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News From ACFAS

Coding and Billing is Going Virtual!
Now you can get the latest on the upcoming coding and billing changes from the comfort of your home as we take Coding & Billing virtual!

Join us September 10-11, 2020 online for this revamped course to get expert tips and tricks to simplify your coding and reimbursements practices. This course will also cover timely topics, including telehealth coding and coding and billing changes such as coding for prolonged services and several CCI edits relating to foot and ankle surgery. Comprehensive handouts will be mailed to each registrant so you can follow along. This course is eligible for 8 CECH and is open to office staff and coders and billers.

We hope to see you online in September. Find out more about this virtual course, view the full agenda and register by visiting
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August Forefoot Complications Webinar
Experts reveal real-life complications that changed their assumptions in the Forefoot Complications Webinar series. Secure your spot now.

Wednesday, August 26
Metatarsal Fracture Conundrums: A Minor Trauma Played in F Sharp
8pm CT
CME Hour: 1 Credit

If you can’t make this webinar, don’t worry—two more webinars are coming your way in September 23 and October 28, watch for more information. Visit to register for the August webinar, or to see what all OnDemand has to offer.
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Foot and Ankle Surgery

Biomechanical Study Concerning the Types of Resection in Arthrodesis of First Metatarsophalangeal Joint
The study aimed to ascertain the optimal type of joint resection when performing a joint arthrodesis. A three-dimensional digital model of the first metatarsophalangeal joint, including the entire first metatarsal bone and proximal phalanx using CT scans of the forefoot, was created. Using this computer model, four types of resections; ball-and-socket, flat-on-flat, wedge 90 degrees and wedge 100 degrees were simulated. Parameters measured using this model were the force necessary to separate the two fused surfaces, the surface area of the resected surfaces and the shortening of the first ray. By measuring the reactive force necessary to separate the phalanx from the first metatarsal, the 90 degree wedge resection was found to be the most stable, with comparable results in the case of the 100 degree wedge resection. Wedge resections are also more favorable when comparing the shortening of the first ray.

From the article of the same title
Journal of Foot & Ankle Surgery (08/28/20) Bartak, Vladislav; Stedry, Jan; Hornova, Jana; et al.
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Risk Factors for Infection Following Ingrowing Toenail Surgery: A Retrospective Cohort Study
Researchers investigated the frequency and type of ingrowing toenail surgery performed by podiatric surgeons, as well as risk factors for post-operative infection. The study included data for all patients who underwent foot and ankle surgery performed by podiatric surgeons in Australia between January 2014 and December 2017. Infection rates, risk ratios (RR) and 95 percent Confidence Intervals (CI) were calculated to determine postoperative infection risk. Of 7,682 records, 1,831 reported 2,712 diagnoses of ingrowing nails.

Patients with a diagnosis of ingrowing toenails were younger, less likely to have systemic disease and a lower proportion were female compared to those without ingrowing toenails. These patients were also more likely to be diagnosed with a post-operative infection than those without ingrowing toenails. Risk factors for post-operative infection following ingrowing toenail surgery include age greater than 60 years, surgery performed in an office setting and radical excision of toenail bed procedure.

From the article of the same title
Journal of Foot and Ankle Research (08/29/2020) Terrill, Alexander J.; Green, Katie J.; Salerno, Angelo; et al.
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Low Tibial Valgization Osteotomy for More Severe Varus Ankle Arthritis
The study assessed the effect of additional inframalleolar correction followed by low tibial valgization osteotomy with medial opening wedge (LTO) for ankle arthritis with a small talar tilt (TT). It also looked at the preoperative or operation-related factors influencing postoperative TT decrease.

Researchers reviewed the radiographic and clinical findings of 31 patients with more significant varus ankle arthritis who underwent LTO or LTO plus inframalleolar correction. They grouped the included patients according to combination with inframalleolar correction and postoperative decreased TT, and also performed a regression analysis to determine the factors influencing postoperative TT decrease. Although the mean TT was unchanged postoperatively, clinical parameters were significantly increased.

In the group with concomitant inframalleolar correction, researchers found that TT was more corrected with a greater lateralization of the talar center and a greater correction of the hindfoot alignment to valgus. The regression analysis showed a significant relationship between postoperative decreased TT and preoperative talar center migration, hindfoot alignment angle, hindfoot moment arm and hindfoot alignment ratio.

From the article of the same title
Foot & Ankle International (07/31/2020) Choi, Jun Young; Kim, Kun Woo; Suh, Jin Soo
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Practice Management

Preparing For a Second Wave of COVID-19
Even though the first wave of COVID-19 cases is still happening, health experts warn that once the weather gets cooler in the fall, a second wave of cases is likely to arrive, potentially aligning with flu season. Practices should start preparing for this now. With an increase in the number of patients with cough and fever symptoms, it will be critical that physicians learn how to differentiate illnesses. PPE procurement will continue to be a concern; partnerships with state resources and national associations may be helpful in finding solutions.

Telehealth and virtual visits will help ensure continued care delivery during times of high COVID-19 activity. During the upcoming flu season, doctors will need to leverage telehealth to virtually assess symptomatic patients and conduct drive-through flu and COVID-19 testing. Physicians must stay highly engaged with their patients through social media and other channels. Placing prominent signage at the practice can help inform patients about what to expect. A practice's staff must also feel prepared and have the appropriate resources to do their jobs.

From the article of the same title
Medical Economics (08/04/20) Loria, Keith
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Managing and Terminating Staff Who Refuse to Comply With COVID-19 Safety Recommendations
Medical practices are implementing policies to safeguard their employees and patients from the risk of contracting COVID-19. Outside of the practice, however, some staff may travel to hotspots or refuse to wear masks, and post comments and photos of their activities on social media. Employers generally cannot enforce an employee’s conduct on their own time if such conduct is not illegal, such as drug abuse. As a result, practices need to regularly educate staff on the latest data regarding the coronavirus, which travel hotspots to avoid and best practices. Ongoing training can foster a sense of community.

If a practice elects to terminate an at-will employee due to safety concerns, no need exists to give a reason for the termination, but it will lead to an unemployment claim. Employees with written contracts are more challenging for a practice to terminate. Very few employment contracts contain provisions that apply to an employee’s legal activities outside work. Most practices will want to review whether changes are needed in their contract's termination provisions. For example, rather than add a "for cause" termination provision, practices could shorten a "without cause" provision.

From the article of the same title
Physicians Practice (08/03/20) Adler, Ericka L.
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Health Policy and Reimbursement

CMS to Boost Outpatient Payments, Cut 340B Again
The US Centers for Medicare and Medicaid Services (CMS) on Aug. 4 proposed a 2.6 percent pay increase for Medicare outpatient services, but safety net providers could see their payments for 340B drugs actually decline. Under the proposed 2021 outpatient prospective payment system rule, total payments to providers would increase by $7.5 billion to nearly $84 billion. However, CMS wants to cut reimbursements for 340B-acquired drugs by more than 6 percent.

"We propose for CY 2021 and subsequent years to pay for drugs acquired under the 340B program at (average sales price) minus 34.7 percent, plus an add-on of 6 percent of the product's average sales price (ASP), for a net payment rate of ASP minus 28.7 percent based on the results of the Hospital Acquisition Cost Survey for 340B-Acquired Specified Covered Drugs," CMS said in the proposed rule. On July 31, a three-judge panel upheld the agency's earlier cuts to 340B drug payments. The Trump administration may decide to extend the current payment policy of ASP minus 22.5 percent for 340B-acquired drugs if it does not move forward with more cuts, according to the rule.

From the article of the same title
Modern Healthcare (08/04/20) Brady, Michael
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Trump Signs Order Aimed at Boosting Rural HealthcCare, Telehealth
President Trump signed an executive order on August 3 as part of an effort to prop up struggling healthcare providers in rural communities, where an estimated 130 hospitals have shut down over the past decade. Under his plan, Medicare will test new pilot projects under which rural providers are rewarded for extending higher quality care to patients. In addition to the rural health plan, the president proposed a permanent extension of certain telehealth policies that propelled the takeoff of virtual care during the pandemic. Medicare teleheath appointments mushroomed to more than one million per week during the height of the national shutdown period, up from just a few thousand per week before COVID-19.

To maintain the momentum, Trump wants to make permanent Medicare payment of telehealth technology for certain providers. The proposals follow a number of other healthcare-related moves in recent weeks, including stepped up pressure on Congress to protect consumers against surprise medical bills and executive orders targeting exorbitant drug prices. The president has yet to deliver, meanwhile, on a pledge to roll out a health plan of his own to replace the Affordable Care Act.

From the article of the same title
Politico (08/03/20) Diamond, Dan; Cancryn, Adam; Roubein, Rachel
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COVID-19 Long-Term Toll Signals Billions in Healthcare Costs Ahead
Healthcare experts agree the long-term costs of COVID-19 will not manifest for years to come, but evidence already suggests that those who recover from the disease may face months or years of residual complications. The virus can cause pulmonary damage, neurological and cognitive dysfunction, heart issues and kidney injury — all of which may require ongoing, and expensive, medical attention.

“On a global level, nobody knows how many will still need checks and treatment in three months, six months, a year,” says Marco Rizzi, MD, co-chair of the World Health Organization's international panel tasked with recommending standards for mid- and long-term care of COVID-19 survivors. The costs stemming from that additional care — well into the billions, according to one estimate — could lead to inflated health insurance premiums in the United States, where more than half of the population subscribes to private coverage. Some health plans have already raised 2021 premiums on comprehensive coverage by as much as eight percent in response to COVID-19, the Kaiser Family Foundation reports.

From the article of the same title
Reuters (08/03/20) Hunter, Caroline; Brown, Nick; Parodi, Emilio
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Federal Unemployment Benefit Lapse Will Hurt Healthcare Workforce
Healthcare workers still furloughed or laid off will feel the pain after generous federal unemployment benefits lapsed on July 31. The CARES Act, passed in March, provided for the additional payout of $600 per week; but a Congressional Budget Office report in June determined that most recipients would make more from unemployment benefits than they would from their paycheck, discouraging them from returning to the workplace. An estimated 848,000 healthcare and social services workers were temporarily laid off in June, down from 1.7 million in April according to government reports.

Expiration of the extra benefits, however, could force both employers and their workers to make crucial decisions, says Ani Turner with the nonprofit consulting firm Altarum. While some employees who cannot sustain themselves on furlough or temporary layoff may be left with no option but to seek a different job, employers may not be able to bring some workers back because of the COVID-19 resurgence. "It's kind of a double whammy, running out of benefits and that we haven't been able to get the pandemic under control," Turner says.

From the article of the same title
Modern Healthcare (08/03/20) Cohrs, Rachel
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Medicine, Drugs and Devices

New Report Finds Drug Prices Have Become More Affordable to Most Patients
A recent report from The IQVIA Institute for Human Data Science gauged medicine affordability trends in the last five years. The report found that patients paid a record $67 billion out-of-pocket for all prescriptions filled in community pharmacies in 2019, up from $61 billion in 2015, largely due to a higher volume of prescriptions. Medicare patients filling prescriptions under Part D paid $16.1 billion out-of-pocket in 2019, up 27 percent from 2015 due to a growing older population.

Annually, 90 percent of all patients pay less than $500 in out-of-pocket costs; however, 20 percent of Medicare Part D patients pay more, due in part to a greater disease burden and associated higher per capita medicine use by older adults. Across all patients, the average out-of-pocket cost for an insulin prescription was $31 in 2019, down from a record high of $35.70 in 2015.

Twenty-four percent of all prescriptions carried an out-of-pocket cost of more than $35, but 31 percent of Medicare and 58 percent of cash payments reached this level, compared with 22 percent for those commercially insured. If all patients nationally had insulin costs capped at $35, patients would have saved $837 million in out-of-pocket costs in 2019, according to the report.

From the article of the same title
Chain Drug Review (08/04/20)
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Patient and Plan Spending After State Specialty-drug Out-of-pocket Spending Caps
Specialty drugs are used to treat complex or life-threatening conditions, often at high financial costs to both patients and health plans. Three states — Delaware, Louisiana and Maryland — passed legislation to cap out-of-pocket payments for specialty drugs at $150 per prescription. A concern is that these caps could shift costs to health plans, increasing insurance premiums. Estimates of the effect of the caps on patient and health plan spending could inform future policies.

Researchers from Kaiser Permanente Washington Health Research Institute, the University of Washington, Vanderbilt University and the National Bureau of Economic Research analyzed a sample that included 27,161 persons under 65 years of age who had rheumatoid arthritis, multiple sclerosis, hepatitis C, psoriasis, psoriatic arthritis, Crohn’s disease or ulcerative colitis and who were in commercial health plans from 2011 through 2016 that were administered by three large nationwide insurers. The researchers concluded that caps for spending on specialty drugs were associated with substantial reductions in spending on specialty drugs among patients with the highest out-of-pocket costs, without detectable increases in health plan spending, a proxy for future insurance premiums.

From the article of the same title
New England Journal of Medicine (08/06/20) Vol. 383, No. 6, P. 558 Yeung, Kai; Barthold, Douglas; Dusetzina, Stacie B.; et al.
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FDA Purple Book Database Now Includes All CBER-, CDER-licensed Biological Products
The Purple Book, the US Food and Drug Administration's (FDA's) online database of its licensed biologic products, is adding exclusivity information for biological products and a glossary. FDA noted it will not further update the existing list of products maintained by the Center for Biologics Evaluation and Research. FDA also said its Purple Book database release in February 2020 "contained a limited data set that included all approved biosimilar products and their related reference products." Moreover, the database had both simple and advanced search functionality. FDA added the information in later releases for all FDA-licensed biologic products, including those regulated by the US Center for Drug Evaluation and Research. The Purple Book now contains biosimilar and interchangeable biological products and allergenic, cell and gene therapy, hematologic and vaccine products. Transition biologic products that were originally approved via New Drug Applications but transitioned to Biologic License Applications also appear in the database.

From the article of the same title
Regulatory Focus (08/03/2020) Oakes, Kari
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This Week @ ACFAS
Content Reviewers

Caroline R. Kiser, DPM, AACFAS

Elynor Giannin Perez DPM, FACFAS

Britton S. Plemmons, DPM, 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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