News From ACFAS

ACFAS has developed a comprehensive new toolkit for members to use with hospital decision-makers when applying for or renewing privileges.

The College’s Professional Relations Committee and individual members who have overcome their own significant barriers in hospitals compiled the Privileging Toolkit as a practical guide to assist members in obtaining privileges appropriate to the education, training and scope of foot and ankle surgeons. It includes a "how-to" list and several useful documents such as:

• ACFAS Position Statement on History and Physical Privileges for Foot and Ankle Surgeons.
  
• ACFAS Position Statement on Education and Training of Foot and Ankle Surgeons


• ACFAS Position Statement on Credentialing and Privileging

The Privileging Toolkit also contains a detailed Protocol for Handling Privileging Problems.

You can view the documents online or, to request a copy in the mail, call the ACFAS Health Policy Department at (773)693-9300 or e-mail adriann.gerardi@acfas.org.





Perhaps you've got a challenging case, and you remember that a foot and ankle surgeon at the last conference you attended talked about a similar case.

Or perhaps you need to contact an ACFAS member to refer a patient who has relocated out of state.

The ACFAS Web site can help you. The "My ACFAS" section contains a member directory which allows you to search by various criteria. You can also update your own contact information so others can find you. Don't squander opportunities; make the connection.

Last week, an article in this e-newsletter reported that The Centers for Medicare and Medicaid Services (CMS) issued a clarification of its existing policy for billing routine foot care services.

CMS has since decided the policy needs further clarification. The MLNMatters article referenced last week has been rescinded by CMS.

Continue to bill for routine foot care services as indicated in the Medicare Benefit Policy Manual (MBPM) chapter applicable to foot care services. Watch "This Week at ACFAS" for updates as CMS issues further clarification on its policy.

Foot and Ankle Surgery

Combined Lateral and Transcuneiform Without Medial Osteotomy for Residual Clubfoot for Children

Researchers in Singapore have described a corrective procedure for resistant clubfoot in children under five years of age, involving a closing wedge cuboidal osteotomy and trans-midfoot rotation procedure without a medial opening wedge osteotomy. A retrospective review of 12 patients who had undergone the procedure to correct forefoot adduction and midfoot supination deformities found qualitative improvement in correction of adduction and supination deformities in all of the patients. The minimum follow-up time was two years, and improvement was seen in mean anteroposterior talo-first metatarsal and calcaneo-fifth metatarsal angles as well as in supination and cavus.



New Nerve Block May Change Pain Management

A new slow-release anesthetic drug-delivery system developed by scientists at Children's Hospital Boston has the potential to change how physicians treat chronic pain and pain experienced during and after surgery. The delivery system uses specially designed liposomes to package the strong anesthetic saxitoxin, and it has been seen to provide long-lasting local anesthesia in rats without apparent nerve or muscle cell toxicity—something that had been a problem with previous efforts to create slow-release anesthetics. "The idea was to have a single injection that could produce a nerve block lasting days, weeks, maybe even months," says Dr. Daniel Kohane, senior author of the report detailing the development. "It would be useful for conditions like chronic pain where, rather than use narcotics (that) are systemic and pose a risk of addiction, you could just put that piece of the body to sleep, so to speak." Kohane said he is working with the formulation to increase its effectiveness duration even further, and it is possible that clinical trials could begin soon. The research appears in the online edition of the Proceedings of the National Academy of Sciences.

Practice Management

Pharma Dinner Meetings Banned in the Bay State

Massachusetts has enacted new restrictions on meeting venues, gifts, meals, and entertainment related to pharmaceutical and medical device marketing. Under the Massachusetts Pharmaceutical and Medical Device Manufacturer Code of Conduct, informational presentations held at restaurants will no longer be allowed under the new rules, as presentations accompanied by a meal will have to happen at a medical office, hospital, or device training facility. "There are a lot of differing interpretations of the code," says Boston healthcare attorney William M. Mandell. "The wording is not 100 percent clear. It's possible that a medical device training program accompanied by a meal could be held in a hotel room that simulates an operating room, but that would be a broad interpretation." CME providers, medical education companies, and other third parties, meanwhile, can use unrestricted grants from pharmaceutical companies to offer meals at events that meet the definition of scientific conferences under the code. Companies will also not be allowed to provide entertainment or recreation to healthcare practitioners, although this is open to interpretation as well. Mandell said that many meeting professionals continue to ask about the law's jurisdiction, as well, although he said supplemental materials from the state government explicitly say the code does not put restrictions on doctors licensed outside Massachusetts. Meanwhile, Mandell said he has requested clarifications for various other matters related to the code.



What the 'Red Flags Rule' Means for You

The Federal Trade Commission's (FTC's) new requirement that creditors implement written policies to fight identity theft is likely to apply to medical practices that extend, renew, or continue credit for patients, which includes all those that bill patients for services rendered. Compliance with this "Red Flags Rule" involves creating a written program for identifying relevant red flags, detecting them when they happen, and prevent and mitigate identity theft, while also being able to update the program from time to time. Four categories of red flags identified by the FTC are: alerts, notifications, or warnings from a consumer reporting agency; suspicious documents; suspicious personal identity information; and suspicious activity relating to a covered account or notices about possible identity theft. The practice's written program must include appropriate ways to find and respond to red flags, including contacting the payer and law enforcement, changing account measures to prevent abuses, increasing monitoring of accounts, or a combination of these. The practice could be subject to significant monetary penalties if it is in violation of the rule.



How to Calculate the Right Staffing for a Smaller Practice

When a physician retires from a practice, it is necessary to examine the practice to determine the optimal number of employees. This involves examining payroll reports to see how much overtime is being paid and to whom. When considering overtime expense as a percentage of payroll expense, research shows that most practices aim toward 2 percent or less. The next step is to examine management reports and to monitor the office to detect backlogs, which could include old accounts receivable or unfiled medical records and reports. In general, a single biller can process and follow up on 10,000 claims annually. This means that if a practice produces 15,000 claims a year, its billing unit will require at least 1.5 full-time equivalent employees, which could vary due to differing technologies and billing practices. If layoffs are unavoidable, they should be done with a sense of fairness. This entails that a practice has policies in place that specify such things as position criteria, length of employment, termination processes, and assistance or benefits for departing employees.

Health Policy and Reimbursement

Legislation Introduced to Reverse Cuts in Bone Density Testing Reimbursement

The proposed Medicare Fracture Prevention and Osteoporosis Testing Act of 2009 intends to reverse large cuts in Medicare reimbursement for Dual Energy X-ray Absorptiometry (DXA) bone density screening. A press release on the Web site of Rep. Shelley Berkley (D-Nev.), co-sponsor of the House version of the bill, says that Medicare's reimbursement for DXA outside of hospitals has been reduced to far less than the cost of performing the procedure. The Congressional findings in the Senate legislation say that osteoporosis is a highly manageable disease and critical women's health issue but that it remains underdiagnosed and untreated. The Senate legislation says that DXA is a superior screening method and if its under-utilization is not remedied, Medicare's budget will be adversely impacted in the future. "Osteoporosis is a silent disease that often goes undetected until a fall or other injury results in a broken bone. The utilization of DXA testing is one of the best ways we have to help prevent osteoporosis-related fractures, which are costly and can be devastating to the overall health of older patients," said Berkley in her online press release. "As someone who has been diagnosed with osteoporosis, I want all Americans to have access to these tests. We need to build awareness of this disease and the proper steps needed to maintain healthy bones."



Patient-centered Sites to Be Paid More

Blue Cross Blue Shield of Michigan has said it plans to increase reimbursement to doctors who take part in model patient-care programs known as patient-centered medical homes. This increasingly popular type of facility is a physician practice that uses coaches, nurses who coordinate care plans, and other professionals to focus on wellness, chronic disease management, and electronic medical records creation. In mid-June, Blue Cross will start publicizing the names of physician practices participating in the program. The insurer has provided $100 million in the past five years to establish the system for 300 primary care practices in Michigan with a total of 1,000 doctors.



New Rules Could Cut Physician Medicare Income

New Medicare rules could not only deny revenue for practices but even get them kicked out of the program. The new rules, which went into effect at the start of April, dramatically reduce the time-frame under which physicians can bill retroactively for services after a successful enrollment or re-enrollment from 27 months to 30 days. Practices must also alert contractors of any changes in practice locations within 30 days or risk being expelled from Medicare for up to two years. The changes were originally set to go into effect January 1 but were delayed after the American Medical Association and Medical Group Management Association successfully lobbied the Centers for Medicare & Medicaid Services (CMS) for a delay. CMS is telling physicians that it will not punish practices that are doing their best to comply and notes that there's a workaround for the enrollment problem that can extend the retroactive billing window.



U.S. Sen. Jay Rockefeller Eyes Health Cost Savings in Proposal

Sen. Jay Rockefeller (D-W.Va.) is proposing the creation of a new National Director for Health Care Quality to focus on reducing U.S. healthcare costs and improving the quality of patient care. "We must enact transformative healthcare reform now, or we will be back here in 15 to 20 years trying to fix the same, broken system," says Rockefeller, who chairs the Senate Finance Subcommittee on Health Care. Rockefeller's healthcare delivery principles also include giving the Medicare Payment Advisory Commission (MedPAC) and the Agency for Healthcare Research and Quality more power. The Senate Finance Committee is set to hold a hearing next week on draft legislation for how Americans receive healthcare, and Rockefeller timed his legislation to go along with this. "More is spent per person on healthcare in the United States than in any other nation in the world, and yet America has some of the worst health outcomes," Rockefeller said in a statement.

Technology and Device Trends

FDA Convenes Rare Meeting to Discuss Complaints on Device Approval

Dr. Donna-Bea Tillman, director of the FDA's Office of Device Evaluation (ODE), called an internal meeting on April 22 that included all scientists within the ODE. The meeting was reportedly intended to address concerns raised by nine scientists that the agency approved medical devices that could put patients at risk, despite significant and often unanimous objections from scientific reviewers. Device types cited by the scientists include imaging equipment used to detect breast cancer and certain orthopedic devices. Dr. Tillman's decision to call the meeting follows a number of letters and memorandums sent by the scientists to President Obama and the agency's principal deputy commissioner, Dr. Joshua Sharfstein. A congressional investigation and a recent Government Accountability Office report have both echoed concerns regarding the FDA's device approval office. As a result, Congress is expected to propose legislation that will ask the Institute of Medicine to investigate concerns surrounding the device division.



Custom Ankle Replacements

Mark Myerson, MD, an orthopedic surgeon at the Mercy Medical Center Institute for Foot and Ankle Reconstruction in Baltimore, Md., has developed a customizable implant that extends deep into the heel bone. Typically, a prosthesis has a very small stem that can cause the ankle to collapse under the pressure of the foot. Myerson customizes the stem of his implant for each patient, and if bone loss, damage, or dead bone exists, he builds up the prosthesis so that it sits all the way into the heel bone, ensuring support by the entire back of the foot and not just the ankle. "It's a very clever device that allows patients to have an ankle replacement who otherwise would not be suitable candidates for this procedure," says Myerson. "Certainly in the short term the complication rate and the failure rate has been significantly less, so it's very exciting to see over the course of the next decade to see how these will outlive the more standard ankle replacement."



High Tech Device Helps Immobile Walk Again

A new computer-controlled knee-ankle-foot orthosis developed by Otto Bock HealthCare and the Mayo Clinic uses special pressure sensors in the footplate of the orthosis and a microprocessor in the knee joint to control a user's movements, recognizing when to flex and when to lock. "It sounds rudimentary," says Jon Smith, a CPO with Pacific Medical Prosthetics and Orthotics. "But this technology is very difficult to do, to be able to engineer something like this is a big deal for patients who are now able to stay stable and walk much more normally and do so in a safe manner." The U.S. Department of Defense is using the technology to help wounded soldiers recover, and efforts are underway to get insurance companies to help pay for the devices.



The Nonstick Stem Cell?

Transplanted pancreatic precursor cells coated in the lubricant polytetrafluorethylene (also known as PTFE or by its DuPont brand name Teflon) were proven effective in preventing attacks from the immune system in mice in research that could have implications for the treatment of Type 1 diabetes. Researchers at the Burnham Institute for Medical Research and the University of California (UC)-San Diego School of Medicine showed that the PTFE-coated precursor cells, after transplantation, grew into functional cells. The coated cells also improved the transplant's success rate. "The results exceeded our expectations," says Pamela Itkin-Ansari, assistant adjunct professor at the UC San Diego School of Medicine. "We thought that T-cells, although unable to penetrate the device, would cluster around it. But we found no evidence of an active immune response, suggesting that the cells in the device were invisible to the immune system." One of the biggest obstacles to cell transplantation therapy for diabetes is the need to suppress the autoimmune response for an extended period of time, usually through use of drugs, which poses health risks. PTFE has a long history in medical research and treatment and is used in vascular grafts, sutures, bone replacement procedures and surgical implants. The study appears online in the journal Transplantation.



Abstract News © Copyright 2009 INFORMATION, INC.

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