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Setting Our Course throughCollaborative Strategic PlanningThe Academy and its Foundation regularlyreview and adjust priorities of the organizationevery three-to-five-year period through amultistep strategic planning process. We are beginningpreparations for our upcoming strategic planningsession to be held in January under the leadership ofCarol R. Bradford, MD, who will be our presidentat the time. A well-done strategic plan allows anorganization to focus its energy and resources onpriorities deemed essential to the membership andfactors affecting their ability to succeed in moving boththeir situations and field of endeavor forward. That isparticularly true for medical associations where thereare frequent and unexpected changes that influence bothcontemporary and future needs.The AAO-HNS/F has had a robust strategic planningprocess for over a decade that has served us well interms of operationalizing priorities of the leadershipand members consistently without the year-to-yeardirectional changes seen in many medical associationsas elected leadership changes. Recent experience hasshown me that not all organizations rely on or valuemember-led planning events, particularly those whoseleadership is dominated by academia. Our last strategicplanning exercise was led by Gavin Setzen, MD,three years ago and set the direction that allowed us toexpand our Clinical Data Registry, Reg-entSM, to thepoint we are ready to conduct clinical research whenit will be needed the most; adopt our “We Are One”mantra that emphasizes the multiple levels of diversityin otolaryngology; originate ENThealth.org, our patientcentered website; and institute a new state-of-the-arteducation platform with our flagship product FLEX—while contributing to reserves without raising dues.The upgrade of our technologic capabilities allowedus to seamlessly move to teleworking status during theCOVID-19 pandemic and provide the otolaryngologycommunity with the information urgently needed byotolaryngologists worldwide.Successful planning exercises are criticallydependent on identifying the essential stakeholdersand selecting engaged representatives for each that canrepresent key needs of their constituents as well as theorganization as a whole. For the Academy’s purpose,that includes spokespersons conveying the interestsof all demographic groups, specialty societies withinotolaryngology, academic and private practitioners,members of the healthcare delivery team who typicallywork with otolaryngologists, industry leaders specificto otolaryngology, patient-based organizations, andAcademy leadership and staff. Working with anexperienced facilitator, leadership and staff will createsurvey materials and disseminate these to the abovementioned groups as well as the general membershipfor their preliminary thoughts. This informationwill be submitted to the representatives chosen toparticipate in the virtual strategic planning meetingand who will thoroughly discuss the issues and makeinitial recommendations. One of the most essentialgoals of this group will be to review the organizational“mission” and “vision” and either affirm or adapt ourcurrent course. Our current vision, “The global leaderin optimizing quality ear, nose, and throat patientcare” and mission statement, “We help our membersachieve excellence and provide the best ear, nose, andthroat care through professional and public education,research, and health policy advocacy” have served ourmembers well over the last several years. This StrategicPlanning Committee will consist of the representativesof diverse interest groups included in the initial survey.Leadership and staff will then curate and formalizethe discussion and recommendation into a preliminarystrategic plan.The entire process and resultant preliminarydocument will be reviewed and edited first by theExecutive Committee of the Boards of Directorsand subsequently by the entire Boards of Directors,including invited guests. The final strategic plan willbe used to direct future budgeting priorities over theensuing several years, review current programs andstaffing allocation, create new programs, and set theoverall direction for the organization. The upcomingfive-year period promises to be one of the mostdisruptive times for healthcare delivery in recentmemory. The COVID-19 pandemic has exposedthe significant weakness in our public health systemas well as the marked disparity in “usable” accessaffecting large swaths of the population. Following thepresidential election in November, there will almostcertainly be attempts to modify and improve our currentsystem. There have been several proposals vetted duringthe campaign, most of which would result in significantchange that will set the course for decades to come.While we are well positioned now for mosteventualities, it is critical that we stay ahead of thecurve. Input from our members and colleaguesthroughout the healthcare industry will allow us toformulate a strategic plan that makes that possible.ENTNET.ORG/BULLETINthe leading edgeJames C. Denneny III, MDAAO-HNS/F EVP/CEOWhile we are wellpositioned now formost eventualities, itis critical that we stayahead of the curve. Inputfrom our members andcolleagues throughoutthe healthcare industrywill allow us to formulatea strategic plan thatmakes that possible.AAO-HNS BULLETINAUGUST 20205

wellness seriesBe Present, Mindfulness WorksSonya Malekzadeh, MD, Member of the AAO-HNSPhysician Wellness Task ForceIn the space of a few weeks, thecoronavirus outbreak became an allconsuming global, national crisis.Changing day-to-day life in unprecedentedways, it touched all of us and will be thefocus for many more months to come.The collateral effect of this pandemicon healthcare providers’ well-being isemerging as clinicians face even greaterworkplace distress that will likelyexacerbate existing levels of burnout. It isnot surprising that the National Academy ofMedicine warns of a wave of physical andemotional harm amounting to a “parallelpandemic,” urging us to develop clearstrategies to address clinician well-beingduring and after the COVID-19 crisis.1Although this complex problem requires ashared response at the national and healthsystem levels, there are individual strategiesthat can help mitigate the uncertainty andanxiety surrounding this particular time.Mindfulness has gained traction as atool to combat physician stress and burnout.Most of us have heard the term, and it canevoke a whole host of ideas but essentiallyrefers to paying attention on purpose, nonjudgmentally, to what is happening in thepresent moment. In other words, we need tointentionally focus our attention on the hereand now instead of dwelling on the pastor worrying about the future. Our focus isnot meant to judge thoughts, emotions, andphysical sensations but to experience and6AUGUST 2020AAO-HNS BULLETINENTNET.ORG/BULLETINacknowledge them with compassion. As webecome aware of our internal and externalsurroundings, we are creating a sense ofcalm and acceptance.Based on Buddhist philosophy,mindfulness was first introduced intoWestern medicine by Jon Kabat-Zinn inthe 1970s. His techniques were primarilydeveloped for stress management butevolved to include the treatment ofa variety of health-related disorders.According to his research, mindfulnesspractices can lead to a less intense stressresponse, which in turn has severalbenefits, such as decreasing hypertension,strengthening the immune system, andreducing pain levels. These skills canalso enhance day-to-day well-being byimproving mood and alleviating feelings ofunease, anxiety, and fear.To better understand the positive healtheffects of mindfulness, let’s reflect on thestress response and the connection betweenour chronically stressful lives and ourbody’s response to stress. When the mindperceives an emotional or physical threat,cortisol and other stress hormones arereleased in the “fight or flight” response,preparing us to meet the challenge.Unfortunately, this survival mechanism canalso kick in during non-life-threateningsituations, such as work burden and familytension. When the threat disappears,cortisol levels drop. The trouble is that werarely deal with one stressor at a time andchronic low-level stress keeps cortisol fromreturning to baseline. Over time, the bodyis dysregulated and there are deleteriouseffects of chronic stress. Mindful practiceutilizes our mind-body connection to“de-stress” or counter the stress response.Being mindful doesn’t need to becomplicated. There are simple andbrief exercises that can be effortlesslyincorporated into your daily routine.Mindfulness techniques vary ineffectiveness from one individual toanother, and the key is to experimentuntil you find which resonates best withyou. For some it’s focused breathing, andfor others it’s movement and exercise—whatever technique works for you is whatyou should pursue. Like learning any newskill, mindfulness takes time and practice.The mind is a busy place and it’s naturalfor the mind to wander, but when it does,you can learn to quiet your mind by gentlyrefocusing thoughts back to the exercise.Mindfulness is like a muscle; the more youexercise it, the better it will work whenyou need it. Remember, with mindfulnessthere is no way of doing it wrong. Acceptwhatever you might be feeling or thinkingwithout trying to change it or yourreactions. Recognize unpleasant sensations,thoughts, and feelings as temporary andfleeting, observing them objectivelywithout reaction or judgment and notworrying about doing it right or differentbut noticing what is.My first introduction to mindfulnesswas through a required institutionalsponsored mind-body medicine retreaton Maryland’s Eastern Shore. Always

wellness seriesthe skeptic, I was reluctant to invest thetime and energy on what I viewed as anoverhyped trend, lacking substance orscientific basis. Over the ensuing four days,I gained a different perspective. I realizedthat mindfulness did not require me tochant, hold hands, or sing “Kumbaya.” Infact, all I needed was the willingness tosit quietly, giving my mind the space andsilence to process thoughts. Like mostphysicians, my life is full of stressorsfrom work, home, and digital devices.A self-professed multitasker, I am notalways fully present for patients or family.As my practice of mindfulness develops,I have learned to slow down and becomeless reactive and more accepting of eventsout of my control. While I can’t entirelyeliminate stress, I can be more adaptable tothe pressures. Mindfulness is the self-caretool I need to be the best possible doctorfor my patients and the healthiest possibleversion of me for my family.Mindfulness is not a magic bullet. Itwill not address the increasing pressures ofan ever-evolving healthcare system, nor theanxieties surrounding a global pandemic.However, it can play an important role inhow we respond to these physically andemotionally demanding times. After all, wehave to take care of ourselves in order tohave something left to care for others.References1.Dzau VJ, Kirch D, Nasca T. Preventing a Parallel Pandemic— A National Strategy to Protect Clinicians’ Well-Being. NMindfulness ToolkitFree Access to Headspace: A meditationand sleep app that is now available for U.S.healthcare and public health professionalsthrough 2020. /Want to Be Happy? Stay in the Momentby Matt Killingsworth. TED Talks. 2011.https://www.ted.com/talks/mattkillingsworth want to be happier stayin the moment?language en20-Minute Guided Mindfulness Exercisehttps://www.youtube.com/watch?v thYoV-MCVs0All It Takes is 10 Mindful Minutesby Andy Puddicombe. TED Talks. 2012.https://www.ted.com/talks/andypuddicombe all it takes is 10 mindfulminutes.RAIN Method of MindfulnessMindfulness instructor Tara Brachencourages physicians experiencingstress to recognize, allow, investigate, andnurture. First, recognize what is happening,then allow the experience to be therejust as it is, investigate with interest andcare, and nurture with compassion. Thiscan help you avert the sense of beingoverwhelmed and allow you to focus andtake action during stressful rabrach.com/meditationpractice-rain/Mindfulness -exercises-3/Mindful Eating, Raisin Meditationhttps://www.youtube.com/watch?v z2Eo56BLMjMEngl J Med. 2020 May 13. doi: 10.1056/NEJMp2011027.ENTNET.ORG/BULLETINAAO-HNS BULLETINAUGUST 20207

at the forefrontat theforefrontInformation, resources, andupdates in this sectionPrivate Payer Advocacy:Aetna Sinus Surgery2020 AAO-HNS/F CommitteeExcellence Awards AnnouncedHumanitarian Travel Grant:Otolaryngology in UgandaCoding Update: How to ReportCPT 31298BOG Awards AnnouncedBOG 2020 CandidatesAAO-HNSF Quality Resourceson Facial Plastics andReconstructive SurgeryREAD MORE ONLINEHumanitarian Travel Grant:Otolaryngology in UgandaPrivate Payer Advocacy: Aetna Sinus SurgeryOver the past several months, membershave alerted the Academy’s HealthPolicy Advocacy team that they havebeen receiving sinus surgery reimbursementdenials from Aetna. In these denials, Aetna statesthat the procedure is considered experimental/investigational. In response, the PhysicianPayment Policy (3P) workgroup, supported byHealth Policy Advocacy staff, have been workingwith Aetna to gain insight into these denials.Aetna clarified that these denials are basedon inadequate documentation, rather than aninappropriate designation of "investigational" forproven services like FESS, which are consistentwith the standard of care. For example, forfunctional endoscopic sinus surgery for chronicrhinosinusitis (longer than 12 weeks) with nasalpolyps with persistent symptoms, providers mustproperly document that the patient has failedoptimal medical treatment and provide objectiveevidence of disease by CT imaging.In order to be fully reimbursed for sinussurgeries, the Academy recommends thatmembers submit detailed documentation relatedto: Evidence of abnormal CT scans. AbnormalCT findings include, but are not limited to: air fluid levels air bubbles greater than 3 mm of mucosal thickening pansinusitis diffuse opacification Documentation demonstrating that maximalmedical therapy has been tried, as indicated byall of the following: antibiotic therapy (if bacterial infectionis suspected) saline nasal irrigation trial of nasal steroids allergy testing (if symptoms areconsistent with allergic rhinitis)and appropriate pharmacotherapy(e.g., antihistamines or intranasalcorticosteroids or leukotrieneantagonists, etc.) Clinical notes that are clear, legible, andprovide rationale for the proposed treatment.Examples include: stating a patient has had four or moredocumented episodes of recurrent acuterhinosinusitis within 12 continuousmonths and providing objective evidenceof disease via nasal endoscopy and CTimaging stating that chronic rhinosinusitis hasbeen present for at least 12 continuousweeksThe Academy strongly encourages membersto carefully read through the Aetna sinussurgery policy (http://www.aetna.com/cpb/medical/data/900 999/0937.html) to ensurethat all documentation requirements have beenmet prior to submitting claims. If you receivean inappropriately denied sinus surgery claimfrom Aetna or another insurer, please emailhealthpolicy@entnet.org.BOG 2020 Candidate Statements2020 Committee Excellence Awards AnnouncedLaryngology Bronchoesophagology EducationCommitteeChair: Thomas L. Carroll, MDPatient Safety and Quality Improvement CommitteeCo-chairs: Emily F. Boss, MD, MPH,and C. W. David Chang, MDHead and Neck Surgery Education CommitteeChair: David M. Cognetti, MDRhinology and Paranasal Sinus CommitteeChair: Sanford M. Archer, MDHumanitarian Efforts CommitteeChair: Mark E. Zafereo, Jr., MDWIO Program and Awards CommitteeChair: Evelyne Kalyoussef, MD

at the forefrontHUMANITARIAN TRAVEL GRANTOtolaryngology in UgandaIn November 2018, Kathryn R. Hoppe,MD, had the opportunity to participate in asurgical mission trip to Kampala, Uganda, aspart of the Head and Neck Outreach (HNO)team from University Hospitals ClevelandMedical Center. This is a well-establishedmedical and educational exchange withthe Uganda Cancer Institute (UCI) and theMakerere University School of Medicine.This exchange was started by Chad A.Zender, MD, in 2014, and since then theprogram has expanded to biannual missiontrips in which over 250 patients have beenevaluated and over 150 procedures havebeen performed. Throughout the weekDr. Hoppe and theHNO team workedalongside theUgandan physiciansto completeapproximately 25advanced head andneck surgeries.“The healthcaresystem in Uganda is very patient- andfamily-oriented. It is a very tight-knitcommunity and family members not onlyhelp care for their loved ones but alsoother families and patients who may needassistance. This has been an irreplaceableexperience of my otolaryngologyresidency, making a great impact on thephysician I will strive to be by continuinghumanitarian effortsREAD MORE ONLINEthroughout myLonger article availablecareer."Coding Update: How to Report CPT 31298In January 2018, the Centers for Medicare& Medicaid Services (CMS) implementedsignificant changes to the functionalendoscopic sinus surgery (FESS) and balloonsinus dilation (BSD) family of codes, revisingthese code sets to bundle frequently reportedcodes within each family together. Withthese changes, CMS required four new codecombinations, including CPT 31298 Nasal/sinus endoscopy, surgical, with dilation (e.g.,balloon dilation); frontal and sphenoid sinusostia. Among the new codes, 31298 wasthe only bundled code in the family that isperformed using BSD.As part of the RUC valuation process,specialty societies are asked to present on directpractice expense (PE) inputs typically (i.e.,items and quantities utilized greater than 50%of the time) required to perform a service orprocedure. The direct practice expense inputsare broken down into three categories: clinicalstaff time (activities performed by an RN, LPN,etc.), disposable supplies, and non-disposableequipment. CMS and the American MedicalAssociation’s RVS Update Committee (AMARUC) then monitor all “high-cost” suppliesincluded within codes, as many of theseservices represent a large portion of overallMedicare expenditure. The BSD codes fall intothis category due to the inclusion of the highcost supply SA106 kit, sinus surgery, balloon(maxillary, frontal, or sphenoid). This supplyis currently valued at 2474.99 by CMS.The AAO-HNS wants our members to fullyunderstand the long history surrounding thisparticular supply. When the BSD codes werefirst valued in 2010, the RUC recommended,and the Academy supported, that CMSassign a HCPCS code to the balloon kit inorder to reimburse providers directly for thenumber of balloons used per procedure. Thisrecommendation was made based on that factthat balloon kits are sometimes used to accessmore than one sinus at a time during sinussurgery. Through rulemaking CMS declinedto accept this recommendation, and insteadassigned half a balloon kit to the existingBSD codes under the premise that if a ballooncould be used twice on two separate sinuses,providers should only be reimbursed half a kitwhen accessing one sinus.In contrast, when CPT 31298 wasdeveloped in 2016, the PE Subcommittee statedthe following during their review of the code:The Subcommittee also verified that a fullballoon is necessary for the 31XX5 (now31298) because this service includes twosinuses. The Subcommittee noted that a halfcatheter for each balloon is necessary for therest of the services because multiple sinuses,typically two, could be balloon dilated at thesame time. The RUC recommends the directpractice expense inputs as modified by thePractice Expense Subcommittee.As noted above, CMS accepted thisrecommendation within the 2018 MedicarePhysician Fee Schedule. This update resultedin 31298 being the only code i

Executive Vice President, CEO, and Editor of the Bulletin James C. Denneny III, MD Managing Editor Tina Maggio bulletin@entnet.org INQUIRIES AND SUBMISSIONS bulletin@entnet.org MAILING INFORMATION Postmaster: Send address changes to the American Academy of Otolaryngology-Head and Neck Surgery, 1650 Diagonal Road, Alexandria, VA 22314-2857