News From ACFAS

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Put your surgical skills to the test—challenge yourself by applying to be a part of the Total Ankle Arthroplasty course, April 18–19, in Denver.

If you’re ABFAS-certified in foot and ankle or reconstructive/rearfoot ankle and meet the course prerequisites, you’ll spend an entire weekend performing primary implantation and revision implants of all FDA-approved ankle replacement systems. Among your peers and experienced faulty, you’ll also learn the role of total ankle arthroplasty in managing degenerative, post-traumatic and systemic ankle arthritis; better understand perioperative, intraoperative and post-operative protocols; and identify scenarios where supplementary procedures may be necessary. Expert faculty will guide you step by step as they share their own personal experiences and case studies.

Course includes three cadavers for each accepted registrant, breakfast and lunch on Saturday and Sunday as well as refreshment breaks. Space is limited, visit acfas.org/education to apply today and see your surgical skills soar to new heights! Did you miss some of the more than 250 case study or scientific posters on display at ACFAS 2015 in Phoenix? No worries—you can now view these, as well as this year’s award-winning posters, at acfas.org/phoenix. ACFAS’ annual poster competition brings together the very best in clinical and scientific research, and this year was no exception. Be inspired by your colleagues’ latest developments in discoveries in foot and ankle surgery and get yourself motivated to share your own research at ACFAS 2016! Looking for fast and focused training on the surgical coding process to streamline your practice? Take advantage of ACFAS’ Interactive Surgical Coding Workshop set for July 17–18 in Tysons Corner, Virginia (Washington, DC).

Case-based sessions will cover ICD-10, modifiers, office policies, coding for evaluation, management and wound care, durable medical equipment and meaningful use of electronic health records as you code cases together as a group.

Don't miss this opportunity to give your practice a competitive advantage. Register today at acfas.org/practicemanagement.

Foot and Ankle Surgery

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A study was conducted to assess radiographic and clinical outcomes of distal tibial osteotomy without fibular osteotomy in patients with medial ankle osteoarthritis and mortise widening. Eighteen patients—15 women and three men—were treated. The patients were followed for an average of 34 months, with mortise widening diagnosed via valgus stress radiographs and intra-operative examination. Clinical outcome was evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score for pain and the ankle osteoarthritis scale (AOS) score. The AOFAS score improved from 78.4 points to 89 points. The VAS score for pain also fell from 6.7 points to 2.7 points. The average AOS score was 29.8 points at the latest follow-up. The center of the talus shifted laterally within the ankle mortise after the distal tibial osteotomy. The average medial distal tibial angle changed from 86.6 degrees to 92.9 degrees, and the average anterior distal tibial angle changed from 81.1 degrees to 84.3 degrees. However, there was no significant correction of talar tilt.


A hypothesis that a minimally invasive peroneus brevis tendon transfer would be effective for management of chronic rupture of the Achilles tendon was tested with 17 patients, with an average follow-up of 4.6 years. At the most recent review, the average maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, nor was it significantly less than that of the contralateral limb. The average peak torque and the strength of eversion of the operated ankle were substantially lower than those of the contralateral limb. The average Achilles tendon total rupture score significantly improved from 58 pre-operatively to 91 at the time of final review. Ten out of 13 patients who practiced sport at the time of injury still undertook recreational activities.


A study published in the Journal of Nuclear Medicine offers a chronic foot pain diagnosis option via imaging with 18F-fluoride positron emission tomography and magnetic resonance imaging (PET/MRI). This combination of modalities was found to effectively identify different possible causes of foot pain by testing and comparing the diagnostic performance of the PET/computed tomography (CT) and the PET/MRI on 22 patients with undiagnosed foot pain. Overall, image quality was higher using PET/MRI than using PET/CT. The researchers say 18F-fluoride PET/MRI yielded more information on bone metabolism and included key findings such as bone marrow pathology as compared to PET/CT. Another benefit is less radiation exposure in using MRI.

Practice Management

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Successful operation of a practice's corporate components depends on effective staff management and efficient business monetization. Most physicians lack the training or the time to assume double-duty as human resource and financial experts, which is why some practices can benefit from setting up a co-management structure instead of relying on traditional top-down management. One possible co-management framework is round management, where patients form the core business imperative, and each practice member has a unique responsibility that will add to the health of the patients or the business. The practice owner/physician is responsible for holding everything together by overseeing the staff's professionalism and the practice's economic success, while also supporting the patients and the practice team. The second co-management model is triangle management, a three-pronged strategy that includes a people manager to guide human resources; a financial manager to handle fiscal accountability, supplies and payroll; and a medical manager to serve as the in-house authority on medical practices, procedures and records. A third co-management structure is spiral management, which is appropriate for practices with one or two physicians and a small number of auxiliary staff. Patients are the central point of the spiral, with physicians, support personnel and administrative staff surrounding them in varying rings of care. People working in these practices generally have a vested interest in the success of the business because they like the autonomy offered by spiral management.


The U.S. Department of Health and Human Services announced in January that by the end of 2016 and 2018, it plans to tie 30 and 50 percent, respectively, of Medicare reimbursements to the “quality or value” of providers’ services. Meeting the demands of this mandate will require practices to keep track of which quality metrics their payers expect them to disclose in a given year. Experts recommend maintaining regular contact with payers to review quality-related priorities and benchmarks. Payers will target the metrics they want providers to meet according to areas that show the most potential for cost savings, such as prescribing generic medications. In addition, payers are increasingly using the patient-centered medical home designation as a sign of a practice’s devotion to measuring quality and outcomes and estimating their reimbursements accordingly. Payers also are adding financial incentives such as per-patient per-month payments on top of their fee-for-service reimbursements; practices use these funds to hire nurses and other providers as case managers to conduct tasks such as following up with patients recently discharged from hospitals. Experts concur electronic health record systems are essential to the quality reporting process.

Health Policy and Reimbursement

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A permanent "doc fix" plan negotiated by House Speaker John Boehner and Minority Leader Nancy Pelosi will need to gain traction in the coming days if it is to have a realistic shot at enactment before Congress adjourns for spring break at the end of the month. Congress has until March 31 to take action on the issue. Otherwise, doctors would face a 21.2 percent decrease in payments for treating Medicare patients. The proposed $215 billion package would include permanent repeal of Medicare's sustainable growth-rate formula, a two-year extension of the Children's Health Insurance Program and a two-year extension of a package of healthcare-related tax and spending provisions.


The Next Generation Accountable Care Organization (ACO) Model, a new initiative from the Centers for Medicare and Medicaid Services (CMS) Innovation Center, is part of the Department of Health and Human Service's efforts to move 50 percent of all Medicare provider payments to an alternative payment model by 2018. CMS expects about 15 to 20 ACOs to participate. Next Generation ACOs will have higher performance risk than ACOs in current models but will also have the possibility of sharing in greater savings. The objective is to test if strong financial incentives for ACOs, combined with tools to support better patient engagement and care management, can improve health outcomes and reduce expenditures. ACOs will be accepted into the Next Generation ACO Model through two application rounds in 2015 and 2016 and will participate for up to five years.


The Government Accountability Office (GAO) reported that programs such as Medicare, Medicaid and tax credits paid an estimated $124.7 billion to ineligible recipients in 2014. Although the federal government has attempted to reduce improper payments, it saw a nearly 18 percent increase in costs. This is the first jump in four years, with the highest amount for the Obama administration occurring in 2010, with an estimated $125.6 million in losses. Medicare reported the highest number of improper payments last year, accounting for nearly $60 billion in incorrect disbursements. The Earned Income Tax Credit contributed to $17.7 billion in lost revenue and Medicaid was responsible for $17.5 billion. GAO reported that federal agencies “continue to face challenges, such as statutory limitations and compliance issues” in preventing losses.


The American Medical Association (AMA) and 99 other state medical, medical specialty and professional associations are asking the Centers for Medicare and Medicaid Services (CMS) acting Administrator Andrew Slavitt to improve transition plans for the Oct. 1 conversion to ICD-10 diagnostic and procedural codes. "By itself, the implementation of ICD-10 is a massive undertaking," AMA and other groups write in a letter. "The undersigned organizations remain gravely concerned that many aspects of this undertaking have not been fully assessed and that contingency plans may be inadequate if serious disruptions occur on or after Oct. 1." To show evidence of the need for plans, the group pointed to February's release of mixed results from a first round of so-called end-to-end testing of the Medicare claims flow. In a statement, CMS said that the testing demonstrated that CMS systems are ready to accept ICD-10 claims. Out of the nearly 15,000 claims submitted by 661 providers, suppliers and clearinghouses, only 10 were rejected due to CMS system errors. The overall acceptance rate, including errors by submitters, was 81 percent. AMA notes that the normal acceptance rate for Medicare claims is between 95 percent and 98 percent.


The Centers for Medicare and Medicaid Services (CMS) has released the 2015 National Impact Assessment of Quality Measures Report, demonstrating that the U.S. has made significant progress in improving the healthcare delivery system to achieve better care, smarter spending and healthier people. The report summarizes key findings from quality measurement efforts. Specifically, 95 percent of the 119 publicly reported performance rates across seven quality reporting programs showed improvement from 2006 to 2012. About 35 percent of the 119 measures were classified as high-performing, which means performance rates above 90 percent.

Medicine, Drugs and Devices

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The ideal way to protect the public from hazardous medical devices, the Food and Drug Administration (FDA) says, is a brand-specific identification number on devices. If one malfunctions, the thinking goes, doctors can quickly tap large insurance databases to find out whether the malfunction was rare or part of a broader public health threat. Congress passed this “unique device identifier” (UDI) concept into law in 2007. By 2012, FDA planned to use billing claims form data—with that UDI number—to monitor medical device safety. Last year, manufacturers started placing numbers on their products, but the initiative has hit a barrier. The Centers for Medicare and Medicaid Services opposes FDA’s plan, saying that putting the UDI on medical claims forms it receives from hospitals poses technical hurdles and costs too much.


A study by the Leiden Early Arthritis Clinic cohort, an ongoing, population-based, inception cohort in the Netherlands, shows that fatigue was associated with inflammation in patients with rheumatoid arthritis, but treatment did not eliminate fatigue, suggesting a continuing unmet need in these patients. Researchers studied 626 patients with rheumatoid arthritis (RA), evaluating 66 swollen and 68 tender joint counts (SJC and TJC). Hand and foot radiographs were taken, along with blood samples that were analyzed for C-reactive protein (CRP), hemoglobin, rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA). Patients who experienced fatigue did not differ in age, gender, SJC, TJC or frequency of positive ACPA or RF status from patients who did not report fatigue, although patients with fatigue had slightly higher CRP levels. Patients treated with mild disease-modifying anti-rheumatic drugs or methotrexate (DMARDs) did not report decreased fatigue severity over time, compared to patients who were treated with nonsteroidal anti-inflammatory drugs or delayed DMARDs. The study was published in RMD Open.


A recent review of data from the Canadian Multicentre Osteoporosis Study found that patients who continually used warfarin for at least five years did not see a significant bone mineral density decline in key areas. However, there was increased density at the lumbar spine. "We think these findings are reassuring to patients on warfarin therapy who may be concerned about osteoporosis," co-author Dr. Stephanie Kaiser said at the group's poster presentation during The Endocrine Society annual meeting. "At this point, we do not believe that the incidental finding of the statistically significant increase at the L1-L4 represents a clinically meaningful finding."