News From ACFAS

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What a week! The Annual Scientific Conference in Austin broke records again as being the most attended conference with over 1,900 attendees and we didn’t stop there. The Exhibit Hall was not only sold out – it was the largest number of exhibitors ever at an ACFAS conference! Thank you to our exhibitors and to everyone who joined us in Austin to celebrate 80 years of ACFAS!

ACFAS 2022 kicked off with our keynote address from former NFL safety, Rhodes Scholar and neurosurgery resident at Massachusetts General Hospital, Myron Rolle, MD, MSc who shared his mantra of the 2 Percent Way. The College installed our 70^th ACFAS President, Michael Cornelison, DPM, FACFAS and D. Scot Malay, DPM, MSCE, FACFAS received this year’s Distinguished Service Award. Dr. Malay also handed the reigns of JFAS Editor-in-Chief to Naohiro Shibuya, DPM, MS, FACFAS, who will take over as editor starting in May. This year’s meeting had another packed lineup of cutting-edge education, interactive labs, workshops, and of course went out with a Texas-style bang at Saturday’s Wrap Party at the Lustre Pearl on Rainey Street.

“Registrants and exhibitors alike could sense the excitement throughout the conference,” Michael Cornelison, DPM, FACFAS, president of ACFAS said. “This is a testament to the fact that the ACFAS Annual Scientific Conference is the pre-eminent opportunity for foot and ankle surgeons to reconnect with one another while receiving the best in continuing education, including cutting edge content, delivered in innovative formats -- all for the advancement of patient care.”

Full conference coverage and photo highlights will be featured in the next issue of ACFAS Update. We look forward to seeing everyone next year in Los Angeles for the 81^st Annual Scientific Conference February 9-12, 2023. Let your patients know you attended last week’s Annual Scientific Conference in Austin by downloading the free fill-in-the-blank press release from the ACFAS Marketing Toolbox.

Once you complete the press release with your information, you can distribute it to your local media, include it in your office newsletter or post it on your practice website and social media accounts.

For other free resources to help promote your practice, educate patients and increase office referrals, visit the Marketing Toolbox at acfas.org/marketing. Congratulations to Scot Malay, DPM, MSCE, FACFAS for receiving the 2022 Distinguished Service Award winner for his dedicated service as the Editor-in-Chief of The Journal of Foot & Ankle Surgery. Dr. Malay received the award last week during the Opening Ceremony of ACFAS 2022 in Austin.

This award is presented each year to a member whose service to the College goes above and beyond the call of duty through various volunteer roles. Dr. Malay has been the editor of The Journal of Foot & Ankle Surgery for the past 15 years. ACFAS Immediate Past President Thanh Dinh, DPM, FACFAS shared, “The 15 years Dr. Malay was at the College’s premiere research publication’s helm were some of the most exceptional years in the life of foot and ankle surgery’s scientific breakthroughs.” She added, “Under his leadership, 90 journals were produced with the highest quality bringing cutting-edge science directly to those providing patient care. We are all, as foot and ankle surgeons, indebted to Dr. Malay for his excellent work in our Journal.”

Watch for more on Dr. Malay’s accomplishments and service to the College in an upcoming issue of ACFAS Update. We’re hitting the road again with the new ACFAS Regional Learning Series—Common Pathologies: How to Resolve and Maximize Function by Restoring Structure. Next up is Berkeley Heights, NJ April 29-30.

This course combines case presentations, lightning lectures, hands-on labs and opportunities to share knowledge for you to gain insight into the depth and breadth of your current foot and ankle knowledge. You’ll walk away with a better understanding of contributing factors associated with foot and ankle surgery complications and be able to apply new skills to help you maximize function and restore structure.

Don’t miss us in Berkeley Heights or the many other cities we are headed to with this program! View the course brochure or visit acfas.org/ComingToYou to register today. Join expert faculty for a deep dive into podiatric internal fixation surgery with Comprehensive Fixation for the Ankle and Foot: A Resident's Course. This course (continuing from the previous AO/AAFAO workshops) brings together innovators in the field of podiatric internal fixation surgery.

Comprehensive Fixation for the Ankle and Foot: A Resident's Course
May 12-13 (Thursday/Friday)
Marriott O’Hare Chicago
Chicago, IL

This two-day workshop will give the knowledge and skills to:

• Apply the principles of internal and external fixation to foot and ankle surgery—including major rearfoot and ankle arthrodesis techniques.
• Identify the problems, complications, and intraoperative difficulties that can result from internal and external fixation.
• Implement principles and techniques in a wide variety of complex foot and ankle fractures, multiple revisional and reconstructive surgical techniques of the lower extremity—including specialty plating and external fixation techniques.
• Avoid complications and improve outcomes through preoperative planning.
• Apply psycho-motor skills developed in extensive practical lab exercises.

Visit acfas.org/skills for more information and to register today!

Foot and Ankle Surgery

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Refractory pain to the fourth and fifth tarsometatarsal (TMT) joint can be a source of disability and functional impairment. While pain has been attributed to injury, post-traumatic arthritis, and arthrofibrosis, the principal causes of pain in the absence of arthritis are not well elucidated. The purpose of this study is to characterize arthroscopic pathology associated with chronic refractory pain to the fourth and fifth TMT joints. At their academic institution, researchers retrospectively examined 24 patients who underwent arthroscopic surgery of the fourth and fifth TMT joints for refractory pain between 2015–2019. They used the Outerbridge classification for chondral lesions, the Kellgren Lawrence radiographic classification for osteoarthritis, and described intraarticular pathologies as acute hypertrophic synovitis, chronic synovial fibrosis, hyaline bands, meniscoid bodies, loose joint bodies, and arthrofibrosis. Approximately 31 of 45 TMT joints (68.9 percent) presented with radiographic evidence of arthritis. In addition, approximately 14 of 45 TMT joints (31.11 percent) were absent of radiographic signs of arthritis. The frequency of soft tissue pathology seen in these patients without radiographic evidence of arthritis comprised arthrofibrosis (87.5 percent), chronic synovial fibrosis (75.0 percent), and acute hypertrophic synovitis (62.5 percent). This study is the first to report arthroscopic pathologies associated with refractory pain to the fourth and fifth TMT joints.


Several studies probe the association between prolonged time to surgery and postoperative complications in ankle fractures, but little is known about how a longer wait time affects clinical outcomes. The present study aims to assess the association between time from injury to surgery and patient-reported outcomes after operative treatment of severe ankle fractures. Patients treated operatively for low-energy ankle fractures that also involve the posterior malleolus from 2014 to 2016 were included. Patient charts were reviewed for patient demographics, type of trauma, fracture characteristics, treatment given, and complications. Ankle function was evaluated on a follow-up visit by clinical examination, radiographs, and patient-reported outcome measures. Researchers compared patients treated within one week to those treated later than a week from injury for analyses. Follow-up visits of 130 patients were performed at mean 26 months after surgery. Mean Self-Reported Foot and Ankle Score (SEFAS) was 34 in patients treated later than a week from injury versus 38 in those treated earlier. Patients operated on later than seven days from injury reported more pain and lower satisfaction than those treated earlier. In this retrospective patient series of low-energy ankle fractures with posterior malleolar fragments, the researchers found that waiting more than seven days for definitive surgery was associated with poorer clinical outcomes and more pain compared with those who had surgery earlier.


Minimally invasive repair techniques are typically reserved for the surgical treatment of acute Achilles tendon ruptures, with surgery performed within two weeks of injury. In a study, researchers presented two successful cases of percutaneous Achilles tendon repair performed in the subacute setting. At final follow-up (15 and 18 months, respectively), both patients had American Orthopaedic Foot and Ankle Society hindfoot scale scores of 100 and had returned to their normal and recreational activities. Percutaneous Achilles tendon repair techniques may have expanded use in the subacute setting, which may mitigate wound issues and infection rates associated with more open approaches, while still providing a quality repair to allow for the most optimal functional outcome.

Practice Management

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A key part of a practice's coding regimen is making sure each encounter can be efficiently billed. The Dacey Group's Bill Dacey says being familiar with the new outpatient coding guidelines released last year will help practices expand their revenues. Regarding code 99213, for example, he says, "with the changes that came in 2021, it makes it a whole lot easier to call that a 99214." Dacey says if a practice "wanted to supercharge their coding, I would do it with the codes that had the real money" rather than billing for smaller things that it was not already doing. Nancy Enos with Enos Medical Coding says practices must focus on properly documenting time spent. Physicians should undergo brief internal or external training that addresses documentation, including non-patient facing activities performed "on the same date as the billable visit." Non-patient facing activities include preparing to see the patient; ordering medications, tests, or procedures; documenting clinical information in the electronic or other health record; and care coordination. Enos also recommends making sure that a practice keeps track of time related to telehealth appointments.


As patients become more savvy, successfully fulfilling health information requests is essential. Practices may unknowingly have compliance issues if they have inconsistencies in policy. The federal Office of Civil Rights (OCR) assists physicians with staying compliant in relation to patients' right of access. OCR investigators should be regarded as a resource who can provide guidance on compliance issues and help avoid costly civil monetary penalties. The OCR addresses patient complaints via phone calls, technical assistance, or data requests. If a provider receives a phone call from the OCR about a complaint and follows the OCR's directions, a formal document detailing the patient complaint will be sent, and the complaint will be closed. The OCR will issue technical assistance if it deems a more formal method of communication is warranted. The OCR will review the complaint and documentation provided by the patient, and may offer education and direction. This will be noted in the technical assistance letter and show the case as closed. However, the OCR expects the provider to implement the advice provided. Finally, if the OCR determines a severe violation of its policy has occurred, it may issue a data request. It may benefit physicians to contact the patient directly to better understand the complaint. The provider should then document the conversation to show due diligence to the OCR in satisfying the patient's issues.


Healthcare business consultant Nathaniel Arana says in recent years, some payors have been offering excessively low reimbursement rates. These organizations are often for-profit and publicly traded companies whose stockholders call for consistent positive financial performance. It may be worthwhile for doctors to request their insurance company for an increase. In one instance, a doctor was denied an increase despite being the only specialist in the area. Arana intervened by presenting the information and argument in a way that the insurance company would comprehend and respond. The doctor was able to get a rate that was higher than what the other payors were reimbursing for the same services. After the rationale behind the increase was strategically conveyed, the insurer was in no position to deny it.

Health Policy and Reimbursement

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The US Centers for Medicare and Medicaid Services has announced it will replace the Global and Professional Direct Contracting Model (GPDC) with a more equity-focused and provider-led Accountable Care Organization Model in 2023. The redesigned model, called the ACO Realizing Equity, Access, and Community Health Model—or ACO REACH—includes new health equity requirements, changes to risk adjustment and additional application scoring criteria. As with GPDC, the US Center for Medicare and Medicaid Innovation will run the model.

CMS' announcement comes after Direct Contracting, started by the Trump administration to build off previous ACO models, came under fire from progressive lawmakers, who objected to Medicare Advantage and private equity influence in the program and worried profit-driven motives would compromise patient care. Meanwhile, provider associations and some Obama administration health officials have urged CMS recently to keep the GPDC and make changes. Applications for GPDC have been on hold since last year.


Some states have initiated a federal public-option insurance plan mired in political gridlock, encountering opposition from the healthcare establishment. Washington state's plan has involved coercing hospitals to participate. Officials from the Washington State Hospital Association noted the public option depends on slashing payments to hospitals to control costs and linking reimbursement to Medicare rates, which do not cover hospitals' cost of providing care. "If patients opt to join a public-option plan rather than private insurance, over time it could create financial challenges, especially for small, rural providers operating on thin margins," said the group's Chelene Whiteaker. State legislators last year mandated that hospitals contract with a public-option plan if they were unavailable in each county in 2022, and other states are following a similar approach of coercion in setting up their own public-option schemes.


Updates to frequently used billing codes implemented by the US Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) led to "no meaningful changes" in note length or time spent on electronic health records (EHRs), according to new research in Annals of Internal Medicine. AMA and CMS said the updates to evaluation/management (E/M) codes were made to allow physicians to devote more time to patients and less time to paperwork. "The AMA also streamlined the logic in applying E/M visit codes based on medical decision making to facilitate less ambiguous synthesis of the complexity of problems, complexity of data and risks for complications in a given visit," the researchers noted.

The authors wrote that the absence of an "immediate reduction in EHR documentation burden ... underscores longstanding frustrations with competing priorities that often sideline efforts to reduce provider burden. Healthcare organizations will likely need explicit guidelines and incentives to take a comprehensive approach to measuring and addressing EHR usability."


Many House and Senate lawmakers are urging the Biden administration not to impose any cuts on Medicare Advantage (MA) plans in the coming 2023 rates. The Centers for Medicare & Medicaid Services (CMS) proposed a 2023 MA and Part D Advance Notice rule calling for a nearly 9 percent increase in MA rates for 2023 and several regulatory reforms designed to boost health equity, which prompted over 60 senators to respond with a letter. They told CMS Administrator Chiquita Brooks-LaSure that any "payment or policy changes allow Medicare Advantage plans to continue to provide the patient-centered care that 43 percent of Medicare-eligible Americans rely on every day," while CMS should uphold stability within the MA program, including furthering any "flexible in-plain benefit offerings and promoting care coordination."

CMS also proposed updating MA and Part D star ratings to factor in how the plan affects health equity, seeking suggestions on what potential equity measures to add to the star ratings, as well as on how MA payments can better impact care for underserved populations. An earlier letter from 346 House members called on CMS to provide a stable rate and policy environment to ensure MA can continue to provide affordable and high-quality care.

Medicine, Drugs and Devices

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Surgical instruments and other critical devices are reprocessed and reused every day in health care facilities. Ensuring these instruments and devices are reusable – that they are in good condition and are cleaned and sterilized following validated manufacturer’s instructions – is critical to patient safety. A new Quick Safety advisory from The Joint Commission highlights reprocessing guidance from the US Food and Drug Administration (FDA), as well as special circumstances for single use devices (SUDs). While a SUD is intended for use on one patient during a single procedure and is not intended to be reprocessed and used on another patient, there are special circumstances under which third parties only may reprocess.

The Quick Safety details how most SUDs are not designed for reprocessing and do not allow for thorough decontamination after use, including that some are made of lower quality metals or components that will not withstand cleaning and sterilization processes and may deform, rust, pit, chip or crack if subjected to reprocessing methods.

The advisory also includes several recommended safety actions for reprocessing reusable instruments and devices, including standardized instrument and device visualization occurring during each step of the decontamination, cleaning and sterilization processes with final inspection prior to use and removal of any instrument inappropriate for use. It also recommends education, training and competency of staff responsible for reprocessing, oversight and/or supervision of reprocessing sterile products for their role in reprocessing reusable instruments and related job duties.


More than half of the connected medical devices in hospitals pose security threats due to critical vulnerabilities that could potentially compromise patient care. According to the 2022 State of Healthcare IoT Device Security Report from Cynerio, 53 percent of internet-connected medical devices analyzed were found to have a known vulnerability, while one-third of bedside devices were identified to have a critical risk.

The report warns that if these medical devices were to be accessed by hackers, it would impact service availability, data confidentiality and even patient safety. Some of the causes of these vulnerabilities result from relatively simple things, such as outdated programs. For example, the report found that most medical IoT devices were running older Windows versions, specifically, older than Windows 10. In addition, default passwords that are the same throughout an organization are common risks, especially since these weak default credentials secure about 21 percent of devices.

Cynerio says the solution to mitigating these vulnerabilities to reduce ransomware attacks is network segmentation. By dividing up a hospital's network, more than 90 percent of critical risks in medical devices would be addressed.