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News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Technology and Device Trends

News From ACFAS

Billing for Routine Foot Care Services

The Centers for Medicare and Medicaid Services (CMS) issued a clarification of its existing policy for billing routine foot care services. Medicare pays for routine foot care provided by podiatrists when there is documentation that, in the six-month period prior to the provision of such services, the patient has seen an M.D. or D.O. for treatment/evaluation of the complicating disease process that warrants the need for routine foot care.

View the MLNMatters article on how to properly submit foot care claims.

The Medicare Benefit Policy Manual (MBPM) chapter applicable to foot care services is also available.
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Foot and Ankle Surgery

Incidence and Risk Factors for Venous Thromboembolic Disease in Podiatric Surgery

Venous thromboembolism presents a low risk in podiatric surgery but practitioners should consider prophylactic treatment if the patient has at least two risk factors, conclude Andrew H. Felcher, MD, of Northwest Permanente Medical Group in Portland, Ore., and colleagues. The researchers collected electronic medical records for a 485,000-plus-member HMO in the Pacific Northwest and analyzed the records of 7,264 patients who had 16,804 podiatric surgeries between 1999 and 2004. They identified 22 instances of post-operative venous thromboembolism for an incidence rate of 0.30 percent. The three leading risk factors associated with venous thromboembolism in the podiatric setting were previous venous thromboembolism, hormone replacement therapy or oral contraceptive use, and obesity. "We identified a low overall risk of venous thromboembolism in podiatric surgery, suggesting that routine prophylaxis is not warranted," say the researchers. "However, for patients with a history of venous thromboembolism, periprocedure prophylaxis is suggested based on the level of risk. For podiatry surgery patients with two or more risk factors for venous thromboembolism, periprocedure prophylaxis should be considered."

From the article of the same title
Chest (04/01/09) Vol. 135, No. 4, P. 917; Felcher, Andrew H.; Mularski, Richard A.; Mosen, David M.

Tarsal Coalition as a Cause of Failed Tarsal Tunnel Release for Tarsal Tunnel Syndrome

A wide variety of potential causes of tarsal tunnel syndrome have been proposed, including trauma, foot deformity, and space-occupying lesions, and operative treatment is frequently attempted to decompress the involved nerve. However, one reason tarsal tunnel release treatment has been found to fail is because of tarsal coalition, which was seen in a 28-year-old woman who continued to have dysesthesia and tingling in her right foot five months after a tarsal tunnel release. When a slight prominence and bony hardness was found at the distal and posterior side of the medial malleolus, radiographs indicated a talocalcaneal coalition, which was verified by computed tomography and magnetic resonance images. Upon new surgery, the bony protrusion from talocalcaneal coalition was found compressing nerves at the middle facet of the subtalar joint; it was excised following elevation of the periosteum and the joint capsule, which was repaired later to give the neurovascular bundle in the tarsal tunnel a smooth contact surface. Three months after the operation, the patient's tingling and dysesthesia were no longer present and she was satisfied with the outcome.

From the article of the same title
Ortho Supersite (04/01/2009) Yoo, Jae Ho; Kim, Eung Ha; Kim, Byung Sung

Osteoporosis Drug Promotes Healing of Fractures, Study Finds

A drug used to treat severe osteoporosis promotes healing of hard-to-mend fractures, according to preliminary studies by Dr. Susan V. Bukata of the University of Rochester Medical Center and colleagues. In a study of 145 patients who had unhealed bone fractures—some for as long as six months—93 percent had significant healing after only eight to 12 weeks on teriparatide, or Forteo. "This is a drug with a good clinical track record that has proved to be remarkably safe, and it could have great utility," says Dr. Richard S. Bockman, chief of the endocrine service at the Hospital for Special Surgery in New York, who was not involved in the study. Bukata's team reported its findings at a February meeting of the Orthopaedic Research Society and is now submitting a report to a major journal. Approximately 5 percent of the 6 million fractures suffered by Americans each year are slow to heal or do not heal at all.

From the article of the same title
Los Angeles Times (04/15/09) Maugh II, Thomas H.

Practice Management

The Problem With EHRs and Coding

The Obama administration, the Senate Finance Committee, and the Centers for Medicare & Medicaid Services (CMS) are among the political players pushing for adoption of health information technology (HIT) including electronic health records (EHRs). However, some physicians who have adopted EHRs have unwittingly found themselves victimized when government audits find that their software systems have allowed, or even promoted, noncompliant and potentially fraudulent claims for evaluation and management (E/M) services. A number of factors have led to this unfortunate circumstance, including a lack of effective policies from organizations such as CMS, the Certification Commission for Healthcare Information Technology (CCHIT), the U.S. Department of Health and Human Services (HHS), and EHR software vendors and trainers. Doctors have also complained that the inflexible format in which the software demands that they enter clinical information causes them problems when following up with the patient later, which is collaborated by a study in the New England Journal of Medicine. "Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care," said the study. "Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be 'efficient' for the purpose of documentation but not for creative clinical thinking." There are four interrelated areas in which these history and physical (H&P) problems crop up: the integrity of the clinical information; the usability, quality, and workflow; malpractice protection; and E/M compliance. Audits that find a lack of compliant documentation from physicians using electronic H&P are often the first warning of further problems regarding data integrity, quality of care, and malpractice protection. To reduce the danger of E/M noncompliance, practices that are using EHRs should obtain E/M compliance experts' help and should insist that vendors get rid of non-compliance documentation and coding functionality; meanwhile, practices looking to adopt EHRs should include compliance and quality documentation experts in the team that chooses the EHR system.

From the article of the same title
Medical Economics (04/03/09) Grinder, Deborah; Linker, Robin; Thurston, Susan

Motivating Staff in Lean Times

Motivating personnel in frugal times is a challenge for medical practice administrators, and Ken Hertz with the Medical Group Management Association's Health Care Consulting Group says developing new concepts for nonfinancial incentives is the best way to prevent talented staffers from decamping. Flexible schedules that allow employees to spend more time with their families are highly prized, and advantages to the practice can include a raise in worker productivity. Offering free healthcare services to workers' immediate family members also can pay dividends, while another valuable nonmonetary perk is reimbursement for education that earns employees new credentials. Granting employees a more senior title and expanding their responsibility over a division or project can head off attrition, as can acknowledgment of workers' contributions throughout the year, especially if it is done in front of their peers. Administrator Sue Shive stresses the need for administrators to keep staffers apprised of the practice's financial status on a regular basis, and she adds that doctors' willingness to take salary cuts to ensure that all employees—especially the most valued ones--get paid can be a good motivator. Hertz points out that practices that issue bonuses and raises according to performance have a better chance of success. "Create some kind of formula that says if the practice hits these milestones in collections, patient volume, or accounts receivable, each employee will receive a bonus of X amount," he suggests. "That tells your staff that if the practice does well going forward then you're all going to share in that success and if it doesn't do well then we won't have the resources."

From the article of the same title
Physicians Practice (04/09) Schwartz, Shelly K.

Reducing Improper Internet Use in Your Office: A Quick, Easy and Free Solution

James Dom Dera, MD, writes that OpenDNS offers a free, easy and fast way to block Web sites that are inappropriate for practices, reducing the chances of lost productivity and compromised security. OpenDNS works by limiting access to certain Web sites either on one computer or on the whole computer network by changing the Domain Name System (DNS) setting. Installation is unnecessary and the process only takes a few minutes, while other advantages Dera lists include speed, security and customization. OpenDNS supports one of the largest Web site lists or caches that enables OpenDNS to quickly retrieve a site rather than having to search for an IP address. "If you create a free account with OpenDNS, you or your network administrator can then control the Web traffic on your practice's computers," says Dera. Additional useful features Dera highlights include the ability to set up shortcuts to eliminate the typing of Web sites, automated typo correction, and a log of employee-requested sites. Among OpenDNS' drawbacks is its use of advertiser links, which could become a distraction; its use with only known Web sites; no prohibitions on users using instant-messaging clients, downloading software or employing peer-to-peer file-sharing applications; and its exclusive applicability to DNS requests. Dera also notes that the service "is only available to those with permission to change the network server settings."

From the article of the same title
Family Practice Management (04/09) Dera, James Dom

Health Policy and Reimbursement

Obama Budget Makes No Assumptions About Medicare Sustainable Growth Rate Cuts

The $3.5 trillion spending plan passed by the U.S. House and Senate reflects the recent reality of applying the Medicare sustainable growth rate policy on physician fees, anticipating that once again Congress will intervene to head off the pending 21 percent cut to physician fees next year. The spending plan actually forecasts that payments will increase by $147.1 billion from 2010 to 2014. The American Medical Association (AMA) voiced its support of the administration's handling of sustainable growth rates (SGR). An anonymous AMA official asserted that the omission of SGR's impact in the president's budget is a "big step forward toward permanent reform." Although the absence of cuts in the budget does not reveal the president's position on SGR, it sets the stage for congressional action, the official said. Orrin Marcella, the American College of Radiology's director of congressional affairs, said the treatment of SGR is an outgrowth of Obama's emphasis on transparency for his $3.5 trillion proposal. "The president is not making policy. He is making a budget that reflects reality," Marcella said. "A policy change is up to Congress."

From the article of the same title
Diagnostic Imaging (04/03/09) Brice, James

Technology and Device Trends

Horse Stem Cell Technique to Be Tested in People

British biotech firm MedCell Bioscience has announced that it will soon begin human testing on a stem cell repair technique that has already proven effective in repairing tendon damage in race horses. Patients with damaged Achilles tendons will receive injections containing millions of their own stem cells, which have been extracted and multiplied in a laboratory, to regenerate new tissue to repair the damaged regions. Testing on more than 1,500 race horses showed a 50 percent reduction in re-injury over a three year period compared with conventional treatment. "The move from clinical veterinary to human medicine is inspiring and unusual—we normally see the translation happening the other way around," says Nicola Maffulli, an orthopedic surgeon who will help conduct the trial. The repair technique was pioneered by surgeons at the Royal Veterinary College north of London, who helped establish MedCell.

From the article of the same title
Reuters (04/15/09)

Autologous Nonmyeloablative Hematopoietic Stem Cell Transplantation in Newly Diagnosed Type 1 Diabetes Mellitus

The impact of autologous nonmyeloablative hematopoietic stem cell transplantation (HSCT) in 15 patients with type 1 diabetes mellitus (DM) was measured in 2007, and the majority of the patients became insulin free with normal levels of glycated hemoglobin during an average 18.8-month follow-up. Continued monitoring of C-peptide levels was performed following HSCT in the 15 original and eight additional patients to determine if retention of beta-cell mass was responsible for this effect. Twenty patients without previous ketoacidosis and not receiving corticosteroids during the preparative regimen became insulin free during a seven- to 58-month follow-up. A dozen patients remained insulin free for a mean 31 months, while eight patients relapsed and restarted insulin use at low dose. In the continuous insulin-independent group, glycated hemoglobin levels were below 7 percent and mean area under the curve (AUC) of C-peptide levels rose significantly. Mean AUC of C-peptide levels also increased substantially in the transient insulin-independent group, with two patients regaining insulin independence after treatment with sitagliptin. Nine patients developed oligospermia, three developed late endocrine dysfunction, and two developed bilateral nosocomial pneumonia, with no incidence of mortality. The conclusion of the study was that C-peptide levels increased significantly and most of the patients became insulin free with good glycemic control after a mean follow-up of 29.8 months after autologous nonmyeloablative HSCT in patients with newly diagnosed type 1 DM.

From the article of the same title
Journal of the American Medical Association (04/15/09) Vol. 301, No. 15, P. 1573; Couri, Carlos E.B.; Oliveira, Maria C.B.; Stracieri, Ana B.P.L.

Doctor, I've Got a Problem With My Genome...

DNA profiling is poised to one day become an affordable and desired medical test in view of falling technology costs and the genetic insights the technique can supply, and Mark Henderson writes that the method could help usher in the era of personalized medicine if physicians can learn to correctly interpret patients' DNA data and use it judiciously in clinical practice. However, Henderson sees little indication that the medical profession is ready for this milestone, as "the existing syllabus ... is founded on the way that genetics has affected medicine in the past and not on the challenges it will create in the future." He notes that genetic training currently concentrates on rare mutations in single genes that usually have severe consequences. "A knowledge of these rare diseases ... is not going to be much help when patients start to visit their [doctors] waving printouts from genome scans," Henderson argues. The scans study scores of common genetic variances that, when combined in certain ways, may significantly increase or decrease a patient's odds of developing diseases or conditions, and the test's reliance on probabilities makes interpretation notoriously difficult. Henderson also points out that the body's response to drugs is affected by genetic variation, which implies that doctors will need to revise their prescription methodology as they gain access to DNA profiles. He concludes that doctors require "an appreciation of how genetic discoveries are likely to become integrated into medical practice, and basic skills to make the most of them."

From the article of the same title
The Times (London) (04/14/09) Henderson, Mark

U.Va.'s Institute on Aging Teams University Researchers With Health Care Technology Company to Develop Novel Sensor Devices for the Elderly

University of Virginia researchers are developing wireless body sensor networks that could be used to monitor a person's gait, potentially helping prevent falls among older adults. The researchers are developing wearable sensors for residents of long-term care facilities and are running "living laboratories" to test and improve the technology. Falls are the leading cause of injury death among people older than 65, according to the Centers for Disease Control and Prevention, and they also are the major cause of non-fatal injury and hospitalizations for trauma. The wireless body sensors will help identify problems in a person's gait that could cause a fall. By wirelessly connecting a network of sensors, the researchers will be able to receive real-time data on nursing home residents' gaits. Virginia professor John Lach has developed sensors that can quantitatively measure the walking patterns that will likely lead to a fall. This information will be used to create a system that will enable geriatricians to accurately assess gait problems and provide interventions before a fall occurs. Lach says his research could lead to a new standard of care that is more cost effective and can be applied to a variety of real-world settings. The same technology could potentially be adapted and used by the military to monitor and analyze soldiers' movements in combat.

From the article of the same title
University of Virginia (04/13/09) Richards, Zak

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April 22, 2009