March 2019 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

M AR C H 2019

E! QU IZ M

Tips To Prevent Denials From the TPE Program

EARN

BUSINESS CE

CREDITS P.18

P.16

When Diabetes and Cancer Complicate Care P.30

Researcher Discusses New Cranial Remolding Study

WWW.AOPANET.ORG

P.36

TRENDS

UPPER-LIMB O&P

CLINICIANS LEVERAGE NEW TECHNOLOGIES, MATERIALS, AND CONTROL STRATEGIES TO DESIGN ADVANCED PATIENT SOLUTIONS. P.22

This Just In: How CBO Scoring Sealed the Fate of H.R. 4772 in the 115th Congress P.20

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contents

MARCH 2019 | VOL. 68, NO. 3

FEATURES COVER STORY

22 | Trends in Upper-Limb O&P From pattern recognition control to user interfaces to osseointegration and more, advances in upper-limb O&P are equipping patients with more functionality and empowering clinicians to design more patienttailored solutions. Uncover the six trends that are making a powerful impact on upper-limb patient care, leading to more versatile and comfortable devices geared toward a larger swath of O&P consumers.

COLUMNS Reimbursement Page.......................... 16

TPE and the Big Three

The most common denial reasons from the Target, Probe, and Educate program

CE Opportunity to earn CREDITS up to two CE credits by taking the online quiz.

TARGET

TPE

Program PROBE

EDUCATION

Member Spotlight................................ 40 n

PFS Med Inc.

Prosthetics in Motion

By Christine Umbrell

20 | This Just In

Preventing a Rushed Decision

DEPARTMENTS P. 20

Last-minute changes and unexpected CBO scoring led advocates of H.R. 4772 to pull the bill before it came to a vote at the end of the 115th congressional session. The legislation, crafted to clarify the definition of “minimal self-adjustment” for off-the-shelf orthotic devices, will be re-examined as part of AOPA’s legislative strategy for the 116th Congress.

30 | Complicating Conditions Health challenges and comorbidities—on top of limb loss or limb difference—are a problem for many O&P patients. Clinicians can do their research to understand how conditions such as diabetes, cardiac disease, cancer, and even depression may affect their patients, and be prepared to adjust care, offer resources, and lend a compassionate ear.

AOPA Contacts............................................6 How to reach staff

Numbers........................................................ 8

At-a-glance statistics and data

Happenings............................................... 10

Research, updates, and industry news

P. 30

By Christine Umbrell

PRINCIPAL INVESTIGATOR | SPECIAL EDITION

Tiffany Graham, MSPO, CPO, LPO................ 36 Meet the lead investigator on a new study on the effectiveness of repositioning and cranial remolding orthoses for cranial deformation, a study being funded by AOPA and the Center for O&P Learning/Evidence-Based Practice as part of the Orthotics 2020 initiative. 2

MARCH 2019 | O&P ALMANAC

Views From AOPA Leadership......... 4

AOPA Board member Linda M. Wise offers tips on building your brand

People & Places........................................ 14

Transitions in the profession

AOPA News............................................... 44

AOPA meetings, announcements, member benefits, and more

PAC Update...............................................46 Careers........................................................ 48

Professional opportunities

Marketplace............................................. 50 Ad Index....................................................... 52 Calendar...................................................... 54

Upcoming meetings and events

Ask AOPA................................................... 56 Billing for patients in hospice facilities and prisons

PROPRIO FOOT

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% of amputees

have fallen in the last year

% of falls result in injury

with half needing medical attention

% reduction in falls

while using Proprio Foot3

1. Miller, William C., Mark Speechley, and Barry Deathe. “The prevalence and risk factors of falling and fear of falling among lower extremity amputees.” Archives of physical medicine and rehabilitation 82.8 (2001): 1031-1037. 2. Kaufman, K. Risk factors and costs associated with accidental falls among adults with above-knee amputations: a population-based study. American Orthotic and Prosthetic Association 2016.(Mayo Clinic). http://www.aopanet.org/resources/research/ 3. Ludviksdottir A, Gruben K, Gunnsteinsson K, Ingvarsson Th, Nicholls M. Effects on user mobility and safety when changing from a carbon fiber prosthetic foot to a bionic prosthetic foot. Presented at Orthopadie&Reha-Technik Congress, Leipzig, May 2012.

VIEWS FROM AOPA LEADERSHIP

Building Your Brand

ECENTLY I ATTENDED

a seminar at which the keynote speaker opened his presentation by singing his company jingle. Immediately, the majority of the audience joined in with a smile on their face. During the singing, words that came to mind as I thought about this company were convenience, easy to work with, professional, and understanding. None of these words were in the jingle or in the company logo. However, they are words I associated with the speaker’s company brand due to my personal experience with the company and to their ability to keep an emotional connection with me through their various marketing channels. As we go through our daily activities, we run across our own brands every day. We see our logos, our brand colors—the specific fonts and taglines. But when was the last time you stopped to ask yourself what all those elements represent? And, more importantly, what do they represent to your customers? As you plan your marketing strategy, it’s critical to first identify the personality you want your brand to convey. Then you can start building on those personality traits through consistent messaging that elicits the desired feelings and emotions in the consumer. This is the part when you may start to feel overwhelmed. With so many channels being used to gather and deliver information, how do you choose which channels are best suited to build your brand? AOPA feels your pain and is here to help, no matter how big or small your marketing budget. Offering a variety of opportunities, AOPA can help you reach more than 12,000 orthotic and prosthetic professionals each month via various marketing channels including print, email, digital, and events. For example, consider the following: • Get your brand noticed through display ads, via product spotlights, or by highlighting an upcoming event within the print and digital issues of the O&P Almanac magazine or the digital version of O&P News. • Position a leader of your company as an interview or clinical resource for the O&P Almanac and O&P News editorial staff or submit thought leadership articles for their consideration to publish. • Are you struggling to increase the traffic on your website? Place a banner ad on the AOPA website, mobile app, or twice-monthly O&P Almanac email blast, which would link directly to your site. • Finally, there are several event marketing opportunities at the AOPA Policy Forum and the annual AOPA National Assembly that could help boost your brand and professional network.

Specialists in delivering superior treatments and outcomes to patients with limb loss and limb impairment.

Board of Directors OFFICERS President Jim Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO President-Elect Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Vice President Traci Dralle, CFM Fillauer Companies, Chattanooga, TN Immediate Past President Michael Oros, CPO, LPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Treasurer Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics Inc., Exton, PA Executive Director/Secretary Eve Lee, MBA, CAE AOPA, Alexandria, VA DIRECTORS David A. Boone, BSPO, MPH, PhD Orthocare Innovations LLC, Edmonds, WA J. Douglas Call, CP Virginia Prosthetics & Orthotics Inc., Roanoke, VA Mitchell Dobson, CPO, FAAOP Hanger Clinic, Grain Valley, MO Elizabeth Ginzel, MHA, CPO NovaCare P&O, Fort Worth, TX Kimberly Hanson, CPRH Ottobock, Austin, TX

Regardless of the marketing channels you choose to increase your company’s brand awareness, consistency is essential to building and maintaining an emotional connection with your customers where they don’t just know your brand—they feel your brand as well.

Teri Kuffel, JD Arise Orthotics & Prosthetics Inc., Spring Lake Park, MN

Linda M. Wise is a member of AOPA’s Board of Directors.

Linda M. Wise WillowWood, Mount Sterling, OH

MARCH 2019 | O&P ALMANAC

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AOPA CONTACTS

American Orthotic & Prosthetic Association (AOPA) 330 John Carlyle St., Ste. 200, Alexandria, VA 22314 AOPA Main Number: 571/431-0876 AOPA Fax: 571/431-0899 www.AOPAnet.org

Publisher Eve Lee, MBA, CAE Editorial Management Content Communicators LLC Advertising Sales RH Media LLC

Our Mission Statement Through advocacy, research, and education, AOPA improves patient access to quality orthotic and prosthetic care.

Printing Sheridan

EXECUTIVE OFFICES

REIMBURSEMENT SERVICES

SUBSCRIBE O&P Almanac (ISSN: 1061-4621) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/431-0899, or email ymazur@AOPAnet.org. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices.

Eve Lee, MBA, CAE, executive director, 571/431-0807, elee@AOPAnet.org

Joe McTernan, director of coding and reimbursement services, education, and programming, 571/431-0811, jmcternan@AOPAnet.org

ADDRESS CHANGES POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314.

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@AOPAnet.org

Copyright © 2019 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.

Our Core Objectives AOPA has three core objectives—Protect, Promote, and Provide. These core objectives establish the foundation of the strategic business plan. AOPA encourages members to participate with our efforts to ensure these objectives are met.

Tina Carlson, CMP, chief operating officer, 571/431-0808, tcarlson@AOPAnet.org MEMBERSHIP & MEETINGS Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, kelly.oneill@AOPAnet.org Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org Yelena Mazur, communications specialist, 571/431-0835, ymazur@AOPAnet.org Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0836, rgleeson@AOPAnet.org Kristen Bean, membership and meetings coordinator, 571/431-0876, kbean@AOPAnet.org AOPA Bookstore: 571/431-0876

SPECIAL PROJECTS Ashlie White, MA, director of strategic alliances, 571/431-0812, awhite@AOPAnet.org O&P ALMANAC Eve Lee, MBA, CAE, executive director, 571/431-0807, elee@AOPAnet.org Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com Catherine Marinoff, art director, 786/252-1667, catherine@marinoffdesign.com Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net

Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com

Design & Production Marinoff Design LLC

MARCH 2019 | O&P ALMANAC

Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

Advertise With Us! Reach out to AOPA’s membership and more than 11,400 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac19 for advertising options!

For whatever comes .

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NUMBERS

Uninsured On the Rise Nearly 14 percent of U.S. adults did not have health insurance in the fourth quarter of 2018

UNINSURED RATE OF ADULTS BY AGE IN 4Q18

21.6 Percent

13.7 Percent

3.7 Percent

Ages 18-34, compared to 16.8 percent two years earlier.

Ages 35-64, compared to 11.0 percent two years earlier.

Ages 65 and older, compared to 2.3 percent two years earlier.

HEALTH-CARE HABITS AMONG UNINSURED

50 Percent

20 Percent

Percentage who have “no usual source of care.”

Percentage who went without needed care due to cost.

24 Percent

19 Percent

Percentage who have postponed care due to cost.

Percentage who postponed or did not get a needed prescription drug due to cost.

Percentage of Uninsured U.S. Adults, By Annual Household Income Annual Household Income Under $24,000

Q4 2016

Q4 2018

22.6%

25.4%

$24,000-$47,999 16.1% 19.1% $48,000-$89,999 7.8% 9.1% $90,000-$119,999 3.2% 5.9% $120,000 or higher

2.4%

SOURCE: “U.S. Uninsured Rate Rises to Four-Year High,” Gallup, January 2019

MARCH 2019 | O&P ALMANAC

3.6%

“Providers incur billions in the cost of uncompensated care for the uninsured, not all of which is offset by funding to defray these costs.” —“The Uninsured and the ACA: A Primer,” Kaiser Family Foundation, January 2019

SOURCES: “U.S. Uninsured Rate Rises to Four-Year High,” Gallup, January 2019; “The Uninsured and the ACA: A Primer,” Kaiser Family Foundation, January 2019.

O&P facilities may experience an uptick in patients without health insurance this year. The uninsured rate rose to 13.7 percent in the fourth quarter of 2018, with 14.5 percent of adult males and 12.8 percent of adult females lacking coverage. This is the highest rate of uninsured since the first quarter of 2014; the rate has risen steadily since 2016, according to new reports from Gallup and the Kaiser Family Foundation.

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Happenings RESEARCH ROUNDUP

Study Shows Possibility for Regeneration of Joint Structures in Mammals

Lower-Limb Amputation Rates Decline in Germany The number of lower-limb amputations declined by 11.1 percent in Germany over the 10-year period between 2005 and 2015, according to a new study published in BMC Health Services Research in January. Recognizing that lower-limb amputation levels were relatively high in Germany compared to neighboring countries, researchers studied national discharge data in Germany to analyze trends over time and to study outcomes of care concerning in-hospital mortality and reamputation rates during same hospital stays. While lower-limb amputation rates declined for both sexes, the numbers for female amputees showed significantly greater improvement: 10

MARCH 2019 | O&P ALMANAC

Men showed a relative decrease of 2.6 percent in amputations over the study period while women showed a relative decrease of 25.0 percent. In studying trends by amputation level, the researchers found that hip joint/ femoral amputations decreased significantly (26.8 percent of all amputations in 2005 compared to 17.3 percent in 2015), and knee/lower leg amputations also declined (16.7 percent in 2005 compared to 11.5 in 2015). Despite the overall decline, amputations of toes and feet increased 12.8 percent during the 10-year period, according to the researchers. The percentage of reamputations during the same hospital stay fell from 13.2 percent to 10.2 percent.

The researchers also found that the in-hospital mortality rate of all cases involving lower-limb amputation fell from 11.2 percent to 7.7 percent. Other changes over time included a decrease in the number of hospitals providing amputation surgery and a decrease in average length of stay, from 30.6 days to 24.0 days. The overall decline in lower-limb amputations can be attributed to improvements in perioperative health care in Germany, the researchers concluded. “Despite the indications for improvements, the distinct increase in case numbers at the level of toe/ foot ray calls for additional targeted prevention efforts, especially for patients with diabetes,” they said.

PHOTOS: Texas A&M University, College of Veterinary Medicine & Biomedical Sciences

Texas A&M University researchers have devised has been regained in some animals,” he said. a method to stimulate joint regeneration “There’s good evidence that there is selecfollowing injury in mice, using a combination of tive pressure to gain or lose generation.” growth factors called bone morphogenetic proMuneoka’s new research has significance tein BMP-2 and BMP-9. Led by Ken Muneoka, for individuals with joint injuries and PhD, at Texas A&M’s College of Veterinary diseases. “Joints and joint tissues don’t Medicine & Biomedical Sciences (CVM), this regenerate, nor does articular cartilage, Regenerated digit joint research builds on a previous study showing which forms at the ends of your bones that the treatment of digit amputation wounds (MicroCT and section) and buffers the stress that we experience in mice with BMP-2 promotes elongation of the stump bone. on a day-to-day basis. Joint injuries, sports injuries, or With the new research, Muneoka’s team found that BMP-9 diseases like osteoarthritis are really debilitating. I think stimulates the formation of joint structures comprising a they are the biggest cause of disability in the world,” he said. synovial cavity and a skeletal element lined with articular “The question of how you can replace articular cartilage cartilage. Treating a mouse’s wound with BMP-2, followed is in the backdrop of what we’ve been working on, which by BMP-9, leads to the formation of bone and joint cells. is what we’re able to regenerate in the process. It really The research provides evidence that cells in a mammalian demonstrates that these cells have the ability to replace amputation retain the capacity and information for joint themselves, and we just haven’t figured out how to do that.” regeneration, according to Muneoka. He has been working The work of Muneoka and his team suggests that it is on similar studies for the past nine years, all relating to the possible to regenerate portions of a joint in an animal and “question of why some animals regenerate and some can’t. For recapitulate that structure, according to Larry Suva, PhD, head example, salamanders regenerate wonderfully, but mammals, of CVM’s Department of Veterinary Physiology & Medicine. for reasons we don’t understand, don’t regenerate at all. There’s The latest study was published in the February 5 edition of this basic idea that regeneration is really ancient property that Nature Communications. The next step in the research will be evolved very early and then disappeared in some animals and exploring the engineering of an articular cartilage.

HAPPENINGS

Amputees May Retain Detailed Neural 'Picture' of Missing Limbs

COOL CAREERS

Similar representation in primary somatosensory cortex (SI) for amputees’ missing hand and controls’ nondominant hand, but not for congenital onehanders’ missing hand.

O&P Makes U.S. News ‘Best Jobs’ List

A multi-international team of scientists has been able to detect the neural “fingerprints” of a missing hand decades after amputation. The scientists, affiliated with universities in the United Kingdom, Canada, and Italy, conducted a study that revealed detailed hand information in the brains of amputees compared with individuals with congenital hand loss. The researchers used a braindecoding technique based on the pattern of brain activity in 18 amputees who had lost their hand, on average, 18 years previously. The subjects experienced a wide range of phantom sensations—from almost none to a significant amount. The research team also studied 13 individuals who were missing a hand from birth so they could examine whether development of the hand’s neural fingerprints requires some prior experience of having a hand. Study participants in all groups were placed in magnetic resonance imaging scanners and were asked to “move” the fingers of their missing and intact hands. The researchers compared the results to those of two-handed participants. Amputees who had the strongest phantom sensations of being able to move each of their phantom fingers retained the clearest information of their missing hand in their brain, according

to the researchers. Significantly, those amputees who did not experience much phantom hand sensation also had the same information preserved in their brains. By contrast, those with congenital hand loss showed some brain activity during phantom limb movement but did not have the same neural fingerprint correlating to their missing hand. The findings indicate it may be more challenging to design neuroprosthetics for individuals with congenital limb loss compared to individuals with amputation, according to the researchers. “We’ve shown that once the hand ‘picture’ in the brain is formed, it is generally unlikely to change, despite years of amputation and irrespective of the vividness of phantom sensations,” said senior author Tamar Makin, PhD, associate professor and Sir Henry Dale Fellow at the University College London Institute of Cognitive Neuroscience. “Our work suggests that daily life experience could shape the fine-grained aspects of hand representation, but that the largescale functional organization of the hand area is fundamentally stable.” The study, “Obtaining and Maintaining Cortical Hand Representation As Evidenced From Acquired and Congenital Handlessness,” was published in eLife in February.

The job of “orthotist/prosthetist” ranked Number 47 on the latest U.S. News “Top 100 Jobs” rankings, published in January. The U.S. Bureau of Labor Statistics projects 22.2 percent employment growth for O&P professionals between 2016 and 2026. An estimated 1,700 jobs should become available during this time period.

NUMBER

U.S. News also ranked the orthotist/ prosthetist job

NUMBER 5 on its list of “Best Health-Care Support Jobs.”

O&P ALMANAC | MARCH 2019

HAPPENINGS

FAST FACT

U.S. Health Spending On the Rise

DIABETES DOWNLOAD

Senior Diabetic Patients Found To Be Frequent Visitors to Emergency Rooms

Health spending in the United States is expected to grow from $3.6 trillion in 2018 to

$6.0 trillion by 2027,

according to a new report from CMS actuaries. The 5.5 percent growth in spending annually over the next eight years will be driven by an aging baby boomer population enrolling in Medicare, income growth, and the rising costs of medical goods and services, according to the projections. SOURCE: “National Health Expenditure Projections 2018-2027: Forecast Summary,” CMS

Older adults visit emergency departments (EDs) more often than other age groups, according to new research from the American College of Emergency Physicians. Among “geriatric frequent users” of EDs, diabetes is the most common condition (26 percent), followed by chronic pulmonary disease (22 percent), kidney disease (19 percent), congestive heart failure (16 percent), and peripheral vascular disease (15 percent). Researchers, led by Edward M. Castillo, PhD, MPH, associate adjunct professor in the Department of Emergency Medicine at the University of California—San Diego, conducted a multicenter retrospective cohort

study using data from 326 licensed, nonfederal California hospitals. The geriatric patients included in the study were aged 65 or older and had at least one visit to the ED in 2014. “Frequent users” had visited the ED at least six times over a 12-month period. Geriatric frequent users are more likely to have been admitted/ transferred (86 percent) or to discontinue care (8 percent) than less frequent users (45 percent and 2 percent, respectively). Frequent users are more likely to have comorbid conditions, and 20 percent of geriatric patients visit three or more hospitals in the year. “Efforts to improve care for vulnerable older Americans should focus on enhancing delivery and decreasing utilization,” said Castillo. “Older patients are more likely to have multiple chronic conditions, which makes emergency care increasingly complex. A better understanding of older patients opens the door for interventions in and beyond the emergency department.”

DISABILITY DOLLS

Mattel To Introduce Prosthesis-Wearing Barbie

MARCH 2019 | O&P ALMANAC

The Barbie Fashionistas line, which will hit the market in June, will feature several new dolls, including two with disabilities. A doll with a removable prosthetic leg and a doll with a wheelchair are among the new products. “As a brand, we can elevate the conversation around physical disabilities by including them into our fashion doll line to further showcase a multidimensional view of beauty and fashion,” said Mattel in a press release. The wheelchair doll will have an articulated body so she can easily sit the chair.

HAPPENINGS

NATIONAL ASSEMBLY NEWS

Last Call for Papers—March 25

Submissions for papers to be presented during the 2019 AOPA National Assembly are due March 25, 2019. AOPA is seeking submissions for the clinical free paper sessions, symposia/instructional courses, the technician program, and the business education program at the conference, which will take place Sept. 25-28, 2019, in San Diego, California.

All free paper abstracts must be submitted electronically. All abstracts will be considered for both podium and poster presentations. The review committee will grade each submission via a blind review process and reach a decision regarding acceptance of abstracts. Contact AOPA Headquarters at 571/431-0876 or rgleeson@AOPAnet.org with questions about the submission process or the AOPA National Assembly in general. Visit the AOPA website for more information and to see full submission guidelines for the 2019 AOPA National Assembly.

TECH TALK

Prosthetic Emoji Now Available The Unicode Consortium has released a new roster of emoji that Apple, Google, and other tech vendors are making available on consumers’ smartphones, tablets, and computers. Among several new emoji that offer representation of people with disabilities are two of special interest to amputees: a prosthetic arm and a prosthetic leg.

O&P ADVOCACY

April Marks Limb Loss Awareness Month Each April, the Amputee Coalition celebrates Limb Loss Awareness Month, providing an opportunity to educate elected officials and the general public about the issues affecting and improve outcomes for the limb loss community. This year, the Amputee Coalition is seeking recognition from every state’s governor acknowledging Limb Loss Awareness Month through a formal proclamation. O&P patients, clinicians, and other stakeholders are encouraged to submit a proclamation request to their governor, encouraging him or her to recognize April Limb Loss Awareness Month.

April Is Limb Loss Awareness Month

For more information on how to submit a proclamation request, visit the Advocacy and Awareness #AmplifyYourself page on the Amputee Coalition’s website. The Amputee Coalition will host its annual Hill Day on April 8-9. Members and advocates will meet with elected officials to educate and bring attention to the limb loss community. © 2018 Amputee Coalition™

amputee-coalition.org | 888.267.5669

O&P ALMANAC | MARCH 2019

PEOPLE & PLACES PROFESSIONALS ANNOUNCEMENTS AND TRANSITIONS

Paul Leimkuehler, CPO, LPO, has joined the staff of Leimkuehler Orthotic & Prosthetic Center. Leimkuehler studied at Northwestern University’s Feinberg School of Medicine and received his orthotics Paul Leimkuehler, certification in 2011 and prosthetics certifiCPO, LPO cation in 2012. He specializes in upper- and lower-extremity prostheses; running-style prostheses; and elevated vacuum designs and subischial sockets. Prior to rejoining the family business, Leimkuehler was clinical director at Physio O&P in Milwaukee, Wisconsin. Jack Richmond, CPOA, will retire from his role as president/chief executive officer (CEO) of the Amputee Coalition. He will remain in his position for the next several months and work actively with the organizaJack Richmond, tion’s Board of Directors during the search CPOA for his successor. “I am extremely proud of what the Amputee Coalition has accomplished over the past few years in my role as the president/CEO and working together with our volunteers, board members, and staff,” he said. “We are stronger than ever, and more than ever before are poised to reach out to help more people impacted by limb loss and limb differences.”

BUSINESSES ANNOUNCEMENTS AND TRANSITIONS

The American Academy of Orthotists and Prothetists (AAOP) has announced it will continue as a corporate-level sponsor for OPAF & The First Clinics and is enhancing the relationship with added benefits. OPAF First Clinics are now included on the AAOP calendar with links and further information. Additionally, AAOP has designated its members who are volunteers or sponsors of the First organization as Academy Heroes. “The Academy and its members are pleased to continue to support the outstanding programs that OPAF provides in the profession,” said AAOP Executive Director Chellie Blondes.

MARCH 2019 | O&P ALMANAC

Hanger Inc. has announced it has become the first full-service U.S.based O&P provider to acquire the HP Multi Jet Fusion 3-D printing technology. Both companies will work closely to determine best uses for the 3-D printing manufacturing technology in current processes and to explore new disruptive designs and solutions, according to Hanger. “We believe 3-D printing and automation will be important in the future of O&P, and we’re dedicating resources and talent to exploring these new possibilities,” said Hanger President and Chief Executive Officer Vinit Asar. Hanger Inc. plans to leverage advanced 3-D printing technology to validate testing of existing O&P devices that could be produced with 3-D printing and test new designs made possible through the technology. Össur and Kinneir Dufort (KD) have been honored with a 2019 iF Design Award in the competition’s “Medicine/Health” category. The award recognizes Össur’s RHEO KNEE® XC, an advanced prosthesis that features a weatherproof design cover created by KD. The competition received more than 6,400 entries submitted from 50 countries. “It is an honor to receive an iF Design Award along with KD for our RHEO KNEE XC, which is a wonderful affirmation of our dedication to our mission and acknowledgment of an important technology that has helped countless amputees around the world,” said Össur President and Chief Executive Officer Jon Sigurdsson.

THE LIGHTER SIDE

Getting You Back to What Matters

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REIMBURSEMENT PAGE

By DEVON BERNARD

E! QU IZ M

TPE and the Big Three

EARN

Breaking down the top three denial reasons identified in the Target, Probe, and Educate program

Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 18 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

CREDITS

TARGET

TPE

Program PROBE

ORIDIAN, THE DURABLE MEDICAL EQUIPMENT Medicare

administrative contractor (DME MAC) for Jurisdictions A and D, has published the results of its Target, Probe, and Educate (TPE) audits for the period spanning July 2018 to September 2018. The audits focused primarily on orthotic claims—specifically, ankle-foot orthosis/ knee-ankle-foot orthosis, knee orthosis, and lumbosacral orthosis/thoracolumbosacral orthosis claims. The results were mixed. Some audits showed an increase in potential improper payment rates, and others showed a decrease over previous results. The potential improper payment rates ranged from as low as 25 percent to as high as 79 percent. This month’s Reimbursement Page reviews the top three denial reasons that appear to be consistent across all of the TPE audits but are not policy-specific.

TPE Program Review EDUCATION

MARCH 2019 | O&P ALMANAC

Let’s start with a quick recap of the TPE program, which was introduced as a way to reduce the current backlog of appeals by reducing claim denials and educating suppliers and providers. The program focuses its audit efforts on only a select set of high-risk claims and providers/ suppliers and encourages resolution of appeals earlier in the process. The TPE program consists of potentially three rounds of prepayment reviews, and each round involves between 20 and 40 claims. If the results of the first round of reviews are deemed acceptable, the provider/ supplier receives a notice that it will be removed from the audit pool for

BUSINESS CE

CREDITS P.18

a period of one year. If the results are not acceptable, the provider/supplier will be scheduled for a personalized education session with the appropriate DME MAC claims review department. This session will focus on common errors and strategies to improve the error rates. After the personalized education session is complete, a second round of prepayment reviews will take place, about six to eight weeks after the first education session. If the results are still not acceptable after the second round of reviews and subsequent education sessions, a third round may take place. During each round of prepayment review, providers can be removed from the audit pool if their results are considered acceptable. However, if after three rounds a supplier still has a high error rate, that supplier may be referred to CMS for additional action.

DENIAL REASON 1: Invalid, Incomplete, or Missing DWO

To be considered a valid detailed written order (DWO), an individual who is approved by Medicare to order items or services must sign the order itself. While a supplier may create the DWO, it is imperative that an approved individual sign it. Medical doctors (MDs) and doctors of osteopathic medicine (DOs) qualify as “approved individuals,” but so do nurse practitioners and physician assistants—if certain criteria are met. A nurse practitioner, a clinical nurse specialist, or most other individuals with advanced nursing degrees are eligible to sign a DWO if the following criteria are met:

REIMBURSEMENT PAGE

• The nurse practitioner is the individual treating the beneficiary, responsible for their care. • He or she is not practicing under a physician but is practicing independently. • He or she has his or her own National Provider Identifier (NPI) number. • He or she bills Medicare for other covered services or items. • He or she is authorized to practice in the state. A physician assistant is eligible to sign a DWO if the following criteria are met: • The physician assistant is treating the patient for the condition for which the item was ordered. • He or she is working under the direct supervision of an MD or DO. • He or she has his or her own NPI number. • He or she is eligible to practice in the state. It’s also important to verify that the nurse practitioner or physician assistant is an eligible provider to order and refer orthotics and prosthetics by checking his or her status in the CMS enrollment database. The DWO is only considered valid if it contains the beneficiary’s name and an order date/date of the order/signature date. The date of the order will be the same as the date on the initial order, and this may be separate from the signature date. If the physician, nurse practitioner, physician assistant, or other authorized individual writes the DWO, then only the order date is required to be present. In this case, the order date may be the date that the authorized individual signed the DWO. If the supplier creates the DWO, then it must be signed and dated by the ordering physician, nurse practitioner, physician assistant, or other authorized individual. In this scenario, two dates are required: an order date and a prescriber-entered signature date. The DWO also must contain the signature and name of the authorized individual who ordered the item. In addition, a valid DWO must contain a detailed description of the items/services being provided, including

New Rule From the SDR The Standard Documentation Requirements (SDR) article has recently been revised, and new information about the use of delivery services has been posted: The SDR has removed the option of using a postage-paid delivery invoice—a self-addressed stamped envelope where the patient returns a signed proof of delivery and that becomes your delivery date.

quantities and any supplies that may be replaced on a regular basis (including an estimated schedule of when they will be replaced). This description may be accomplished in one of four ways: • List the name, manufacturer, and model number of the item(s) you are providing; • Provide a narrative description of the item(s) you are providing; • List all of the Health-Care Common Procedure Coding System (HCPCS) codes and their descriptors; or • List just the HCPCS codes. The DWO must be completed and on file before you submit your claim to Medicare for payment, but it’s good to understand when a new DWO may be required. A new DWO is not required when you are providing or replacing minor components or supplies but is required when providing a full replacement or replacement of major components. In addition, a new order is not required for repairs and adjustments as these are covered under the original order for the lifetime of the item. But if you were not the original biller, then you will want to obtain a new order for the repairs and adjustments—unless you have obtained a valid copy of the original order from the original supplier.

DENIAL REASON 2: No Response to ADRs

When you are a subject of a TPE review, you will be sent an additional documentation request (ADR), and you will be given 45 days to respond to that ADR. This is 45 days from the date listed on the ADR letter and not the date you receive the letter. If you don’t respond within that 45-day timeframe, you will receive an automatic denial for the claim(s) under review and may be subject to other unintended consequences. To ensure you are receiving and responding to ADR requests in the allotted amount of time, start by verifying your mailing addresses. First, check your correspondence address as listed on your Medicare application to be sure it matches your existing location’s address. If the addresses don’t match, update the address with Medicare. If you have multiple locations, including satellite offices you may not use or visit on a routine basis, make sure those addresses are correct as well—and consider changing the Medicare correspondence address, on your applications, for those satellite offices to the address of your main office so all Medicare correspondence goes to one central location. O&P ALMANAC | MARCH 2019

REIMBURSEMENT PAGE

Implement procedures or protocols outlining who is responsible for opening, sorting, and delivering the mail. This person should be able to identify ADR requests and pass them along to the appropriate individuals. In addition, designate at least one person in charge of collecting all of the information requested by the ADR and responding to the ADR; this will eliminate any duplicate work and will ensure that the ADR is not forgotten. Once all of the requested documentation is assembled, but sure to submit it on time. Failure to submit is an automatic denial, but that’s not all. The DME MAC could report you to the National Supplier Clearinghouse (NSC) for violation of the Supplier Standards, primarily Standard 28, which requires you to keep all ordering and referring documentation on file, and Standard 21, which provides to CMS, upon request, any information required by the Medicare statute and implementing regulations. If referred to NSC, NSC could conduct a review and then suspend or revoke your billing privileges for violating either of those standards.

Failure to submit is an automatic denial, but that’s not all. The DME MAC could report you to the NSC for violation of the Supplier Standards. ... [The] NSC could conduct a review and then suspend or revoke your billing privileges for violating those standards.

MARCH 2019 | O&P ALMANAC

DENIAL REASON 3: Missing Verification That the Item Was Lost, Stolen, or Irreparably Damaged Medicare will typically cover the cost of a replacement (an entirely identical or nearly identical) item or device under two established guidelines: • If the original brace or prosthesis has been lost or stolen, or • If the original item is irreparably damaged, damage not caused by normal everyday wear and tear.

In these two instances, Medicare would cover a replacement item. In addition, under some instances Medicare could cover a replacement if the patient has had a documented change in condition. We will examine the first two scenarios, as these have been a focus of some the TPE denials. According to the Standard Documentation Requirements (SDR) article, the DME MACs can request to see documentation verifying the reason for a denial, and in most cases the information is missing. When replacing an item, be sure you have documented that the item was lost or stolen. For example, include copies of insurance claims and/ or police reports if the item was stolen. You also may include a statement from the patient or the facility/hospital if the item was lost during an inpatient stay. If replacing the item due to damage, document the exact event that caused the damage and show that it was not caused by “normal” wear and tear—that

it was irreparably damaged in a specific incident. This documentation could be a narrative in your records or a statement from the patient, and in such an instance a picture truly is worth 1,000 words. You also may want to consider a statement as to why the item cannot be repaired. Remember to seek verification that the item is still medically necessary and is still needed and being used by the patient. In this case, because the item is being replaced, a new DWO would be in order—which would help establish the continuing medical use and need.

Preventing Denials

The three reasons for denials outlined above are not all of the reasons why a claim may have failed a TPE audit, but these are all reasons over which you have control. Take a hard look at how you’re currently conducting business and determine whether it’s time to make changes to your documentation practices. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@AOPAnet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:

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This Just In

Preventing a Rushed Decision Why the 115th Congress adjourned with no final action on H.R. 4772

OWARD THE END OF the 115th

congressional session, the focus of AOPA’s legislative actions was primarily on H.R. 4772, legislation that would have clarified the definition of “minimal self-adjustment” for off-the-shelf (OTS) orthotic devices. Many AOPA members advocated for this bill by making calls, visiting the Hill, and writing letters in support of the legislation. While the saying, “We were so close,” still sounds like failure, the story of how close we came and AOPA’s decision to pull the bill is an important one. On the positive side, our sponsors/co-sponsors

H.R. 4772

Code Concerns

The Congressional Budget Office proposed cutting the fee schedule by 35 percent for more than 50 codes that are currently considered off-the-shelf by CMS: L0120

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MARCH 2019 | O&P ALMANAC

and their staff understand this issue and support our efforts. It was clear from the flurry of activity right at the end that we have some educated individuals in Congress who will be willing to help us moving forward. Ultimately, the decision to pull H.R. 4772 came down to the simple fact that the bill that would have been presented for a vote on the floor was not the bill for which our members had been advocating. AOPA also did not have time to do a thorough analysis of the impact that the bill would ultimately have had on our profession. Late on the evening of December 19, the night before the bill was scheduled to be taken to the floor for a vote, the Congressional Budget Office (CBO) scored the bill with a price tag that surprised us all. The offset proposed by CBO would cut the fee schedule by 35 percent for more than 50 codes that are currently considered to be OTS by CMS. (See the sidebar for a list of the codes that would have been affected.) AOPA called an emergency Executive Committee meeting to discuss the potential fallout from allowing this bill to go to the floor. With only hours until the bill would be presented for a vote, AOPA did not have time to consult its sister organizations or patient groups to assess the potential damage a reduction of this magnitude to the fee schedule could cause.

This Just In

Additionally, a sentence was added to the end of the code set identified in the bill that read: “and as subsequently modified by the Secretary.” This addition did not sit well with AOPA’s counsel, staff, or Executive Committee. AOPA had received previous reports from CBO suggesting that the provision would be budget-neutral. AOPA is investigating the nature of the reversal and its causes. The fact that CBO ultimately scored this provision with such a hefty price tag is a fact that AOPA will undoubtedly have to address in our legislative strategy moving forward. Another factor that led to AOPA’s decision to pull the bill was the unfortunate potential of burning bridges with the Democrats who have championed this cause for AOPA. Because the action was being driven by our Republican sponsors, and due to the late addition of the offset, there was not enough time to circle back around with the Democrats to inform them of the change or secure their support. AOPA received indications from our

AOPA Sets Date for 2019 Policy Forum O&P stakeholders are making plans now to take part in the 2019 Policy Forum May 7-8 in Washington, D.C., where the fate of H.R. 4772 and many other legislative issues will be discussed. AOPA members also will advocate on behalf of O&P issues during one-on-one meetings with their legislators and staff. Register today for the 2019 Policy Forum at bit.ly/policyforum2019. lobby team that Democrats were not happy with the changes to the bill, or the fact they had been kept out of the loop during the process. AOPA is proud to push a legislative agenda that is supported by both sides of the aisle. Our political capital in both houses and with both parties is important, and knowing that we could lose favor also factored into our final decision. AOPA’s leadership and lobby team have followed up with our champions and explained the nature of our situation and ultimate position. We

have received supportive feedback from the staffers with whom we have been working, and they have expressed a clear willingness to work with us again in 2019. Our lobby team also has advised us that we saved many relationships with the Democrats by not forcing this bill through during the 115th Congress. We certainly have our work cut out for us, but our goals remain the same. Strategy meetings are underway with our lobby team and leadership to carefully craft our legislative strategy for the 116th Congress.

O&P ALMANAC | MARCH 2019

COVER STORY

TRENDS in

O&P

Upper-Limb

Six trends demonstrate the growth in options for

upper-limb patients, enabling clinicians to offer more technologically advanced and customized solutions By CHRISTINE UMBRELL

MARCH 2019 | O&P ALMANAC

COVER STORY

Need To Know • Rapid growth in upper-limb prosthetic technology has led to the development of new devices, designs, control strategies, and materials, offering more options for clinicians who focus on the upper-limb patient population.

• Advances in pattern recognition control allow for more intuitive prosthetic control for upper-limb patients. A new clinical study indicates that not only traumatic amputees, but congenital amputees as well, may benefit from this technology.

• Remote access of computers and systems via video conferencing and similar methodologies now allow for remote programming of externally powered prostheses, a useful tool offering clinicians greater access to patients to diagnose prosthesis issues.

• Osseointegration for upper-limb amputees is in its early stages, but successful implants have been documented overseas. The field is moving toward making the technology available to patients in the United States.

• Many newer upper-limb prosthetic designs allow for increased user adjustability, and some manufacturers have developed apps that enable patients to make their own adjustments—within a well-controlled range of adjustability and under the guidance of prosthetists.

• With improvements in technologies have come improvements in materials, such as advanced silicones and high-consistency rubber. Implantable myoelectric sensors also represent a significant technology leap.

ECENT ADVANCES IN MATERIALS,

technologies, control strategies, implants, and sensors are among the latest trends propelling upper-limb patient care forward. Historically, advances in upper-limb technologies have lagged slightly behind their lower-limb counterparts—which is not surprising, given the percentage of U.S. upper-limb amputees (35 percent) compared to lower-limb amputees (65 percent), according to the Amputee Coalition. But a significant evolution is occurring. “It’s an exciting time,” says Tim Russo, CPO, LPO, a clinician with upper-limb experience at Scheck & Siress in Oak Park, Illinois. Most of his patients are happy to learn about recent advances. “Even if an individual faces difficulty in obtaining higher-end componentry, they are excited to hear that energy is being committed to developing such devices, as this is a lifelong journey for them.” “It’s pretty amazing to see this rapid growth of upper-limb prosthetic technology,” says Branden Petersen,

Tim Russo, CPO, LPO CP, LP, an upper-limb specialist for Hanger Clinic’s Upper-Limb Program. He notes that there have been many “amazing innovations in upper-limb prosthetics that have skyrocketed just since about 2007.” Today’s clinicians are drawing from an expanding pool of resources to create more tailored and effective O&P design solutions. From pattern recognition control to osseointegration to apps and more, the following is a sampling of the trends that are making a positive impact on outcomes for the upper-limb patient population. O&P ALMANAC | MARCH 2019

COVER STORY

TREND

Advances in technologies such as videoconferencing and similar conferencing methods have opened the door to remote access of computers and systems. These innovations often mean that clinicians gain greater access to their patients, to the benefit of the upper-limb patient population. “Externally powered prostheses are microprocessor-controlled components with Bluetooth or radiofrequency login capabilities,” explains Petersen. “Since these components are microprocessorenabled, that has given us the capability to remotely connect to various components—with the patient’s participation and permission.” Remote access can be an especially useful tool for clinicians who specialize in upper-limb prosthetics because they tend to cover large territories. For example, when patients arrive at Hanger Clinic locations needing adjustments to their terminal device microprocessor, “I can be hundreds of miles away and still assess what problem they are experiencing with their prosthesis by visually evaluating the software connected to the component,” Petersen says. “With remote login, I can see battery life, configuration of components, component failure, wiring issues, and lack of electrode skin contact by how the EMG [electromyography] appears on the screen; co-contraction of muscles affecting prosthesis function; as well as a myriad of other diagnostics.” The ability to remotely evaluate the functionality of the prosthesis and quickly diagnose prosthesis issues “gets these patients back to their daily lives and activities more quickly.”

MARCH 2019 | O&P ALMANAC

Branden Petersen, CP, LP

Increased User Adjustability

TREND

Another important trend affecting upper-limb patients is increased user adjustability of devices, especially prostheses. With upper-limb devices, “there are absolute limits in any prosthesis we make,” says Russo. Traditionally, “broad-function designs are really challenging because there are some activities for which the device will always fall short—in contrast to specific-function devices, of which I can ensure intended function before the patient leaves my office,” he says. But recently, “manufacturers and researchers are doing a better job of providing us with prostheses that have multifunctional abilities that allow for versatility,” Russo says. For example, he points to devices that offer several grasp patterns where “a component may have increased modularity, allowing for improved function in an unpredictable environment.” In addition, some manufacturers have developed apps that can be used not only by clinicians but also by patients, allowing users to make their own adjustments in specific circumstances. “It’s challenging to predict what a patient will need to do during a given day,” Russo says. “New devices that are adjustable on the fly” enable patients to make changes via app, within a well-controlled range of adjustability. “Being able to communicate with a prosthesis using a graphic user

interface has proven to be a powerful tool to optimize an individual patient’s prosthesis,” adds Petersen. In the past, patients were required to visit a prosthetic clinic, where a hard-wired connection was plugged into their prosthesis for programming. But now, “many component manufacturers have switched to Bluetooth or radiofrequency connections to log in to various upper-limb components,” he explains. “Many of the manufacturers have created specific apps just for patients to log in to their prosthesis,” says Petersen. “There is definitely some excitement from patients for the freedom to customize their own prosthesis settings” when the situation warrants it, under advice from their clinicians. “In the future, as upper-limb prosthetic devices continue to become more complex and, as a society, we continue to advance technology, I believe we will see user login capabilities become mainstream features for all prosthetic systems,” Petersen concludes. “These are powerful tools that empower our patients.”

Advances in Pattern Recognition Control for Amputees—and Congenital Patients

Pattern recognition control, a control scheme for upperlimb prostheses, has gained widespread clinical acceptance as a way to provide high levels of functionality for some transradial and transhumeral amputees when paired with externally powered prostheses. Pattern recognition control strategies are advancing and “seem to be paving the way to a more intuitive prosthetic control for upper-limb patients,” according to Petersen. Pattern recognition utilizes a surface-mounted electrode array that encompasses the residual limb skin and captures data on the patient’s residual limb muscle contractions. “Muscle contractions produce a myriad of unique characteristics that are decoded by the pattern recognition system,” Petersen says. “Being

TREND

Remote Programming of Externally Powered Prostheses

COVER STORY

able to break examined the users’ down, decode, and calibration accuracy— analyze this EMG to determine whether information into they made distinct usable data allows enough contractions for more complete for the software to and comprehendifferentiate—and sive control of a their targeted achieveprosthesis. ment control scores. “The exciting The subjects did well part about pattern generating distinct recognition is that muscle contractions Brian Kaluf, BSE, CP, the patient trains and achieving pattern FAAOP the prosthesis to recognition calibrations work how they for control of multiRecently, several upper-limb want it to and does not have to rely on degree-of-freedom prostheses. The patients have received implants specific system parameters like we see study ultimately demonstrated that the overseas, indicating the science is in older, traditional two-site control subjects were able to control a prosbeginning to progress to the point systems,” he says. “In the future, I see thesis using their congenital residual where it may become an option for pattern recognition coupled with other limb with comparable accuracy and Americans in the near future. technologies to greatly improve prosproficiency as achieved using their own Last year, for example, surgeons in thetic outcomes.” sound limbs. Individuals with congenAustria performed the first singleAnd positive outcomes may be ital limb loss “do have muscle control operation osseointegration procedure more widespread than previously and contractions in their residual limb,” to implant a metal rod into the bone thought. While past evidence-based explains Kaluf, “and they can reliably of a patient’s arm to install a “click” research on pattern recognition produce those contractions required prosthesis that the brain controls via control in the United States has been to use pattern recognition to control signals on the missing hand. After limited to traumatic amputees, a multi-degree-ofjust six weeks, the recent clinical study carried out by freedom prostheses.” patient was able to clinicians as Ability Prosthetics & Kaluf hopes this control six different Orthotics and OrthoCarolina demonresearch will increase functions of a robotic strates that congenital amputees may awareness of the prosthetic arm. He benefit, as well. abilities of the congenalso reported the Brian Kaluf, BSE, CP, FAAOP, ital population and, ability to move his clinical outcome and research director ultimately, increase arm more freely, at Ability P&O, notes that individuals access to advanced compared to the with congenital limb loss actually have technologies such as restricted movement much more brain activity related to pattern recognition provided by a socket. their congenital residual limb than control and myoelecEarlier this year, some medical professionals realize, tric prostheses for surgeons performed Matthew Garibaldi, with more motor control and sensation these patients. He a pioneering proceMS, CPO in their residual limbs than expected. encourages other dure at Sahlgrenska So, while many U.S. studies on pattern upper-extremity experts who provide University Hospital in Gothenburg, recognition control have not included prostheses to pursue similar studies. Sweden. They placed titanium congenital limb loss patients, Kaluf implants in a patient’s forearm bones, and his team were motivated to test Upper-Limb from which electrodes to nerves and whether congenital amputees could Osseointegration muscle were extended to extract use the control strategy. While osseointegration— signals to control a robotic hand and Kaluf’s team worked with seven direct connection between to provide tactile sensations. The team congenital patients ages 8 and older, bone and an implant, to which claims that this surgery resulted in the with residual limbs of different lengths a prosthesis is attached—has “first clinically viable, dexterous, and and with varying prosthesis experibeen an option for some sentient prosthetic hand usable in real ence. The researchers used a handheld lower-limb amputees for life.” A team led by Max Ortiz Catalan, evaluation kit to simulate prosthesis years, the procedure is just MD, at Integrum AB and Chalmers control using pattern recognition. now becoming possible for University of Technology in Sweden They limited the study to one visit and upper-limb patients. developed the new implant technology.

TREND

O&P ALMANAC | MARCH 2019

COVER STORY

As more studies are completed, “the field is moving toward making enhanced or electronic osseointegration available to patients in the United States, similar to a trial that is underway in Europe,” says Matthew Garibaldi, MS, CPO, director at University of California—San Francisco (UCSF) O&P Centers and associate clinical professor in the UCSF Department of Orthopaedic Surgery. “Transhumeral osseointegration is possible under a U.S. Food and Drug Administration Investigational Device Exemption Study, the investigational nature of which precludes funding from thirdparty payors at this time.” Advances in the United States are expected to be announced in the future.

More Options Allow for Creativity in

Jacob Townsend, CPO

MARCH 2019 | O&P ALMANAC

PHOTOS: Jacob Townsend, CPO, Ability P&O

There are more options than ever device-wise today— but finding the “exact right” solution for upper-limb amputees can still be a challenge. Even with today’s advanced technologies, prosthetists continue to be creative in their design solutions. Jacob Townsend, CPO, for example, has designed several upper-limb prostheses by combining body-powered and myoelectric elements: He combines a body-powered cable-driven elbow with Jacob Townsend, CPO, combined a body-powered an externally powered wrist rotator and elbow with an externally multiarticulating hand. powered wrist rotator and multiarticulating hand to “The biggest hurdle with upper-limb fit a patient who could amputees is a high rejection rate, especially not handle the weight of a myoelectric elbow. due to the weight of the prosthesis,” says Townsend, who works for Ability P&O in the Asheville, North Carolina, location. Myoelectric elbows offer many degrees of freedom, but those capabilities “add to the complexity and weight of the device.” In addition, for patients with long transhumeral residual limbs, “if you try to fit a traditional myoelectric elbow, the joint center can be very different from the sound side, then the arm can end up out of proportion and an improper length” compared to the sound side. So Townsend decided to try something different for a patient who complained of suspension and weight problems. “I wanted to take advantage of all of the technology, but make it as light and easy as possible.” He recognized that the elbow “is usually the easiest part of the prosthesis for an amputee to control with body power, and the hand is usually the hardest to control with body power.” So he opted for a combined body-powered/myoelectric design. “Due to this patient’s long limb, I used outside locking hinges to keep the overall proportions of the prosthesis similar to their sound limb. Not using an externally powered elbow allowed me to match the patient’s elbow joint center on the contralateral side while also eliminating much of the weight associated with a powered elbow,” he explains. “This also freed the patient to use his myoelectric control to power increased degrees of freedom at the wrist and hand.” The result is improved functionality—there are fewer degrees of freedom at the elbow, but The resulting prosthesis offers fewer increased feelings of control for the patient. degrees of freedom Townsend has used combination designs for but increased feelings of control a couple of other patients, who report for the patient. that the prosthesis feels more natural and is easier to move through space. The increase in component choices in the upper-limb space means more options than ever—and more room for creativity in device design to meet patients’ unique needs.

Advanced Materials for Improved Function

Advanced materials are enabling prosthetists and technicians to build more patient-friendly devices, says Kevin Barnes, CP, CTP, a clinician at Prosthetic Orthotic Solutions International in New Jersey. “We have a lot of materials available now to get a more dynamic flexible socket, for a better fit,” including advanced silicones, thermoplastics, and resins, he says. Rather than relying on traditional—and more rigid—polyethylene, “we’ve been adapting these newer materials for a more dynamic socket fit—and that’s started to help a lot of our patients.” Barnes says that high-consistency rubber (HCR) can be particularly useful in the transition from the rigid section of the frame to the flexible section of the socket. “I use HCR for partial hands and for upper-extremity socket design,” he says, noting that the material offers more control while maximizing comfort and durability. “This material also is very skinfriendly,” he says. Petersen likewise says that “custom silicone sockets [made from HCR] are a significant leap in socket technology that have greatly improved patient wearing times, comfort, and function in

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COVER STORY

upper-limb prosthetic patients.” This type of silicone socket is very labor intensive and completely handmade, and the custom silicone is pigmented to the patient’s choice, he explains. “Rollers are then used to create the proper thickness for socket fabrication. This rolled silicone is hand molded and worked onto a dehydrated rectified mold of the patient’s residual limb.” Custom silicone sockets allow for customizations such as the addition of zippers, integration of electronics, integration of batteries, reinforcing mounting anchors, suction valves, and pre-impregnated carbon. “Silicone sockets also can be manufactured with built-in air bladders that can be filled to take up lost residual-limb volume over the course of a day’s usage,” Petersen says. “The manufacturing process allows for strategic positioning of different stiffness of silicone to further customize the design to meet each patient’s unique clinical presentation for improved outcomes.” He frequently relies on custom silicone for challenging, unique congenital limb shapes and characteristics. “I have several patients who were transitioned out of thermoplastic sockets into custom silicone designs, who report that they will never return to thermoplastic sockets again,” Petersen says. “As a clinician, I am seeing longer wear times and improved acceptability, especially in the pediatric population.”

Implantable Myoelectric Sensors

TREND

An evolution toward implantable sensors that further prosthetic ability and control is another exciting trend, says Barnes. Surface electrodes are already advancing the abilities of current upper-limb prostheses, and implantable sensors are next on the horizon. Implantable myoelectric sensors (IMES) “represent a significant leap in sensing technology,” says Petersen. IMES consist of a multichannel EMG sensor system first developed by Richard Weir, MD, and his team in

MARCH 2019 | O&P ALMANAC

maintenance servicing, and inconsistencies in donning. “The IMES system presents an option to better connect the human to the machine for improved complex, simultaneous, and multiple-degree-of-freedom control that is intuitive for the user.”

Playing Catch-Up

Kevin Barnes, CP, CTP

conjunction with Illinois Institute of Technology, Sigenics Inc., and the Alfred Mann Foundation, according to Petersen. “The IMES sensor capsule is derived from the BION capsule that is used in other medical applications,” he explains. “The capsule is about the size of a grain of rice and is placed intramuscular through a minimally invasive surgical technique, essentially eliminating the issues seen in traditional surface-mounted electrodes.” The injectable IMES capsule is biocompatible and designed for long-term use with no routine maintenance requirements. “This sensing technology has the capability to receive and process signals from 32 implanted sensors within the residual limb, essentially creating more control site options to control a prosthesis and other technology,” explains Petersen. The implanted electrodes communicate directly through the skin, from within the source of muscle contraction, to the prosthesis microprocessor. “This intramuscular electrode location places that electrode in the optimum position to capture the best quality of EMG for improved prosthesis functionality.” Petersen says the IMES sensors are an improvement over the currently used skin-surface-mounted electrodes because surface-mounted technologies may be compromised by electrode lift-off during muscle contractions, volumetric residual limb changes over the course of the day, artifact signals from the environment, wiring and

Russo, Petersen, Barnes, and Kaluf all see a bright future for upper-limb patients, as technological advances allow for advanced functionality, ease of use, and comfort. But the evolution is sometimes slow-going due to obstacles such as the rising costs of R&D as well as reimbursement challenges, according to Russo. Petersen notes that the L-code system has not moved at the same pace as the advances in upper-limb prosthetics and do not adequately describe or reimburse for the substantial technology shift. “I think this advanced technology has the capability to significantly improve the overall functionality in the upperlimb prosthetic patient population; however, there needs to be updating of the current L-code system to assist all patients in having equal accessibility to these advancements in technology.” Despite the coding challenges, the current trends point to an increasingly high-tech future for upper-limb patients—many of whom will benefit from more customized, comfortable, and functional solutions than in years past. “We are seeing a lot of amazing technology that is allowing sophistication in control of components,” says Petersen. “Even though there are significant limitations to access of emerging prosthetic technology applications,” adds Russo, “there are a lot of great minds working on creating techniques and new prosthetic componentry with the objective of easing the burden of going through life with upper-extremity limb loss/difference.” Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

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Complicating

CONDITIONS O&P clinicians share tips on treating patients as they experience new or continuing health crises NEED TO KNOW Many of the patients who visit O&P facilities are faced with health-care issues in addition to their orthotic and prosthetic needs. O&P clinicians should be prepared to display empathy, offer resources, and suggest that patients visit appropriate specialists. Diabetes is a problem for a significant proportion of O&P patients, so clinicians should implement strategies to educate patients about how wearing a prosthesis may affect their blood sugar levels and look for signs of ulcers or wounds on patients’ sound sides. The risk of cardiac disease is increased among some lowerlimb amputees, so clinicians should advise patients to talk with doctors and nutritionists about their risks. It may be helpful to educate patients about the link between obesity and heart health.

MARCH 2019 | O&P ALMANAC

Patients who are diagnosed with cancer can be a particularly challenging patient demographic. Clinicians may need to be more flexible with appointment scheduling and expect socket sizes to change as the disease progresses. It’s important to consider patients’ mental health, as there is a psychological component to limb loss and limb difference. Clinicians can suggest that patients speak to mental health professionals as needed, and be on the lookout for symptoms of depression. When treating patients with multiple health-care issues or comorbidities, communication is key. In addition, clinicians can become more knowledgeable about various conditions and offer peer support resources from the Amputee Coalition and disease-related associations.

ATIENTS IN NEED OF O&P

intervention are often at the beginning of health-care journeys that can be plagued by new or recurring pathologies, such as diabetes, cancer, circulatory and cardiac problems, and mental health issues. Prosthetists and orthotists need to be prepared to serve as sounding boards and resources to patients who present with health complications—and to alter O&P patient care if warranted.

Justin Ozee, MS, CPO

“Our profession is unique in that it crosses borders with a lot of other services, such as vascular, family medicine, orthopedic, oncology, and neurology,” says Justin Ozee, MS, CPO, a clinician at Wright & Filippis in Ferndale, Michigan. “Many of our patients are without a primary care physician,” so Ozee uses existing referral sources to help patients find

general and specialized physicians when needed. “We become confidants to our patients that we see on a regular basis,” he says. “We use that rapport to steer them in the right direction.” “Being empathetic and listening” are essential actions for clinicians when dealing with patients in crisis, says Nina Bondre, CPO, a clinician at Dankmeyer Inc. in Linthicum, Maryland. But it’s also important to offer resources and suggest visits to appropriate specialized health-care providers to ensure patients prevent and treat conditions outside of the purview of O&P care.

“There seems to be a lack of education, globally, with many diabetic patients not quite grasping or understanding their blood sugar levels.” –SHAMEL ALLEN, CP, MPT NOVACARE PROSTHETICS AND ORTHOTICS

Nina Bondre, CPO

Diabetes Complications

O&P facilities see high percentages of diabetic patients—some for orthotic care, and others for prosthetic care following amputations. So, understanding diabetes and helping patients manage their health crises as they relate to O&P is an important responsibility of O&P clinicians. Individuals who have had one diabetes-related amputation are at higher risk of having another, according to the Mayo Clinic. “By the time [patients who have diabetes] get referred to us,” it’s past the stage for “early” warning signs, says John “Mo” Kenney, CPO, FAAOP, president of Kenney Orthopedics and chair of the Amputee Coalition. But, he recommends a “maintenance protocol” to his clinicians to look for signs of disease progression. “We ask and document their blood sugar level, we ask if they’re dieting and exercising, and we look at patients’ extremities for ulcerations and sores,” he says. Even if these patients are visiting their primary care doctors regularly, “it doesn’t hurt for them to have an extra set of eyes on them,” says Kenney—“particularly since bad vision is part of the pathology.”

John “Mo” Kenney, CPO, FAAOP “For my diabetic patients, managing blood sugar levels is very important,” says Shamel Allen, CP, MPT, a center manager for NovaCare Prosthetics and Orthotics in St. Louis. Allen, who practiced physical therapy for several years before migrating to prosthetics, notes that some patients need more education than others. “There seems to be a lack of education, globally, with many diabetic patients not quite grasping or understanding their blood sugar levels—how important it is to check consistently, and how activity affects your blood sugar,” she says. Allen spends extra time talking with her patients, seeking to determine whether they understand what their ideal blood sugar levels are and how nutrition and exercise affect their levels. “New amputee patients using

a prosthesis may not understand that walking, stretching, and biking” at the O&P facility and in therapy are forms of exercise and that these activities could lower their blood sugar. “If something happens in the clinic, I like to know what my patient’s normal range is,” she says. It’s also important to watch closely those amputee patients who have peripheral vascular disease or poor vascular flow to help prevent complications on their sound leg, says Allen. “If they have a wound and can’t feel their leg or foot on the sound side, I make sure to spend some time explaining the importance of checking not just their foot but also in between their toes. I tell them to always make sure there’s nothing inside their shoe” before they put it on, because they won’t be able to feel an injury, she says. She also encourages patients to confer with nutritionists about healthy food choices and a good diet—one that includes eating protein, which can speed up healing in the event they have an open wound. O&P ALMANAC | MARCH 2019

Cancer Recurrences Kenton Kaufman, PhD, PE

Cardiac Disease

Amputees in general may expend more energy in walking than others, and some may be at risk for heart-related problems. “For many amputees, loss of a limb is part of a larger problem with the blood vessels, including the blood vessels to the other major structures like the heart,” reported Terrence P. Sheehan, MD, in the Amputee Coalition’s brochure, “Preventing and Caring for the Secondary Conditions of Limb Loss.” “If the heart is not functioning well, all efforts will take more energy, and the stress of ambulating with a limb difference can exacerbate the heart problems.” Allen advises patients who have cardiac or respiratory diseases to stay in close contact with physicians and nutritionists. She also encourages these patients to stay as active as possible, within their comfort zone and without overdoing it.

Shamel Allen, CP, MPT

“If this is a new amputee, they need to understand that wearing their prosthesis takes a lot of extra work and energy,” says Allen. With the patient’s permission, she will reach out to their cardiologist or pulmonologist to make sure the patient has been cleared to use a prosthesis, and that they’re healthy enough to do so without further injuring themselves. “Make sure patients know that [their prosthesis] will have an increased energy demand on their system,” she says. Patients who have had an amputation due to dyvascular disease are at particular risk for significant heart problems. Kenton Kaufman, PhD, PE, 32

MARCH 2019 | O&P ALMANAC

was part of a team that studied this correlation and published on this topic late last year. “Individuals with a transfemoral amputation due to dysvascular disease had an approximately four-fold increased risk of a major cardiovascular event after undergoing an amputation,” says Kaufman, who is director of the Motion Analysis Lab and a consultant at the Mayo Clinic. The risk for a cardiovascular event in individuals receiving an amputation due to trauma or cancer did not differ from control subjects, leading Kaufman and his team to conclude “that the dysvascular disease progression is a significant factor for a major cardiovascular event.” Given those odds, O&P clinicians should remind patients with dysvascular disease of the importance of following clinical guidelines to reduce the risk of cardiac events. “These guidelines include reducing cholesterol, controlling diabetes, reducing hypertension, stopping smoking, increasing activity, losing weight, using acetylsalicylic acid, and using angiotensin-converting enzyme inhibitors,” says Kaufman. In addition, activity is vital. “Anything that can be done to increase mobility is certainly helpful.” When meeting with overweight patients, O&P clinicians should discuss with them the link between obesity and heart health. While obesity increases patients’ risk of heart disease, high blood pressure, and diabetes, even modest weight loss can improve or prevent the health problems associated with obesity, according to the Mayo Clinic. O&P clinicians can talk to their overweight patients about making healthier choices and refer them to primary care physicians and nutritionists to aid in appropriate weight-loss efforts.

It’s important for clinicians to have a plan in place when treating patients who have cancer. “This is a pathology that’s huge in our field, and it’s often a terminal pathology,” says Kenney. “Unless you have personal experience” with a family member battling cancer, “it can be a little foreign to a lot of providers. It takes some time to learn to be a good provider of someone with cancer.” Elliot Weintrob, CPO, president of Orthotic Prosthetic Center in Fairfax, Virginia, agrees that patients who are diagnosed with cancer are a particularly challenging demographic. He sees a fairly high percentage of patients who fall into this category because he gets referrals from several orthopedic oncologists. “We work with a lot of patients who have had cancer. The challenge comes if the cancer returns. And if it has, where has it returned, and is it spreading?”

Elliot Weintrob, CPO

Unfortunately, Weintrob has, on several occasions, been involved in end-of-life care for amputees. “I look at it as ‘dying with dignity,’” he says. “If a patient is going through chemo, or not eating a lot, their mobility may become compromised,” so ensuring they have a prosthesis that works is important. “The socket may no longer be fitting, and we may need to make a smaller, better fitting socket,” Weintrob explains. At times, providing new sockets for cancer-stricken amputees in the later stages of the disease can create reimbursement challenges, requiring extra documentation and explanations to ensure coverage for devices. “But no one knows exactly when end of life will happen—it could be two months, or it could be two years, so I will fight for my patients to have properly fitting prostheses,” says Weintrob.

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John “Mo” Kenney, CPO, FAAOP, believes it's important to be on the lookout for changes in patients' mental health as well as their physical health.

MARCH 2019 | O&P ALMANAC

Mental Health and Depression

When considering health-care issues that patients may be facing, mental health should be included. “There’s a huge psychological component that may affect not only prosthetic patients but also orthotic patients,” says Kenney. Some patients “slip through the cracks” and do not get the psychological care that they require. “I always tell patients that they should seek psychological care” if they are struggling with their amputation or any other health issues, says Kenney. “I tell them that it’s not a sign of weakness, but of strength,” to focus on their mental health. Depression is one mental health ailment that can have potentially devastating effects on O&P patients. Depression, a common and serious medical illness that negatively affects how you feel, think, and act, is often triggered or worsened by traumatic or stressful events—such as limb loss or limb difference.

PHOTO: John M. Kenney, CPO, FAAOP

Sometimes it’s necessary to go “above and beyond” when caring for these patients, he adds. “We have patients who have been with us for a very long time,” and when cancer returns, “the family may be overwhelmed at caring for the patient.” In these cases, Weintrob has been known to go to patients’ houses to make adjustments. “The family really appreciates it,” he says. “And you’re also showing your appreciation to the patient and the family” for their loyalty and dedication to your facility. Kenney encourages clinicians to be forgiving of missed appointments or a lack of communication from patients as they undergo treatment. “It’s important for providers not to have tunnel vision,” he adds. “Patients may have chemo or other hard-core treatments, and they may not have been feeling well that day. We as practitioners need to be cognizant that our specialty is not always a priority in the overall health care of a given patient.”

Being on the lookout for patients who are displaying symptoms can help clinicians identify individuals in need of professional help. Signs of depression include feelings of sadness, irritability, loss of interest in activities once enjoyed, fatigue and sleep disturbances, reduced appetite, increased anxiety, and slowed speaking, according to the Mayo Clinic. O&P clinicians who recognize these symptoms can offer support, resources, and referrals—but should not try to “treat” the depression. “Our specialty is in orthotics and prosthetics; most of us are not trained to handle depression, and it is often best to refer to professionals,” says Bondre. “By nature we are ‘helping’ people, but we need to make sure we are caring for our patients properly.” Bondre says that O&P clinicians— particularly those who see the same patients time and again—should be on the alert for patients experiencing any symptoms. For example, she recalls one patient who missed several appointments in a row. Having built a positive relationship with this patient, she felt comfortable asking him if everything was OK. The patient mentioned a death in the family, in addition to the loss of his leg, as negatively affecting his mood and behavior. For this particular patient and others who disclose symptoms of depression, “I express that I am happy they felt comfortable to share with me, and that they are always welcome to talk to me, but it is still best to speak with a trained professional,” says Bondre. “We may not be able to solve the problem, but we know where to point them.” Bondre emphasizes that prosthetists and orthotists are just “one piece of the health-care puzzle.” She works as part of multidisciplinary teams at Johns Hopkins and Kennedy-Krieger Institute, so she has made many connections with depression experts, such as behavioral psychologists, therapists, and other health-care professionals. In addition to picking up on symptoms in repeat patients, Bondre

suggests equipping new amputee patients with tools to help prevent depression. “We see many amputees postoperatively,” she says. At that point, she and her colleagues offer contact information for multidisciplinary prosthetic clinics and for the Amputee Coalition, which offers peer support programs including support groups, hospital partnership programs, youth camps, and its Certified Peer Visitor Program. Ozee similarly encourages patients to take advantage of his facility’s peer support program. “We have a bank of patients who are credentialed as peer visitors. We make them available to any patient whether their issue is new, existing, or unrelated to their current prosthetic/orthotic care.”

Caring Clinicians

Regardless of the condition or comorbidity a patient is facing, communication is key. “Whichever disease they have, it’s really important to establish a climate

of trust and respect, and to keep the dialogue open,” says Allen. It’s essential to take seriously the responsibility of acting as an educator and information source for patients, says Weintrob. He conducts research on different conditions and seeks out area health-care providers competent in treating various ailments. “You become a referral source” to point patients in the direction of many different specialties, he says. While this is easier to do in larger cities, such as his, it’s important for

clinicians in all types of geographies to network and reach out to other members of the health-care team. “We can offer patients a place to vent and express frustration, and be an empathetic ear,” says Ozee. “The best place to start is to make yourself available to listen, and to offer whatever resources or contacts you have.” The bottom line, according to Kenney, is that being empathetic, no matter what a patient is going through, is key to being a good prosthetist or orthotist: “It’s not the smartest practitioner that’s the best— it’s the most caring, because that practitioner will go the extra mile to help their patients.” Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

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O&P ALMANAC | MARCH 2019

PRINCIPAL INVESTIGATOR

Shaping the Future

Special Edition

Tiffany Graham, MSPO, CPO, LPO, leads a research initiative focusing on cranial remolding orthoses

MARCH 2019 | O&P ALMANAC

LPO, is having one of her most productive years yet. The lead investigator on a new study called “Effectiveness of Repositioning and Cranial Remolding in Infants With Cranial Deformation,” she recently started enrolling the first subjects in the study, which was funded by AOPA as part of the Orthotics 2020 initiative last summer. As a practicing clinician and instructor at the University of Texas (UT) Southwestern Medical Center who has specialized in cranial remolding since 2009, Graham has fit approximately 1,000 patients with cranial remolding orthoses over the course of her career. During that time, she has noticed that while some published research about these types of infant orthoses and their efficacy exists, it is not nearly enough. So she designed a study, received approval from the Institutional Review Board last March, and contacted AOPA to apply for funding as part of the Orthotics 2020 initiative. “At UT Southwestern, I work in the clinic, I conduct research, and I teach— Orthotics 2020 incorporates all aspects of my work,” she explains. To carry out the study, which involves enrolling 100 2-month-old infants who have been diagnosed with a deformational head shape, she assembled an interdisciplinary team that includes herself; Rami Hallac, PhD, an imaging scientist

PHOTO: Tiffany Graham, MSPO, CPO, LPO, UT Southwestern

Tiffany Graham, MSPO, CPO, LPO, works with a cranial remolding patient.

IFFANY GRAHAM, MSPO, CPO,

Fulfilling AOPA’s mission to advance research in the profession, O&P Almanac introduces individuals who have undertaken O&P-focused research projects. In this “Special Edition” series of Principal Investigator, we profile participants in the Orthotics 2020 initiative established by AOPA and the Center for O&P Learning/ Evidence-Based Practice. Here, you will learn about some of the research being conducted as part of the Orthotics 2020 initiative, which is a vital enterprise created to protect the orthotic services upon which O&P patients depend, and to begin populating a stronger research base around issues on the value of orthotic services.

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PRINCIPAL INVESTIGATOR

from the Children’s Medical Center Plastics & Craniofacial Surgery Department; and Susan Simpkins, PT, EdD, a pediatric physical therapist from UT Southwestern. An orthotic resident and another UT Southwestern student also will be involved in the study.

2022 to allow for the subjects who enrolled in the last group to complete their treatment. Graham and her team will write a final report in September 2022 with the hopes of submitting it for publication soon after.

Expectations

The current study is the first of its kind, so the results it will yield are Graham and her colleagues uncertain. But Graham’s clinical began enrolling the first experience leads her to expect patients in their study in that cranial remolding orthoses January. Once an infant with will have a better outcome than a deformational head shape repositioning alone. Of course, has been identified, and his this is hard to predict because, in or her parents have agreed to regular practice, “I typically don’t enroll in the study, the investisee the patients who have good gators will evaluate the infant’s outcomes with repositioning head shape and educate the because they do not come caregivers on repositioning back” for orthotic follow-up. Graham and her team instruct families on repositioning therapy. If, after two to four “Doing a long-term follow-up techniques. Infants are re-evaluated after repositioning at 12 months of age will be quite months of repositioning therapy to determine whether they would benefit therapy, the infant’s head telling,” Graham says. “We’re also shape deformity is still present, from cranial remolding orthoses. doing surveys at each follow-up caregivers will have the visit to check compliance and option to transition to cranial remolding System will be involved in the study. find out whether patients are in daytherapy. If needed, the participants Although recruitment is through care—do these details affect outcome?” also will receive physical therapy for Parkland, participants will receive treatGraham is happy to report that torticollis. All subjects will be examined ment at UT Southwestern’s Prosthetics/ the referral source for the study is 100 at frequent follow-up appointments Orthotics Clinic and Physical Therapy percent Texas Medicaid patients—“so and will undergo scans using a 3dMD Clinic. The goal is to enroll 100 none of them would have coverage scanner at Children’s Hospital. patients during the next 30 months. for [cranial remolding] treatment” if The state-of-the-art scanner is a In addition to the subjects with crathey were not enrolled in the study. noninvasive device that takes photonial deformations, the study will include Part of her goal with this project is “to graphs and creates a computer model a control group of 20 healthy infants; combat the idea that [patients without of the deformation, says Graham. these participants also will be scanned appropriate health insurance coverage] Hallac “has developed an algorithm to using the 3dMD scanner at 2 months do not need treatment,” she says. measure deformations, versus regular and 12 months of age to document the In fact, ensuring appropriate treatgrowth,” she explains. The team will normal changes to cephalic shape and ment for infants without adequate study the scans from the infants at size with normal infant cranial growth. coverage is what inspired Graham to 2 months of age and at 12 months to Several other controls will be in begin this particular study. “In 2012, examine the corrections that have taken place: All participants will use the when Texas Medicaid withdrew covplace after repositioning therapy and same orthosis (the STARband by erage for cranial remolding orthoses, I (for many) cranial remolding therapy. Orthomerica). Graham plans to treat knew I needed to do something to help The team will collect and analyze each patient so that only one orthotist these families who could not afford the accumulated data to determine the consistently evaluates patients. Simpkins treatment for their infants,” she says. overall success rate of repositioning will be the one physical therapist Many of her patients had Medicaid as a percentage of the study group, seeing each subject, and Hallac will insurance, and she noticed many and will further study subjects divided oversee all of the scans. Consequently, families faced challenging financial into subsets according to severity it is important for the team to have burdens due to the lack of coverage. of deformation at initiation. plenty of time to enroll new patients. “For the families who were able to Several clinics that are part of the Enrollment in the study is schedachieve charitable funding [to cover the Community-Oriented Primary Care uled to close in July 2021, then a data treatment], the process of obtaining Centers within the Parkland Hospital analysis will follow, beginning in May this funding delayed treatment, so the

Research Methodology

MARCH 2019 | O&P ALMANAC

PHOTO: UT Southwestern Prosthetics-Orthotics Program

PRINCIPAL INVESTIGATOR

infants either did not get as significant correction … or they needed to be in treatment longer in order to achieve the correction they needed.” Graham is hoping the current study will help demonstrate the value of orthotic intervention for infants with cranial deformation. This initiative represents her most significant research undertaking, as she spent the early years of her career focusing on patient care. “Until 2016, I was unable to perform much research because I was a full-time clinician,” she explains. “In January of 2016, I joined UT Southwestern and through the university, I have been able to start my significant research endeavors.” One of the important projects Graham has accomplished since joining the university is a retrospective chart review on deformational plagiocephaly outcomes through cranial remolding treatment, which she completed with the assistance of five students. “I have presented various results from this

study at two state meetings, three national meetings, and one international meeting,” and she has displayed related posters at both local meetings and national meetings. “I am currently working to publish part of this study, which was presented at the 2018 AOPA National Assembly and received the

Thranhardt Award,” she says. Looking to the future, Graham says her team is excited to be getting started with the Orthotics 2020funded project. “I love doing this,” she says. “We offer a treatment and make a permanent change in these patients’ lives.”

Notable Works Tiffany Graham, MSPO, CPO, LPO, has been involved in the publication and presentation of several important articles and papers over the course of her education and career. Some of her most impactful works include the following: • Graham, T. “Significant Factors Influencing the Effectiveness of Cranial Remolding Orthoses in Infants With Deformational Plagiocephaly.” Thranhardt Presentation at AOPA National Assembly in Vancouver, Canada, September 2018. • Graham, T. “Making Better Use of the CAD Technology Already in Your Clinic.” The Academy Today 2017. 13(3), 5-6. • Graham, T. “Dermatological Conditions Often Seen During Cranial Remolding Orthotic Treatment.” The Academy Today 2018. 14(3), 5-7. • Graham T. “Repositioning Therapy or a Cranial Orthosis? It’s a Clinical Decision.” O&P News 2018. 27(10), 4-9.

SA VE d!

C E L E B R AT I N G 1 0 Y E A R S O F S U P E R I O R A D H E S I O N

What have you pulled off With pluSerieS ? Share Your PLUSeries story:

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1/31/19 2019 8:53 AM39 O&P ALMANAC | MARCH

MEMBER SPOTLIGHT

PFS Med Inc.

By DEBORAH CONN

Healing Products Orthosis manufacturer boosts the well-being of both consumers and employees

ACK IN THE EARLY 1990s,

MARCH 2019 | O&P ALMANAC

PFS Med conducts about 80 percent of the manufacturing process in its own facility, which occupies two buildings in Springfield, Oregon.

COMPANY: PFS Med Inc. OWNER: Robin Irish, MS, OT LOCATION: Springfield, Oregon HISTORY: 26 years

Technicians at work at PFS Med

distributor with a national customer base. The company has 10 employees and occupies two buildings in Springfield, Oregon: A 6,500-square-foot space houses punching, forming, and welding activities, as well as administrative functions, and a 4,600-squarefoot building is dedicated to clean finishing production and shipping. Although Irish is no longer practicing occupational therapy, her profession had a strong influence on the way she has organized her business. “We manufacture a healing product,” she says, “so the way we make it must not cause harm.” She is adamant about providing a safe and healthful workplace for employees, and she takes practical steps to prevent their daily activities from causing cumulative trauma. Each workstation can be modified for its user—particularly important, says Irish, because no one in her company right now is taller than 5 feet, 8 inches. PFS Med has its own woodshop where workstations can be built to fit the height and workflow of each employee.

Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: PFS Med Inc.

Robin Irish, MS, OT, planned on continuing her career as an occupational therapist working with trauma patients. But when she was approached to provide a device that wasn’t readily available, her path took an unexpected turn, and Irish launched a new business to manufacture that orthosis. She created PFS Med in 1993 and transformed herself from therapist to successful business owner. “We needed a malleable splint,” she explains. “I found a machinist who could think like a therapist, and we created an orthosis that was not currently offered. Ours came in more sizes, it was fleece lined, and it had a longer lever arm and an expanded heel pocket.” The malleable metal device, available as a tibial ankle-foot orthosis and a posterior knee orthosis, immobilizes the limb and keeps the ankle in a functional position. It can conform to patients’ size or dressing patterns, and it has glued-in liners, although it is available without liners for burn patients. When the business began, Irish continued as an occupational therapist and hired one employee, who would assemble the orthoses from outsourced parts. As time went on, PFS Med brought more of the manufacturing process in-house, acquiring a CNC punch to create blank parts and then a forming press for those parts. PFS Med currently conducts about 80 percent of the manufacturing process in its own facility. Today, the company is a sole-source manufacturer and

Since 2017, Irish has required an assessment and treatment as recommended for each employee by a physical therapist (PT). A PT evaluated work movements and determined that employees needed conditioning activities to be at their best. Since then, the company has instituted 35-minute walking breaks three times each week as part of the work day. “I was surprised to find that regular walking not only improved workers’ stamina, it improved our morale, productivity, and creativity,” she says. Turnover these days is low, and Irish says many of her employees are getting more involved in the company and assuming more responsible supervisory duties. PFS Med relies primarily on word of mouth to reach new customers. The company cultivates its existing customer base with regular communication and gift boxes of Oregon fruit, nuts, and chocolates. “We strive to find a way to prioritize our customers, a way to maintain a personal connection. The people are what connects us. That’s harder these days as so many businesses rely on outsourcing to communicate with their vendors,” she says. Looking ahead, Irish hopes to bring another function in-house: cutting of the fleece material for liners. “That would make us about 90 percent self-functioning,” she estimates. She has no plans to introduce new devices but prefers to focus on continual improvement of team mastery of each process of the PFS Med orthosis. Growth has been steady every year, and Irish expects it to continue. “Gratitude, building slowly, developing staff—and consistently providing a quality product—that is why we are so strong today,” she says.

Who is an innovator? Who is held to the highest O&P standards? Who is committed to life-long learning? I AM. I am a big part of great possibilities.

I AM ABC. Visit ABCop.org today to find out what ABC can do for you. 703.836-7114

MEMBER SPOTLIGHT

Prosthetics in Motion

By DEBORAH CONN

Custom-Built Facility New York company’s recent move allowed for the design of a state-of-the-art space

FTER 14 YEARS OF practice

as a prosthetist/orthotist, Christopher Kort, CPO, knew the time was right to launch his own facility. He had always planned to run his own business and worked in several practices to gain as much experience as he could. In April 2009, Kort opened Prosthetics in Motion in Manhattan, and a week later, he hired an office manager, Rachael Hartman, who is with him to this day.

Prosthetists and technicians work in the lab at Prosthetics in Motion's new facility.

FACILITY: Prosthetics in Motion

Technicians grinding plastic

MARCH 2019 | O&P ALMANAC

LOCATION: New York, New York HISTORY: 10 years

Christopher Kort, CPO

Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTO: Prosthetics in Motion

“We had no patients; we started with nothing,” he recalls. “It was during the recession and bank funding was not available. My wife and I took all the money out of our house, borrowed from our parents, and managed to secure a Small Business Administration loan with the help of the New York Business Development Corp.” While waiting for Medicare approval, which took 190 days instead of the expected 30 to 60, Kort treated private-pay patients and did not receive a salary. After his Medicare application was approved, Kort set a goal of treating 25 patients the first year. He tripled that number. “I worked closely with Ottobock, doing a C-leg road show at hospitals, knocking on doors, doing in-services for physical therapists, and advertising

OWNER: Christopher Kort, CPO

in newspapers,” he says. Kort was quick to see the advantages of the Internet and social media, optimizing his website so that it appeared near the top of Google searches for prosthetics and garnering 19,000 followers on Facebook and close to 9,000 on Instagram. The company has a social media coordinator who posts a video every work day. “New patients find us through research, Facebook, Instagram, Youtube, and Yelp, as well as through referrals from physicians I’m associated with,” he says. “Word of mouth from existing patients is a major referral source.” Today, Prosthetics in Motion employs four prosthetists, five technicians, an occupational therapist, an Internet specialist, and administrative staff, as well as occasional contract administrative employees. The company has three amputees on staff: two below-knee and one hip disarticulation, says Kort. Prosthetists see patients only in the facility, and they come not only from New York but from as far away as Alaska, Europe, and South America.

In September 2018, Prosthetics in Motion moved to an 8,100square-foot facility in midtown Manhattan. “The space was an open shell, so I was able to design it exactly as I wanted,” says Kort. “We have seven patient rooms, and five of them open onto a walking area that’s 72 by 16 feet. The waiting room is in that space as well, so patients can interact and support each other.” Another 87-foot hallway offers space for walking and running, and the facility features a kitchen and lunchroom for employees. Prosthetics in Motion fabricates all prostheses in-house, so designing safe and efficient lab spaces was a priority for Kort. The facility includes a general workshop area with work benches for techs and stations for prosthetists. “Because I work with Ottobock, they helped me design two of my rooms with their equipment, including a state-of-the-art dust collector and three brand-new routers, all environmentally friendly for my staff. I have an exhaust fan for specialty fabrication rooms that draws out all contaminants.” Kort expects 2019 to be his best year ever, serving his current patient base of 600 patients in addition to newcomers. “Now that the stress of building the facility is over, I can concentrate on what we do best, which is caring for patients,” he says. The biggest challenge is coping with insurance companies, he notes. “We have people who are candidates for great technology and insurance companies won’t allow it. We are working through it, both by my great staff and by patients serving as their own advocates. They fight, we fight, and we’re getting it done.”

THE PREMIER MEETING FOR ORTHOTIC, PROSTHETIC, AND PEDORTHIC PROFESSIONALS

Experience all the AOPA National Assembly has to offer while visiting San Diego.

SEPTEMBER 25-28 / 2019 SAN DIEGO CONVENTION CENTER

Driving the Waves of Change Join AOPA next year in San Diego, known for incredible panoramic views. Located in the downtown Marina district, the San Diego Convention Centre has many top attractions within walking distance.

ADVANCE YOUR CAREER: SUBMIT A PAPER

#AOPA2019

Learn more at: bit.ly/AOPACallForPapers

SOUTHERN CALIFORNIA

San Diegoâ&#x20AC;&#x2122;s unbeatable location makes it the perfect gateway providing you with outstanding opportunities for pre- and post-conference travel.

AOPAnet.org

AOPA NEWS

AOPAversity: Webinar Series Subscription During the one-hour monthly webinars, AOPA experts provide the most up-to-date information on a specific topic. Webinars are held the second Wednesday of each month at 1 p.m. EST. One registration is all it takes to provide the most reliable business information and CE credits for your entire staff. If you’ve missed a webinar, AOPA will send you a recording of the webinar and quiz for CE credits, so you can still take advantage of the series discount and the valuable learning opportunities.

AOPA Members Nonmembers

Price Per Seminar

$99.00* $199.00*

Price for Full Year

$990.00 $1,990.00

* Includes an unlimited number of participants per telephone line. AOPA members may use code “member” when registering for the $99 price.

Earn 1.5 Business CEs each by returning the provided quiz within 30 days and scoring at least 80 percent. All webinars begin at 1 p.m. EST. Webinar registration fees are nonrefundable. AOPA can provide the webinar recording if registrants cannot make the scheduled webinar.

MARCH 13

APRIL 10

Advanced Beneficiary Notice: Get To Know the ABN Form

Shoes, External Breast Prostheses, Surgical Dressings, and Other Policies

The advanced beneficiary notice (ABN) can be a valuable tool in protecting your financial liability. Take part in the March 13 AOPAversity webinar, when AOPA experts will examine proper usage of the ABN form: • Learn when use of an ABN is appropriate. • Examine common scenarios regarding proper ABN usage. • Determine how to use the ABN when billing for upgraded features. • Find out how the ABN can ensure a partial payment for services rendered. • Avoid the most common mistakes that can render an ABN invalid. • Understand all of the modifiers associated with an ABN.

MARCH 2019 | O&P ALMANAC

The April 10 webinar will cover some of the most frequently overlooked policies in O&P, including the Surgical Dressing Policy and the External Breast Prostheses Policy. Take part in the webinar and hear AOPA experts share their knowledge regarding these policies. • Review the nuances of the Therapeutic Shoes for Persons With Diabetes Policy. • Review the Orthopedic Shoe Policy, including a discussion regarding when the L3000 series of codes are covered. • Review the External Breast Prostheses Policy. • Learn when and how compression garments are covered.

AOPA NEWS

NOW AVAILABLE:

‘2018 Operating Performance Report’ AOPA Releases Results From Member Benchmarking Survey

AOPA Announces 2019 Call for Papers Submissions Due March 25

AOPA is seeking high-quality educational and research content for the 2019 AOPA National Assembly, which will be held September 25-28, 2019, in San Diego, California. All submissions are due March 25, 2019. Your submissions will set the stage for a broad curriculum of high-value clinical and scientific offerings at the National Assembly. All free paper abstracts must be submitted electronically. Abstracts submitted by email or fax will not be considered. All abstracts will be considered for both podium and poster presentations. The review committee will grade each submission via a blind review process and reach a decision regarding acceptance of abstracts. AOPA is seeking submissions for the clinical free paper sessions, symposia/instructional courses, technician program, or business education program. Contact AOPA Headquarters at 571/431-0876 or rgleeson@AOPAnet.org with questions about the submission process or the AOPA National Assembly in general. Visit the AOPA website for more information and to see full submission guidelines for the 2019 AOPA National Assembly.

Are you curious about how your O&P business is performing compared to others? Have you been asking questions like these: • How does our spending on materials, advertising, or other expenses compare with other companies similar to ours? • Is our gross margin better or worse than other facilities of the same size? • Are our employees generating enough sales? Copies of the “2018 Operating Performance Report” are now available. The annual report provides a comprehensive financial profile of the O&P industry, including balance sheet, income statement, and payor information organized by total revenue size, community size, and profitability. This year’s data was submitted by more than 90 patient-care companies representing 1,022 full-time facilities and 191 part-time facilities. Copies of the “2018 Operating Performance Report” are available electronically in AOPA’s bookstore: • “2018 Operating Performance Report” (Electronic)—Member/Nonmember: $185/$325

O&P ALMANAC | MARCH 2019

O&P PAC

Registration is Now Open

HE O&P PAC UPDATE provides information on the activi-

ties of the O&P PAC, including the names of individuals who have made recent donations to the O&P PAC and the names of candidates the O&P PAC has recently supported. The O&P PAC would like to thank the following AOPA member for his contribution to the O&P PAC*: • James Young Jr., CP The purpose of the O&P PAC is to advocate for legislative or political interests at the federal level that have an impact on the orthotic and prosthetic community. The O&P PAC achieves this goal by working closely with members of the U.S. House of Representatives and Senate and other officials running for office to educate them about the issues, and help elect those individuals who support the orthotic and prosthetic community. To participate in, support, and receive additional information about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online: bit.ly/pacauth. *Due to publishing deadlines this list was created on Feb. 1, 2019, and includes only donations/contributions made or received between Jan. 1, 2019 and Feb. 1, 2019. Any donations/ contributions made or received on or after Feb. 1, 2019, will be published in the next issue of the O&P Almanac.

MAY 7-8

WASHINGTON, DC

America Prosthet 330 John Alexandr

HOST HOTEL:

RITZ CARLTON PENTAGON CITY 1250 SOUTH HAYES STREET ARLINGTON, VA 22202

JOIN MAY 7-8 WASHINGTON, DC, WWW.AOPANET.ORG YOURUS CONNECTION TO IN EVERYTHING O&P FOR THE 2019 POLICY FORUM Learn the latest legislative and regulatory details and how they will affect you, your business, and your patients. The O&P profession has a great story to tell. Help us educate members of Congress on how the O&P profession restores lives and puts people back to work.

NEW FOR 2019

New schedule with an opening keynote luncheon. New Lobbying 101, pre-event course. Great for first-timers or anyone who just wants a civics refresher course. New breakout discussion sessions.

Register today for the 2019 Policy Forum at bit.ly/policyforum2019 Not familiar or intimidated by Washington D.C.? Take our new Lobbying 101 course. We will provide you with simple and effective measures to familiarize you with the laws, procedures, and how to get your point of view across.

May 7-8, 2019 | Washington, DC HOST HOTEL: RITZ CARLTON, PENTAGON CITY | ARLINGTON, VA

AOPA’s O&P Career Center

Connecting highly qualified O&P talent with career opportunities

EMPLOYEE

• Research who is hiring • Apply online for job openings • Free résumé review

EMPLOYER

• Post your job in front of the most qualified group of O&P professionals • Search anonymous résumé database to find qualified candidates • Manage your posted jobs and applicant activity easily on this user-friendly site.

LOG ON TODAY! 46

MARCH 2019 | O&P ALMANAC

https://jobs.aopanet.org

Recruitment

AOPA Coding Experts ARE COMING TO

Indianopolis

June 3-4, 2019

ATLANTA

FEB. 26-27 | 2018

AOPA MASTERING MEDICARE:

ESSENTIAL CODING & BILLING TECHNIQUES SEMINAR Join AOPA June 3-4 2019, in Indianapolis to advance your O&P practitioners’ and billing staff ’s coding knowledge. Join AOPA for this two-day event, where you will earn 14 CEs and get up-to-date on all the hot topics.

EARN 14 CEs

AOPA experts provide the most up-to-date information to help O&P practitioners and office billing staff learn how to code complex devices, including repairs and adjustments, through interactive discussions with AOPA experts, your colleagues, and much more. Meant for both practitioners and office staff, this advanced two-day event will feature breakout sessions for these two groups, to ensure concentration on material appropriate to each group.

Don’t miss the opportunity to experience two jam-packed days of valuable O&P coding and billing information. Learn more at bit.ly/2019billing.

The Indianapolis Marriott Downtown 350 West Maryland Street Indianapolis, Indiana 46225 Book your hotel by May 10 for the $189/night rate by calling (877) 640-7666 and asking for the AOPA room rate.

Top 10 reasons to attend: 1.

Get your claims paid.

Increase your company’s bottom line.

Stay up-to-date on billing Medicare.

Code complex devices.

Earn 14 CE credits.

Learn about audit updates.

Overturn denials.

Submit your specific questions ahead of time.

Advance your career.

10. AOPA coding and billing experts have more than 70 years of combined experience. Find the best practices to help you manage your business.

Participate in the 2019 Coding & Billing Seminar!

For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. .

www.AOPAnet.org

AOPA NEWS

CAREERS

Opportunities for O&P Professionals

- Northeast - Mid-Atlantic - Southeast - North Central - Inter-Mountain - Pacific

Hire employees and promote services by placing your classified ad in the O&P Almanac. When placing a blind ad, the advertiser may request that responses be sent to an ad number, to be assigned by AOPA. Responses to O&P box numbers are forwarded free of charge. Include your company logo with your listing free of charge. Deadline: Advertisements and payments need to be received one month prior to publication date in order to be printed in the magazine. Ads can be posted and updated any time online on the O&P Job Board at jobs.AOPAnet.org. No orders or cancellations are taken by phone. Submit ads by email to ymazur@AOPAnet.org or fax to 571/431-0899, along with VISA or MasterCard number, cardholder name, and expiration date. Mail typed advertisements and checks in U.S. currency (made out to AOPA) to P.O. Box 34711, Alexandria, VA 22334-0711. Note: AOPA reserves the right to edit Job listings for space and style considerations. O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Listing Word Count 50 or less 51-75 76-120 121+

Member Nonmember $140 $280 $190 $380 $260 $520 $2.25 per word $5 per word

Member Nonmember $85 $150

For more opportunities, visit: http://jobs.aopanet.org.

A large number of O&P Almanac readers view the digital issue— If you’re missing out, apply for an eSubscription by subscribing at bit.ly/AlmanacEsubscribe, or visit issuu.com/americanoandp to view your trusted source of everything O&P.

MARCH 2019 | O&P ALMANAC

Pittsburgh, Pennsylvania De La Torre Orthotics and Prosthetics is seeking a pediatricfocused CO, BOCO, or CPO to join our growing pediatric orthotics practice. The qualified candidate will see patients in our local clinical offices, various physical therapy departments, and rehab facilities in the greater Pittsburgh area. The candidate will be working primarily with children but will also have exposure to our adult patients. Requirements: • A minimum of two years of recent, successful patientbased experience in orthotics, preferably in pediatrics • Must work well in a team environment • Excellent oral communication skills with patients and referral sources • Ability to learn and use an EMR system • Experience with scoliosis, CP, spina bifida, pectus, plagiocephaly, and lower-extremity orthotics all a plus. De La Torre O&P offers competitive compensation and benefit packages including 401(k), medical, disability policies and certification reimbursement and is an AAP employer. Email résumé to jobs@delatorreop.com with subject line orthotist job.

Nonmember $678 $830

ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org.

Pediatric-Focused CO, BOCO, or CPO

Job location key:

Job Board

Mid-Atlantic

De La Torre Email: jobs@delatorreop.com Subject line: Orthotist job

Pacific

CPO

Southern California A well-established, privately owned, multioffice, ABCaccredited corporation is seeking experienced CPOs who will support the company’s vision, mission, and values and provide premier prosthetic and orthotic patient care to join our team. Candidates must be energetic, self-driven, motivated, and knowledgeable individuals who possess strong clinical, technical, and interpersonal interaction skills. They must be patient oriented and innovative, and desire a long-term career with a growing company. We offer competitive salaries, benefits, and a rewarding place to take the next step in establishing a great career and make a difference. Salaries are commensurate with experience. Local ABC-accredited practitioners are preferred. Apply by email to: Email: Box100@AOPAnet.org Reference Job ID: 45402723

CAREERS Southeast

2019 AOPA Coding Products

CPO

Miami-Dade and Broward County, Florida Mahnke’s Orthotics & Prosthetics is looking for a selfmotivated, experienced CPO who wants to join a team dedicated to outstanding patient care for the MiamiDade and Broward County, Florida, area. The position requires excellent communication and time-management skills. Our company offers competitive salary. Mahnke’s Orthotics & Prosthetics Email: mahnkesop@gmail.com www.mahnkesop.com

WANTED! A few good businesses for sale. Lloyds Capital Inc. has sold over 150 practices in the last 26 years.

Get your facility up to speed, fast, on all of the O&P Health-Care Common Procedure Coding System (HCPCS) code changes with an array of 2019 AOPA coding products. Ensure each member of your staff has a 2019 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors.

If you want to sell your business or just need to know its worth, please contact me in confidence. Barry Smith Telephone: (O) 323-722-4880 • (C) 213-379-2397 e-mail: loyds@ix.netcom.com

• 2019 Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers • 2019 Quick Coders: $30 AOPA members, $80 nonmembers Order at www.AOPAnet.org or call AOPA at 571/431-0876.

Realize the facts. O&P care improves quality of life and is cost effective! Learn more at MobilitySaves.org. Reasons to visit MobilitySaves.org

O&P CARE IS A SAVER, NOT AN EXPENSE TO INSURERS!

Visit MobilitySaves.org MobilitySaves.org. Follow us on social media!

Learn about the study proving orthotic and prosthetic care saves money

Find supporting data to get your device paid for

See how amputees rallied when their prosthetic care was threatened

“Search Mobility Saves” on Facebook, Twitter, and LinkedIn

O&P ALMANAC | MARCH 2019

MARKETPLACE

Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac19 for advertising options.

ALPS Smart Seal Liner Our Smart Seal Liner features raised bands that grip to the socket wall to form a secure interface. The bands are coated to ensure longer life and extra security for a smarter seal. The Smart Seal Liner has a new seamless knitted construction with a modern look and is available in locking and cushion suspension. The locking version features a new distal construction to control distal distraction with no matrix. The Smart Seal Liner is just what you need to achieve great suspension! Call us or visit www.easyliner.com for more details.

Apis Apis custom program offers practitioners best options and services for patient compliance. All products are covered under risk-free guaranteed fit promise. We stand firmly behind our words. Call us at 1-888/937-2747.

The Original Pre-Flexed Suspension Sleeve ESP created the Flexi family of suspension sleeves as a comfortable, durable, and cost-effective alternative to traditional suspension sleeves. Pre-flexed at 43 degrees for maximum comfort and natural unrestricted movement. For more information, call ESP LLC at 888/932-7377 or visit www.wearesp.com.

MARCH 2019 | O&P ALMANAC

Sutti Bounders Store and Return Energy— Mimicking Normal Muscle Function New “Sutti Bounders” modular pediatric dynamic elastomers are a patent-pending elastomer technology that offer two progressive solutions. Sutti Bounders store and return energy—mimicking normal muscle function to produce both eccentric and concentric contractions and, if needed, a ground-reaction force. Smart and simple modular design, standardized sizes, and three levels of performance to choose from add up to an easy-to-use expandable dynamic system to treat your pediatric and young adult patient base. For more information, visit www.fabtechsystems.com/ bounders or call 1-800/322-8234.

Fillauer 5x Al Aluminum • Lightweight aluminum body • Canted “fingers” allow visual feedback • Canted shape allows the user to pick up paper, coins, and other small fine objects from the side with ease • Available in 1/2-20 in. or M12x1.5 mm thread • Variety of anodized colors available: black, blue (pictured), gold, or red (pictured). For more information, visit www.Fillauer.com.

Motion Control’s Next-Generation ETD2 A U.S. Department of Defense grant, awarded to Motion Control of Salt Lake City, Utah, funded development of a new Electric Terminal Device and wrist system. For many in U.S. military hospitals, the ETD is the first-choice hand replacement for function and versatility. The ETD is the only device that achieves true resistance against water, dirt, dust, and grease. The next generation ETD2 is available now. For more information, contact Motion Control, a division of Fillauer, at 1-888/696-2767, or visit www.UtahArm.com.

MARKETPLACE Discover Ottobock’s X-ible Flexure Joints

LEAP Balance Brace Hersco’s Lower-Extremity Ankle Protection (LEAP) brace is designed to aid stability and proprioception for patients at risk for trips and falls. The LEAP is a short, semirigid ankle-foot orthosis that is functionally balanced to support the foot and ankle complex. It is fully lined with a lightweight and cushioning Velcloth interface, and is easily secured and removed with two Velcro straps and a padded tongue. For more information, call 800/301-8275 or visit www.hersco.com.

X-ible joints are flexible, self-aligning joints featuring a free-motion or dorsi-assist function. • Small, lightweight • No preassembly or extra tools required, making fabrication incredibly efficient • Aesthetically pleasing flat design • Available in adult and pediatric sizes. X-ible joints are great for use with orthoses designed to address dorsiflexion weakness, valgus/varus deformities, and ML instabilities. For more information, call 800-328-4058 or visit professionals.ottobockus.com.

Naked Prosthetics Naked Prosthetics designs and manufactures high-quality prosthetic devices specifically for finger loss. Our mission is to assist people with digit amputation(s) and positively impact their lives with fully articulating, custom finger prostheses. Our product aims to restore the ability to perform most tasks, supporting job retention and an active lifestyle. Our customers have lost fingers to power tools, equipment malfunctions, injury in the line of military service, random accidents, and infections; in some cases, multiple digits have been lost. NP provides a viable functional prosthesis, as opposed to a passive cosmetic solution. Our design mimics finger motion and utilizes the remainder of an amputee’s digit to power the device. For more information, visit www.npdevices.com.

MyoBock Accessory Kits From Ottobock With the new MyoBock Accessory Kits, we have simplified ordering an upper-limb prosthesis. By combining our best myoelectric accessories into a single purchase, we’ve taken the guesswork out of choosing componentry. Visit professionals. ottobockus.com or speak with your sales rep to order. For more information, call 800-328-4058 or visit professionals.ottobockus.com.

Discover PROTEOR USA

Proprio Foot® Proprio Foot® debuted in 2006 with a simple goal: to reduce trips and falls. This latest-generation microprocessor ankle, built upon a Pro-Flex® LP foot module, provides 44 percent more toe-off power—taking us one step closer to our goal. Visit ossur.com/proprio-foot to learn more.

Delivering an extensive, progressive product line that includes everything today’s active amputees need to live the life they love. Offering an innovative portfolio that includes everything from the virtually indestructible RUSH Foot collection to the world’s first microprocessor-controlled hydraulic four-bar knee with both stance and swing functionality, the ALLUX. The EASY RIDE, multi-use extreme sports knee to the KEASY, renowned prefabricated cones. The K2 GERY foot to the flexible, all-terrain, DynaTrek foot. Discover the exciting PROTEOR USA product line today! A whole new look. A whole new vibe. A whole new world. #HumanFirst. Visit us at proteorUSA.com. O&P ALMANAC | MARCH 2019

MARKETPLACE Propulsion / Pre-Preg Carbon Fiber

JAWS Prehensor

Propel your stride to perfection with Propulsion® bracing from Tillges Technologies. The Propulsion bracing line includes custom-fabricated, dynamic response, pre-preg carbon-fiber AFO, partial foot prosthesis, and KAFO brace designs. These designs are crafted using dynamic response carbon fiber, which stores energy to aid in ambulation. To learn more or to place an order, visit tillgestechnologies.com/fabrication/ propulsion or call 1-855-4TILTEC. For more information, contact Tillges Technologies at 1-855-4TILTEC (484-5832) or visit www.tillgestechnologies.com.

JAWS is an innovative, versatile, heavy-duty, voluntary opening prehensor that can be used with and without a cable-harness system. Powerful and adjustable with four grip settings, easily “shift-controlled” by wearer. Perfect for yard, ranch, and farm tools with special capability at handling handlebars for ATVs, snowmobiles, and watercraft. Truly a “cross-over” terminal device with multiple functions and capabilities. Crafted at 5 inches long with aircraft aluminum, stainless steel, and highperformance gripping polymer rubbers. L code 6721. Order now for delivery in February/March 2019. Technical description and video on the website. JAWS IS THE ANSWER For more information, email trsprosthetics.com or call 800/279-1865

AD INDEX

Advertisers Index Company

Website

American Board for Certification in Orthotics, Prosthetics, and Pedorthics

41 703/886-7114

www.abcop.org

ALPS South LLC

www.easyliner.com

800/574-5426

Amfit

31 800/356-3668

www.amfit.com

Apis Footwear Co.

888/937-2747

www.apisfootwear.com

College Park Industries

800/728-7950

www.college-park.com

ESP LLC

888/WEAR-ESP

www.wearesp.com

Fabtech Systems LLC

27, 39

800/FABTECH

www.fabtechsystems.com

Fillauer Companies Inc.

7, 37

800/251-6398

www.fillauer.com

Hersco

1 800/301-8275

www.hersco.com

Naked Prosthetics

www.npdevices.com

Össur

Page Phone

888/977-6693

3 800/233-6263

www.ossur.com

Ottobock

C4 800/328-4058

www.professionals.ottobockus.com

Proteor USA

855/450-7300

www.proteorusa.com

Tillges Technologies

855/484-5832

www.tillgestechnologies.com

TRS

21 800/279-1865

MARCH 2019 | O&P ALMANAC

www.trsprosthetics.com

Help Show Elected Officials

Mobility Saves Members of Congress are working on legislation that can have a very real impact on you, your business, your employees, and most importantly your patients. The Policy Forum is the best opportunity to advocate for your business and bring you face-to-face with your policymakers. The conference gives you the opportunity to explain your business, share how policies will directly affect your business and our profession, and clarify the critical impact O&P intervention has on saving lives.

Educate lawmakers on key issues important to YOU and your PATIENTS: Veterans right to choose their own O&P provider

O&P be excluded from competitive bidding

Patients ability to receive prompt and effective care

O&P care only be provided by qualified individuals

Questions regarding registration, travel or the agenda should be directed to Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0836. Questions regarding programming, congressional visits or key issues should be directed to Devon Bernard dbernard@AOPAnet.org or 571/431-0854.

New for 2019 •

New schedule with an opening Keynote luncheon

•

New Lobbying 101, pre-event course. Great for first-timers or anyone who just wants a civics refresher course.

•

New breakout discussion sessions

The 116th Congress, with it it’s wave of activism and fresh faces, is an opportunity for O&P to both educate and reinforce the critical reality that O&P intervention saves lives and money.

HOST HOTEL: Ritz Carlton, 1250 South Hayes Street, Arlington, VA 22202 AOPA has a special rate of $284/night until April 16, 2019.

bit.ly/policyforum2019

CALENDAR

APPLY ANYTIME! BOC Certification. Apply anytime and www.bocusa.org test when ready for the orthotic fitter, mastectomy fitter, and DME specialist certifications. To learn more about BOC’s nationally recognized, in-demand credentials and to apply today, visit www.bocusa.org.

Cascade Dafo Institute

Eight free ABC-approved online continuing education courses for pediatric practitioners. Take anytime, anywhere, and earn up to 11.75 CE credits. Visit cascadedafo.com or call 800/848-7332.

2019

April 10

Shoes, External Breast Prostheses, Surgical Dressings, and Other Policies. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

April 18–20

International African-American Prosthetic Orthotic Coalition Annual Meeting. Texas Scottish Rite Hospital for Children, Dallas. Contact Tony Thaxton Jr. at 404/875-0066, email thaxton.ir@comcast.net, or visit www.iaapoc.org.

May 1

ABC: Practitioner Residency Completion Deadline for June Written & Written Simulation Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

May 3–4

March 13

Advanced Beneficiary Notice (ABN): Get To Know the ABN Form. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

March 25

AOPA National Assembly Call for Papers Deadline. For general inquiries, contact Ryan Gleeson at 571/431-0836 or rgleeson@AOPAnet.org, or visit www. AOPAnet.org.

ABC: Orthotic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

May 7-8

AOPA 2019 Policy Forum. Register online at bit.ly/policyforum2019. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

May 8

Are You Compliant? Know the Supplier Standards. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

April 1

ABC: Application Deadline for June Certification Exams. Applications must be received by April 1 for individuals seeking to take the June Written and Written Simulation certification exams. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

April 1

ABC: Practitioner Residency Completion Deadline for Spring CPM Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

April 8–13

ABC: Written and Written Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and technicians in 300 locations nationwide. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

MARCH 2019 | O&P ALMANAC

May 17–18

ABC: Prosthetic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

June 1

ABC: Application Deadline for August Certification Exams. Applications must be received by June 1 for individuals seeking to take the August Written and Written Simulation certification exams. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

June 1

ABC: Application Deadline for Fall CPM Exams. Applications must be received by June 1 for individuals seeking to take the August and September CPM exams. Contact 703/836-7114, email certification@ abcop.org, or visit www.abcop.org/certification.

CALENDAR June 3–4

Coding & Billing Seminar. Indianapolis. SEMINAR Book your hotel by May 10 for the $189/ night rate. For more information, email Ryan Gleeson at rgleeson@ AOPAnet.org.

June 3–8

October 9

Performance Reviews: How Is Your Staff Doing? Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

November 3–9

Health-Care Compliance & Ethics Week. AOPA is celebrating Health-Care Compliance & Ethics Week and is providing resources to help members celebrate. Learn more at bit.ly/aopaethics.

November 13

The Holiday Season—How To Provide Compliant Gifts. Register online at bit. ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

June 12

Documentation—Understanding Your Role. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

December 11

July 10

Target, Probe, Educate—Get To Know WEBINAR the Program & What the Results Are Telling You. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

August 14

Are You Ready for the Worst? WEBINAR Contingency Planning. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

New Codes for 2020, Other Updates, and Yearly Roundup. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

AOPA Supplier Plus Partners Thank you to our AOPA Supplier Plus Partners for their continued support of the association.

September 11

Veterans Affairs Updates: Contracting, Special Reports, and Other News. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

September 25–28

AOPA National Assembly. San Diego Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0836 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.

Calendar Rates CE For information on continuing education credits, contact the sponsor. Questions? Email ymazur@AOPAnet.org. CREDITS

Let us share your next event! Phone numbers, email addresses, and websites are counted as single words. Refer to www.AOPAnet.org for content deadlines. Send announcement and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711, fax 571/431-0899, or email ymazur@AOPAnet.org along with VISA or MasterCard number, the name on the card, and expiration date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit calendar listings for space and style considerations.

Words/Rate

Member

Nonmember

25 or less

$40

$50

26-50

$50 $60

51+

$2.25/word $5.00/word

Color Ad Special 1/4 page Ad

$482

$678

1/2 page Ad

$634

$830

O&P ALMANAC | MARCH 2019

ASK AOPA CALENDAR

Unusual Addresses Billing advice when treating patients in hospice facilities and prisons

AOPA receives hundreds of queries from readers and members who have questions about some aspect of the O&P industry. Each month, we’ll share several of these questions and answers from AOPA’s expert staff with readers. If you would like to submit a question to AOPA for possible inclusion in the department, email Editor Josephine Rossi at jrossi@contentcommunicators.com.

How do I bill for an item I delivered to a patient in a hospice?

When a beneficiary elects hospice care, he or she has elected not to receive any care or treatment for his or her terminal illness. The hospice is only responsible, and being paid for, palliative care—care designed to alleviate the symptoms of, but not treat, the beneficiary’s terminal illness. If the device you are providing is not related to the beneficiary’s terminal illness, you may bill Medicare—and use the GW modifier when you submit your claim. This will indicate that the item or service you provided is unrelated to the beneficiary’s terminal condition.

If a patient is incarcerated, are we able to bill Medicare?

When a beneficiary is incarcerated—under arrest, under supervised release, under home detention, etc.—Medicare would typically not be billed or pay for claims because Medicare presumes that a state or local government that has custody of the Medicare beneficiary has a financial obligation to pay for the cost of health-care items and services. However, if a state or local law requires that incarcerated beneficiaries repay the cost of medical services they receive while in custody, and the state or local government enforces this requirement to pay by actively pursuing the collection of the amounts they owe,

MARCH 2019 | O&P ALMANAC

then Medicare could be billed. When you bill under this scenario, you must append the QJ modifier to your claim. What is Medicare’s reasonable useful lifetime (RUL) for orthoses and prostheses?

The RUL for orthoses and prostheses is determined by program instructions from Medicare. When there are no program instructions, the durable medical equipment Medicare administrative contractors (DME MACs) may establish RULs for orthoses and prostheses, but in no case may a RUL be more than five years. In other words, if Medicare doesn’t establish a RUL for an item, the DME MACs may then create a RUL through policy—but if they don’t create a policy, then the RUL for an item is set at five years. Prostheses have a RUL that is less than five years. Medicare, through the Benefits Improvement and Protection Act (BIPA) of 2000, has provided program instructions for the RUL for prostheses, stating that “prosthetic devices which are artificial limbs” may be replaced at any time regardless of useful lifetime, if the replacement is reasonable and necessary. For orthoses, there are no direct program instructions from Medicare, so the RUL for orthoses is set at five years. The exceptions to this RUL are knee orthoses. In the Knee Orthoses Policy, the DME MACs have established a RUL ranging between one and three years, depending on the type of knee orthosis.

How Does Your Business Measure Up? AOPA Helps Run Your Business

NEW REPORT AVAILABLE

BENCHMARKING: the process of comparing one’s business processes and performance metrics to industry bests.

YOUR REPORT CARD Performance Area:

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Good

Fair

Needs Work

Gross Margin Sales Generated Per Employee

Cost of Goods Sold Compensation & Benefits

AOPA Products & Services

For Orthotic, Prosthetic, & Pedorthic Professionals • Do you need to know how your compensation and benefits compare with similar sized O&P companies or those in your geographic region? • As a forward thinking manager, do you want to know how your company’s financial performance compares with O&P industry leaders? • There is no better industry resource for this type of information. 2018 Operating Performance Report member/nonmember $185/$325

Order Your Report Today!

What are AOPA members saying about the 2018 Annual Operating Performance Report (OPR) and the 2017 Biannual Compensation Report?

“The OPR is one of the most valuable deliverables that AOPA provides….” “Having industrywide benchmarks … gives me data that helps us run our business.”

To order, visit www.aopanetonline.org/store. For more information contact bleppin@aopanet.org or call 571-431-0810.

Know the difference

Michelangelo

Adaptive wrist

• Learn more at professionals.ottobockus.com Ottobock US · P 800 328 4058 · F 800 962 2549 · professionals.ottobockus.com Ottobock Canada · P 800 665 3327 · F 800 463 3659 · professionals.ottobock.ca

Durability

Aesthetic acceptance