News From ACFAS

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To work toward a solution to the national opioid crisis, ACFAS has issued the position statement, Opioid Prescribing by Foot and Ankle Surgeons. It outlines standardized opioid protocols and policies for foot and ankle surgeons to follow when prescribing opioids for acute and chronic pain.

“Numerous articles on the opioid crisis, as well as positions taken by other professional organizations, helped lead the Professional Relations Committee (PRC) to develop this position statement for foot and ankle surgeons,” says Samuel Nava, Jr., DPM, FACFAS, PRC Committee chair. “We wanted to produce a statement that the College could be proud of and that would hold ACFAS members to the highest standards. We want our members to be leaders in this battle that affects us all.”

ACFAS strongly recommends continued research, organizational collaboration and adoption of best practices to combat the opioid crisis. The College will continue to provide foot and ankle surgeons with educational resources to guide their prescribing habits. Coding for office/outpatient Evaluation and Management (E/M) services will change starting January 1, 2021. The American Medical Association’s (AMA) Current Procedural Terminology (CPT) Panel voted on these changes during its February meeting.

CPT 99201, which relates to office or other outpatient visits for the E/M of new patients, will be deleted due to low use, plus:

• Criteria used to determine the level of an office or outpatient E/M service will change.
• Time values associated with each office/outpatient E/M code will change, meaning foot and ankle surgeons will no longer need to specify how much time they spend counseling and coordinating.
• Titles of three elements used to determine medical decision-making level will change.

The AMA CPT Panel may still adjust these changes before they are made final. For more information, visit ama-assn.org. Refresh your practice marketing efforts with the spring issue of FootNotes, now available in the ACFAS Marketing Toolbox. Articles in this latest edition include:

• Enjoy Pregnancy Without Foot Pain
• High Ankle vs. Lateral Ankle Sprains: What’s the Difference?
• Healthy Feet Can Reduce Seniors’ Risk of Falling

Enter your office’s contact info into the editable box on page 2 then:

• Post the issue on your practice’s website and social media pages
• Leave printed copies in your office or include them in mailings
• Distribute copies at any local health events or speaking engagements you have scheduled this spring

Log into acfas.org/marketing to access this issue and be sure to explore the many other free resources in the Toolbox to spotlight your practice throughout the year.

Foot and Ankle Surgery

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A study examined the perioperative complications of implant removal in ankle fractures and analyzed the associated factors of such complications. Enrollees included 80 patients who underwent open reduction and internal fixation using metal implants for ankle fractures and had their implants removed between 2010 and 2015. Perioperative complications occurred in 14 percent of patients, including arterial injury in one patient, blistering in three, nerve injuries in three, skin necrosis in two and infection in two.

In those with perioperative complications, the rate of patients with peripheral vascular disease and multiple skin incision was significantly higher. The operative time was also significantly longer compared to patients without perioperative complications.


A prospective, double-blinded, randomized controlled trial compared the results of noninvasive interactive neurostimulation (NIN) in terms of improvement of a foot functional score, lower level of reported pain and return to sports in two cohorts of contact sport athletes affected by a grade I or II lateral ankle sprain. Patients were randomized using random blocks to the NIN program (group I) or a sham device (group II). The outcome measurements were the use of a self-reported Inability Walking Scale, patient-reported subjective assessment of the level of pain using a standard visual analogue scale and daily intake of nonsteroidal antiinflammatory drugs (etoricoxib 60 mg).

Of the 70 athletes admitted to the study, 61 eligible patients were randomized using random blocks to group I (n=32) and group II (n=29). Group I patients showed better improvement in terms of functional impairment (Inability Walking Scale), reported pain (visual analogue scale) and daily intake of etoricoxib 60mg. Athletes of group I registered a faster resuming of sport activities.


A study was conducted to assess the wide-awake local anesthesia no tourniquet (WALANT) technique as an alternative method for equivalent hemostasis and pain control in ankle fractures without the use of a tourniquet. Thirteen consecutive patients who presented ankle fractures and required open reduction and internal fixation from January 2017 to December 2017 were enrolled. Fracture types included lateral malleolar fracture, bimalleolar fracture, bimalleolar equivalent fracture, medial malleolar fracture and trimalleolar fracture. The physicians used a solution of 1 percent lidocaine combined with 1:40,000 epinephrine for WALANT.

All patients with an initial numerical pain rating scale (NPRS) score of 0 without using a tourniquet underwent surgery. Only two needed another 5 ml of local anesthesia due to NPRS score elevation during surgery, and no dose exceeded the safe limit of 7 mg/kg. No local complications happened, and no transitions to other anesthesia methods were required due to the failure of WALANT.

Practice Management

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The impeding penetration of telemedicine into mainstream healthcare raises questions about whether virtual appointments are better than in-person visits. Some doctors practicing telemedicine, especially younger ones, envision the practice as a career goal. Certain experts say many illnesses for which people go to a primary care doctor can just as easily be treated via telemedicine, and in many cases—such as those involving conditions that might prompt a visit to an urgent-care center—telemedicine allows doctors to deliver better care. On the other hand, some physicians are concerned that telemedicine undermines the doctor-patient relationship or will reduce their compensation.

Harvard Medical School Professor Ateev Mehrotra agrees telemedicine is an excellent option for treatments, such as mental health or urgent care. However, its effectiveness and relevance may be lessened if the patient requires a physical examination.


Before engaging with a third party for offshore billing, a practice should know its own vulnerabilities, which usually requires an outside viewpoint and evaluation. A risk assessment will identify areas where someone with access could collect sensitive patient, vendor and personnel data, which could cause brand reputation damage and loss of revenue in the event of a breach. Properly vetting billing vendors first involves a full investigation that defines the ownership structure, policies, protocols and practices in place to protect sensitive data. Practices should determine the exact steps vendors take to protect information, the systems and software they use and the monitoring mechanisms in place.

A list of all employees who will be working on the practice's account and given access to its data should be obtained. After choosing the billing vendor, the practice should make an effort to prevent sale or misuse of information, perhaps by anonymizing financial and personal data before release.


Negative online reviews can wreak havoc for practices and their reputations, and steps to mitigate this include seeking legal advice to learn what options are available. In some cases, the poster may be a patient with a grudge, especially if the review contains allegations about the physician, the practice and staff. It can therefore be inferred that the same individual has posted them, and because the practice knows who the patient is, it may have additional legal recourse.

Practices and physicians must be careful in responding to postings, as identifying someone as a patient may introduce HIPAA issues. The safest likely tactic would be inviting posters to “Please call to the practice to discuss your patient experience.” Practices should encourage satisfied patients to write reviews because positive reviews can quickly counter the negative ones.

Health Policy and Reimbursement

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The Trump administration has broadened its attack on the Affordable Care Act (ACA), telling a federal appeals court that it now believed the entire law should be invalidated. The administration had previously said the law's protections for people with preexisting conditions should be struck down but that the rest of the law, including the expansion of Medicaid, should survive. If the appeals court accepts the Trump administration's new arguments, millions of people could lose health insurance, including those who gained coverage through the expansion of Medicaid and those who have private coverage subsidized by the federal government.


The U.S. Government Accountability Office (GAO) reports that Medicare made more than $23 billion in improper payments in fiscal 2017, largely due to scant or no documentation. The report examines improper payments in Medicaid fee for service, which amounted to about $4.3 billion. GAO said improper payments for Medicaid have remained relatively steady since 2011, while improper Medicare payments have spiked since 2009. Most of Medicare's payment errors went to durable medical equipment, laboratories and home health services, with hospice coming next, according to the report.


Centene has agreed to acquire WellCare for about $15.3 billion. The deal would create a healthcare giant, cementing Centene's dominance in Medicaid coverage and in the Affordable Care Act (ACA) market, where it is the largest player, and increasing its presence in the growing market for private plans under Medicare. In addition, WellCare would be able to expand its presence in the ACA market. The combined company, with revenues expected to approach $100 billion in 2019, would cover 22 million people in all 50 states.

Medicine, Drugs and Devices

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The U.S. Centers for Medicare and Medicaid Services (CMS) has launched a competition to accelerate development of artificial intelligence (AI) technologies for better predicting health outcomes. The agency said the Artificial Intelligence Health Outcomes Challenge aims to find and "unleash" new tools to help with the migration to value-based care. CMS officials said the three-stage challenge "will begin with the Launch Stage, in which participants will submit an application at ai.cms.gov," with up to 20 participants qualifying.

Selectees will develop predictive algorithms, using CMS datasets to analyze Medicare fee-for-service data, as well as strategies and methods to explain AI-driven predictions to frontline clinicians and physicians while building trust in the data. Said CMS Administrator Seema Verma, "For artificial intelligence to be successful in healthcare, it must not only enhance the predictive ability of illnesses and diseases, but also enable providers to focus more time with patients."


The U.S. Food and Drug Administration (FDA) should issue a moratorium on new opioid analgesic approvals, according to the advocacy group Public Citizen. In a letter to FDA Commissioner Scott Gottlieb and HHS Secretary Alex Azar, the group asserts that, along with the industry itself, "it is beyond question that FDA is also culpable." The letter—signed by Sidney M. Wolfe, founder and senior adviser to Public Citizen's Health Research Group, and Raeford E. Brown Jr., a University of Kentucky professor who is chair of FDA's advisory committee on pain products—includes a petition to FDA to issue the moratorium.


The U.S. Food and Drug Administration (FDA) plans to revamp rules governing how medicines are manufactured in the wake of the increasing number of recalls of contaminated imports from developing countries. "We've seen a lot of instances of adulterated products—contamination, impurities—recently," said FDA Commissioner Scott Gottlieb. "The underlying causes have been traced back to manufacturing, inadequate quality controls and generally poor management oversight."