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Claim Your ACFAS 75 CME Credits Online
ACFAS 75 attendees, to claim your Continuing Medical Education (CME) credits:
  1. Visit and click on the red CME Information box in the center of the page.

  2. Log in to with your user name (ACFAS ID number) and password (ACFAS ID number + first and last name initials or your unique password you created).

  3. After you’ve logged in, visit the CME Credit Website to access your records.
If you have any questions or need assistance, contact the ACFAS Education Department at (800) 421-2237.
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Success Starts in 2017 Coding & Billing Seminars
Learn how to get reimbursed for the care you provide in Coding and Billing for the Foot and Ankle Surgeon, July 21–22 in Philadelphia and October 13–14 in Phoenix. Gain the tools you need to simplify your coding and reimbursement practices and better understand:
  • CPT coding and documentation options for deformity reconstruction, arthrodesis, arthroscopy, trauma and diabetic foot surgery
  • CPT coding for minor office procedures
  • Evaluation and management surgical codes
  • Modifiers to avoid appeals
  • New government reimbursement systems and methods
You’ll also bring the coding and billing process to life as you code real-time patient scenarios under the guidance of expert faculty. Don’t miss out on this popular seminar—register now at
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Register Now for Total Ankle Arthroplasty Course
It’s the total package—Total Ankle Arthroplasty, scheduled for May 19–21 in Aurora (Denver), Colorado, will combine implantation with in-depth discussion to give you hands-on experience working with six ankle replacement systems (four primary and two revision implants).

Expert faculty will share their own cases and proven tips to help you sharpen your surgical decision making and achieve the best outcomes for your patients. As you perform implantation of each system, you’ll learn practical strategies for primary and revision replacements while taking into account perioperative, intraoperative and postoperative protocols.

This course is worth 17.5 continuing education contact hours and includes three cadavers for each registrant. Visit today to apply.
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Foot and Ankle Surgery

Gait Biomechanics Following Lower-Extremity Trauma: Amputation vs. Reconstruction
Injuries once requiring lower-limb amputation are now frequently managed with limb reconstruction surgery. However, comparisons of functional outcomes between the procedures are inconclusive, prompting researchers to conduct a study to compare gait biomechanics following lower-limb reconstruction and transtibial amputation. Twenty-four individuals with unilateral lower-limb reconstruction wearing a custom ankle-foot orthosis; 24 with unilateral, transtibial amputation; and 24 able-bodied control subjects underwent gait analysis at a standardized Froude speed based on leg length. Lower-extremity joint angles, moments, powers and ground reaction forces were analyzed on the affected limb of patients and right limb of able-bodied individuals. The ankle, knee and hip exhibited significant kinematic differences between amputated, reconstructed and able-bodied limbs. The reconstruction group exhibited less ankle power and range of motion, while the amputee group exhibited lower-knee flexor and extensor moments and power generation. Gait deficiencies were more pronounced at the ankle following limb reconstruction with orthosis use and at the knee following transtibial amputation with prosthesis use. Although both groups in the cohorts tested can replicate many key aspects of normative gait mechanics, some deficiencies still persist. These results add to the growing body of literature comparing amputation and limb reconstruction and provide information to inform the patient on functional expectations should either procedure be considered.

From the article of the same title
Gait & Posture (02/17) Esposito, Elizabeth Russell; Stinner, Daniel J.; Fergason, John R.; et al.
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Local Heating Test for Detection of Microcirculation Abnormalities in Patients with Diabetes-Related Foot Complications
The goal of researchers in this study was to use a wavelet analysis of skin temperature (WAST) to assess the mechanisms of microvascular tone regulation during a local heating test in patients with diabetic foot syndrome (DFS). Participants included control subjects and 36 hospitalized patients with DFS between 52 and 79 years old. They were distributed among five groups: 15 control subjects, 8 patients with DFS who did not develop ulcerative or necrotic disorders, 10 patients who developed the neuroischemic form of DFS complicated by foot ulceration, 12 patients with DFS complicated by toe necrosis and six patients with DFS and foot gangrene. A comparison among the groups was made using a nonparametric Mann-Whitney U test and Spearman correlation coefficients were used to assess the relationship between WAST results, aortoarteriography and ultrasonic dopplerography data. In control subjects, a local increase in temperature (up to 42° C) caused a more than threefold increase in the amplitude of foot skin temperature oscillations. In patients with DFS, the response to the local heating test was much weaker. High correlations of WAST results to arterial patency of the lower extremities and the state of the vascular walls were established. The researchers concluded that the WAST technique may have considerable value in evaluating the progression of DFS and the effectiveness of therapeutic interventions. The low cost of an individual test makes the WAST technique suitable for routine use in most healthcare facilities, they said.

From the article of the same title
Advances in Skin & Wound Care (04/17) Vol. 30, No. 4, P. 158 Parshakov, Aleksey; Zubareva, Nadezhda; Podtaev, Sergey; et al.
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Total Ankle Replacement in Patients with Haemophilic Arthropathy: Primary Arthroplasty and Conversion of Painful Ankle Arthrodesis to Arthroplasty
Total ankle replacement (TAR) and ankle arthrodesis are the two general surgical approaches for operative treatment of end-stage haemophilic ankle arthropathy. In this study, researchers sought to determine intraoperative and postoperative complications and to evaluate the midterm clinical and radiographic outcomes of TAR in patients with haemophilic arthropathy. Fourteen patients with a mean age of 51.4 years were treated for end-stage haemophilic ankle arthropathy. Nine procedures consisted of primary arthroplasties, and five procedures were conversions of painful ankle arthrodesis to TAR. The mean duration of follow-up was 5.8 years. Component stability and alignment were assessed with weightbearing radiographs. One patient sustained an intraoperative medial malleolar fracture, two patients experienced delayed wound healing and another patient underwent open arthrolysis due to painful arthrofibrosis. Complication rates and clinical/radiographic outcomes were comparable in patients with primary TAR and conversion of ankle arthrodesis to TAR. Visual analogue scale significantly decreased from a mean of 8.5 to 1.3. The summarized components of the Short Form 36 physical and mental outcomes score significantly improved at the latest follow-up. The researchers concluded that the midterm results following TAR or a conversion procedure in patients with haemophilic arthropathy were encouraging, but for postoperative success, access to an experienced, multidisciplinary team that includes a haematologist is mandatory.

From the article of the same title
Haemophilia (03/17/17) Preis, M.; Bailey, T.; Jacxsens, M.; et al.
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Practice Management

Are You Liable for Retirement Plan Malpractice?
Many physicians in America are unaware of their liability exposure to retirement plan malpractice. Physicians offering retirement plans, such as a 401(k), to employees are a plan sponsor as well as a fiduciary to their plan participants and thus have important responsibilities. For example, according to the Employment Retirement Income Security Act of 1974 (ERISA), a fiduciary must act solely in the interest of plan participants and their beneficiaries, carry out duties prudently, follow the plan documents, diversify plan investments and plan expenses. As a fiduciary, their personal assets could be at risk and could be used to compensate for fiduciary losses. Physicians can reduce liability exposure by creating an investment policy statement that is easy to follow and by communicating it effectively to plan administrators and plan participants so that everyone clearly understands it. They can work with a record keeper who uses a fixed, per participant fee model, is not being compensated by revenue sharing and can get a second opinion from a fee-only registered investment adviser who specializes in retirement plans. Also, physicians can maintain the required ERISA Fidelity Bond of no less than 10 percent of the plan's assets as of the beginning of the year and can obtain fiduciary liability insurance.

From the article of the same title
Medical Economics (03/10/17) Swenson, Seth
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Managing Patient Flow: How to Keep It Moving
Bottlenecks can make patients anxious and lead to complaints, and it can be easy for doctors to miss things as the pressure to push forward intensifies. Out of respect for patients, doctors should try to reduce wait times as much as possible, and teamwork is key to optimizing patient flow, writes Linda Girgis, MD. Everyone needs to be aware of the schedule and recognize when it is lagging behind. "My nurse usually adds vital signs to the EHR before I see the patient, but when the lag starts, it waits until the patient is seen," notes Girgis, who adds that scheduling is important. Only double-book acute visits and quick follow-ups, and if a doctor knows a procedure will take time, he or she should allow for that in the schedule. Doctors should find out where the bottlenecks are, and retraining may be needed to address them. Also, doctors should focus on eliminating no shows, fixing persistent lateness, fitting patients in when they can and ending unwanted interruptions.

From the article of the same title
Physicians Practice (03/22/17) Girgis, Linda
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Outcomes for High-Needs Patients: Practices with a Higher Proportion of These Patients Have an Edge
New research sheds light on what types of physician practices perform best for high-needs patients. Researchers examined two scale-related characteristics that could predict how well physician practices delivered care to this population: practice size (number of physicians) and the proportion of patients in the practice with multiple physical, mental or behavioral health conditions. The team reviewed four years of data on commercially insured, high-needs patients in Michigan primary care practices and found lower spending and utilization among practices with a higher proportion of high-needs patients (more than 10 percent of the practice's panel) compared to practices with smaller proportions. Small practices (those with one or two physicians) had lower overall spending, but not less utilization, compared to large practices. However, practices with a substantial proportion of high-needs patients, as well as small practices, performed slightly worse on a composite measure of process quality than their associated reference group. Practices that have more high-needs patients might have structural advantages or have developed specialized approaches to serve this population. If so, this raises questions about how best to make use of this knowledge to foster high-value care for high-needs patients, conclude the researchers.

From the article of the same title
Health Affairs (Winter 2017) Vol. 36, No. 3, P. 476 Cross, Dori A.; Cohen, Genna R.; Lemak, Christy Harris; et al.
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Health Policy and Reimbursement

CMS Delays Expansion of Bundled Payment Programs
The U.S. Centers for Medicare and Medicaid Services (CMS) has delayed the expansion of the Comprehensive Care for Joint Replacement (CJR) program and implementation of its bundled payment initiatives for cardiac care from July 1 to October 1. It also delayed the effective date of a final rule laying out the implementation of CJR and other bundled payment programs from March 21 to May 20. The moves raise questions about efforts to shift healthcare from a fee-for-service model to a value-based payment scheme, a major focus of the Affordable Care Act.

From the article of the same title
Modern Healthcare (03/20/17) Whitman, Elizabeth
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CMS Prereleases eCQM Changes for the 2018 Reporting Period
With the Merit-Based Incentive Payment System (MIPS) taking full effect this year, the U.S. Centers for Medicare and Medicaid Services (CMS) has released information on upcoming adjustments to electronic clinical quality (eCQM) measure standards, terminology and specifications for quality reporting and incentive programs in 2018. CMS plans to publish the adjustments in the spring. The agency decided to release the information early to give providers advanced notice of what to expect. “This transparent prerelease of expected changes and requirements will help health information technology developers, eligible professionals, eligible clinicians and eligible hospitals prepare for the 2018 reporting periods,” according to a post on the CMS eCQI Resource Center page. CMS also has updated its eCQM specifications for eligible professionals for the 2017 reporting period to match up with the domains listed in the 2016 Medicare Physician Fee Schedule, MIPS and Advanced Alternative Payment Model tracks of the Quality Payment Program. Moreover, CMS is giving vendors and stakeholders the chance to review and offer commentary on draft eCQM measure packages including logic and header adjustments for eCQMs eligible for CMS quality reporting and payment programs. The moves by CMS could allow for a smoother reporting period in 2018 and beyond.

From the article of the same title
EHR Intelligence (03/17/2017)
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Republicans Revamp U.S. Healthcare Bill, Boost Benefits to Older Americans
Congressional Republican leaders plan to propose a series of amendments that mark major legislative changes to their Obamacare replacement bill, but it is not immediately clear whether they would help win more Republican support amid solid opposition from Democrats. House leaders will propose an approximately $85 billion fund for tax credits to help people aged 50-64 get health insurance. In an unusual move, the House wants to provide the Senate flexibility to offer more help to that age group, which may need a larger tax credit to help cover their healthcare costs. The Trump administration and House leadership need to shore up support from moderate Republicans who fear the bill dismantling President Barack Obama's signature Affordable Care Act will hurt millions of Americans enrolled in the program. They must also appeal to hard-right conservatives who believe the original bill did not go far enough in repealing the law. The Congressional Budget Office (CBO) analysis of the original House Republican bill severely damaged its prospects. Democrats as well as hospitals and insurers have urged Republicans to consider how their plan would affect access to healthcare for the 20 million people insured by Obamacare.

From the article of the same title
Reuters (03/20/17) Cornwell, Susan; Volcovici, Valerie
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Medicine, Drugs and Devices

Longer Initial Opioid Prescription Ups Risk of Chronic Use
A new study from researchers at the U.S. Centers for Disease Control and Prevention (CDC) shows longer initial opioid prescription raises the risk of chronic use. Researchers looked at a sample from IMS Lifelink+, a large database of managed care users, from 2006 to 2015. Overall, nearly 1.3 million adults met the inclusion criteria: at least one opioid prescription during the time period and at least six months of continuous enrollment without an opioid prescription prior to their first opioid prescription. They tracked them from the first day of prescription until the loss of enrollment, study end date or discontinuation of opioids (defined as less than 180 days without opioid use). The researchers wrote in the Morbidity and Mortality Weekly Report that the probability that an opioid-naive patient would become a chronic opioid user increased sharply after as little as five days of use. A second opioid prescription or refill and a cumulative dose of 700 morphine-milligram equivalents also led to the sharpest increases in probability of continued opioid use among commercially insured, opioid-naive, cancer-free adults. Only six percent of patients with at least one day of opioid therapy continued to use opioids a year later, but that percentage increased to 13.5 percent among patients whose first episode of opioid use was at least eight days and jumped to 29.9 percent when patients first used opioids for at least 31 days.

From the article of the same title
MedPage Today (03/16/17) Walker, Molly
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Maternal, Fetal Vitamin D Levels: No Effect on Child Bone Health
A study published online in the Lancet Diabetes & Endocrinology led by Dutch researchers has found that concentrations of 25-hydroxyvitamin D (25(OH)D) in pregnant mothers and newborns show no association with childhood bone health. Researchers measured maternal 25(OH)D concentrations in midpregnancy and 25(OH)D concentrations at birth in the baby, to reflect fetal concentrations. Total body bone mineral density, bone mineral content, area-adjusted bone mineral content and bone area were measured in the same children at six years old. Severe maternal 25(OH)D deficiency midpregnancy was associated with higher offspring bone mineral content and larger bone area at six years old, compared with maternal 25(OH)D sufficiency midpregnancy. The data suggests that 25(OH)D concentrations during childhood are more relevant for bone health than in utero levels.

From the article of the same title
Medscape (03/17/17) McCall, Becky
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Shortage of Drug to Treat Low Blood Pressure from Septic Shock Associated with Increased Deaths
New research assesses changes to patient care and outcomes associated with the 2011 shortage of norepinephrine. Hannah Wunsch, M.D., M.Sc., of Sunnybrook Health Sciences Center in Toronto, and colleagues report that patients with septic shock admitted to hospitals affected by the shortage had a higher risk of in-hospital death. The study group included 27,835 adults with septic shock admitted to 26 U.S. hospitals between July 2008 and June 2013. Compared with hospital admission with septic shock during quarters of normal use, hospital admission during quarters of shortage was associated with an increased rate of in-hospital mortality (9,283 of 25,874 patients [35.9 percent] vs. 777 of 1,961 patients [39.6 percent], respectively; absolute risk increase = 3.7 percent). Several factors may explain the observed association, including that other specific vasopressors selected to replace norepinephrine may result in worse outcomes for patients with septic shock, and that observable decreases in norepinephrine use in the setting of a shortage may be a marker of related unmeasured factors that affected patient outcomes, according to the researchers. The U.S. Food and Drug Administration announced the shortage in February 2011 in response to production interruptions at three drug manufacturers. Drug shortages are an increasing problem, but their effect on patient care and outcomes has rarely been reported.

From the article of the same title
Science Daily (03/21/2017)
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This Week @ ACFAS
Content Reviewers

Mark A. Birmingham, DPM, FACFAS

Daniel C. Jupiter, PhD

Gregory P. Still, DPM, FACFAS

Jakob C. Thorud, DPM, MS, AACFAS

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This Week @ ACFAS is a weekly executive summary of noteworthy articles distributed to ACFAS members. Portions of This Week are derived from a wide variety of news sources. Unless specifically stated otherwise, the content does not necessarily reflect the views of ACFAS and does not imply endorsement of any view, product or service by ACFAS.

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