News From ACFAS

---

Register for the last Coding and Billing for the Foot and Ankle Surgeon Seminar for 2019 in Teaneck, New Jersey on September 20-21, and learn how to make sure you’re being properly reimbursed for the care you provide.

This interactive course puts you and your fellow attendees in the driver’s seat as you work together to code and bill for a week’s worth of clinics, surgeries, calls, office procedures and complex cases typically seen in a foot and ankle surgical practice. Instructors will also guide you in how to use modifiers to avoid denials and win appeals.

A special breakout session focused on private and multispecialty practices will close the seminar.

Register yourself and your coding and billing office staff at acfas.org/practice management to secure your spot today.
ACFAS members have an entire on-line database filled with patient education resources right at their fingertips? That’s right – FootHealthFacts.org is the College’s own “encyclopedia” designed to educate patients from around the world on all types of foot and ankle conditions.

How can you take advantage of this valuable resource with your patients?

• Link your practice website directly to FootHealthFacts.org so your patients can read all the valuable health information right from your site.
• Use FootHealthFacts.org as a visual with your patients while in the exam room to explain certain conditions and then print the page for them to take home for reference.
• Gain patients from FootHealthFacts.org through the Find a Physician search tool by simply making sure your ACFAS member profile is up-to-date in our database. Visitors to the site can search for a foot and ankle surgeon in their area by entering their location and find you – a great referral source!

For information on how to link your website to FootHealthFacts.org, visit acfas.org/marketing (the ACFAS Marketing Toolbox) to see the instructions and for other valuable free practice marketing tools. To make sure your profile is up-to-date, log in to your account at acfas.org and make any edits.
It's easy to join! Dues for PGY-1 residents are waived thanks to the local ACFAS Regions’ support. Your new, free ACFAS membership will help you get a head start on your post-graduate training with the help of the many resources available to ACFAS members:

• print and electronic subscription to The Journal of Foot & Ankle Surgery (JFAS),
• discounted resident member pricing on conferences, surgical skills courses, and e-Learning,
• listing and application information for fellowships recognized by ACFAS, and
• member access to acfas.org.

Don't miss out on this valuable membership--download a membership application today.

Foot and Ankle Surgery

---

The study aimed to determine whether toe pronation is an influential factor in the everity of hallux valgus (HV). Six big toe donor proximal phalanges were used to create a radiographic calibrating system controlling pronation at 0° to 60°, and linear regression was used to predict proximal phalanx pronation in radiographs. Researchers then evaluated big toe pronation in HV with a prospective study using 132 patients from their surgical waiting list and a control group of 30 patients without HV. Patients standing barefoot on a rigid platform were used to obtain the nail-floor angle, and data was obtained at several different angles. After obtaining an equation to predict proximal phalanx pronation according to the proportion of the rotated phalanx, the researchers found a statistically significant relation between HV severity and proximal phalanx pronation, nail-floor angle and first metatarsal pronation.


Anterior talofibular ligament (ATFL) injury is usually treated according to the ATFL remnant condition during surgery, which is determined by MRI-based signal intensity of the ATFl, represented by the signal/noise ratio (SNR) value. The authors used a cohort study aimed to evaluate whether the MRI-based ATFL ligament SNR value is related to functional outcomes after ATFL repair for ankles with chronic lateral ankle instability. First, a preliminary study was performed to measure the ATFL SNR in preoperative MIR, which found a preoperative SNR below 10.4 indicative of poor ATFL condition. A cohort study was then retrospectively performed with consecutive patients who underwent open repair of ATFL injuries between 2009 and 2014. Patients were divided into two groups according to whether they had high SNR (HSNR; over 10.4) or low SNR (LSNR; under 10.4).

Functional outcomes between the groups were compared according to the American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS) and the Tegner Activity Scale. Ultimately, 37 patients in the HSNR group and 33 in 70 patients were available for the final follow-up. At the final follow-up, the mean AOFAS score in the LSNR group was higher than in the HSNR group, although no significant difference was detected postoperatively. The mean KAFS in the LSNR group was significantly higher than in the HSNR group postoperatively, as was the mean Tegner score. Patients in the LSNR group had a significantly higher percentage of sports participation than those in the HSNR group postoperatively.


In a Level II prospective comparative study, the authors addressed the selection of assistive devices for weight-bearing restrictions following foot and ankle surgery. The study compared physiologic demand, perceived exertion and patient preference between a hands-free single crutch (HFSC) and standard auxiliary crutches (SACs) in foot and ankle patients. The study used 44 (35 male, 9 female) preoperative orthopaedic foot and ankle patients with a mean age of 32 years, a mean BMI of 26, a mean height of 1.7 m and a mean weight of 82 kg. All patients were randomized to either an HFSC or SACs, then crossed over to the other device after vitals returned to within 10 percent of their baseline heart rate.

Each subject completed a 6-minute walk test (6MWT) using both assistive devices in a crossover manner. Immediately following each 6MWT, researchers obtained post-activity heart rate, self-selected walking velocity (SSWV), perceived exertion using the OMNI Rating of Perceived Exertion (OMNI-RPE) and perceived dyspnea using the Modified Borg Dyspnea Scale; patients were then asked which assistive device they preferred, and 86 percent of patients said that they preferred the HFSC over the SAC. Using the HFSC was associated with significantly lower dyspnea scores, pre-activity and post-activity change in heart rate, and mean post-activity heart rate compared to the SACs, while the SAC group trended toward a higher SSWV. 68 percent of patients complained of axillary/hand pain with the SACs, and 7 percent complained of proximal leg strap discomfort with the HFSC; neither group had any falls.

Practice Management

---

The article explores vulnerabilities in the billing process and provides advice on how to maintain compliance. To avoid denials due to incorrect evaluation and management (E/M) levels, physicians should ensure that the E/M code supports the specific patient encounter and refer to E/M guidelines whenever possible. Copy and paste functionalities should be used with caution, as should pre-populated electronic health record templates, which can lead to contradictions. Time-based billing for E/M services is only appropriate when a physician spends more than half of the encounter counseling or coordinating care in person, so these services should be documented in detail. Physicians should also be careful in reporting prolonged services, documenting why this additional time was necessary in as much detail as possible.

Always report a prolonged service code with an E/M code, and check how much time is required before prolonged service can be billed. Denials may also occur when incident-to services are billed for a new patient visit or for an established patient with a new problem, so all first visits related to a new patient or new problem should be with a physician; follow-ups may be billed as incident-to that physician. Payers may also check physician schedules to ensure that supervision requirements are met for incident-to billing, so a supervising physician should always be present and immediately available. In addition, a commercial payer may require an SA modifier to denote incident-to services, so providers should know if and when this is required.


Practice growth tech provider PatientPop recently surveyed health providers about online reputation management. The survey found that, while 76 percent of providers express concern about negative patient feedback, only 44.5 percent regularly check online reviews of their practice. The report further indicated that about half of all providers have no process in place to monitor online reviews or patient feedback, and 47 percent are unsure of what it takes to manage their online reputation. Furthermore, 33.7 percent of providers do not request patient feedback, and 17.6 percent of providers do not respond to negative feedback online. However, compared to PatientPop’s 2018 survey report, this year’s results indicate a 17.5 percent increase in providers who understand that their online reputation is critical to their business.


When engaging third parties to perform activities or functions on their behalf, providers must ensure that those third parties maintain the confidentiality of information learned in the course of their services. The HIPAA Privacy rule permits covered entities to share protected health information (PHI) with third parties, defined as business associates, under certain circumstances. Recently, the HHS Office for Civil Rights (OCR) issued a fact sheet that articulates the only situations where a business associate has direct liability under HIPAA. These situations include: failure to provide HHS with records and compliance reports; retaliating against any individual for filing a HIPAA complaint; failure to comply with the Security Rule; failure to provide breach notification to a covered entity; impermissible uses and disclosures of PHI; failure to disclose a copy of electronic PHI to the covered entity or individual; failure to enter into business associate agreements with subcontractors that create or receive PHI on their behalf and failure to address a breach of the subcontractor’s agreement.

The fact sheet underlines the fact that a business associate could cause a breach of HIPAA without being directly liable to OCR, meaning that the provider would likely be held liable to OCR for the associate's actions. To address these situations, when writing agreements, providers should incorporate language requiring business associates to indemnify the provider “for any actions or omissions of the business associate that cause the provider to fail to satisfy its obligations under the HIPAA Rules.”

Health Policy and Reimbursement

---

The U.S. Centers for Medicare and Medicaid Services (CMS) issued new guidance regarding Medicaid drug utilization review programs for states and managed-care programs to incorporate by the end of this year. The new mandates, which apply to both public and private entities, require states to set opioid prescription limits and monitoring Medicaid patients for potential abuse. States have until Dec. 31 to set their own limits on opioid prescriptions and refills and overhaul how they track patients at risk of overuse, including those who may be taking multiple prescribed opioids, benzodiazepines and antipsychotics concurrently.

States will also be required to design and implement a program to track and manage the prescription of antipsychotic medications for children in Medicaid. The CMS urged states to set up trainings to keep clinicians on the same page about the new requirements. The guidance implements part of an opioid law that Congress passed last year, and it shows that clinicians may have to walk a fine line in prescribing opioids while they try to follow the new law.


In an August 2 blog post published in Health Affairs, U.S. Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma outlined several changes the agency's Inpatient Prospective Payment System (IPPS) that aim to fight antibiotic resistance among Medicare patients. She notes that Medicare's current payment system bundles all costs for services related to a single diagnosis into a diagnosis-related group, incentivizing hospitals to use “older, cheaper antibiotics that may not be effective against drug-resistant infections.” Verma also noted that most new cases of drug-resistant infections and deaths involve Medicare patients, who often have compromised immune systems and greater catheter use.

To address this issue, CMS' 2020 IPPS rule has been updated to feature an alternative New Technology Add-On Payments pathway to encourage more antibiotic development. The alternative pathway drops the “substantial clinical improvement” criteria for drugmakers and increases payment from 50 percent to 75 percent for antibiotics that the CDC has designated as Qualified Infectious Disease Products. CMS also updated the severity level designation for several ICD-10 codes involving antibiotic resistance, allowing hospitals to classify such cases with a “CC” designation to indicate the presence of a complication or comorbidity requiring them to use more resources than typically used for a diagnosis, granting them more financial flexibility in treatment.


Physicians, health organizations and students are increasingly lobbying for the incorporation of climate change into medical education. A total of 187 schools and programs have joined a coalition launched by Columbia University's Mailman School of Public Health that supports this goal. Meanwhile, the Global Consortium on Climate and Health Education offers links to slides, videos, online courses and curriculum suggestions. The American Medical Association also has modified its policy to support climate change education to all physicians and medical students, and the International Federation of Medical Students' Associations wants medical schools to add the topic by 2020.

Medicine, Drugs and Devices

---

The federal government is scrutinizing proposals for pay-to-play clinical trials, highlighting ethical and other issues amid the growing perception that such trials are on the rise. The U.S. Food and Drug Administration recently requested that a federal advisory panel consider how the research community should regard such trials, and committee members are currently organizing recommendations. The U.S. National Institutes of Health also asked the same committee to consider whether their current resources to guide patients mulling a clinical trial are sufficient for pay-to-play situations.


Brands have started to preempt the threat of generic competition by launching generics of their own medications, protecting sales even after a patent runs out. Because brand-drug manufacturers have complete control over their marketing and production, these "authorized generics" do nothing to promote competition or drive down prices, yet there are nearly 1,200 of them approved in the United States, with more appearing every week. The practice is possible because of a loophole present in the 1984 Hatch-Waxman Act, which, in establishing foundational rules for the modern generic business, grants six months of market exclusivity to the first generic rival to each brand.


Some commenters on the U.S. Food and Drug Administration's proposal for fixed-quantity unit-of-use blister packaging for certain opioids recommended that the agency review the proposal's effectiveness in reducing opioid abuse and potential consequences before implementing it. The proposal aims to encourage more appropriate prescribing and reduce the number of unused opioids available for misuse or abuse.