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Category: Other; Midfoot/Forefoot Introduction/Purpose: Coding is an essential part of a foot and ankle surgeon’s duties and can both quantify the amount of work done by the surgeon and influence compensation. The purpose of this study was to evaluate the coding patterns among foot and ankle orthopaedic surgeons and to quantify the effects of these on reimbursement using real-life patient cases. Methods: A survey consisting of 12 commonly encountered real deidentified patient cases was administered to all foot and ankle fellowship-trained orthopaedic surgeons of a large, combined academic-private practice orthopaedic group. The scenarios included pre-operative diagnostic imaging and reports, intra-operative imaging, and post-operative radiographs. Surgeons were asked which Current Procedural Terminology (CPT) codes would be applied and if any Modifiers to these codes would be utilized. If multiple CPT codes were utilized, surgeons were asked to list the codes in the same order as would be theoretically listed on their operative notes. Respondents were allowed to use any sources of information they desired to complete the survey. Total work-relative value units (RVUs) and the generated reimbursement values were calculated for each case and respondent using the 2024 Centers for Medicare & Medicaid Services (CMS) conversion factor ($32.74 per RVU), with the primary procedure reimbursed at 100%, with additional procedures reimbursed at 50%. Results: Five surgeons completed the survey. Among case scenarios, four of the 12 cases had at least four of the five respondents in agreement on the primary CPT code, whereas only one case had 100% agreement among respondents on the primary CPT code. Similarly, only five of the 12 cases had at least four of the five respondents in agreement regarding modifier usage, with only one case having 100% agreement among respondents on modifier utilization. Modifier 59 was most utilized. The total RVU and reimbursement difference between the respondents with the highest and lowest listed RVUs was 216.06 and $3,627.92, respectively (Table 1). The cases with the most variability among both RVUs and modifiers involved a Lisfranc injury, Charcot reconstruction, and midfoot fracture-dislocation. Conclusion: Great variability exists between foot and ankle surgeons when coding common foot and ankle procedures. Surgeons should be aware of these differences and the large effect they can have on quantifying reimbursement. Increasing competency with coding and maximizing reimbursement for work performed should continue to be emphasized.

Background: Weightbearing computed tomography (WBCT) is becoming a valuable tool in the evaluation of foot and ankle pathology. Currently, cost analyses of WBCT scanners in private practice are lacking in the literature. This study evaluated the costs of acquisition, utilization, and reimbursements for a WBCT at a tertiary referral center, information of particular interest to practices considering obtaining such equipment. Methods: All WBCT scans performed at a tertiary referral center over the 55-month period (August 2016 to February 2021) were retrospectively evaluated. Patient demographics, pathology location, etiology, subspecialty of the ordering provider, and whether the study was unilateral or bilateral were collected. Reimbursement was calculated based on payor source as a percentage of Medicare reimbursement for lower extremity CT. The number of total scans performed per month was evaluated to determine revenue generated per month. Results: Over the study period, 1903 scans were performed. An average of 34.6 scans were performed each month. Forty-one providers ordered WBCT scans over the study period. Foot and ankle fellowship-trained orthopaedic surgeons ordered 75.5% of all scans. The most common location of pathology was the ankle, and the most common etiology was trauma. The device was cost neutral at 44.2 months, assuming reimbursement for each study was commensurate with Medicare rates. The device became cost neutral at approximately 29.9 months when calculating reimbursement according to mixed-payor source. Conclusion: As WBCT scan becomes more widely used for evaluation of foot and ankle pathology, practices may be interested in understanding the financial implications of such an investment. To the authors’ knowledge, this study is the only cost-effectiveness analysis of WBCT based in the United States. We found that in a large, multispecialty orthopaedic group, WBCT can be a financially viable asset and a valuable diagnostic tool for a variety of pathologies. Level of Evidence: Level III, diagnostic.

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Previous studies have reported increasing metatarsus adductus angle (MAA) to be associated with delayed union and refracture following intramedullary screw fixation of fifth metatarsal Jones fractures. The purpose of this study was to determine the influence of MAA on postoperative course following intramedullary screw fixation of Jones fractures. We also sought to identify associations between elevated MAA and both fracture and patient characteristics. Methods: We performed a retrospective review of all Jones fractures treated with primary intramedullary screw fixation by 4 foot and ankle fellowship-trained orthopaedic surgeons at a single institution from 1995 through 2015. Exclusion criteria included concomitant foot/ankle procedures and revision surgery. Charts were reviewed for patient and injury characteristics, implant, and postoperative course. Radiographs were examined for fracture classification, radiographic union, and MAA. MAA calculations were performed on standard weight-bearing digital radiographs using the traditional method, with the 5th metarso-cuboid joint as a reference. Based on severity of MAA, comparative and correlation analyses were performed. Primary outcomes were the number of surgical failures (defined as delayed union, nonunion, or refracture) and time to radiographic union, weight bearing, and pain resolution. Data was analysed using independent T test, one-way ANOVA, chi-square, and correlation analyses with significance defined as p<0.05. Results: 59 feet in 58 patients were identified with a mean age of 30 years and average follow-up of 9.6 months. The pooled union rate was 96.6%. The mean MAA was 20.9 (SD 6.7). Eleven feet had MAA<15, 18 mild (MAA 15-20), 12 moderate (MAA 20- 25), 18 severe (MAA>25), and 1 unknown. 11 patients had failures (18.6%), which consisted of 7 delayed unions (11.9%), 2 delayed unions (3.4%), and 3 refractures (5.1%). Compared to the uncomplicated unions, there was no significant difference in mean MAA (24.3 vs. 20.1, p=0.16). Three of the 4 non-union or refracture patients had MAA>25. MAA was correlated with time to weight bearing (r=0.365, p=0.005), weight (r=0.503, p<0.001), BMI (r=0.280, p=0.03), and approached significance with age (r=0.230, p=0.082). No significant correlation was found with time to radiographic union. Conclusion: To our knowledge, this is the largest series investigating MAA in fifth metatarsal Jones fracture patients treated with intramedullary screw fixation. Our mean MAA is consistent with previous reports. We found an association between increased MAA and postoperative recovery time, given increased time to initiate weight bearing. We did not find significant associations with prolonged radiographic healing, age, nor failure. The prolonged time to weight bearing may reflect surgeon preference in patients with higher MAA. These results suggest that reported associations with MAA may not be as strong as previously thought.

Category: Other; Ankle Arthritis; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Allograft is routinely used to enhance bone healing in foot and ankle surgery. One allograft in particular employs viable cells and bone scaffolding in a gel base. There is little evidence that compares how this material effects rate of fusion (ROF) and time to fusion (TTF) when compared to autograft in routine forefoot, midfoot, and hindfoot fusions. Our study investigates the use of a viable cellular allograft and its effect on these two variables in a population of patients undergoing fusions in the foot and ankle. Methods: A retrospective review was conducted over a five-year span of patients undergoing fusions in the foot and ankle where the cellular allograft was used. We compared the ROF and TTF between the following three graft groups: cellular allograft alone, autograft alone, and combined allograft + autograft. Data was retrieved from the patients' electronic medical record and TTF was recorded as the time, in days, it took for a solid radiographic fusion to form. Secondary variables collected included etiology of disease (post-traumatic, inflammatory, or diabetic arthropathy) and also analyzed for effect on ROF and TTF. Results: Two hundred and twenty-five patients underwent a fusion in the foot or ankle over a five-year period. Autograft alone was used in 101 patients, the cellular allograft alone was used in 88 patients, and a combination of autograft and the cellular allograft was used in 36 patients. Each group were similar in their comorbid conditions and demographics. The ROF of the autograft only group was 88% (89/101), compared to the cellular allograft group's ROF of 89% (78/88), and the combination graft group's ROF of 75% (27/36). The average TTF between each group varied slightly, with the cellular allograft group fusing the fastest at 86, followed by the autograft alone group at 97 days, and the combined group at 112 days. Conclusion: Our study investigated the use of a viable cellular allograft and its effect on ROF and TTF compared to autograft alone and autograft combined with said cellular allograft. We found no significant difference in ROF between autograft alone and the cellular allograft alone but did find a significant difference in ROF for the combined group resulting in lower rate of fusion. Additionally, use of the cellular allograft resulted in fastest time to fusion compared to autograft alone or a combination of the graft types.

Category: Other Introduction/Purpose: Weightbearing Computed Tomography (WB CT) is becoming a valuable tool in the evaluation and understanding of foot and ankle pathology. With this, more practices may be interested in acquiring WB CT scanners and understanding cost effectiveness of acquisition. To date there are currently no US based reports of cost analysis of WB CT scanners. Our study is a cost analysis of WB CT at tertiary referral physician owned practice. Methods: Data was collected for all patients who underwent imaging utilizing a weight bearing CT scanner at our institution from the date of acquisition in 2016. For ease of analysis and applicability of information across orthopedic practices, Medicare reimbursement was used as a uniform estimation of reimbursement across all insurances at a rate of $163.50 per scan. We then compared the number of scans obtained per month to total costs related to acquiring and maintaining the WB CT machine. Secondary variables collected included patient demographic information, pathology location (forefoot, midfoot, hindfoot), and utilization of the device by subspecialty. Results: A WB CT scanner was acquired by a private group in 2016. A proforma analysis demonstrated $179,000 to acquire the machine, $30,000 for extended warranty, $995 for additional licenses. Between August 2016 and February 2021, 1702 unilateral studies and 100 bilateral studies were performed. Patients ranged in age from 6 to 92. Average age was 45 years with 45.9% male and 54.1% female. Forty-one staff utilized the CT scanner from various subspecialties with 5 Foot and Ankle (F&A) surgeons ordering 80% of scans. When dividing total costs by number of months since acquisition the monthly cost of the device is $3,318 which requires 20 scans per month when using Medicare reimbursement rates. Over a 55 month the average number of scans per month is 34. When dividing the cost of acquisition by reimbursement per scan, the breakeven point was 1,284 scans which occurred at approximately 3 years. Conclusion: As WB CT scans become a valuable tool for the analysis of foot and ankle pathology, groups may be interested in understanding the financial implications of such an investment. Our study is the only cost analysis based in the United States of WB CT. We found that WB CT is a cost-effective tool that can be used to evaluate a number or pathologies in the foot and ankle.

Category: Other; Midfoot/Forefoot Introduction/Purpose: Custom and off-the-shelf orthotics frequently are prescribed by foot and ankle orthpaedic surgeons. This study aimed to quantify the rate at which patients receive their prescribed orthotic and explore the variables that could be predictive of patients’ receiving and using orthotics. Methods: We analyzed the demographics of 382 patients who received an orthotic prescription from a group of foot and ankle surgeons to assess variables predictive of patients receiving their prescribed orthotic. Of these 382 patients, 186 (49%) completed a survey regarding insurance status, cost of the orthotic, education, income, and satisfaction with the orthotic. This information was used to identify variables that may help identify patients who are at an increased risk of failing to receive their prescribed orthotic. Results: Patients received their orthotic at an overall rate of 61.2% (235/382). Patients with commercial insurance were more likely to receive their orthotic (67%) than patients with Medicaid (40%). Of the 186 patients who completed the survey, those whose insurance covered all or part of their orthotic were more likely to receive their orthotic (100% and 96%, respectively) compared to those whose insurance did not cover the orthotic (81.5%). Overall 86.5% reported being ‘better’ or ‘completely relieved’ with orthotic use, and 13.4% reported ‘no difference’ or ‘worse.’ There were no differences in receive rates according to age or gender, but there was a disparity in race, with 71% (155/219) of white and only 48% (72/151) of black patients receiving their orthotics. Conclusion: A substantial number of patients (38.8%) do not receive their physician-prescribed orthotic. Patients who do receive and use their orthotic report positive results. Insurance status, race, and coverage of costs by the insurance company play important roles in predicting which patients are at risk for failing to receive their orthotic.

Coding is an essential part of a foot-and-ankle surgeon's responsibility and can quantify the amount of work done by the surgeon and influence compensation. The purpose of this study was to evaluate the coding patterns and variation among foot-and-ankle orthopedic surgeons and to quantify the potential effects of these on reimbursement using real-life patient cases. Our hypothesis was that there would be large variability between the coding of common foot-and-ankle cases between surgeons, with subsequent effects on reimbursement values. A survey consisting of 12 patient cases was administered to all foot-and-ankle, fellowship-trained orthopedic surgeons of a large, combined academic-private practice group. The scenarios included pre-operative diagnostic imaging and reports, intra-operative imaging, and post-operative radiographs. Surgeons were asked which Current Procedural Terminology (CPT) codes would be applied and if any modifiers to these codes would be used. Total work-relative value units (RVUs) and the generated reimbursement values were calculated for each case and respondent using the 2024 Centers for Medicare & Medicaid Services conversion factor ($32.74 per RVU), with the primary procedure reimbursed at 100% and additional procedures reimbursed at 50%. Five surgeons completed the survey. Among case scenarios, wide variability in CPT coding was demonstrated, with only 33.3% (four out of 12) of cases having at least four of the five respondents in agreement on the primary CPT code, whereas only one case had 100% agreement. Similarly, only 41.7% (five out of 12) of cases had at least four of the five respondents in agreement regarding modifier usage, with only one case having 100% agreement. The total RVU and reimbursement difference between the respondents with the highest and lowest listed RVUs was 216.06 and $3,627.92, respectively. Large variability exists between foot-and-ankle surgeons when coding common procedures, particularly those involving the midfoot. Surgeons should be aware of these differences and the large effect they can have on quantifying work and reimbursement. Increasing competency with coding and billing should continue to be emphasized in all medical specialties.