ACFAS Position Statement

Credentialing of Foot and Ankle Surgeons and Guidelines for Surgical Delineation of Privileges

Approved by the ACFAS Board of Directors, January 2024

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Background
The American College of Foot and Ankle Surgeons (ACFAS) is a surgical specialty society of more than  8,000 foot and ankle surgeons. Founded in 1942, ACFAS seeks to promote the art and science of foot, ankle, and related lower extremity surgery; address the concerns of foot and ankle surgeons; advance and improve standards of education and surgical skills; and advance and advocate for the highest standards of patient care and safety.

Foot and ankle surgery is a subspecialty of podiatric medicine (Doctors of Podiatric Medicine or DPM). Podiatric foot and ankle surgeons conduct medical history and physical examinations, diagnose, and perform medical and surgical management of all diseases, deformities, injuries and defects of the foot, ankle and related lower extremities, as governed by appropriate state statute(s).

The Council on Podiatric Medical Education (CPME) sets rigorous criteria for residencies in podiatric medicine and surgery. ACFAS members have had extensive training in foot, ankle and related lower extremity surgery and are examined and board certified (or board qualified) in foot and ankle surgery by the American Board of Foot and Ankle Surgery (ABFAS)1. Additionally, medical staff privileges in acute and ambulatory settings are held by most ACFAS podiatric surgeons.

The position of ACFAS is that the credentialing processes for granting privileges for the specialty of foot and ankle surgery should be uniformly applied to all surgeons seeking foot and ankle surgery privileges, regardless of medical degree. These privileges should be based on the completion of a residency that is duly accredited by the surgeons’ official medical and surgical associations, with a focus on foot and ankle surgical training. In addition, the privileging process should also evaluate specialized foot and ankle fellowship documentation, surgical residency training logs, and/or demonstration of current clinical and surgical experience, continuing education, and accreditation, along with board qualification or certification. 

Allopathic (MD) and osteopathic (DO) physicians are not certified in specialty foot and ankle surgery, nor do they presently function under the quality assurance tool of a certificate of added qualifications for the same within their respective specialties. Any credentialing comparisons between MD and DO colleagues and podiatric foot and ankle surgeons should be based on specialty-specific foot and ankle training, not generalized years of training.

Application
Podiatric foot and ankle surgeons should complete the same application process as all other surgeons seeking staff appointments. Equal processing standards consistent with the acute and ambulatory settings’ bylaws, rules and regulations that govern all surgical specialties should be fairly applied to all surgeons seeking appointment.

Privileging
The granting of clinical privileges for a foot and ankle surgeon with a DPM degree should be based on fair and objective analysis that follows the same requirements as set forth in evaluating other physicians consistent with The Joint Commission (TJC) standards and/or Medicare Conditions of Participation (CoP).2

TJC standards specify that evidence of current license, competence, relevant training and ability to perform the procedures that the privileges request should form the basis of privilege delineation. The available clinical privileges in an acute or ambulatory setting should represent the scope of practice as defined by state law.

Credentialing for Podiatric Foot and Ankle Surgeons
Foot and ankle surgical training, demonstration of current clinical experience in foot, ankle and related lower extremity surgery, and continuing medical/surgical education are also important credentialing elements recognized by TJC. These key elements allow for measurable and uniform objective criteria to be applied in evaluating a DPM for privileges in foot and ankle surgery. In addition, consideration of scholarly and academic achievements may be factored into the decision-making process.

Individual credentialing and surgical privilege delineation is determined by an individual’s qualifications and documentation consistent with other specialties and TJC standards or Medicare CoP.

Delineations
Specific procedural delineation is based on individual training and documented experience. Two core categories of surgical delineation are defined by ACFAS:

  • Foot and ankle
  • Reconstructive rearfoot, ankle, and related lower extremity structures

A “special procedures” category is also defined for specialized and evolving technologies and procedures.

Criteria

  • ABFAS Certification or Qualification
  • Demonstration of training and achieved competency in specific procedures for which the DPM is requesting privileges, including:
    • Current clinical experience
    •  Documented surgical logs or operative reports
    • Post-graduate continuing medical education
    • Verification of competency to perform the requested procedure(s) from residency/fellowship director.

American College of Foot and Ankle Surgeons Guidelines for Surgical Delineation of Privileges

Core Level 1 Privileges: Foot and Ankle
Privileges to perform admission history and physicals, admit as qualified, evaluate, diagnose, provide consultation, order diagnostic studies and perform surgical and non-surgical procedures of the foot, ankle and lower leg meeting the standard of care.

  1. Soft tissue procedures of the foot, ankle and lower leg including: incision and drainage; lesion and mass excision; ligament and tendon repair; adjunctive tendon lengthening of the related lower leg; skin grafts/flaps; lower extremity nerve surgery.
  2. Osseous procedures including fusion and osteotomies of the foot; ostectomies of the foot and ankle;; osseous fusions of the forefoot and midfoot and nonreconstructive.
  3. Open and closed reduction of forefoot and midfoot fractures/dislocations; closed  management of rearfoot and ankle fractures/dislocations.
  4. Amputations of portions of or all of the foot.

Core Level 2 Privileges: Reconstructive Rearfoot, Ankle, and Related Lower Extremity Structures
Privileges to include performance of complex, rearfoot, ankle, and related lower extremity structures using any method within the standard of care. This is inclusive of all of Core 1, plus the following:

  1. Fusion and osteotomy of the ankle, rearfoot and related structures.
  2. Soft tissue coverage, repair and reconstruction (including tendon transfers) of the rearfoot, ankle and related structures.
  3. Fracture repair: open and closed repair of fractures of the rearfoot and ankle.
  4. Arthroscopy of the foot and ankle.
  5. Total Ankle Replacement

Isolated procedures from Core 2 may be granted with proper documentation as defined within this document.
Certain Procedures may require additional training and/or education.

Special Procedures *

  1. Extracorporeal shock wave therapy.
  2. CO2 laser use.
  3. Other:
*Credentialing for “Special Procedures” requires additional documentation of training, qualification  or post-graduate training courses specific to the procedures or technologies.

Chair, Department or Section Chair, Credentials Committee, Date of Review
Comments:

Footnotes
1 Formerly the American Board of Podiatric Surgery (ABPS) Privileging
2 Neither CMS nor The Joint Commission requires board certification for staff membership or clinical privileges, and CMS specifically prohibits the use of board certification as the sole criteria for credentialing or granting privileges: “Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship, or membership in a specialty body or society.”3(§482.12(a)(7))

See ACFAS privileging guidelines for total ankle replacement at www.acfas.org/positions