News From ACFAS

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Get ahead in your coding and billing with the Coding and Billing for the Foot and Ankle Surgeon and Coding Fundamentals pre-conference programs on Wednesday, February 8 at ACFAS 2023 in Los Angeles! Learn from the experts and ensure you understand the upcoming changes you’ll need to utilize for reimbursement.

Coding and Billing for the Foot and Ankle Surgeon
8 CECH
Sean Grambart, DPM, FACFAS; Jacqueline Reiss-Kravitz, CPC, AAPC Fellow
Get properly reimbursed for the care you provide! Participate in surgical coding scenarios including forefoot reconstruction, arthrodesis, office procedures, rearfoot and ankle reconstruction, tendon surgery, arthroscopy, trauma and diabetic foot surgery.

Coding Fundamentals
3.5 CECH
Scott Nelson, DPM, FACFAS; Danielle Butto, DPM, FACFAS
Start or refresh your coding and billing foundation! Walk away with an understanding of CPT and E&M codes, common modifiers and their use, and how to code minor in-office procedures. Ideal for anyone who wants to learn more of the basic coding and billing terminology and process.

Learn more about these coding courses and register today at acfas.org/asc. Medicare Physician Fee Schedule conversion factor cuts scheduled to be put into effect in 2023, were addressed in the draft omnibus funding bill recently negotiated by Congress. The CF is used to calculate Medicare reimbursement. The draft bill would offset more than half of the cut the Centers for Medicare and Medicaid Services (CMS) planned to enact on January 1. The initial cuts proposed by CMS would have resulted in a 4.5% cut to the conversion factor, it will now be increased by 2.5%, resulting in a 2% cut in 2023. The bill would also include a 1.25% increase to the conversion factor in 2024.

It is likely that the medical community will continue its advocacy for full restoration of the conversion factor and potentially broader Medicare payment reform in 2023. ACFAS will keep members informed of these efforts as they move forward. Plan to join us to celebrate another successful Annual Scientific Conference at the College’s popular Wrap Party! You won’t want to miss this year’s party at the GRAMMY Museum, conveniently located in L.A. LIVE.

Join your friends and colleagues for for food, drinks, music, and the opportunity to check out select museum exhibits on Saturday, February 11.

Visit acfas.org/asc for all the details and to get your tickets today. Be sure to catch the next installment of the ACFAS Virtual Journal Club!

TARs
Thursday, January 19 | 7:00 pm CT
Host: Pennsylvania Intensive Lower Extremity Fellowship
Fellowship Directors: Jason R. Miller, DPM, FACFAS and Krista Kotzeva, DPM

Brought to you by the ACFAS Research Committee, the Virtual Journal Club is complimentary for ACFAS student and resident members and provides an informative and interactive way to learn about research. Monthly sessions will be presented by research experts from fellowship programs with ACFAS status.

Register and learn more at acfas.org/virtualjournalclub.
Prepare for your career as a foot and ankle surgeon when you join us for Residents Day during ACFAS 2023 in Los Angeles! You won’t want to miss education, fun and prizes on Wednesday, February 8 from 8:30 am – 2:15 pm. Breakfast and lunch will be provided.

Experienced foot and ankle surgeons will provide tips on completing your post graduate education with discussions on non-surgical topics including:

• We Are Family: AC-FAS, AB-FAS, and C-P-M-E!
• The Simple Rules for Achieving Board Certification
• The Art of Negotiation: From CVs to Interviews and Contracts
• Don’t Be a Dropout: How to Be Cool and Avoid Burnout

Get even more out of your time in LA when you stick around for Coding Fundamentals, immediately following Residents Day. Learn the foundation of coding and billing and get a head start on preparing for your future practice.

This year’s Residents Day is generously sponsored by Organogenesis. Visit acfas.org/asc for more information and to save your spot.

Foot and Ankle Surgery

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Researchers used marker-based radiostereometric analysis to quantify motion in the first tarsometatarsal (TMT) joint and evaluate the radiological outcome in 10 patients with unstable Lisfranc injuries treated with temporary bridge plate fixation. All patients underwent treatment with a dorsal bridge plate over the first TMT joint and primary arthrodesis of the second and third TMT joints. The plate was removed four months after. The researchers observed detectable first TMT joint motion in two of 10 patients after one year, and in six of nine patients after five years. The mean first TMT dorsiflexion was 2.0 degrees at final follow-up. Radiologically, the incidence of posttraumatic osteoarthritis was present in four of 10 patients after one year, and five of nine patients after five years. TMT joint stability was noted in all patients throughout the follow-up period.


A meta-analysis was held to find the optimal treatment for ankle arthrodesis. Included were nine studies comparing arthroscopic ankle arthrodesis (AAA) and open ankle arthrodesis (OAA) in 467 patients. AAA resulted in a lower overall complication rate, shorter intraoperative tourniquet time, shorter length of the hospital stay, lower non-union rate and higher rate to fusion than OAA. However, there were no significant differences in delayed union and postoperative infection rate between treatment groups. The implication is that AAA is better than OAA alone in treating ankle arthritis, although further high-quality randomized controlled trials with appropriate blinding methods are needed to verify these conclusions.


A retrospective case-control study sought to identify risk factors for deep surgical site infection (DSSI) after surgically treated peri-ankle fractures. Analysis included 2,147 patients, with 74 having a DSSI, signaling an incidence rate of 3.4 percent. Seventy cases of DSSI and 140 controls without DSSI were matched following propensity score matching. Univariate analyses yielded significant deviations between groups in terms of history of surgery, time to operation, surgical wound classification, smoking, alcohol drinking, red blood cell count, hemoglobin concentration and hematocrit. Conditional logistic regression analysis revealed time to operation of nine days, while unclean wound, current smoking, high-energy injury mechanism and lower hematocrit were independent DSSI risk factors.

From the article of the same title
Journal of Orthopaedic Surgery and Research (12/15/22) Vol. 17, No. 542 Zhao, Haitao; Meng, Jinghong; Sun, Tao; et al.

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Practice Management

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Congress Saves Big Healthcare Decisions for Last

Congress' year-end spending package decrees that the 4.5 percent cut to the Medicare physician fee schedule will be reduced by 2.5 percentage points in 2023 and 1.25 percentage points in 2024. Providers in independent or small practices warned the reductions, plus inflation and staffing pressures, could be economically disastrous and spur consolidation; American Medical Association President Jack Resneck was disappointed at the small concessions, suggesting some practices will stop accepting new Medicare patients. Meanwhile, the winding down of pandemic relief legislation means people could begin to be kicked off Medicaid if they fail to meet eligibility requirements starting April 1, but the process will occur over 12 months so the decline in enrollees should not be sudden. Savings from that policy will partly pay for a year of Medicaid postpartum coverage, and a year of continuous Medicaid eligibility for children.

Also included in the package are several US Food and Drug Administration reforms, such as the overhaul of a fast-track drug approval process that lets drugmakers sell their products based on preliminary evidence. Language designed to modernize fragmented diagnostic testing oversight at the agency was excluded. Although parts of a pandemic preparedness bill were included, absent was a mandate to set up a 9/11-style commission to examine the COVID response. However, the position of Centers for Disease Control and Prevention director will become a Senate-confirmed occupation. Furthermore, Medicare telehealth flexibilities will be extended for two more years. The package also will have legislation to strip out a requirement that healthcare providers obtain a special waiver from the Drug Enforcement Administration before being allowed to prescribe buprenorphine to treat opioid addiction.

From the article of the same title
Axios (12/20/22) Knight, Victoria; Sullivan, Peter; Goldman, Maya

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Preparing for a Coding Audit: A Guide for Physicians

Physicians should prepare for the US Centers for Medicare and Medicaid Services' (CMS) 2021 changes to the documentation of Evaluation and Management codes for outpatient office visits. To handle errors with their Electronic Health Record system, they should remember that CMS considers medical necessity the overarching payment criterion. Inaccurate data in the chart, especially when carried forward from a previous service date or entry without required editing, often denies an auditor the ability to understand if the doctor needed to see that patient, perform that test, order that script and so on. Moreover, auditors frequently deny claims based on allegations that the provider simply cloned prior notes, which can also refer to pieces of a progress note that are not accurate. Conflicting information can further breed suspicion of cloning, while an overabundance of information in progress notes can be another red flag. The new CMS guidelines eliminate pre-existing requirements to “quantify” patient history and physical examination, although physicians should continue to document those aspects of history and exams to back their clinical decision-making and any tests or treatments ordered. Notes also should always have an interval history of present illness that is clearly labeled as such.

From the article of the same title
Physicians Practice (12/20/22) Roberts, Abdul J.; Tudor, Jim

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Health Policy and Reimbursement

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Biden Administration to Publish Hospital Ownership Data for First Time

The Biden administration on Dec. 21 will release ownership data for all 7,000 Medicare-participating hospitals for the first time in order to instill greater transparency amid rapidly growing private equity investments. Such data was previously only available after a change in ownership. The US Department of Health and Human Services (HHS) said the data will be issued in an easily searchable format online and feature information about each owner, including whether it is an organization or an individual and whether a hospital operates under a direct or indirect ownership model. Updated hospital ownership data will be published each month. HHS said making facility ownership data transparent can help enforcement agencies identify common owners with poor performance histories, as well as examine the effect of market consolidation on consumers. "As we work to expand access to high-quality, affordable healthcare, we will make sure there is transparency to ensure that facilities are held accountable and people can make the best-informed decisions on their care," stated HHS Secretary Xavier Becerra.

From the article of the same title
The Hill (12/20/22) Weixel, Nathaniel

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Many US Hospitals Sue Patients for Debts or Threaten Their Credit: Investigation

A Kaiser News Network (KHN) investigation revealed hundreds of US hospitals support policies to pressure indebted patients through litigation, selling patient accounts to debt buyers and reporting patients to credit rating agencies. The implication is that most of the nation's roughly 5,100 hospitals serving the general public harbor such policies, and few institutions have halted what federal rules call "extraordinary collection actions," even as millions of Americans face crushing medical debt. Moreover, most hospitals probed by KHN conceal their collection activities, publicly posting incomplete or no information about what patients risk if they cannot pay. Many hospital officials claim they have an obligation to collect what patients owe, while leaders also highlight the industry's commitment to help low-income patients and others who cannot cover their debts. Yet about one in five hospitals checked by KHN do not post aid policies online. "Nobody should be denied care because they have an outstanding medical bill," said patient advocate Mark Rukavina. "Nobody should have a lien on their home because they got sick."

From the article of the same title
NPR (12/21/22) Levey, Noam

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One-Fifth of Older Adults with Health Concerns Skip Emergency Care Due to Cost: Research

Research published in the American Journal of Managed Care found more than 20 percent of over 2,000 surveyed older Americans between the ages of 50 and 80 forgo emergency care because of cost. Persons in their 50s and early 60s, women, those without health insurance, people with household incomes under $30,000 and those who describe their mental health as fair or poor were most likely to say they would skip emergency care because of cost. The authors noted that the pandemic strained many Americans' household finances, and data indicates out-of-pocket health spending this year increased at the highest rate recorded since 1985. Four out of five adults who had not experienced a medical emergency during the previous two years and first few months of the pandemic said they were worried about the cost of emergency care, with 45 percent saying it was very concerning; 18 percent said they lacked confidence in being able to afford a visit to the emergency department. "Some groups that are medically vulnerable or have suffered worse outcomes from COVID-19 were more likely to report cost-related avoidance of the [emergency room] than their counterparts," said lead author Rachel Solnick with the Icahn School of Medicine at Mount Sinai Health System. "These findings highlight the importance of reducing the number of uninsured individuals and the need for insurers to clearly communicate coverage for emergency services."

From the article of the same title
The Hill (12/19/22) Melillo, Gianna

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Medicine, Drugs and Devices

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As Flu Rages, US Releases Medicine from National Stockpile

The US government announced that amid a rise in flu cases, doses of a prescription flu drug will be distributed to states from the Strategic National Stockpile. There have been 150,000 hospitalizations and 9,300 deaths related to the flu already this season, according to estimates from the US Centers for Disease Control and Prevention. It remains unknown exactly how many doses of Tamiflu will be released. The announcement follows a decision last week by the US Department of Health and Human Services allowing access to statewide Tamiflu stockpiles.

From the article of the same title
Associated Press (12/22/22) Seitz, Amanda

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Can Metformin Reduce Need for Total Joint Replacement in Diabetes?

Research in the Canadian Medical Association Journal indicated the oral medication metformin reduced the risk of total knee and hip replacement (HR) in diabetics by 30 percent over two years. The researchers looked at 20,347 metformin-treated participants and 20,347 nonusers at an average baseline age of 63 years, and nearly half of subjects were women. Metformin users' diabetes tended to be more severe; common comorbidities included hypertension and hyperlipidemia, but only about 16 percent in both cohorts had osteoarthritis. In addition to a lower likelihood of total knee or HR among metformin users, the occurrence of total knee replacement among metformin nonusers and users was 4.15 per 10,000 person-months and 2.96 per 10,000 person-months, respectively. Incidence of total HR was 0.83 per 10,000 person-months in nonusers and 0.44 per 10,000 person-months in users, while adjusted HR was 0.71 for total knee replacement and 0.61 for total hip replacement among metformin users. The effect was noted at daily doses of less than 1 gram, as well as daily doses of 1 gram or more. "This suggests that metformin at a lower dosage could have effects on osteoarthritis," said the University of Tasmania's Changhai Ding.

From the article of the same title
Medscape (12/20/22) Swift, Diana

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Can a Federally Funded 'Netflix Model' Fix the Broken Market for Antibiotics?

Recent shortages of amoxicillin have put a spotlight on the world’s shrinking arsenal of potent antibiotics and the lack of incentives to develop them. The broken marketplace for new antimicrobial drugs has stirred debate over a bill, languishing in the US Congress, that would dramatically reconfigure the way antibiotics are discovered and sold in the United States. The Pasteur Act would upend the conventional model that ties antibiotic profits to sales volume by creating a subscription-like system that would provide pharmaceutical companies an upfront payment in exchange for unlimited access to a drug once it is approved by the US Food and Drug Administration. The measure attempts to address the vexing economics of antibiotics: Promising new drugs often gather dust on pharmacy shelves because health providers would rather save them for patients whose infections don’t respond to existing ones. New antibiotics also tend to be expensive, a disincentive for hospital-based prescribers who will often turn to cheaper ones, making it even harder for drug companies to earn back their initial investment. By separating profits from sales volume, supporters of the bill hope that prescribers will save new drugs for patients whose infections are resistant to existing medications. Limiting their use, experts say, can help extend the life of a new antibiotic before evolutionary pressure creates a “superbug” all but impervious to available antimicrobials.

From the article of the same title
Wall Street Journal (12/17/22) Jacobs, Andrew

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Many Hospitals Get Big Drug Discounts. That Doesn't Mean Markdowns for Patients

Some of the most successful nonprofit health systems in the US are benefiting from big drug discounts offered by a federal program, but this has not translated into lower costs for patients. The 340B program lets hospitals purchase medications for less and sell them to patients and their insurers at inflated prices. 340B requires pharmaceutical companies to sell drugs to participating hospitals at reduced prices and currently includes about 2,600 nonprofit and government hospitals, which spent at least $38 billion on discounted drugs last year, according to the Health Resources and Services Administration (HRSA). Participating hospitals are not mandated to pass on discounts to patients, insurers or Medicare, and there is no rule limiting how much they can charge for the drugs. Analysis of federal records showed that hospitals often extend their 340B discounts to clinics in affluent communities, where they can charge privately insured patients more than Medicaid beneficiaries.

An HRSA report estimated that hospitals qualifying as rural referral centers are accelerating drug purchases under 340B at a faster rate than any other type of 340B hospital, by more than 700 percent over five years. Collectively, 340B hospitals wrote off 2.7 percent of patient revenue as charity care or aid to needy patients, in their latest Medicare filings; non-340B hospitals wrote off 2.6 percent. Many hospitals claimed they use 340B proceeds to support various services, including free vaccinations, mental health care and subsidizing care for Medicaid enrollees. The Biden administration has asked Congress to require 340B hospitals to disclose drug savings and how they employ the proceeds.

From the article of the same title
Wall Street Journal (12/20/22) Mathews, Anna Wilde; Overberg, Paul; Walker, Joseph; et al.

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