News From ACFAS

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ACFAS’ new Coding and Billing Education Series is coming to the Walt Disney World Dolphin Resort in Orlando August 25-27. Start with Coding Fundamentals and stay for Coding and Billing for the Foot and Ankle Surgeon with your newly established foundation. Courses can be taken individually or as a series with bundle pricing.

Coding Fundamentals
August 25
Walt Disney World Dolphin Resort
Orlando, FL

Coding and Billing for the Foot and Ankle Surgeon
August 26-27
Walt Disney World Dolphin Resort
Orlando, FL

Don’t miss out on this in-person opportunity and walk away with the tools you need to simply your coding and reimbursement practices. Visit acfas.org for more information and to register. Give your patients more seasonal safety tips with the latest issue of FootNotes—now available in the ACFAS Marketing Toolbox! This issue covers:

• Don’t Let Bunions Become a Pain: highlighting the mechanics of a bunion, what might worsen them and how to treat them if they become painful.
• How to Avoid Running Injuries: identifying common injuries that runners are vulnerable to and what to do to treat them.
• Travel Tips for Preventing Deep Vein Thrombosis: tips for long plane or car trips to avoid developing this serious condition.

Use the latest issue as you wish and help maximize your reach with patient education and marketing your practice. Add your practice information to the customizable second page and keep copies in your office, post it to your practice website and share it on your social media accounts.

Read this issue and access more free tools to help ramp up your practice marketing efforts at acfas.org/Marketing.

Foot and Ankle Surgery

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Research sought to establish a digital model of the ankle joint through three-dimensional 3D imaging technology and survey preoperative placement of ankle replacement prostheses. The authors collected computed tomography images of intact ankle joints from 54 cases in the outpatient and inpatient departments of a hospital. The dataset featured 48 cases of the sub-data set (26 males and 22 females), including 27 cases of left ankle and 21 cases of right ankle. The average medial malleolar angle was 18.67 degrees ± 2.87 degrees, the average amount of bone resection was 12.13 ± 1.86 centimeters³, the mid-anterior distance was 1.72 ± 0.19 centimeters, the mid-posterior distance was 2.00 ± 0.19 centimeters, the ratio of mid-anterior to mid-posterior was 0.87, the mid-medial distance was 1.26 ± 0.17 centimeters, the mid-lateral distance was 1.19 ± 0.16 centimeters and the ratio of mid-medial to mid-lateral was 1.06. Following osteotomy, the anteroposterior diameter was 3.73 ± 0.32 centimeters, the transverse diameter was 2.46 ± 0.27 centimeters, and the ratio of anteroposterior diameter to transverse diameter was 1.53. The projection point of the lower tibia centerline on the tibial horizontal osteotomy surface is sited at a position slightly anterior to the midpoint of the transverse diameter following ankle arthroplasty. The rational positioning of the total ankle replacement is located at both a position slightly anterior to the midpoint of the transverse diameter and midpoint of the anteroposterior diameter, which can function as a reference technique prior to total ankle arthroplasty surgery.


A study was held to evaluate bone attenuation between the distal 5 percent and 10 percent mark of the tibia in 1 percent slices through Hounsfield unit measurements on computer tomography scans based on previously established correspondence between Hounsfield units and bone mineral density in dual-energy x-ray absorptiometry scans. A total of 105 distal tibia segments were assessed with an average interval in percentile slices of 3.8 millimeters. The gradual decrease in bone attenuation observed with each proximal percentile segment met expectations. A statistically significant difference in bone attenuation exists amongst males compared to females as well as those older than 60 years versus younger than 60 years. The findings imply fixation constructs in the tibia medullary canal may find limited benefit proximal from 7 percent segment in females = 60, or 26.1 millimeters from tibial plafond. Fixation constructs in tibia medullary canal may subsequently find limited benefit proximal from 8 percent segment in males younger than 60, or 32.3 millimeters from tibial plafond.


A retrospective observational study assessed treatment outcomes of pediatric patients with congenital pseudarthrosis of the tibia (CPT) using the Ilizarov method plus intramedullary fixation. There were 18 patients treated and mean age was 6.2 years, while 14 patients had a primary bone union at the site of pseudarthrosis. Four patients achieved union after secondary surgical intervention. The mean duration of the Ilizarov method was 8.1 months, and eight patients developed a pin-tract infection during treatment, while four had proximal tibial valgus with a mean angle of 12.1 degrees. Seven patients had ankle valgus deformities with a mean angle of 10.3 degrees, and 11 had an average 1.4 centimeters of limb length discrepancy postoperatively. Five underwent refracture and recovered after secondary surgery. The average postoperative American Orthopaedic Foot and Ankle Society score at the final follow-up was 72.

Practice Management

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Medical practices should choose software packages that are best suited for the specific group they fall into, be it beginners, expanding clinics or well-established providers. Beginning practices need tools that enable efficient work, like an electronic health record solution, a patient scheduling tool and billing software. Growing clinics can avail themselves of mobile technologies, and experts recommend a mobile-friendly patient portal as a starting point. They also recommend installing a telemedicine solution after launching a portal. Medical software for well-established providers focuses on process optimization, with examples including direct messaging solutions and speech recognition software. Analytics solutions can also facilitate new levels of decision-making.


The Association of American Medical Colleges projects a total physician racial and ethnic representation deficit of between 37,800 and 124,000 physicians by 2034, as numbers and proportions of Black, Hispanic and American Indian or Alaska Native medical school matriculants have risen more slowly than their age-matched peers in the US population. A cross-sectional study compared the self-reported demographics of the US population with those of the US physician workforce for the years 2010 and 2015. A total of 20,349 allopathic medical school matriculants and 961,098 practicing physicians of all races and ethnicities were calculated in 2015, with 1,231 Hispanic and 1,228 Black medical students in that population, as well as 60,549 Hispanic and 46,133 Black physicians. Given the expected representation of those groups, a deficit of 113,758 Hispanic and 81,358 Black physicians was observed.

Compared with the US population, there were 196 and 191 fewer Hispanic and Black physicians, respectively, per 100,000 Hispanic and Black people in the country. It would therefore take 92 years of a sustained doubling of the number of Hispanic matriculants in 2015 to correct the deficit of Hispanic physicians from 2015 and 66 years of a sustained doubling of Black medical students to correct the deficit of Black physicians. In view of this, the establishment and expansion of medical schools that prioritize Black, Hispanic and other underrepresented students' education would decrease the overall physician shortfall, as well as accelerate the time needed to secure a representative physician workforce and help alleviate the societal damage inflicted by long-term institutionalized racism.


Practices armed with a solid argument for more pay can negotiate fee-for-service payment contract increases. One tip is to use contracts and fee schedules to set a baseline, while other tactics include exploring alternative payment models, supplying cost and quality metrics, making the practice stand out from peers and specifying the volume of active patients. An escalator clause can also work to the practice's advantage in contract negotiations, and a payer analysis can help build a case for higher rates. Negotiating carve-outs for highly utilized services is another tool, while adding services to the fee schedule can yield higher payouts for the same service. Finally, practices should reserve the option to terminate a contract when the payer refuses to pay comparable rates or increases.

Health Policy and Reimbursement

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The US Centers for Medicare and Medicaid Services (CMS) issued its first fines under the federal price transparency law that took effect in January 2021. Georgia-based Northside Hospital Atlanta and Northside Hospital Cherokee were fined nearly $1.1 million in total fines for failing to disclose their prices. Meanwhile, a recent analysis of compliance with the law that examined hospital websites between July and September 2021 found that just 6 percent of over 5,200 US hospitals complied by posting the two required price lists on their websites. About 14 percent had just posted the comprehensive price list, and 30 percent published the list of shoppable prices. CMS has sent over 350 warning letters to hospitals as of June, and about 160 hospitals have yet to be in compliance after having been asked to outline their plan to get there.


The 2023 ICD-10-PCS procedure code set and the ICD-10-PCS Official Guidelines for Coding and Reporting were recently released by the US Centers for Medicare and Medicaid Service. The procedure code update includes 331 new codes to be used for discharges occurring from October 1, 2022, through September 30, 2023. The procedure coding guidelines include new guidelines for reporting procedures of certain extremities.

Medicine, Drugs and Devices

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California Governor Gavin Newsom of California wants state lawmakers to allocate $100 million to fund an effort to create a generic drug label in California, dubbed CalRx. He hopes CalRx would be able to launch the production of insulin in the next few years, according to Newsom spokesperson Alex Stack. The state is also exploring other costly and shortage-prone generic drugs it could potentially bring to market. CalRx initially would reduce insulin prices and make it available to "millions of Californians" via pharmacies, mail order and stores, said Mark Ghaly, secretary of the California Health and Human Services Agency (CalHHS). State health officials are currently discussing a potential contract with a drugmaker to manufacture and distribute insulin; it is uncertain how much it would cost to make the insulin and what patients would pay. CalHHS assistant secretary Vishaal Pegany told lawmakers in May: "Insulin has long epitomized the market failures that plague the pharmaceutical industry, which have resulted in keeping insulin prices high," and asserted that high prices "have directly harmed Californians." Newsom said last month that California could successfully intervene to disrupt monopolistic drug prices because the state "has market power." However, Luke Koushmaro, a senior fiscal and policy analyst with the nonpartisan Legislative Analyst's Office, warned at a recent legislative hearing that the effort could be hindered by "considerable uncertainties."


The US Federal Trade Commission (FTC) is investigating CVS Caremark, Express Scripts and other big pharmacy-benefits managers (PBMs) regarding what impact their business models have on the accessibility and affordability of prescription drugs. The FTC has said it would require the six biggest PBMs to provide records and other data about their business practices in order for a study to be conducted of the PBM industry. PBMs reimburse pharmacies for patients' prescriptions and create lists of prescription drugs that are paid for by health plans and other policies. Independent pharmacies have long criticized PBMs for charging them high fees and for steering consumers to PBM-owned mail-order pharmacies.


The healthcare industry accounts for 8.5 percent of the United States’ greenhouse gas (GHG) emissions. The US Department of Health and Human Services has asked hospitals, health suppliers, drug companies and others in the industry to pledge to reduce their GHG emissions to net zero by 2050, inventory their supply chain emissions and develop a climate resilience plan for their facilities. Some hospitals have already taken carbon-cutting steps like installing on-site solar power, purchasing renewable energy and improving energy efficiency in their buildings. But the vast majority of emissions in the sector come from the medical supply chain. These are difficult for hospitals to address because they’re not under their direct control.

Chemicals, pharmaceuticals, medical devices and food are among the largest contributors to hospitals’ supply-chain emissions, according to Jodi Sherman, a professor at the Yale School of Medicine and director of the Yale Program on Healthcare Environmental Sustainability. Addressing the unsustainable supply chain has become even more critical after hospitals experienced shortages during the pandemic. Nurses and doctors had to reuse masks and gowns using protocols that hadn’t been fully tested for safety. Finding ways to use those items more efficiently could help with both emissions and future disruptions, including those stemming from climate-related weather events.


To assess trends in prices for newly marketed brand-name drugs, researchers examined drugs marketed from 2008 to 2021 within SSR Health, a database with quarterly list prices known as wholesale acquisition costs. The assessment included 548 of 576 drugs (95 percent) first marketed in 2008-21, excluding 3 diagnostics and 25 drugs for which the researchers were unable to estimate price per year. In all, 357 (65 percent) of the drugs were new molecules, 139 (25 percent) were biologics, 182 (33 percent) treated rare diseases, 64 (12 percent) received accelerated approval, 119 (22 percent) were oncologic agents and 282 (51 percent) were orally administered. The highest prices were for drugs for rare diseases (median $168,441 per year) and oncology drugs (median $155,091 per year). The researchers found that median launch prices increased from $2,115 per year in 2008 to $180,007 per year in 2021. The proportion of drugs priced at $150,000 per year or more was 9 percent in 2008-13, increasing to 47 percent in 2020-21. The paper also noted that prices for new drugs outpaced growth in prices for other healthcare services. Moreover, manufacturers regularly raised prices over time even after drugs were marketed. "In response to the current trends, the US could stop allowing drug manufacturers to freely set prices and follow the example of other industrialized countries that negotiate drug prices at launch," the researchers conclude.