things from their physicians: greater connectivity, online tools, convenience (via text) and more time with their doctors. Given that the study also shows that an average of one in three patients is switching physicians, striving to meet patients' ideals is not just a noble endeavor—it's a necessary one. One way to improve connectivity is to leverage mobile apps that let patients communicate with practice staff, make appointments or pay bills. To respond to the demand for online tools, physicians can use patient-facing tools, such as e-newsletters, that help them target specific populations, such as individuals over age 65. Physicians can easily accommodate the patient preference for convenience (via text) by using automated text reminders, recare messages, follow-up reminders, patient confirmations and last-minute scheduling notifications via patient relationship management tools. Nothing can replace in-person visits, but the right technology, such as text and email marketing tools, would allow patients to freely ask and answer questions in an unhurried environment and gain access to personalized education materials that demonstrate the effectiveness of an emerging therapy or treatment offered at the practice. Whatever tools and tactics a physician deploys, by addressing each of these four components through automation, primary care providers are likely to improve their own workflows while simultaneously creating higher levels of patient satisfaction.


Recent research indicates better data privacy and security employee training programs will help healthcare organizations as they work to keep pace against cyberthreats. MediaPro's 2017 State of Privacy and Security Awareness Report found 70 percent of employees in numerous industries lack awareness to stop preventable cyberattacks, while 78 percent of healthcare employees exhibited a lack of readiness with common privacy and security threat scenarios. About 25 percent of physicians and other types of direct healthcare providers were unaware of phishing email, as were 8 percent of nonprovider employees. In addition, 24 percent of healthcare employees had difficulty identifying common signs of malware. "Beyond training geared toward HIPAA compliance, healthcare employees need a comprehensive approach to awareness education that includes security and privacy awareness," say the MediaPro researchers. "Keeping within HIPAA regulations, while vital, does not educate users on how to spot a phishing attack, for example. Additionally, mere compliance does not equate to a fully security-aware culture." Healthcare employees were also found to be more unaware than the general population in terms of physical security, with 33 percent of healthcare workers taking unnecessary risks in scenarios related to permitting others access to their office buildings. "Organizations of all types are best served when their whole employee population knows the importance of sound security principles," the researchers note. "Such a state comes from multifaceted and integrated awareness programs, not just training."


HealthTap, a health technology company, has released a report that says compassion is more important than cost to patients and doctors when ranking physicians. The results of this report come as cost and access are increasingly considered important issues among healthcare consumers and providers. The report found that 85 percent of patients said compassion was very important, but only 31 percent said cost was important when making healthcare decisions. A majority, 89 percent, of doctors also said compassion was important when providing care to patients. Doctors noted that being compassionate made it more likely that patients would follow advice, which results in better health outcomes.

Health Policy and Reimbursement

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A report compiled by the National Academy for State Health Policy, released on February 7, found that states running their own insurance marketplaces under the Affordable Care Act (ACA) outperformed states using the federal marketplace in terms of 2018 enrollment numbers. Overall enrollment held steady from the year before in the 11 states plus the District of Columbia with state-based marketplaces, compared with an average decrease of more than 5 percent in states that rely on the federal exchange. The report indicates that the best performers were the five states with hybrid systems. Nearly 11.8 million people chose ACA health plans for 2018, down by about half a million from 2017 and by 900,000 from 2016. "The states live in a period of uncertainty, so when you see stable enrollment, it's good," said Trish Riley, the health policy group's executive director. "The message is, people want coverage, and they came and got it." The report notes that states with their own marketplaces had longer enrollment periods, and some also ran robust programs to encourage signups.


Indiana became the second state after Kentucky to gain approval for introducing work requirements for Medicaid beneficiaries. Medicaid recipients will need to find jobs or undertake related activities, such as training or community work, to avoid being suspended from coverage. The new requirement takes effect in 2019. The move builds on previously adopted changes in Indiana's Medicaid program, including required premiums and blocking coverage for people who do not pay. Indiana officials estimate that about 130,000 of the roughly 400,000 state residents covered by Medicaid would need to comply with the work-related mandate. Under the Trump administration, some GOP-led states are moving beyond work mandates to include drug testing and lifetime caps on benefits.


Amazon, JPMorgan Chase and Berkshire Hathaway hope to transform healthcare for their combined employees by creating their own employer health system. Large companies are able to pool risks because they tend to cover both healthy and sick employees and family members. Employers also pay a large share of insurance premiums, so most workers tend to sign up for plans even if they are healthy. Large employers also typically have the resources to hire human resources professionals and benefits consultants to shop for their health plans. Arnold Milstein, a professor at Stanford Medical School, spent several years with benefits consulting firm Mercer developing unconventional benefit products with companies. Referring to employers, he says, "There is a segment of them that is willing to take the same risk tolerance that characterizes their core business and move it into the health benefit space."

Medicine, Drugs and Devices

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The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed regulations establishing new limits on pharmacies for filling opioid prescriptions for Medicare beneficiaries "to reduce seniors' risk of being addicted to or overdosing on opioids while still having access to important treatment options," says CMS' Demetrios Kouzoukas. "We believe these actions will reduce the oversupply of opioids in our communities." The proposal mandates that Part D plans should implement "hard formulary levels" at pharmacies, which would restrict the amount of opioids that beneficiaries could get. "These are triggers ... [that] can prompt conversations between physicians, patients and plans about appropriate opioid use and prescribing," Kouzoukas says. "The trigger can only be overridden by the plan sponsor after efforts to consult with the prescribing physician." The safety level would be a 90 morphine-mg equivalent with a seven-day supply allowance. The regulations would also limit the number of pills in an initial prescription for acute pain, "possibly with or without a daily dose maximum," Kouzoukas notes. He says CMS is accepting comments on the proposals through March 5, and the agency also "expects sponsors to implement 'soft' safety edits" to flag a potential problem, although those could be overridden by the pharmacist.


A pharmacist's preliminary research suggesting that some patients living with diabetes may be injecting medicine that has partially disintegrated is causing concern. Lead researcher Alan Carter, a pharmacist and adjunct instructor at the University of Missouri-Kansas City School of Pharmacy, bought vials of insulin at a number of pharmacies and found that, on average, the vials had less than one-half of what was listed on the label and none met a minimum standard. The study tested just 18 vials of insulin and questions have been raised about the methods used to test the insulin. Insulin makers, patient advocate groups and diabetes experts assert that if the findings were accurate, patients living with diabetes would be getting sick. The groups are discussing how to quickly mount a major study that would ease fears by involving multiple research labs, different testing methods and many more samples of various insulin types. The original study, published in the Journal of Diabetes Science and Technology, tested insulin solutions in vials bought at multiple pharmacies, supplied by different wholesalers, in Kansas and Missouri. The concentration, or number of insulin units in the liquid solution, was labeled as 100 units per milliliter. But they averaged less than one-half of that, and none met the 95-unit minimum standard, said Carter.


An interactive text messaging system can improve medication adherence, according to a study published in JMIR mHealth and uHealth. In the study, researchers used mPulse Mobile on partially adherent and nonadherent Medicare patients to compare refill rates of a text message group of 12,272 with a control group of 76,068 individuals who did not receive text messages. All participants had experience with other forms of refill and adherence reminders like phone calls, emails and robo-calls. Results showed a 14.1 percent increase in refill rates in the text message group when compared with refill rates of the control group. The findings "support using interactive text messaging as a cost-effective, convenient and user-friendly solution for patient engagement," concluded lead author Rena Brar Prayaga and colleagues. "Program outcomes and insights can be used to enhance the design of future text-based solutions to improve health outcomes and to promote adherence and long-term behavior change."