Outpatient Foot and Ankle Boom Continues

Here’s help making sense of the equipment, staffing and reimbursement info necessary for success at your facility.

Bryanna D. Vesely, DPM, MPH, a fellowship-trained foot and ankle surgeon with Orthopaedic & Spine Center in Newport News, Va., is seven months out from her advanced reconstructive foot and ankle fellowship. As a relatively new practitioner, she is all-in on minimally invasive techniques and the latest technology for foot and ankle.

New techniques and tech

“I’ve done a lot of minimally invasive bunions the past week, and ankle fractures with the recent snow,” says Dr. Vesely. “I commonly do minimally invasive Haglund’s deformity surgeries, and I really like doing reconstructions like flat foot, cavus or high arch.” She tackles difficult deformity correction and performs many ankle stabilization and other sports medicine foot and ankle surgeries as a result of training with the orthopedics group for the NFL’s Las Vegas Raiders.

“Doing smaller incisions in general is becoming more popular,” she says. “Most people are trending toward minimally invasive bunions because it’s easier for patients to recover.”

Dr. Vesely notes that foot and ankle surgery doesn’t have the greatest reputation among many patients, especially those who know people who suffered through recoveries that lasted months or even years. “There are bad connotations about foot and ankle surgery,” she says. “But advancements have helped to improve patients’ experience.”

Dr. Vesely says 3D-printed implants that are customized to an individual patient are part of her practice. “I do 3D-custom printed total ankles so we can correct for the deformity of the ankle as well as fix the ankle arthritis,” she says.

Some of her smaller outpatient procedures can take as little as 10 to 15 minutes, while a major reconstruction can take three hours. Post-op recoveries usually take an hour or two before discharge. She says her average is about five surgeries in a day. In the OR, her team usually consists of a first assist, circulator nurse, anesthesia provider, surgical technologist and vendor rep. Almost all of Dr. Vesely’s surgeries involve conscious sedation and then a block. “I rarely use general anesthesia,” she says. “If I’m doing a big reconstruction, total ankle or an ankle fusion, anesthesia will do a pop saph [combined popliteal and saphenous] block to numb up the whole leg. For something like hammertoes or a bunion, I block it myself at the foot level.” The blocks can numb the patient’s extremity for 24 hours postoperatively. “A lot of patients have the most pain the first couple days after surgery, so if you can get them through the first day with a numb foot, it really helps,” she says.

Postoperatively, Dr. Vesely prescribes opioids, dependent on the procedure. “I just did a huge reconstruction where I did a TTC [tibiotalocalcaneal] nail,” she says. “I took a wedge out of the tibia to realign the ankle joint, as the patient had a significant deformity for decades. I’ll prescribe more pain medicine for that than when I do, say, hammertoes.”

A hand sheet she gives patients when they schedule surgery discusses pain management, citing an article that shows the combination of ibuprofen and acetaminophen can be as effective as opioids for pain relief.

Her decision on performing surgeries at an ASC or HOPD revolves around comorbidities and reimbursement. “If the patient has a lot of comorbidities, we automatically put them in the hospital just to be safe,” she says. “If they have any cardiac history like stroke or a previous heart attack, even if it was years ago, I’d rather do it in the hospital. Our surgery center also has a BMI cut off. If diabetes is under control, either the ASC or hospital is okay.”

Although CMS approved total ankles at ASCs for 2024, reimbursement in that setting is still difficult for procedures that involve expensive implants and large grafts. As a result, Dr. Vesely’s scheduler processes every case through insurance before the procedure. “Some insurances cover certain implants or grafts if they’re in the hospital, but not at a surgery center,” she says. “If I’m going to be using an expensive graft or hardware and the patient’s insurance doesn’t cover it in a surgery center, I have to do it at the hospital.”

“You really need to work on those implant prices to make foot and ankle profitable for your facility.”
Melanie Russell, RN, BSN

As a result, she regularly performs total ankles and other procedures such as repairs of ruptured Achilles or highly diseased peroneal tendons that may require a graft at an HOPD.

Her advice, especially in the ASC setting, is to engage vendor reps to work pricing down, or to bundle more into the price. “I use a lot of anchors that are a little bit smaller than rotator cuff anchors,” she says as an example. “See if you can bundle those in their prices.”

Profit requires effort

At Orthopaedic Institute Surgery Center (OISC) in Metropolis, Ill., William R. Adams II, DPM, FACFAS, is the only podiatric surgeon. The board-certified doctor also operates at two regional hospitals, but is a steady producer for the ASC, says Administrator Melanie Russell, RN, BSN. He most frequently performs metatarsophalangeal joint (MTP), bunion corrections and Achilles repairs at the center. But his high level of engagement extends beyond the OR.

“He’s done a great job negotiating his implant prices,” says Ms. Russell. “Recently, he renegotiated pricing on MTP implants. He just negotiated down an implant price to save us $500, which ended up at around 20% of the total cost. You really need to work on those implant prices to make foot and ankle profitable for your facility.”

Ms. Russell says foot and ankle is traditionally a lower-reimbursement specialty, of which Dr. Adams is well aware. “We go back and forth in terms of what the reimbursement will be for a particular code or a particular insurance, and then we look at the implant price to make sure the procedure will be affordable and profitable for us to do,” she says.

OISC can handle most foot and ankle patients and procedures that CMS deems ASC-appropriate, but occasionally Dr. Adams must use HOPDs for such procedures.

Ms. Russell says her staff who handle insurance contracts are working on carve-outs for foot and ankle. “You may be able to get a carve-out for a particular CPT code that has a better reimbursement,” she says. “I might not get better reimbursement for podiatry across the board, but if we can carve out total ankle, which has the most significant implant cost, and get a better price than by themselves with that CPT code, that’s another way to effectively have a more profitable program.”

Dr. Adams’ OR team usually consists of two scrub techs, an RN and a contracted anesthesia provider, with a radiology tech operating a C-arm when needed. Most of his cases last 60 to 90 minutes, says Ms. Russell. As far as capital equipment, a nine-inch C-arm is required for many of Dr. Adams’ cases. OISC has long had a standard foot and ankle instrument tray, but most of the hardware trays including implants and screws are provided by the vendor rep.

Flagging vascular issues

“Typically, foot and ankle is a good service line, especially if you have musculoskeletal services at your ASC and you have the equipment anyway,” says Deb Yoder, RN, MHA, CNOR, CASC, vice president of facility development with Compass Surgical Partners, an ASC development and management company in Raleigh, N.C. “Hammertoes and bunion correction used to be pretty straightforward cases, but with new technology and implants, they changed some. It’s also exponentially increased the cost of foot and ankle surgery in our surgery centers.

“We have to be very cautious when we’re putting in some of these new implants, because you can get upside down by thousands of dollars for each surgery in a hurry,” says Ms. Yoder. “If the doctor knows or thinks they’re going to use X, Y and Z or more than X number of something, and we can’t do it based on our reimbursement, they stay in the hospital, right, wrong or indifferent.”

Ms. Yoder says patients’ vascular issues are under increasing scrutiny among foot and ankle surgeons due to the increased use of implants. “We’re seeing a bigger alliance with vascular or interventional docs and foot and ankle ASCs,” she says. “Some insurance companies now say you need a vascular study done first. If they don’t have good blood flow, they’re not going to heal, and you start this whole vicious cycle in the hospital with infections or long-term healing needs.”

Get on the same page

Ultimately, foot and ankle success lies in cost containment. “Be very cognizant of all of your costs, and be really savvy,” says Ms. Yoder. “Know exactly what the implant costs are and what the payor is paying. Medicare will pay you a flat fee, but not always additional for the implant. Some insurers will pay you a flat fee plus the cost of the implant. Negotiate those initial costs up front, because it’s not just the cost of the implant, but all the other supplies: staff, IV fluids, pharmacy, anesthesia. For all procedures, HOPDs could get double of what an ASC is paid. It’s cheaper for patients to do it in an ASC, but not if they’re going to end up with more out-of-pocket costs. The docs don’t always know that either. You really need to educate them.”

For foot and ankle, Ms. Yoder says facilities will need small handheld power tools, a tourniquet, a C-arm, positioning devices, ankle distractors and, depending on the case mix, some high-tech imaging equipment. To do this right, ask your physicians targeted, relevant questions about what they want to accomplish and what they’ll need to do so.

“Are the surgeons going to do arthroscopic ankle work? Because then you need different spokes and cameras,” says Ms. Yoder. “What are those CPT codes? Are they all approved for your ASC? What are their costs?

“What are the surgeons’ preference cards? What kinds of toys do they use? Because there are lots of toys and implants out there,” she says. “Be extremely transparent with your providers, because sometimes new toys might make their life a little easier versus what’s been used in the past, but there’s no difference in clinical outcomes. Transparency and education for everybody is key.” OSM