April 2016 Almanac

The Magazine for the Orthotics & Prosthetics Profession

AP R I L 2016

Medicare LCDs Examined

This Just In: Awaiting a Consensus Statement P.20

P.16

New Graduates, New Skill Sets P.34

Take Control of Your Business Financials P.40

Policy Article Coding Guidelines

WHERE

Science MEETS ART PRACTITIONERS REVEAL THEIR MOST CREATIVE SOLUTIONS FOR TREATING PEDIATRIC PATIENTS P.24

P.42

E! QU IZ M EARN

4

BUSINESS CE

CREDITS

WWW.AOPANET.ORG

P.16 & 42

YOUR CONNECTION TO

EVERYTHING O&P

NEW!

AOPA 2016

POLICY

FORUM

You can make a difference!

AOPA O&P Legislation Writing Congress and Policy Forum

APRIL 26-27, 2016

Join us for a new Policy Forum experience!

Former Senator Bob Kerrey will preside over a special session to write a simple one-to-two page piece of legislation to take to the Hill to educate your lawmakers. This is your opportunity to make your voice heard and participate in a landmark event.

Why should you attend?

Educate lawmakers on the issues that are important to YOU: • Participate in the 2016 O&P Legislation Writing Congress • Ensure O&P has fair representation in any O&P LCDs • Make sure Prior Authorization is administered fairly • Help curb RAC audit practices that harm honest providers and don’t prevent fraud • Prevent the expansion of off-the-shelf orthoses and competitive bidding

The 2016 AOPA O&P Legislation Writing Congress and Policy Forum will be held April 26-27 in Washington, DC. Visit bit.ly/aopapolicyforum for more information. Your appointments with your legislators will be arranged by AOPA staff and lobbying team.

Meet your member of Congress and tell them how, through orthotics and prosthetics:

Support your profession!

Make your plans now to attend the 2016 AOPA O&P Legislation Writing Congress and Policy Forum.

American Orthotic & Prosthetic Association

www.AOPAnet.org

THE LATEST

THE MPK THAT JUST WON’T BUCKLE !

Proven durability and dependability MPK with pinpoint programmable gait accuracy

Full range adjustable geometric stance control

Advanced Pneumatics with extremely high exion resistance

Trouble free low maintenance.

5-bar stability, fully adjustable stance exion

Fully programmable centrode Record-able gait data for seamless Bluetooth transfer to another Stealth MP Knee Patient weight: up to 275 lb

This latest New technology detects instantly any change in knee 3-D positioning. The programmable Stealth microprocessor translates the data and provides the optimum extension--exion resistance. Its advanced Pneumatics with unheard of high compression ratio never requires adding air. It can easily be set to provide the desirable resistance while walking down an incline or stairs.

contents

APR I L 2016 | VOL. 65, NO. 4

FEATURES

DEPARTMENTS | COLUMNS Views From AOPA Leadership......... 4 Eileen Levis discusses changes in health-care delivery

AOPA Contacts............................................6

COVER STORY

How to reach staff

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

At-a-glance statistics and data

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

Research, updates, and industry news PHOTO: Presque Isle Medical Technologies

24 | Where Science Meets Art Orthotists and prosthetists encounter some of their greatest challenges when treating pediatric patients. Learn how several practitioners have channeled their creative instincts to develop unique treatment plans for children, including devices for very small neonatal patients, school-age children seeking solutions for extracurricular participation, and pediatric patients who are benefitting from new materials.

By Christine Umbrell

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

Transitions in the profession

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

The LCDs of the Medicare Policies

A breakdown of the coverage issues involving medical necessity

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

CREDITS

20 | This Just In

Awaiting a Consensus Statement

P. 20

Compliance Corner...............................42

Coding Guidelines

Tips for complying with Medicare coding requirements

Representatives from AOPA and the O&P Alliance met with CMS officials to discuss the recently formed Interagency Committee, which is tasked with studying best practices in the care of Medicare amputee beneficiaries in the wake of the proposed Local Coverage Determination for lower-limb prosthetics. Here's what happened.

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

CREDITS

Member Spotlight.................................46 n n

34 | Here Comes the New Guard

P. 34

This spring, a new class of students will be graduating from O&P master's programs. These fresh professionals have new skill sets and expectations for the workplace, and O&P business owners should be prepared to listen.

In the final installment of a three-part series on the financial aspects of running an O&P facility, the O&P Almanac shares tips on how to prepare effective income statements, balance sheets, and monthly cash flow models.

By Jim Weber

AOPA News............................................... 50

AOPA meetings, announcements, member benefits, and more

Welcome New Members .................. 52 Marketplace.............................................. 53

By Adam Stone

40 | Managing By the Numbers

ComfortFit Orthotic Labs Inc. Bremer Prosthetics

Careers......................................................... 58

P. 40

Professional opportunities

Calendar..................................................... 60

Upcoming meetings and events

Ad Index....................................................... 62 Ask AOPA...................................................64

Sequestration pricing and office hour requirements

O&P ALMANAC | APRIL 2016

3

VIEWS FROM AOPA LEADERSHIP

Maneuvering Changes in Health-Care Delivery

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

By EILEEN LEVIS

A

S WE WELCOME APRIL and the change of the seasons, one can't help but reflect on “change.” No single industry is experiencing the level of change that is occurring in health care. I believe the most dramatic changes center around the way health care is delivered and payment reform.

The CMS Alliance to Modernize Healthcare was asked last year to convene a national initiative to drive alignment in payment approaches across the private and public sectors of the U.S. health care system. The Health-Care Payment Learning and Action Network (LAN) was established as the collaborative network of public and private stakeholders. Those stakeholders include health plans, providers, patients, employers, consumers, state and federal agencies, and other partners within the health-care community. The consensus among members of the LAN is that a payment system oriented toward volume as opposed to value is ill suited to support the “triple aim” of better care, smarter spending, and healthier people. The U.S. healthcare system, therefore, must substantially reform its payment structure to incentivize quality, health outcomes, and value over volume.

Enter the alternative payment model framework: The LAN Guiding Committee convened an Alternative Model Framework and Progress Tracking Workgroup to create a framework for categorizing alternative payment models and standardized methods for measuring the progress in the adoption of alternative payment models.

The original four categories were fee-for-service with no link to quality or value, feefor-service linked to quality and value, APM’s build-on fee-for-service architecture, and population-based payment. The four categories were broken into subcategories that included pay-for-reporting, rewards/penalties for performance, gain sharing, risk sharing, condition-specific payment, and comprehensive population-based payment.

Definitions were established for several key terms: • Quality: Appropriate and timely care that is consistent with evidence-based guidelines and patient goals, but also results in optimal patient outcomes and patient experience; quality is evaluated using the harmonized set of process outcome, patient-reported outcome, and patient experience measures, and by ensuring report results can be meaningfully accessed and understood by patients and consumers.

• Cost-effectiveness: Level of severity-adjusted total costs that reflect benchmarked best achievable results and are consistent with the competitive marketplace.

• Patient engagement: This encompasses the important aspects of care that improve the patient experience, enhance shared decision making, and ensure that patients and consumers achieve their health goals.

So what does this mean for O&P? Our world is changing. Although I doubt feefor-service will disappear entirely, it will look very different in the very near future and could be incorporated into an upside reward or downside penalty. Our services may be bundled into “episodes of care or population-based payment.” When you hear news of accountable care organizations, hospital integration, and patient-centered medical homes, they all represent changes to care delivery and incorporate alternative payment models.

So what can you do? The leaders in our industry have focused on survival imperatives for many years. We have all been beneficiaries of that initiative.

Staying engaged and informed, and positioning yourself now, is the key.

Eileen Levis is president and CEO Orthologix LLC, and a member of AOPA board of directors. Reach her at eileen@orthologix.com.

4

APRIL 2016 | O&P ALMANAC

Board of Directors OFFICERS

President James Campbell, PhD, CO, FAAOP Hanger Clinic, Austin, TX President-Elect Michael Oros, CPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Vice President James Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO Immediate Past President Charles H. Dankmeyer Jr., CPO Arnold, MD Treasurer Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA DIRECTORS David A. Boone, PhD, MPH Orthocare Innovations LLC, Mountain Lake Terrace, WA Maynard Carkhuff Freedom Innovations LLC, Irvine, CA Eileen Levis Orthologix LLC, Trevose, PA Pam Lupo, CO Wright & Filippis and Carolina Orthotics & Prosthetics Board of Directors, Royal Oak, MI Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Dave McGill Össur Americas, Foothill Ranch, CA Chris Nolan Endolite, Miamisburg, OH Bradley N. Ruhl Ottobock, Austin, TX

New!

shark-o™ Charcot Orthosis

Custom to Cast or Scan from all industry standard file formats. Features: Liner made from ¼" aliplast foam. Outer shell constructed of polypropylene for maximum control of the foot and ankle complex. Molded copolymer anterior internal shell to limit shear forces and lock the leg in securely. Tri-laminated foot bed consisting of two densities EVA and one layer of P-Cell® to help protect the foot during treatment.

INDICATIONS Used for the prevention and management of pressure ulcers caused by ischemia, direct trauma and/or repetitive stress often found in persons with: • Diabetes Mellitus • Charcot deformity • Decreased sensation and/or paralysis • Foot fractures The “shark-o style” CROW Orthosis is a viable design that makes fitting and follow-up of the Charcot foot easier and more effective. Its design features reduce orthosis weight and pressure to the plantar foot surface as compared to the traditional CROW.

Patent pending design allows adjustable volume changes of the calf while leaving the foot at a set volume. This is achieved by overlapping the foot section, locking it in place while at the same time smoothly underlapping the calf area allowing the anterior shell to slide easily under the posterior.

This transition is made possible by the notched wedge shaped trim cutout at the ankle/instep. The patient can easily adjust for daily calf volume (edema) changes with simple strap adjustments.

© 2016 Orthomerica Products, Inc.

877-737-8444 | www.orthomerica.com

US & International Patents Pending All Rights Reserved.

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 Thomas F. Fise, JD Editorial Management Content Communicators LLC

Our Mission Statement The mission of the American Orthotic & Prosthetic Association is to work for favorable treatment of the O&P business in laws, regulation, and services; to help members improve their management and marketing skills; and to raise awareness and understanding of the industry and the association.

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.

EXECUTIVE OFFICES

REIMBURSEMENT SERVICES

Thomas F. Fise, JD, executive director, 571/431-0802, tfise@AOPAnet.org

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

Don DeBolt, chief operating officer, 571/431-0814, ddebolt@AOPAnet.org

MEMBERSHIP & MEETINGS Tina Moran-Carlson, CMP, senior director of membership operations and meetings, 571/431-0808, tmoran@AOPAnet.org Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, koneill@AOPAnet.org Lauren Anderson, manager of communications, policy, and strategic initiatives, 571/431-0843, landerson@AOPAnet.org Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org Yelena Mazur, membership and meetings coordinator, 571/431-0876, ymazur@AOPAnet.org Ryan Gleeson, meetings coordinator, 571/431-0876, rgleeson@AOPAnet.org AOPA Bookstore: 571/431-0865

6

APRIL 2016 | O&P ALMANAC

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@ AOPAnet.org Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com

O&P ALMANAC Thomas F. Fise, JD, publisher, 571/431-0802, tfise@AOPAnet.org Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com Catherine Marinoff, art director, 786/293-1577, catherine@marinoffdesign.com Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/662-5828, cumbrell@contentcommunicators.com

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Dartmouth Printing Company 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 almanac@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.

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

Copyright © 2016 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.

Advertise With Us! Reach out to AOPA’s membership and more than 13,000 subscribers.

Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net.

Visit bit.ly/aopamediakit for advertising options!

2016 Early Spring Collection Consummate style, superior comfort and industry-leading construction showcase this new collection of Apex footwear.

Each pair is meticulously crafted with the highest quality materials and designed for agility and ultimate durability.

Apex is proud to offer this new collection while continuing its long tradition of manufacturing the finest foot health products available on the market today.

For our new catalog or to order Call 800-252-2739 or log onto apexfoot.com

TM

NUMBERS

Amputation Data From Community Hospitals More than 30,000 below-knee and 20,000 above-knee amputations were performed in 2013

>10,000 UPPER-LIMB AMPUTATIONS

7,835

Finger amputations

965

Thumb amputations

160 405

Amputations through forearm

480

Amputations through humerus 8

70

Forequarter disarticulations

130

Wrist disarticulations

Amputations through hand

155

Elbow disarticulations

165

Shoulder disarticulations

APRIL 2016 | O&P ALMANAC

>144,000 LOWER-LIMB AMPUTATIONS

67,185 Toe amputations

18,290 Amputations through feet

33,325 22,310 Above-knee amputations

305

Hindquarter amputations

760

Ankle disarticulations

880

Amputations through malleoli

AMPUTATIONS BY AGE 6% 85 and Older

1% Newborn-17 11% 18-44

36% 65-84 46% 45-64

AMPUTATIONS BY GENDER 31% Female

Below-knee amputations

735

Knee disarticulations

470

Hip disarticulations

69% Male

AMPUTATIONS BY PAYOR TYPE 4% 7% Other Uninsured

<1% Missing

18% Private Insurance 14% Medicaid *Numbers have been rounded

56% Medicare

SOURCES: Health-Care Cost and Utilization Project Database, hcupnet.ahrq.gov; data complied by the Amputee Coalition. PHOTO: iStock.com/martince2

The Agency of Health-Care Research and Quality from the U.S. Department of Health and Human Services has released its latest data on amputations performed in 2013 at community hospitals that are part of the Health-Care Cost and Utilization Project (HCUPnet). Community hospitals are defined as short-term, nonfederal, general, and other hospitals, excluding hospital units of other institutions (e.g., prisons). National and regional HCUP data include obstetric/ gynecological; ear, nose and throat; orthopedic; cancer; pediatric; public; and academic medical hospitals. They exclude long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals, but these types of discharges are included if they are from community hospitals.

The ‘K’ is silent. The style, loud & clear!

New Knits for Spring

Consummate style, superior comfort and industry-leading construction showcase this new collection of Apex footwear. Each pair is meticulously crafted with the highest quality materials and designed for agility and ultimate durability.

For our new catalog or to order Call 800-252-2739 or log onto apexfoot.com

The Apex FitLite™ Collection Men’s Bolt

Women’s Breeze

TM

Happenings CALL FOR PROPOSALS

RFP Issued for O&P Pilot Grants AOPA, in partnership with the Center for O&P Learning & Evidence-Based Practice (COPL), has announced a Request for Pilot Grant Proposals in 16 potential areas of orthotic and prosthetic research, including an open topic. The topics include orthotic management of osteoarthritis; sockets—methods for measuring proper socket fit and alignment; and utilization and comparative effectiveness of lumbosacral orthoses/ thoracolumbosacral orthoses. The deadline to apply is April 30, 2016.

Details are available at bit.ly/opgrants.

EXHIBITOR UPDATE

AOPA Opens Floor Space at National Assembly

10

APRIL 2016 | O&P ALMANAC

Veterans Receive Embedded Prostheses in VA Clinical Trial Two military veterans have become the first amputees in the United States to be surgically implanted with percutaneous osseointegrated prostheses. Surgeons at the George E. Wahlen Department of Veterans Affairs (VA) Medical Center in Salt Lake City performed osseointegration procedures on veterans Bryant Jacobs and Ed Salau in December and February.

During the initial procedures, lead surgeons Erik Kubiak, MD, and Jayant Agarwal, MD, embedded a titanium stud into the femur of each patient.

Six weeks later, they attached a docking mechanism for the prosthesis.

Both Jacobs and Salau have used traditional prostheses in the past, but have suffered from blisters and open sores on their residual limbs that have prevented them from wearing prostheses for extended periods of time. The VA surgeons believe the new prosthesis design will eliminate some of the extra physical effort Jacobs and Salau must put into walking with traditional devices. With their new implants, the leg post picks up the natural vibrations

of the bone and “communicates” with the prosthesis, similar to a hipreplacement implant that attaches to a bone, say the researchers.

Prior to their surgeries, Jacobs and Salau underwent a series of tests to establish how much energy they expended using their socket prostheses.

Researchers are comparing pre- and postsurgical data to determine the change in energy expenditure with the new devices. The researchers say they hope to see as much as a 30 percent reduction in energy expenditure.

The osseointegration procedure used at Wahlen has been shown to prevent infection in preclinical studies, according to the researchers; infections have been a problem for osseointegration patients in Europe. The researchers will monitor the patients closely for signs of new infections.

The clinical trial is part of a U.S. Food and Drug Administration-approved feasibility study to determine the safety and function of the new implant, and is supported by several grants. Nine other people in the United States will participate in the clinical trial and are expected to be implanted with percutaneous osseointegrated prostheses in the coming months.

PHOTOS: KSL-TV

AOPA is currently accepting exhibit applications for the 2016 National Assembly, which will take place Sept.

8-11, 2016, at the Hynes Convention Center in Boston. The AOPA National Assembly will feature dedicated tracks of the most relevant education for prosthetists, orthotists, technicians, pedorthists, and business managers. See the floor plan, current exhibitors, and more information at bit.ly/2016exhibit.

RESEARCH ROUNDUP

HAPPENINGS

LATE BREAKING NEWS

AOPA’s Efforts Pay Dividends on Proof of Delivery Requirements Last year, the four durable medical equipment Medicare administrative contractors (DME MACs) released a clarification on the type of information that must be included on a valid proof of delivery (POD). The DME MACs stated that the inclusion of the official L-code descriptor, which were the accepted norm for years, are not sufficient on PODs, and that suppliers/providers must include narrative descriptions and/or manufacturer information (serial number, part number, model number, manufacturer name, brand name, etc.). As a result of this sudden shift in policy, the claims of numerous providers/suppliers were denied due to invalid PODs, which had been valid prior to the DME MAC clarification.

AOPA challenged the excessive specificity of that new POD policy, citing the problems it posed for O&P

patient-care providers. AOPA sent a letter to CMS’s Laurence Wilson, director of the Chronic Care Policy Group, and Shantanu Agrawal, MD, CMS’s deputy administrator and director of the Center for Program Integrity. AOPA’s letter argued that only the U.S. Food and Drug Administration received authority from Congress to require serial numbers and other unique device identifiers, and that CMS could not enforce such a “de facto” serial number requirement in the absence of explicit congressional authority. AOPA also addressed the issue of the new POD requirements with the comments submitted in regard to the draft lower-limb prosthesis policy released in July 2015.

All of this work has paid off: AOPA recently learned that CMS has reversed course and will now accept the official L-code descriptors on PODs. Effective

March 4, 2016, the Program Integrity Manual, specifically Chapter 4; Section 4.26.1 - Proof of Delivery and Delivery Methods, has been updated and includes the following statement: “The long description of the Health-Care Common Procedure Coding System (HCPCS) code, for example, may be used as a means to provide a detailed description of the item being delivered; though suppliers are encouraged to include as much information as necessary to adequately describe the delivered item.”

While the complete Program Integrity Manual indicates that “suppliers are encouraged to include as much information as necessary to adequately describe the delivered item,” PODs that include the complete HCPCS code descriptors can no longer be considered invalid or result in a denial of the claim.

RESEARCH ROUNDUP

Swiss Researchers Develop ‘Smart Shoe’ To Relieve Foot Ulcers

PHOTO: ©EPFL / Alain Herzog

Scientists at the École Polytechnique Fédérale de Lausanne (EPFL) in Switzerland have partnered with the Geneva University Hospitals in developing a shoe sole with valves that electronically control the pressure applied to the arch of the foot. The “smart shoe” is designed to alleviate foot ulcers caused by diabetes, and to help prevent the onset of new ulcers and, ultimately, amputations.

Many diabetics are unaware of how serious their ulcers are and continue to walk normally, which prevents ulcers from healing. When the lesions reach the bone, there is an increased risk of secondary infection and gangrene. To prevent these complications, the Swiss researchers sought a way to remove all pressure from the ulcers at initial appearance, and to keep pressure away from the ulcers so they can heal properly.

EPFL researchers have developed a shoe sole with valves that electronically control the pressure applied to the arch of the foot.

The goal is to relieve foot ulcers commonly caused by diabetes and help them heal to avoid dangerous secondary infections.

They designed a prototype sole with approximately 50 small electromagnetic valves filled with magnetorheological material. The rigidity in different parts of the shoe sole can be controlled separately, according to the location of the wounds. “We can control the viscosity of the material, which is made up of suspended iron microparticles,” said Yves Perriard, director of the EPFL’s Integrated Actuators Laboratory.

“When we apply a magnetic field, the particles react immediately and align themselves with it, causing the

material to change from liquid to solid state in a fraction of a second.”

The EPFL research team cites several advantages compared to more traditional solutions; for example, bandages and pressure-relief insoles are more restrictive and must be frequently adjusted. “The advantage of this shoe is that, in addition to relieving the arch of the foot wherever necessary, it immediately adjusts the pressure as some ulcers heal and others appear,” says Zoltan Pataky, an internal medicine specialist at Geneva University Hospitals.

O&P ALMANAC | APRIL 2016

11

HAPPENINGS

RESEARCH ROUNDUP

Prosthetic Fingertip Facilitates Sensation Dennis Aabo Sørensen recently became the first amputee to feel smoothness and roughness in real time using an artificial fingertip. Sørensen used a bionic fingertip connected to electrodes that were surgically implanted above his residual limb, using technology developed by Silvestro Micera and

his team at the École Polytechnique Fédérale de Lausanne in conjunction with the Biorobotics Institute of Scuola Superiore Sant’Anna.

Nerves in the patient’s arm were wired to an electrode-equipped prosthetic fingertip. A machine controlled the movement of the Amputee Dennis Aabo Sørensen holds a bionic fingertip and textured plastic in his right hand.

CODING CORNER

Jurisdiction D Releases Prepayment Audit Results for Walking Boots and Shoes 66% of claims for off-the-shelf walking boots were denied.

84% of claims for A5500 diabetic shoes were denied.

12

APRIL 2016 | O&P ALMANAC

Noridian Healthcare Solutions LLC, the Jurisdiction D durable medical equipment Medicare administrative contractor (DME MAC), has released prepayment audit results for off-the-shelf (OTS) walking boots described by Health Care Common Procedure Coding System (HCPCS) code L4361 and diabetic shoes described by HCPCS code A5500.

During the prepayment audit for OTS walking boots, 74 out of 110 claims were denied, resulting in a claim denial rate of 66 percent. Primary denial reasons included a lack of documentation supporting the medical need for the walking boot, incomplete or missing medical records, incomplete or nonexistent proof of delivery documentation, and a missing or incomplete detailed written order. Based on the results of the initial

prepayment probe review, Jurisdiction D announced it will begin a widespread prepayment review of all claims submitted for L4361.

During the prepayment audit for diabetic shoes described by A5500, 3,354 out of 3,949 claims were denied, resulting in an overall claim denial rate of 84 percent. Primary denial reasons included no response to the additional documentation request, lack of documentation of an in-person visit with the supplier of the shoes at the time of delivery, lack of documentation of one of the prerequisite conditions by the certifying physician, and lack of documentation by the certifying physician that he or she is treating the patient’s systemic diabetic condition. Based on the current results of the ongoing prepayment audit for diabetic shoes, Jurisdiction D will continue to audit claims for A5500 on a prepayment basis.

PHOTOS: ©EPFL / Hillary Sanctuary

Detail of the bionic fingertip electronics that restored sensations of texture to amputee Dennis Aabo Sørensen, and the plastic gratings with rough and smooth textures

fingertip over different pieces of plastic engraved with smooth or rough patterns. As the fingertip moved across the textured plastic, the sensors generated an electrical signal. That signal was translated into a series of electrical spikes, then delivered to the nerves. Using this technology, Sørensen correctly identified the surfaces 96 percent of the time.

Calogero Oddo of the BioRobotics Institute reported that this study provides additional evidence “that research in neuroprosthetics can contribute to the neuroscience debate, specifically about the neuronal mechanisms of the human sense of touch. It will also be translated to other applications such as artificial touch in robotics for surgery, rescue, and manufacturing.”

Details of the study were published in the March in the journal eLife.

HAPPENINGS

PRIOR AUTHORIZATION

Delays Expected in Implementation of Final Rule CMS recently issued a final rule indicating that prior authorization will be part of O&P’s future. However, CMS is expected to take a relatively cautious, long-view approach. While it was originally believed that a list of O&P codes to be subject to prior authorization would be published by the end of February, a delay of six to 12 months seems much more likely, for the following reasons: • CMS would like to see what happens on the pending Local Coverage Determination (LCD) before it sets up a full mechanism for O&P prior authorization.

• CMS sees prior authorization as something of a franchise; so far,

regarding power wheelchairs, it has gotten pretty good reviews, and CMS does not want to risk moving too fast and getting slammed with bad results.

• CMS has heard the comments from AOPA, patients, the O&P Alliance, and others concerning not wanting to have prior authorization result in delays in patients getting their prostheses, and is trying to ensure that the system is sufficiently well-designed that folks who receive a prior authorization approval are not then subject to any postpayment audits.

When a CMS O&P list does become available, an incremental approach with

regional trials is more likely than any immediate national policy.

While any situation with a government agency must be considered somewhat fluid as people and policies can change, AOPA’s assessment on timing is based on a solid sense of reliability of the information we have received, and we are confident that it aligns with current CMS plans and timing. AOPA is offering educational opportunities including webinars, a published guide, and a session at the 2016 AOPA Policy Forum. Learn more about AOPA’s efforts regarding prior authorization at bit.ly/priorauthorization.

PEOPLE & PLACES PROFESSIONALS ANNOUNCEMENTS AND TRANSITIONS

Martin Persson, CPA, MBA, has been named chief financial officer of the Center for Orthotic and Prosthetic Care of North Carolina LLC. David R. Sickles, CPO, CPed, chief operating officer and managing partner of the Center for Orthotic & Prosthetic Care of North Carolina LLC, has been named president. He will be responsible for quality patient care, company growth, efficiencies of systems, employee management, and further development and expansion of Center for Orthotic and Prosthetic Care services throughout North Carolina, New York, and Pennsylvania.

BUSINESSES ANNOUNCEMENTS AND TRANSITIONS

AlliedOP Inc. has announced the acquisition of Rinko Orthopedic Inc., an orthotic and prosthetic provider located in Fair Lawn, New Jersey. This acquisition strengthens AlliedOP’s position in the northern New Jersey marketplace, and further serves to bolster the company’s growing team of O&P practitioners.

14

APRIL 2016 | O&P ALMANAC

The Board of Certification/Accreditation (BOC) has been awarded a Bronze Stevie www.bocusa.org Award for E-Commerce Customer Service in recognition of the organization’s innovative customer service support and social media efforts. The Stevie Awards honor and generate public recognition of the achievements and positive contributions of organizations and professionals.

The recognition was awarded in the category of Customer Service & Contact Center Achievement, and BOC competed against more than 2,100 nominations. Winners were announced on March 4, 2016, at the Stevie Awards ceremony in Las Vegas. This is the fifth Stevie Award BOC has received in four years.

Create Prosthetics in Lake Placid, New York, has partnered with war veteran and double amputee Corie Mapp, a Paralympic bobsledder from Great Britain, in naming Mapp as the company’s first sponsored athlete. Mapp is currently ranked second in the world among Paralympic bobsledders, and he recently became the first bilateral amputee to pushstart a bobsled. Mapp is now using 3D-printed covers on his prosthetic legs, made by Create Prosthetics.

The Prosthetic Care Facility of Virginia has been selected for the 2016 Best of Leesburg Award in the Prosthetic Clinic category by the Leesburg Award Program. The program identifies companies that have achieved exceptional marketing success in their local community and business category.

“By just moving my hand, I can change grips – now if only math were so simple!”

Josh Cathcart (age 9) - i-limb quantum user

precision. power. intelligent motion.

The first multi-articulating prosthesis that can be controlled with simple gestures.

Available in 4 sizes (extra small, small, medium, large) Now compatible with Apple Watch

find out more about gesture control using Touch Bionics’ patented i-moTM technology www.touchbionics.com

technology that touches lives

REIMBURSEMENT PAGE

By DEVON BERNARD

The LCDs of the Medicare Policies

E! QU IZ M EARN

2

BUSINESS CE

CREDITS P.19

Examining the coverage issues involving medical necessity

Editor’s Note—Readers of CREDITS Reimbursement Page are now eligible to earn two CE credits.

After reading this column, simply scan the QR code or use the link on page 19 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

CE

96

L43

J

UST BECAUSE YOU THINK you

know something, doesn’t always mean you are right. You may have read the Medicare coverage policies hundreds of times, but it is possible you may have overlooked some important information.

This month’s Compliance Corner article on page 42 reviews some aspects of the Policy Article portion of the Medicare policies, so this month’s Reimbursement Page takes a look at the Local Coverage Determination (LCD) portion—the portion that addresses coverage issues that involve medical necessity. We also will focus on some of the often misconstrued or overlooked parts of the LCDs.

AFO/KAFO Policy

L4

39

16

7

APRIL 2016 | O&P ALMANAC

Besides a CROW boot, the only other ankle-foot orthoses (AFOs) or knee-ankle-foot orthoses (KAFOs) with a specific diagnosis requirement under the AFO/KAFO policy are the static/dynamic positioning orthoses, L4396 and L4397. These two styles of AFOs are covered under one of two circumstances. If the patient has a documented diagnosis of plantar fasciitis, ICD-10 code M72.2, then the L4396 or L4397 would be covered.

The L4396 or L4397 would be considered medically necessary and covered if the following conditions are met: • The patient has a diagnosis of a contracture, ICD-10 codes M24.571-M24.576.

• The patient’s contracture is nonfixed, meaning that the passive range of motion (measured with a goniometer and recorded in the patient’s medical record) is at least 10 degrees.

• The patient meets three other criteria: There should be a reasonable belief that the orthosis will have the ability to correct the contracture; there is documentation that the contracture is or will interfere with the patient’s functional abilities; and the patient is undergoing a documented therapy program of active stretching (the stretching program may take place in a facility or in the patient’s home).

If any one part of the coverage criteria is not met, then the L4396 or L4397 would be considered not medically necessary and denied as such.

Also note that the L4396 and L4397 are not medically necessary for a patient with a foot drop who does not also have an ankle flexion contracture.

When providing any type or style of KAFO, there are three things to keep in mind and document if you are to demonstrate that the KAFO is medically necessary and eligible for payment per the LCD. First, the patient must be ambulatory. Second, he or she must have some type of knee instability for which the knee portion of the KAFO is required. The policy does not distinguish what type of knee instability is required (no specific diagnosis needed), and it does not state that the knee instability must be the result of a recent injury or surgery; it simply states that the knee instability has to be present. Finally, the patient must meet the basic coverage requirements for an AFO. In other words, you must demonstrate, document, or show that the AFO portion of the KAFO also is required; the AFO portion cannot

REIMBURSEMENT PAGE

simply be used as a means of suspending or keeping the knee orthosis (KO) portion in place on the limb.

The basic coverage criteria for an AFO are that there must be a weakness or deformity of the ankle and foot that requires stabilization, and the patient must have the ability or potential to benefit from the AFO. If the basic coverage criteria for either the AFO or KAFO are not met, then the whole orthosis will be denied as not reasonable and necessary.

KO Policy

PHOTO: iStock.com/SoumenNath

The KO policy has very detailed and specific coverage rules: Each brace is tied to a specific diagnosis code; if your patient doesn’t have that specific diagnosis, then the brace is not medically necessary. However, there are still some points of confusion or irregularities that can trip up providers, auditors, or reviewers, such as the requirement of testing and documenting knee instability and joint laxity as it relates to the provision of KOs described by codes K0901, K0902, L1832, L1833, L1843, L1844, L1845, and L1846. The policy creates two independent scenarios regarding when these particular KOs are covered; only one scenario requires the documented testing for knee instability: • Scenario 1: The patient is either ambulatory or nonambulatory and has had a recent injury to and/ or a recent surgical procedure on the knee(s), and has one

of the requisite diagnoses.

• Scenario 2: The patient has not had a recent surgery or injury to the knee(s), the patient is ambulatory, he or she has knee instability, and he or she has one of the requisite diagnoses.

The patient may qualify for coverage as a result of an injury or surgery, and with this scenario there is no need or requirement per policy to document or test for knee instability and joint laxity. However, to qualify for coverage under Scenario 2, there must be a documented presence of knee instability via an acceptable testing method (e.g., the Drawer Test), and an objective description of the joint laxity (e.g., varus/valgus instability) also must be documented. If the record does not contain test results and there is only a subjective description of the joint laxity and knee instability, the KO will be denied as not medically necessary.

In addition to the above criteria in each scenario, if you are providing an L1844 or an L1846, you must document the medical necessity or need—for example, the physical characteristics of the knee (size, muscle mass, deformity, etc.)—for the use of a custom-fabricated orthosis over a prefabricated orthosis.

The need for custom also must be documented in the physician’s record; if this documentation is not present, the custom KO (L1844 or L1846) will be denied as not medically necessary.

What’s more, an L1844 or L1846 is not medically necessary for the care of knee contractures when the patient is nonambulatory.

External Breast Prosthesis Policy

A custom breast prosthesis (L8035) will always be denied as not medically necessary because it has been determined that the medical necessity of the additional features of an L8035 have not been clearly established and show no benefit above a typical breast prosthesis.

The same rationale holds true for the provision of an L8031 (breast prosthesis with integral adhesive). Medicare will always consider the L8031 not medically

46

L18

L1845

necessary because the L8031 has no “clinical advantage” over those prostheses without integral adhesive (L8030).

Regardless of the type of external breast prosthesis provided, Medicare has established the limit of no more than one breast prosthesis per side; any units above one per side will be denied as not reasonable and necessary.

Lower-Limb Prosthesis Policy

When an initial lower-limb prosthesis or a preparatory lower-limb prosthesis is provided, the substitutions of knee/ feet/hip components are typically covered, as long as they are within the patient’s accepted functional level classification. Also, the majority of socket additions/modifications are covered, but certain socket addition codes are not considered medically necessary and will be denied as such if billed to Medicare. These would include such things as the addition of acrylic to the socket (L5629/L5631) and the addition of a valve for suspension or a suction socket (L5647/L5652); this is not an all-inclusive list.

The use of test sockets for the provision of an individual prosthesis is covered. However, any more than two test sockets per prosthesis will be considered not medically necessary, and this does not mean the automatic use of two test sockets is covered; each test socket must be justified.

O&P ALMANAC | APRIL 2016

17

Products & Services For Orthotic, Prosthetic & Pedorthic Professionals

REIMBURSEMENT PAGE

Also, the use of test sockets in the delivery of a prefabricated preparatory prosthesis is considered not medically necessary.

Just as a reminder on the use of functional levels and bilateral amputees, the policy states the following: “It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.” While this statement recognizes there may be certain circumstances where a bilateral amputee may have a need for items that surpass his or her functional level assessment, it does not mean that bilateral amputees have no limits and any components may be delivered without concern. They must undergo a functional level assessment and, in most cases, will only qualify for prosthetic components within their functional level classification. If there is a specific clinical need for prosthetic components that exceed the patient’s functional level classification, the need must be well documented and supported by information in the patient’s medical record. If this information is not available, the prosthesis could be denied as not medically necessary.

Orthopedic Footwear Policy

The provision and coverage for prosthetic shoes described by code L3250 is diagnosis-driven, unlike the provision of other prostheses. The patient must have one of the diagnoses listed in the policy indicating a partial foot amputation, and that specific diagnosis must be included on the claim for each shoe being provided. If a claim is missing the diagnosis code, or an incorrect diagnosis code is used, the claim will

TLSO

18

APRIL 2016 | O&P ALMANAC

AOPA MASTERING MEDICARE:

ESSENTIAL CODING & BILLING TECHNIQUES SEMINAR

SAN ANTONIO

EARN

JUNE 13-14 | 2016

14 CEs

Top 10 reasons to attend: To learn moreCoding about advanced notices and AOPA Expertsbeneficiary Are 1.

Get your claims paid.

Coming toattend San Antonio 2. Increase your company’s medical necessity, the Coding & Billing Seminar in bottom line.

The world of coding and billing has changed dramatically in the past

3. Stay up-to-date on few years.

AOPAAntonio. experts are here for you! The June 13-14 Coding Portland or The San Visit bit.ly/2016billing. billing Medicare. & Billing Seminar will teach you the most up-to-date information to advance the coding knowledge of O&P practitioners and billing staff.

4.

Code complex devices

5.

Earn 14 CE credits.

features hands-on breakout sessions, whereis needed to reduce pain, but be deniedThe asseminar not medically necessary.

6. Learn about audit updates. you will practice coding complex devices, including repairs restricting the Whenand code L3649 is used to describe adjustments. Breakouts are tailored specifically for reduce pain by 7. Overturn denials. and billing staff .brace Take partand in this seminar and mobility of the spine trunk. a custom practitioners shoe attached to a 8. Submitand your specifi c to better your business, your staff, and your patients! questions • The brace is needed to ahead help of intime. is billed with the KX modifier, the claim Don’t miss the opportunity to experience two jam-packed days of Advance the healing of9.the spineyour or career. similar must include a narrative description valuable O&P coding and billing information. Learn more and see 10. AOPA coding and soft tissues after an injury. of the item provided.

The narrative the rest of the year’s schedule at bit.ly/2016billing. billing experts have more than 70 years • The brace is needed to help in ofthe description must state the medical In this audit-heavy climate, can you afford not to attend? combined experience. healing of the spine or similar soft need for the custom shoe as well. tissues after a surgical procedure.

Find the best practices to help you manage your business.

• The brace is needed to support a Spinal Policy Participate in the 2016 Coding & Billing Seminar! weak or deformed spine or support The spinal policy has its own special weakened spinal muscles. modifier, the CG modifier, which is Register online at bit.ly/2016billing. For more information, www.AOPAnet.org email Ryan Gleeson at rgleeson@AOPAnet.org. . required to show that policy criteria The provision and coverage of a spinal have been met and the lumbosacral brace are not dependent on a specific orthosis (LSO) or thoracolumbosacral diagnosis. As long as one of the four orthosis (TLSO) should be eligible scenarios above has been accounted for payment. However, the CG is not for and documented, the brace will required to be used with every LSO and be considered medically necessary. If TLSO base code; it is only to be used a spinal orthosis is provided and the with the following codes: L0450, L0454, coverage criteria are not met, the item L0455, L0621, L0625, and L0628. The will be denied as not medically necessary.

CG modifier may only be applied to those codes if the brace being provided is constructed primarily of nonelastic Surgical Dressings material, or it contains a rigid posterior When providing a covered gradient panel. If the LSO/TLSO being provided compression wrap (A6545) being used does not meet one of those criteria, in conjunction with a surgical dressing, you must use code A4466, and it will and the patient has an open venous stasis be considered a noncovered service. ulcer, the patient is eligible to receive one Also, when providing any LSO per six months per limb. If you provide or TLSO, your records must clearly more than one wrap, each additional wrap document one of four possible condiwill be denied as not medically necessary. tions or reasons why the LSO or TLSO is being ordered, and then the LSO/ Therapeutic Shoes for TLSO would be eligible for coverage.

Persons With Diabetes The conditions include the following: If you are providing inserts indepen• The particular LSO or TLSO dently of providing shoes, meaning

REIMBURSEMENT PAGE

you were not the entity that originally supplied the shoes, the inserts you provide may be covered. However, you must obtain written verification from the original supplier of the shoes stating that the shoes meet the coverage and coding requirements of diabetic shoes. You will need to use caution when providing additional inserts in this scenario; if the patient has already received his or her eligible allotment of inserts or modifications for the year, additional inserts will be denied as noncovered.

If you are providing custom-molded diabetic shoes (A5501), you must clearly document two things within your records. First, document that the patient has a foot deformity that would not be treatable with an offthe-shelf depth shoe. Second, during one of your in-person evaluations, you must take impressions, make casts, or create CAD/CAM files of the patient’s feet to be used in the fabrication of the custom-molded shoes.

If the severity and nature of the

patient’s foot deformity is not documented in your records, then the shoes will be denied as not medically necessary.

ABNs and Beyond

You may have noticed that the majority of the issues discussed above result in denial as not medically necessary or not reasonable and necessary. This does not mean that the items could not be provided to patients, or that the items could not potentially be covered and paid by Medicare. It only means that you may have additional steps to follow, or you may have to work a little harder for payment.

When reviewing the policies and coverage rules and you see the phrase “not medically necessary” or “not reasonable and necessary,” this should automatically trigger you to have the patient sign an advanced beneficiary notice (ABN). An ABN is used to shift liability from you to the patient, but only when traditionally covered Medicare benefits will be denied as

“not medically necessary” or “not reasonable and necessary.” Also, any items that are denied as “not medically necessary” or “not reasonable and necessary” may be appealed. For example, if you can demonstrate that a KAFO is necessary for a patient who is nonambulatory, then it could be paid and covered by Medicare.

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:

www.bocusa.org

Get Ahead of the Curve ONLINE! CHARLESTON BENDING BRACE CERTIFICATION COURSE Upon completion of this 3 hour online course, participants will receive CBB Certification and have ability to order the Charleston Bending Brace.

Course Includes: Background information on scoliosis.

Review of the types of scoliotic curves.

Indications and contradictions for each type of curve.

Unlike most braces used to treat scoliosis, the Charleston Bending Brace offers a major revolutionary approach. Patients wear this nocturnal (nighttime) orthosis only eight to ten hours at night; they therefore may participate in normal daytime activities, including sports.

C. Ralph Hooper, Jr., CPO will be hosting the course.

Registration fee is $350 Course Dates are March 11th, April 8th, May 27th, and June 24th.

The number of participants is limited so please register early at CBB.org.

For more information please contact Natasha Hardina at 843-577-9577 or email her at nhardina@carolinaop.com

O&P ALMANAC | APRIL 2016

19

This Just In

Awaiting a Consensus Statement AOPA and the O&P Alliance meet with CMS officials about the next stage for the LCD

O

N FEBRUARY 26, AOPA

Executive Director Thomas Fise joined other representatives of the O&P Alliance in Baltimore for a meeting with several officials from CMS to discuss the next steps with regard to the proposed Local Coverage Determination (LCD) for lower-extremity prosthetics. CMS officials in attendance included CMS Deputy Administrator/Chief Medical Officer Patrick Conway, MD; Kate Goodrich, MD, the director of the Center for Clinical Standards & Quality; Susan Miller, MD, who has responsibility for the Interagency Committee relating to the proposed LCD; and other CMS staff.

During the meeting, CMS officials explained that the participants in the Interagency Committee, comprised of government employees, have been identified but their names have not been released. The group is expected to generate a consensus statement, but it is likely to take about a year before it is complete. That consensus document is expected to be available for public comment.

20

APRIL 2016 | O&P ALMANAC

Miller noted that the consensus statement, while spawned in the wake of the 2015 prosthetic LCD, is really not about the LCD; instead, it will focus on best practices in the care of Medicare amputee beneficiaries. A question was raised about whether the public would be allowed the access, thus far denied, to see the comments on the LCD. So far, it appears that information is being made available to the Interagency Committee, but not to the public.

The CMS representatives stated they would not be releasing the names of the individuals comprising the Interagency Committee until that group’s work is complete; the participants’ names may be identified in the final consensus statement. While CMS officials said they would take suitable input, especially new scientific articles, there does not appear to be means by which public/stakeholder input from nongovernment individuals—Medicare amputees or others—can be incorporated into the Interagency Committee’s work until after release of the consensus document.

VALVE INTEGRATED VACUUM ACTIVATED

The Valve Integrated Vacuum Activated gel suction suspension sleeve from ALPS offers a superior fit with a built in valve that helps evacuate air in the socket. The VIVA sleeve provides suction suspension without the need for creating a valve in the socket. Made with ALPS GripGel, the VIVA sleeve adheres well to the patient’s limb to prevent the sleeve from rolling down.

The VIVA built in valve helps evacuate air in the socket creating the ideal fit

TEL: 727.528.8566 TEL: 800.574.5426 WWW.EASYLINER.COM INFO@EASYLINER.COM

This Just In

O&P representatives raised questions about the lack of transparency of this proposed approach. It was noted that one of the perceived difficulties with the draft LCD was that it came as a surprise without any stakeholder input, and that there is the possibility that the interagency consensus document may be perceived in the same light. CMS officials noted that to open the process to one meant opening the process to all, which would likely necessitate shifting to a federal advisory committee model and prolong the process.

O&P representatives also raised the issue of the continued presence of the draft LCD on the websites of CMS and the durable medical equipment Medicare administrative contractors (DME MACs). CMS officials responded that the draft LCD is an essential part of the record, and that it would be highly unusual to remove it from the website. O&P representatives noted that since none of the thousands of submitted comments made in response to the draft LCD were made available to the public, the draft LCD is the only document, among thousands of comments and other materials in the record, that has been deemed of sufficient critical importance that is available for website viewing under the CMS/DME MACsâ&#x20AC;&#x2122; mastheads.

The O&P representatives presented data on the reduction in Medicare spending for prosthetics in each of the past four years: There was a cumulative 15 percent reduction from 2010 to 2014. They also shared Medicareâ&#x20AC;&#x2122;s data indicating that spending on advanced prosthetic devices for Medicare beneficiaries (K3 and K4) had dropped 41.6 percent over that four-year period, while the Medicare spending on the cheaper and less advanced technology prosthetics (K1 and K2) had increased 49.9 percent over that same fouryear period; these findings are clear evidence of a change in the standard of care for Medicare amputees. Patients who have K3/K4 technology will now face an uphill battle in securing a comparable replacement when their current device wears out. Miller said 22

APRIL 2016 | O&P ALMANAC

that dollars are irrelevant to the consensus statement, while O&P representatives maintained that the evidence of a downshift in the Medicare prosthetic standard of care is very germane to best practices.

The O&P representatives also distributed a recent article outlining that a very substantial number of amputees never receive a prescription for a prosthetic device, and that with each advancing 10 years of age, the prospect that an amputee receives such a prescription drops 50 percentâ&#x20AC;&#x201D;an especially relevant point for best practices since Medicare beneficiaries fall into those older patient age levels least likely to receive a prescription for a prosthesis, and thereby have significantly reduced access to any prosthetic care.

Time will tell, but all reports indicate it will take approximately a year before we get a resolution to the

question of whether a) CMS takes the policy for lower-limb prosthetics away from the DME MACs and pursues instead a National Coverage Determination; or b) CMS makes the decision, once the consensus statement is published, to release the matter back to the DME MACs for them to resolve as they wish via one or more LCDs. AOPA, in its communications with legislators, has encouraged consideration for both congressional oversight and potential clarification to ensure that the Department of Health and Human Services statutes and rules clearly allow CMS to properly manage the activities of its contractors on the LCD and all other issues.

AOPA supports the concept of a moratorium to ensure clarity through the end of the Obama administration and into 2017, beyond the inauguration of the next president.

THE NEXT STEP IN THE REVOLUTION.

INTRODUCING THE ODYSSEYK3 FROM COLLEGE PARK

Utilizing our patented curved hydraulic ankle technology, the new OdysseyK3速 foot has a higher frequency carbon composite foot base for increased dynamic response.

facebook.com/CollegeParkInd youtube.com/CollegeParkInd

800.728.7950 | 586.294.0067

college-park.com/odysseyk3

COVER STORY

Practitioners reveal their most creative solutions for treating pediatric patients

Where

Science Meets Art

By CHRISTINE UMBRELL

24

APRIL 2016 | O&P ALMANAC

COVER STORY

Need To Know • The pediatric population presents distinct challenges for prosthetists and orthotists because there often are more variables and stakeholders to consider, as well as unique body sizes and shapes, prompting clinicians to be more inventive in some of their O&P design solutions.

• Neonatal patients presenting with congenital anomalies may be too small for off-the-shelf devices, but may grow too quickly for traditional customized orthoses, necessitating creative solutions such as low-temperature designs, foam devices, or hybrid solutions.

• Practitioners can be prompted to fabricate specialized devices, such as sports prostheses or more flexible spinal orthoses, to assist school-age pediatric patients in achieving goals related to extracurricular activities.

• Some clinicians are experimenting with new materials, including advanced silicones and EXOS material, to design custom orthoses and prostheses.

These materials can be more adaptable than traditional materials; they also may allow for child-friendly adaptations such as unique colors.

• One of the most important skills to master when treating the pediatric population is effective communication—with both patients and parents. O&P design solutions should be considered in the context of the entire family.

T

HE ORTHOTIC AND PROSTHETIC profession has traditionally been known as

both a science and an art. While the scientific aspects of patient care cannot be understated, it is the artistic side that challenges practitioners to develop treatment solutions for some of the most unique patients. Nowhere is this more evident than in pediatric patient care.

The pediatric population presents distinct challenges for prosthetists and orthotists because there often are more variables and stakeholders to consider when designing the best device. “When providing pediatric care, you have to understand the goals of the patient, physical therapist, occupational therapist, parents, and other medical providers to create a device that meets all of their needs,” says Chrysta Irolla, MS, MSPO, CPO, a clinician at the Mission Bay Hospital at the University of California—San Francisco (UCSF).

A typical pediatric O&P device must “meet the demands of higher-activity patients, accommodate some growth, and work within the patient lifestyle so it is actually used,” she says.

O&P ALMANAC | APRIL 2016

25

COVER STORY

Kevin Carroll, MS, CP, FAAOP (D)

“They’re looking up information on their smartphones, and they come in asking a lot of questions—and spurring solutions themselves,” he says.

But just how much creativity is needed to develop the best treatment plans for pediatric patients? O&P Almanac spoke to several clinicians about being inventive while working with the smallest patients, meeting patients’ activity goals, designing firstof-their-kind devices, and leveraging new materials for the patients’ benefit.

Infant Orthoses

Thomas DiBello, CO, FAAOP

Practitioners also are challenged when a patient has a medical condition, or when he or she has a personal preference that puts limits on conventional interventions. “Kids come into our clinics asking about new approaches to their care,” says Kevin Carroll, MS, CP, FAAOP (D), vice president of prosthetics for Hanger Clinic.

PHOTO: Hanger Clinic

Lilly Biagini wears silicone adjustable sockets designed by clinicians at Hanger Clinic.

26

APRIL 2016 | O&P ALMANAC

Roughly 600 to 800 children come through the doors of the Lurie Children’s Hospital of Chicago each month, where Bryan Malas, MHPE, CO, serves as director of the orthoticsprosthetics department. The teaching hospital setting attracts many patients with unconventional presentations.

“Sometimes no precedent has been set in terms of orthotic management,” says Malas. “We frequently have to think outside the box while keeping the underlying biomechanical principles in mind.”

Malas says his team tends to be the most creative when dealing with the neonatal population, who frequently present with congenital anomalies.

For children born with loss of range of motion in their upper extremities, off-the-shelf devices may not be small enough, or even warranted, he says.

But it can take too long to go through the stages of taking an impression, designing, and fabricating a custom orthosis because infants grow so quickly from day to day. Instead, Malas and his team often opt for low-temperature designs—“but even with those designs, there’s not a lot of real estate to work with on a body so small.” In some cases, the team simplifies treatment by creating foam devices to place around the affected body parts.

“Hybrid” devices can do the trick for some infants, particularly those

Three-monthold born at 35 weeks gestation with ulnar deviation, wrist extension posturing, and contractures of interphalangeal (IP) joints. Soft material used due to fragility of patient. Aliplast foam roll supported IP contractures while prefabricated IV board was used dorsally to block extension of wrist, with soft strapping for suspension.

Infant with high tone using several straps that that were as wide as possible in addition to crisscross strapping, which improved ability of orthosis to maintain desired alignment and increased patient’s tolerance to orthotic management.

with multiple congenital anomalies of the cervical spine, according to Malas.

After surgeons do their part to restore stability and alignment, Malas’s team often is asked to provide a cervical orthosis or cervical thoracic orthosis—but those can be too big for many patients. “In these cases, and as an example, we may need to use an anterior shell from an off-the-shelf device, but customize the posterior section,” he says.

Bryan Malas, MHPE, CO

Another segment of the Lurie Children’s patient population who are treated with “extra” customization is children with spinal muscular atrophy who are ambulatory status. “In some instances, an articulated AFO may not give enough stability, but a solid AFO is too rigid for some of these patients,” says Malas. Instead, his team uses a carbon fiber energy-storing design, which provides enough stability while allowing patients to use their own strategies to ambulate.

PHOTOS: Bryan Malas, MHPE, CO, and Lurie Children’s Hospital of Chicago

Practitioners can be pushed to be particularly inventive when a patient has a unique body size or shape. “I think that when you’re talking about pediatric orthotics, the devices for children are a little more complicated because they traverse greater segments of the body,” says Thomas DiBello, CO, FAAOP, clinic regional director at Hanger Clinic. For example, while devices such as ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs) are common in both adults and children, devices such as thoracolumbosacral orthoses (TLSOs), hipknee-ankle-foot orthoses (HKAFOs), and TLS/HKAFOs are much more common in children, says DiBello.

COVER STORY

PHOTO: Presque Isle Medical Technologies

Jonathan Heifetz, CPO, works with one of his "high-aspiration" patients.

Patient-Driven Care

At Presque Isle Medical Technologies, owner Jonathan Heifetz, CPO, sees a large percentage of pediatric patients, as his facility works closely with Shriners Hospital for Children.

He believes in a patient-centered approach to care, working within a team where the patient’s aspirations drive treatment. “Just as important as orthopedic or medical goals are the patient’s goals,” he says. “Sometimes there’s a pie-in-the-sky activity that we can help patients achieve.”

Heifetz recalls several instances where he helped design solutions to facilitate patient participation in activities that some may have designated as “beyond their reach.” In one example, he treated a young girl who had multiple skeletal deformities and was also undergoing spinal lengthening due to scoliosis. The patient needed a scoliosis brace, but she also required KAFOs to stand and walk. Despite her limitations, she wanted to take part in a stage performance at school that required her to dance. “It forced us to come up with an unconventional approach,” says Heifetz.

“We designed an orthosis that would accommodate to the external fixators for her skeletal deformities.” Using that customized device, the patient was 28

APRIL 2016 | O&P ALMANAC

able to dance at school. “This approach allowed her to have the orthopedic outcomes we wanted and remain active enough to participate in extracurriculars,” says Heifetz.

On another occasion, the mother of a young boy with osteogenesis imperfecta requested a solution that would enable her son to be mobile, while preventing the continuing fractures that come with brittle bone disease.

“He required orthotic treatment for

alignment of his bones and couldn’t really weight-bear, but his mom was a physical therapist and wanted him to be able to see the world from a standing position,” says Heifetz. He developed a full reciprocating gait KAFO and incorporated it into a smart walker, which allowed for tracking of his lower extremities while giving him partial unloading so he could stand and ambulate.

In addition to individualized solutions, Heifetz has been involved in developing creative solutions for subsets of pediatric patients. Several years ago, he and his team sought to offer infantile scoliosis patients more freedom from rigid casting during the hot summer months packed with water activities. “We worked with a physician team to extend the Mehta infantile scoliosis treatment protocol to the bracing itself,” says Heifetz. “We developed a TLSO for scoliosis that matched the Mehta bracing protocol.

We used an intraoperative molding technique to mold for the brace.”

Using this device, patients could break from serial casting over the summer months and still receive comparable outcomes to the continuous casting.

Heifetz reports that he now fits several dozen patients using this technique each summer, which makes everyday activities more enjoyable for both the patients and their parents.

Darrell Christensen, CO

Filling a Void

At times, practitioner creativity is borne out of a need to treat a disorder that has no other solution. This was true at UCSF, where an appropriate solution for sunken chest was needed.

“For years, there was no conservative treatment for pectus excavatum,” says Darrell Christensen, CO, of the UCSF’s Mission Bay Hospital. To address this need, pediatric surgical clinicians, clinical engineers, and orthotists came together to create a research

Winner for Thoracolumbar Care

Immediate

Pain Relief for

Adult Scoliosis Learn more at OTWorld

Visit us at Booth A/20 May 3-6, 2016 Leipzig, Germany

Peak Scoliosis Bracing System

TM

We are proud to have won this prestigious award for our revolutionary new bracing system designed specifically for Adult Scoliosis patients. This innovative concept in bracing has been shown to: • Significantly Reduce Pain • Improve the Quality of Life • Increase Mobility

• Promote Better Posture • Increase Patient Compliance

Code L1005 Approved To place an order or for more information, contact your local Aspen Sales Representative or Customer Service at

800-295-2776

Life Changing Spinal Innovation

aspenmp.com

COVER STORY

project aimed at treating this chest wall deformity using a combination surgical and orthotic approach. “First, a small magnet was implanted onto the patient’s sternum. A magnet was then incorporated into an external orthosis, and the attractive force between the two magnets gradually pulled out the deformity.” Christensen reports that this project is in the final stages of the clinical trial phase.

Chrysta Irolla, MS, MSPO, CPO

Practitioners at Mission Bay Hospital also have gotten creative when treating infants with severe clubfoot whose skin is too thin and tender for casting. To address these issues, the team uses custom serial baby AFOs, a procedure developed by UCSF’s Ken Kane, CO. “In this case, the creativity comes in designing something that is effective but also doesn’t irritate the patient skin and is easy to don properly for consistency,” says Irolla.

“Children who are running around all day can get very wet from perspiration inside the socket; these newer sockets allow the perspiration to seep out.”

While adjustable sockets have been around for decades—incorporating laces, straps, Velcro, ski buckles, and, more recently, Boa closures—it is only in recent years that “we have gotten a better understanding of how to custom fabricate sockets with silicone,” says Carroll. In previous usages, fabric was impregnated with silicone, and problems such as the fabric coming through the liner and causing abrasion were common. “Now, this issue has been resolved,” says Carroll. “Silicone has evolved, and it’s very user-friendly.”

Customization allows children to insert their personalities into their devices. For example, Carroll recently fit a child with a glow-in-the-dark socket: While the phosphorescence is not a functional element, it offers a “psychological benefit” for that child, says Carroll. Such child-friendly customizations enable clinicians to

“make children happier with their prostheses.”

A different type of silicone has proven useful to Will Yule, CP, of Hanger Clinic in Phoenix, who uses high-consistency rubber (HCR) silicone to fit some of his pediatric patients, many of whom have congenital and upper-extremity limb loss.

“Unlike poured silicone, HCR silicone is applied by hand to the mold, so you can control the thickness and elasticity of the material, and, additionally, you can embed zippers or incorporate electrodes. It also can be pigmented for a good color match.” The light weight and flexibility of the material make it a good fit for pediatric patients who have unique absences, says Yule.

“Among the pediatric upperextremity population, we have very diverse limb shapes with small, detailed contours, and the congenital group can have unique limb presentations,” says Yule, who works closely with New Touch Prosthetics for HCR silicone fabrication of devices.

Inspiration From New Materials

30

APRIL 2016 | O&P ALMANAC

PHOTOS: Jack Uellendahl, New Touch Prosthetics

Several clinicians say they are inspired to devise creative solutions for pediatric patients using some of the newer materials. For example, clinicians at Hanger Clinic are fitting pediatric patients with silicone adjustable sockets, which offer durability and longevity for an active patient base.

“Children are on the go all day, and [they] put a lot of stress on their prostheses,” says Carroll. “We needed to come up with durable solutions.”

Enter the new generation of silicone sockets, which provide comfort as well as customization—adding an element of excitement for pediatric patients.

“Children grow quickly, but they also have volumetric changes,” due to irregular salt intake and other issues, says Carroll. With adjustable prostheses, children or their caregivers can tighten or loosen the devices as needed. These sockets also accommodate breathability liners, says Carroll:

A young gymnast was fit with a special gymnastics prosthesis made with HCR silicone.

What’s Jennifer’s big secret?

Jennifer wears a Providence brace to treat her scoliosis but her friends will never know, unless she decides to tell them.

That’s because she only wears her brace overnight, at home.

A past study has shown that overnight bracing can be just as effective as daytime bracing*—if not more, since it boosts compliance. Spinal Technology is the exclusive manufacturer of the Providence Nocturnal Scoliosis Orthosis.

technicians, and experts in foam & plastics at Spinal Technology are working to keep it that way.

Find out for yourself. Call to place an order, and we'll show you how Spinal Technology can help you achieve better spinal orthotic results for your patients.

What’s Jennifer’s big secret? At school, she’s like any other 12 year old girl; our team of orthotists, CSRs, mold & finish *Spine Vol 29 No.18

191 Mid Tech Drive West Yarmouth, MA 02673

800 253 7868

spinaltech.com

COVER STORY

Patient and Parent Management O

NE OF THE UNIQUE aspects of working

32

APRIL 2016 | O&P ALMANAC

PHOTO: Will Yule, CP

with pediatric patients is managing expectations of both the patients and their caregivers, says Thomas DiBello, CO, FAAOP, clinic regional director at Hanger Clinic. “There are equally challenging pediatric patient O&P solutions as there are adult solutions—the difference is the dynamic that exists between clinician and patient,” says DiBello.

“It requires a careful approach to establish appropriate expectations with the patient and the caregiver,” he says. “You have a three-part dynamic as opposed to the one-on-one dynamic you might have with an adult.”

Developing and communicating a treatment plan to accommodate patient and parent goals while remaining realistic about what may be possible with O&P intervention “requires a unique skill set,” says DiBello.

Expert communication techniques are especially important when dealing with parents of the youngest patients, says Bryan Malas, director of the orthotics-prosthetics department at Lurie Children’s Hospital of Chicago.

For example, when speaking with parents of babies requiring cranial remolding helmets, “we have to be knowledgeable, but we also have to convey the information tactfully,” he says. “Sometimes if you use the wrong terminology, or words such as ‘severe’ or ‘extreme,’ it can add a whole other layer of stress to the family that doesn’t need to be there. You have to be effective in your messaging to families.”

Malas also recommends approaching pediatric patient care within the context of patients’ families, especially when patients have co-existing conditions. “Sometimes we get tunnel vision and focus too much on a child and not on his or her family,” says Malas. “When we think about orthotic management, we have to think about how our treatment is going to impact the patient’s parents, as well as any siblings. We really need to take a holistic approach when determining the best plan orthotically, especially for those children who come to us with medically complex presentations.”

Will Yule, CP, designed a laser pointer finger for a patient using HCR silicone.

“One of the distinct advantages of working with this material is we can design silicone to be exactly what we want it to be. We can thin the margins so patients don’t lose range of motion.”

Yule has used silicone in fabricating partial hands, partial feet, and Symestype amputations, among others. He notes HCR silicone has been particularly helpful in treating transradial patients with very short residual limbs where there is little room to suspend a prosthesis—the silicone socket can be held in with suction and a humeral sleeve can be integrated.

Yule has noticed increased wear among upper-extremity pediatric patients with devices made with HCR silicone. “This type of material, because it’s more comfortable, results in less perspiration and feels lighter to the amputee, so it helps improve acceptance among younger amputees.”

The customizability when working with HCR silicone also helps when treating young patients with specific requests. Yule recalls one instance when a young boy became septic after a staph infection and eventually lost his kidneys, right eye, one of his legs, and fingers on one side. “While I was treating him in the hospital, his father told me the boy loved Ironman and asked if I could make him a laserpointer finger,” Yule recalls. While unconventional, he agreed to make

COVER STORY

PHOTOS: Jack Uellendahl, New Touch Prosthetics

a silicone digit prosthesis in which a laser pointer could be inserted. “There was no functional benefit, but it helped with the acceptance of his prostheses,” Yule says.

At UCSF, practitioners have found success using a different material: EXOS, a low-temperature plastic with foam and fabric lining that can be heatmolded directly onto the patient. Irolla has used this material for a patient with a very short neck and weak neck muscles who needed a cervical collar to prevent her from pushing out her trach tube while sitting. “I heat-formed EXOS material around her neck to make a custom cervical collar that met the specific dimensions and had a large relief for the trach,” she says.

Irolla also found EXOS material to be useful in treating an 11-month-old with a tibia fracture whose skin was not tolerating casting; the severity of his fracture necessitated total contact immobilization as soon as possible.

“There are no over-the-counter tibia fracture braces for a patient this size, and there was insufficient time to create a custom thermoplastic orthosis,” she says. “Given these constraints, it was decided to heat-mold EXOS material to create a custom anterior shell around the fracture site.” A posterior pelite-foam tongue, Boa closure, and stirrup from splinting material were

Clinicians used HCR silicone to design a shoulder disarticulation prosthesis for a young patient.

PHOTO: Jack Uellendahl, New Touch Prosthetics

added to finish the orthosis. This served as a useful temporary solution while a custom thermoplastic fracture AFO was fabricated for standing.

Christensen also has used EXOS material in creative ways; in one instance, he used it to treat a patient with severe lateral flexion of her neck. Casting this patient would have been very difficult, particularly around a dense head of hair, so he used a piece of EXOS material with prepreg struts to create a custom head and shoulder orthosis.

Improving Outcomes

A "drumming" prosthesis was designed for a young musician using HCR silicone.

O&P practitioners who create uniquely customized devices for pediatric patients do so in the best interest of their patients—rather than their own pocketbooks. “There’s no way to get reimbursed for all of the extra work you do in these special cases,”

says Heifetz. “But there’s so much potential in children that draws you in. For children, the whole universe is open to them.” The rewards come in seeing young patients achieve highreaching goals.

Ultimately, developing creative solutions is a part of the job for all orthotists and prosthetists.

“Particularly in pediatrics, there is very little that doesn’t require some degree of customization,” says Irolla.

While it may take a bit more time and energy to fabricate and adjust innovative devices, “the advantage is that you have an opportunity to really optimize functional outcomes for your patients.”

Christine Umbrell is a staff writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

O&P ALMANAC | APRIL 2016

33

By ADAM STONE

Here Comes the

New Guard Today’s O&P graduates bring a master’s level education—and high career expectations—to patient-care facilities

NEED TO KNOW: • The students graduating from O&P master’s programs this spring have acquired some skill sets that go well beyond traditional lab instruction, including outcomes-based training, documentation proficiency, and technology expertise.

• Along with new skills come new expectations; many of today’s graduates are seeking greater compensation as a result of their in-depth education and costly student loans.

• Most new practitioners are part of the Millennial generation that typically prefers workplace flexibility, ongoing feedback, and a less hierarchical management structure than is typically found at existing patient-care facilities.

• While new hires may find that O&P jobs may not meet all of their expectations, O&P business owners also will need to be flexible to attract bright young practitioners: “The new graduates can significantly enhance your practice in terms of reimbursement and the challenges that face the industry,” says one expert.

34

APRIL 2016 | O&P ALMANAC

S

OME LONGTIME PRACTITIONERS of orthotics and prosthetics are

quick to suggest that today’s newest New Expectations trainees come up short in the basics Charles W. Kuffel, MSM, CPO, FAAOP, of fabrication, fitting, and alignment. sees a disconnect between what new “Typically, clinical practitioners are If that’s so, it is not because of the practitioners expect in an entry-level there from early morning until late. curriculum, which still emphasizes O&P job, and what O&P patient-care You can’t necessarily control when traditional skills, but rather because of facility owners can offer. He encounpatients show up or what issues they a changing society, says Jared Howell, ters this disconnect both in his role may be having. Now these newer MS, CPO. as chair of the National Commission graduates want to work 8:00 to 4:00 “They don’t grow up on Orthotic and Prosthetic and go home. I don’t think you can do in homes where Mom Education and as president or Dad would work with and clinical director of Arise that,” he says.

At the same time, Kuffel says he hand tools,” says Howell, Orthotics & Prosthetics Inc. respects what new clinicians bring to Orthotics and Prosthetics in Blaine, Minnesota. the table. “I went to Northwestern as Program Director “The money they expect a certificate student, and we learned at Baylor College of is just unrealistic,” says more of just the building blocks, where Medicine in Houston.

Kuffel. He’s had recent these students are able to learn more in “That wasn’t the case graduates ask to be paid depth,” he says. two generations ago or $60,000 for jobs that The new work ethic comes as no one generation ago. It’s normally pay $31,000, Jared Howell, MS, CPO surprise to Howell. “We watch the just the nature of the despite having minimal news and see these billion-dollar tech world that we live in.” clinical experience.

Shoes covered in plaster no longer It’s not just the money. Most sources companies where they have a flexible schedule, and people get to spend 20 may be “a badge of honor,” but it’s put the average age of a graduate stupercent of their time just thinking likely graduates of O&P master’s dent at 33—also within the Millennial about new ideas,” he says. “That’s the programs will have other skills. With generation (aged roughly 23 to 34), world we live in, and those a master’s-level education, today’s which notoriously has expectations are being set graduates bring to the table new ways entirely new ideas about outside our industry.” of thinking and new abilities. “The the world of work, accordIt’s not just what the way the world is changing, their time ing to business experts. up-and-coming graduates is going to be taken up with other For example, 88 percent want, but the way they things,” Howell says. of Millennials wish they want it, says Kuffel. “We Meanwhile, some facility owners could have greater opporsee a lot more of ‘what are asking if this education will make tunity to start and finish can you do for me’ versus emerging professionals inherently work at the times they ‘what can I do for you.’ better practitioners? And, more to choose, according to the [They seem to think that] 2016 Deloitte Millennial the point, will it be worth the kind Charles W. Kuffel, I, as the employer, owe Survey. Kuffel also sees of compensation packages they them something.” this in his own experience. MSM, CPO, FAAOP are demanding?

O&P ALMANAC | APRIL 2016

35

The knowledge methodologies, development ought to be worth of expertise in data managesomething in the marment, and business-practice capabilities, including ketplace, say students. the ability to navigate the Also, consider that complicated reimbursement Degner owes $70,000 system. These are the 21st in student loans. That century O&P skills, and many kind of heavy debt load will argue that those who may be a big part of why can master them bring great master’s-level graduvalue to the profession. ates come out looking Dennis Anco Katelyn Degner, 28, has for a more substantial spent hours learning to use paycheck. data to justify her work.

“It has woven Dennis Anco, a first-year student New Capabilities itself into the entire curriculum.

When in the master’s program at Century In O&P educational programs, some of the curriculum remains unchanged. you design a brace, you need to break it College partnering with Concordia down and justify your reason for what College, says the new additions to the Programs still include several trayou are trying to accomplish for your curriculum will justify his worth once ditional O&P courses, including patient. That is a big part of the conhe has gone to work full time. laboratory instruction in anatomy, “The paperwork load is far greater kinesiology, and pathology; normal and versation,” says Degner, who expects than the amount of time you can spend pathological gait; and to complete her Master of with a patient. There is a heavy amount impression procedures, Orthotics and Prosthetics of paperwork, a lot of documentation alignment, fitting, and at Concordia University needed to provide devices,” says Anco, fabrication. in St. Paul, Minnesota, in a former Navy aviation technician. “I Today’s O&P stuJune. “This has become a think we will come out of the gate more necessary thing, especially dents also spend a great prepared not just on the technical side when the field as a whole deal of time on courses but also on the business side.” is anxiety-ridden about adapted for the new At 39 he’s a bit older than the typireimbursements, where business environment. practitioners today are The updated curriculum cal student, but his ideas about work getting hit from all sides,” at some schools includes are solidly in line with those of his Katelyn Degner she says. research into new younger peers. If older students like Anco, along with his Millennial classmates, think their skills entitle them to more money, flexible hours, and other workplace benefits, they are not alone among their generational peers, a group that already has a reputation for such things.

This new way of thinking seems to bump up against long-established practice, leaving some older business owners scratching their heads. Still, students and educators say a valuable trade-off can be had, if both sides can bridge the divide. While they may seem more demanding than their forebears, ascending graduates with their extra years of formal education also bring to the table a range of meaningful new skills.

New Lessons

36

APRIL 2016 | O&P ALMANAC

PHOTO: iStock.com/Minerva Studio

Within these parameters, this diverse group of students comes together over a core of learning unlike any delivered to past practitioners.

“The big distinction is in their understanding of value-based care, clinical outcome measures, and how to validate what they are doing,” Howell says. “Up until now, clinicians in general have provided good clinical care, but they really had nothing to document or prove that. We fully anticipate that the reimbursement climate is going to demand this in the future.”

The New Generation Who are these Millennials, as a group? Findings from several recent research studies paint a broad picture of some of their professional beliefs and values:

• More than 40 percent of Millennials want feedback every week, according to research by Ultimate Software.

• Forty-five percent of employers now expect new college graduates to stay less than two years, according to CareerBuilder.

• Fifty-eight percent of Millennials say communication is the most important leadership skill, followed by relationship building (55 percent), according to a study from WorkplaceTrends.com and leadership training firm Virtuali.

• The vast majority of Millennials—83 percent—prefer to work for a company with fewer layers of management, according to the same study.

• Eighty-four percent of Millennials say that helping to make a positive difference in the world is more important than professional recognition, according to research from Bentley University.

• Forty-seven percent of Millennials believe that the “purpose of business is to improve society/protect the environment,” according to the 2016 Deloitte Millennial Survey.

38

APRIL 2016 | O&P ALMANAC

For O&P, as for many other fields, these characteristics form a sort of substrata, an unseen layer that underlies the present-day workforce. Business owners aren’t just hiring a practitioner any more; they’re hiring a package of expectations and beliefs, say experts.

Some of these will be familiar to those in O&P: the desire to make the world a better place. Some will be entirely new, especially what some would call a lack of loyalty.

In a field where some practitioners stay in place for decades, the idea of a two-year employee may seem simply bizarre.

Of course, not every student falls neatly within the Millennial age parameters; nor do they display exactly the same beliefs and behaviors, as defined simply by year of birth. Each new O&P graduate will come with a unique view of the profession.

Consequently, Kuffel supports the value of students’ outcomes-based training. “They understand not only the how but the why of what we are doing, and how we will record our successes,” he says.

This knowledge will vastly enhance the success of any facility at a time when O&P is finally coming to be regarded as a part of the mainstream health-care delivery community.

Today’s O&P graduates "are being seen on a more equal playing field with other health-care providers. There is more collaboration with our peers in other branches of medicine. We are being seen more as medical providers and less as technicians of devices” in the eyes of regulators and other licensed providers, Howell says. In this environment, a move from the lab bench to the spreadsheet seems almost inevitable.

Still, the O&P technology itself may not be what matters most, but rather the fluency in technology as a whole, with tech-savvy grads able to scout the landscape for promising new O&P tools. “We use the residents and the students in that way, to make us better practitioners. They are far more techsavvy than any of us,” Kuffel says.

spend that much time righting their perceptual wrongs of the profession,” he says. Even before making a hire, “there is a lot of education involved.”

“Both sides will have to give,” Howell says. “The folks who have been in the profession for a long period of time will have to adjust their expectations of what the profession can look like. The new graduates can significantly enhance your practice in terms of reimbursement and the challenges that face the industry. These students can do that, and do it well.”

For the new graduates and the longtime professionals to meet in the middle, the O&P schools may need to play an intermediary role. “We have these discussions extensively with students; we try to set realistic expectations,” Howell says. “We have collected some data on what people have been offered, for example, and we are trying to set realistic expectations based on that.”

While new graduates may bring to the table a challenging different vision and a new set of expectations, many in O&P say the Millennials also bring fresh blood: a new enthusiasm in a profession battered by recovery audit contractors and diminishing reimbursements.

“My motivation is patient care. I feel like I am a different person when I am interacting with a patient,” Degner says. “Flexibility to be able to spend time with my family, time to maintain personal relationships—those are important. But I think there is a healthy balance of responsibilities that needs to come with that.”

Adam Stone is a contributing writer to O&P Almanac. Reach him at adam. stone@newsroom42.com.

Newfound Respect

Here’s one vision of how it all might come together. Students get that fundamental experience in school and in residency. They also glean business skills in class and bring those novel talents to existing O&P practices. They ask for more money, settle for a little less, and the employer takes a financial hit up front but makes it up on the back end thanks to new business savvy.

Not bad, really, if the student has the patience and the practitioner has the resources. All of this is far from settled, so the question on the table today becomes: What can the O&P profession as a whole do to solidify this picture and define its own future?

Part of the burden will fall to the business owners. Kuffel, for example, spends up to three hours with promising residency applicants, briefing them on the realities of the job. “I need to O&P ALMANAC | APRIL 2016

39

By JIM WEBER

Managing by the Numbers Learn to take control of your financial reports

This article is the third in a three-part series written by members of AOPA’s Operating Performance Committee focusing on the financial aspects of running an O&P facility. This month, we discuss income statements, balance sheets, and monthly cash flow models.

I

N THE LAST TWO issues of the

40

APRIL 2016 | O&P ALMANAC

that are updated monthly and reviewed regularly to measure your company’s continued progress.

A monthly financial update of your income statement and balance sheet is absolutely essential. This does not mean getting an email from your accountant and filing the report away each month. Instead, you should spread your financials in a separate Excel file each month: Format a balance sheet and income statement and actually enter the specifics into your spreadsheet.

The effort you put into spreading your financials will help you understand them better. You will notice increases or decreases in receivables, inventory, and fixed assets, or reductions in payables— all cash flow-impacting events.

An income statement is a report of activity for a given time period, and a balance sheet is a picture at the end of the period. The income statement may reflect a very profitable month, but you may turn red with frustration when your staff tells you that cash is very tight! Understanding the ebb and flow of your balance sheet will enlighten your understanding of one very true financial fact: Profits are not cash.

PHOTOS: iStock.com/GlobalStock

O&P Almanac, we explored useful management approaches utilizing the data available to all O&P members in the AOPA Operating Performance Report. In February, we focused on benchmarking, and in March, we discussed the optimal use of trendline data. If your response to the question, “How did you do last month?” is, “I don’t know—I haven’t heard from my accountant yet,” then you should really pay attention to these articles. In today’s health-care markets, business owners and key managers in O&P cannot afford to not be in control of their company’s financial reporting systems.

As an owner or manager of an O&P business, you may not have a financial or accounting background—but that is not an excuse to not be in control of your company’s financials. To effectively benchmark your company’s data against others in your industry and measure trendlines over time, you must have effective financial reporting systems. Whether it is your responsibility, or the responsibility of a key member of your management team, you must have internal financial reporting systems

Sample Cash Flow Model

FEBRUARY February Forecast

Actual**

MARCH Month End Cash Flow

March Forecast

Actual

Month End Cash Flow

Beginning Cash

$10,000

A/R Deposit

$125,000

$125,000

$130,000

$130,000

Cash Available

$135,000

$125,000

$135,000

$130,000

A/P

$60,000

$60,000

$62,000

$62,000

Monthy Recurring Expenses

$25,000

$25,000

$25,000

$25,000

Payroll

$30,000

$30,000

$30,000

$30,000

Other

$5,000

$5,000

$4,000

$4,000

Cash Required

$120,000

$120,000

$121,000

$121,000

Net Cash

$15,000

$5,000

$14,000

$9,000

Bank Line

-$10,000

$0

$5,000

$14,000

ENDING CASH

$5,000

** Enter as it occurs.

Cash is required to operate your business—specifically, positive cash flow. The most challenging, yet most important, point relative to your own financial management system is understanding the nuances in your income statement and balance sheet. To do so, you must develop a systematic cash flow model. If you are not forecasting and anticipating your cash flow, it will catch up to you. Whether your company is growing and increasing inventory and receivables are eating up cash, or poor purchasing controls or aggressive accounts payable payments are the source of disappearing cash, if you don’t have a system of managing the daily cash flow, the business will control you; you will not be in control of your business.

Key benchmarks, such as current ratio, inventory turnover, and number of days of sales outstanding, will help identify cash flow trends. However, in addition to your income statement and balance sheet, managing some form of

a cash flow model will help you stay on top of your business’s day-to-day cash flow. Documentation as simple as the example shown above could get you thinking in terms of a model that works for you.

A cash flow model can help you identify the dynamic relationship between the income statement and balance sheet in your business.

Take advantage of the resources available to you in the AOPA Business Optimization Analysis Tool (BOAT) to benchmark your data against the data of other companies in the O&P industry and identify trendlines of key financial metrics in your business utilizing your internal financial management system. Don’t wait for the call from your accountant—start now to control the financial future of your business.

Jim Weber is president and chief executive officer of Prosthetic & Orthotic Care Inc. and is vice president of AOPA.

Access the BOAT Tool

AOPA’s Business Optimization Analysis Tool (BOAT) offers a number of benefits for AOPA members. Use the tutorial to review the various business management tools. The BOAT tool is the efficient way to participate in and provide your data for the annual AOPA Operating and Performance Report and biannual AOPA Compensation and Benefits Report. The tools BOAT provides, coupled with the AOPA reports, enable you to benchmark your business performance against that of similar O&P businesses.

You will receive your own personalized company report, as well as copies of the published reports.

The BOAT tool is available free to AOPA members who register by creating their own username and password. Visit www.iisecure.com/BOAT/Login.asp.

If you missed the first two articles in this series, be sure to read “Leveraging Data for O&P Business Management” by Mark Ford in the February 2016 issue of O&P Almanac, available at bit.ly/markford; and “Put Trendline Data To Work”

by Michael Oros, CPO, FAAOP, in the March 2016 issue, also at bit.ly/michaeloros.

O&P ALMANAC | APRIL 2016

41

COMPLIANCE CORNER

By DEVON BERNARD

Coding Guidelines Key points from the Policy Articles for remaining compliant with Medicare coding obligations

Editor’s Note: Readers of Compliance Corner are now eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 45 to take the Compliance Corner quiz.

Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

CE

CREDITS

E! QU IZ M EARN

2

BUSINESS CE

CREDITS P.45

The Pricing, Data Analysis, and Coding contractor (PDAC) provides three primary functions for Medicare: pricing of Health-Care Common Procedure Coding System (HCPCS) codes without Medicare allowables; data analysis, which is used to identify utilization patterns of HCPCS codes; and coding verification (either voluntarily or mandated by policy), which is used to establish coding guidance for specific products.

Once a product has been reviewed by the PDAC and assigned a coding verification, the PDAC decision is binding for Medicare purposes, and any claims submitted to Medicare for that product must be coded according to the PDAC coding verification.

Failure to comply with PDAC coding verifications may place your Medicare claim at risk. Medicare claims for devices that are coded in conflict with a PDAC coding verification will be denied as incorrect coding.

If they are inadvertently paid, they may be exposed to postpayment audit and overpayment determinations.

AFO/KAFO Policy

If you intend to provide, code, and bill for a multiligamentus ankle-foot orthosis (AFO), described by code L1906, you must adhere to a few coding guidelines to remain compliant in your coding. First, the AFO must have some type of hinge or joint-type mechanism, which will allow the ankle 42

APRIL 2016 | O&P ALMANAC

However, PDAC coding verifications are not the only coding guidelines you must follow to be compliant with Medicare coding and billing rules.

Medicare Medical Policies—and, in particular, the Policy Article portion of those policies—provide you with some insights and guidelines for proper coding of Medicare claims.

In addition, you should be aware of coding reminders and directives that are jointly released by the PDAC and your local durable medical equipment Medicare administrative contractor (DME MAC).

This month’s Compliance Corner focuses on the coding guidelines portion of the Policy Articles for each of the major O&P policies. This article will not cover all of the information in each Policy Article but will feature some of the key points to ensure you remain compliant with Medicare coding obligations. This article does not address information relating to off-the-shelf vs. custom-fit devices as this topic has been addressed in recent O&P Almanac articles. to dorsiflex and plantarflex. Second, the item must include a rigid stirrup and footplate and wraparound straps.

If your AFO has these qualities, it meets the Policy Article definition of an L1906, but additional coding criteria must be met to remain compliant.

The L1906 is considered an all-inclusive code, meaning there are no addition codes that can be billed with the L1906 base code. If you use any addition codes,

COMPLIANCE CORNER

you are no longer in compliance with the AFO/KAFO policy, and you could not submit your claim with the KX modifier. In addition, any item being coded as L1906 requires a written coding verification from the PDAC. HCPCS code L2340 describes a pretibial shell, and in addition to being custom fabricated (molded to patient model), as described by the office L-code descriptor, three other components must be met to code for and bill code L2340. First, the shell must be rigid and the edges must overlap or interlock; in other words, it must wrap around and not just cover a portion of the tibia. Second, this rigid shell can be constructed from any type of thermosetting materials or any composite-type materials. Third, the L2340 has a height limit. The shell must extend between the tibial tuberosity to a point no greater than three inches proximal to the medial malleolus.

Since its creation in 2011, the L4631 was designed to describe a CROW boot. However, if you wish to use code L4631, the orthosis you provide must meet six specific coding criteria: The orthosis must keep the foot in a locked and fixed position of 0 degrees; it must contain a feature that allows for varus/valgus corrections; it must include a rocker bottom sole with a custom arch support; it must include some type of soft interface material; it must incorporate a rigid anterior tibial shell; and it may only be used with a patient who is ambulatory. If the orthosis you are providing doesn’t meet all of these criteria, then L4631 would not be the appropriate code.

The coding guidelines do not allow for the use of addition codes with the L4631, such as the L1906, because the L4631 is all-inclusive. There may not be any additional codes like straps, closures, or features such as those found on a patellar tendon-bearing orthosis.

If any item—regardless of its design features, components, or fabrication method—is used solely to reduce pressure and off-load the foot, and is not treating any underlying orthopedic condition, then it must be coded as A9283; and it will be

considered noncovered. For example, if you are using a CROW boot, even if it meets the above criteria, to just off-load the foot, then you must use code A9283 and not L4631.

KO Policy

The knee orthosis (KO) policy is unique in its approach to compliance with coding; the policy clearly indicates which addition codes can be used with which base codes, and which addition codes are considered included in the base code.

However, the Policy Article does provide additional criteria that must be met to ensure appropriate coding, including the definition of flexion/ extension joints, padding material for certain braces, and an explanation of the items requiring PDAC approval.

With a brace described by L1830, you must be sure that the stays (which must be rigid metal or rigid plastic) are located laterally and posteriorly, and that the interface/lining is made of canvas or a closed cell foam. Also, any thigh and calf cuffs must be of one-piece construction and held in place by a Velcro strap, or a similar strapping system.

Two KOs require PDAC coding approval: K0902 and L1845. If the item you are providing is considered a K0902 or L1845 and the brace has not received a PDAC coding verification, then you must use code A9270 and the KO will not be covered.

The last piece of coding criteria is the definition of an adjustable flexion and extension joint. It is a unicentric or polycentric joint that enables the practitioner to set limits on flexion and extension but allows the beneficiary free motion of the knee within those limits. The increments of adjustability, or set limits, must be at a minimum of 15 degrees.

Within the KO policy and the AFO/ KAFO policy, there are directives from the PDAC and the DME MACs on the correct coding of concentric adjustable torsion joints used with prefabricated and custom-fabricated orthoses.

If the concentric adjustable torsion joints are used solely to provide an assistive function for joint motion, you may use code L2999. However, all other uses of concentric adjustable torsion joints, including for the treatment of contracture, must be coded as follows: • E1810 – Dynamic adjustable knee extension/flexion device.

• E1815 – Dynamic adjustable ankle extension/flexion device.

External Breast Prosthesis Policy

The coding guidelines in the external breast prosthesis policy provide an in-depth description of the features of each type of mastectomy bra. HCPCS code L8000 describes a bra, without an integrated breast prosthesis, which has pockets designed to hold a mastectomy form/breast prosthesis adjacent to the chest wall.

O&P ALMANAC | APRIL 2016

43

COMPLIANCE CORNER

Codes L8001 and L8002 describe mastectomy bras with integrated breast prostheses. The L8000, L8001, and L8002 also include the following characteristics and features: • May be constructed of any material including, but not limited to, cotton and polyester.

• May include any type of closure/ fastener, and the closure/fastener may be located anywhere on the bra.

• May be of any size.

• May be constructed with or without integrated structural support, e.g., an underwire.

Since the bras described by codes L8000, L8001, and L8002 can include any or all of the above features, you may not bill any of these features as an upgraded or deluxe feature, or as a miscellaneous add-on feature. In essence, the bras have become an all-inclusive code.

Lower-Limb Prosthesis Policy

44

APRIL 2016 | O&P ALMANAC

Orthopedic Footwear Policy

If you are coding for a custom shoe attached to a brace, in order to be compliant with the policy and Medicare, you must use code L3649. Code L3649 will describe any and all types of custom shoes (e.g., high tops, depth inlay, high heels, etc.) and must be billed with the KX modifier.

Prosthetic shoes described by L3250 contain a custom-fabricated insert designed to accommodate for a toe or distal and/or partial foot amputation, and the purpose of the shoe is to hold the insert in place against or on the leg.

Code L3250 is not designed, intended, or covered for shoes that are placed over any other prosthesis described in the lower-limb prosthesis policy (L 5010-L5600), which are suspended or held in place by other means.

Spinal Policy

A majority of prefabricated lumbosacral orthoses (LSOs) and thoracolumbosacral orthoses (TLSOs), including L0450, L0454-L0472, L0488-L0492, L0625-L0628, L0630,

L0631, L0633, L0635, L0637, and L0639, require a PDAC coding verification letter. A majority of the custom-fabricated LSOs and TLSOs, including L0452, L0480-L0486, L0629, L0632, L0634, L0636, L0638, and L0640, also require a PDAC coding verification letter. If you provide an LSO or TLSO that requires PDAC coding verification and the brace has not been verified, you must use code A9270, and your claim will be denied as a noncovered service. For custom-fabricated LSOs and TLSOs that are fabricated in-house, you are not required to obtain a PDAC coding verification. However, you must be able to provide a list of the materials used in the fabrication process and a description of your fabrication methods if requested by the DME MACs, or any other Medicare contractor.

The coding guidelines in the spinal policy also offer some clear rules on what constitutes a posterior panel and what makes a spinal orthosis a body jacket. A posterior panel “must encompass the paraspinal muscle bodies from one lateral border to another,” and it must be tall enough to provide coverage to the anatomical markers indicated by the individual HCPCS codes. For example, a posterior panel for a TLSO described by code L0457 would have to encompass the paraspinal muscle bodies from one lateral border to another, and provide protection to and extend to the area of the sacrococcygeal junction and terminate just inferior to the scapular spine.

To be compliant for the coding of body jackets (L0458-L0464, L0480-L0492, L0639, and L0640), the item you are delivering/billing for must meet three specific criteria.

First, the body jacket must be used to immobilize a specific area of the spine. Second, it must have a snug/ close fit, and it must be designed to be worn under the patient’s clothing.

Third, the body jacket must have a rigid plastic shell with overlapping edges, and the shell must encircle the body; the shell also should be uniform in its construction (e.g., not have a plastic back and a nylon front).

PHOTOS: iStock.com/Johnny Greig

The majority of the coding guidelines in the lower-limb prosthesis section are fairly straightforward; however, two require special consideration.

The first is the proper coding/use of the suction socket codes (L5647 and

L5652), and the second is the coding of repairs with labor code L7520.

Codes L5647 and L5652 are designed to describe the modification to a socket, and only the socket, to allow for the inclusion of a valve.

L5647 and L5652 cannot be used to describe the components of a suspension locking mechanism.

Code L7520 may only be used in 15-minute increments to describe the time it took to actually furnish the repair. In other words, the L7520 may not be used to bill for the evaluation of problems, education, or gait training, or for the programming of electrical components. Also, code L7520 may be billed in conjunction with the L7510 (minor parts), but it may not be billed in conjunction with any other HCPCS codes; in essence, you may not bill additional labor on top of codes that have already reimbursed you for your labor.

COMPLIANCE CORNER

Surgical Dressings

If you are providing an A6545 (gradient compression wrap, nonelastic, below-knee, 30-50 mmhg, each), the wrap you are providing must be reviewed and approved by the PDAC. Remember that compression garments are only covered by Medicare when they are used in conjunction with a surgical dressing and the patient has an open-venous stasis ulcer.

Therapeutic Shoes for Persons With Diabetes

For diabetic shoe coding compliance, rather than reference the Policy Article coding guidelines, we will examine a coding clarification document released by the DME MACs regarding the proper coding of toe fillers and diabetic shoe inserts. The document states that a patient could

not and should not receive both a custom diabetic shoe insert (A5513) and a partial foot toe filler (L5000) on the same foot. The patient should receive one or the other, and the proper coding depends on the need of the patient.

If the patient has diabetes and is missing toes or the forefoot, and doesnâ&#x20AC;&#x2122;t require any extra rigidity or toe-off support for an improved gait, then the insert must be coded as A5513. The custom fabrication nature of the code would include the additional material needed to create a toe filler to accommodate the missing digit(s).

Code L5000 describes a shoe insert with a rigid longitudinal arch support with additional soft material added where contact is made with the residual limb/toes, and is designed to provide standing balance and toeoff support for improved gait. If the patient has diabetes and is missing the hallux or a forefoot, and additional rigidity and support is required for an effective gait, then the L5000

Ferrier Coupler Options!

must be used instead of the A5513.

This article has addressed some aspects of the Policy Article portion of the Medicare policies; for details on the Local Coverage Determination portion of the Policy Article, which addresses coverage issues that involve medical necessity, see the Reimbursement Page article on page 16.

Devon Bernard is AOPAâ&#x20AC;&#x2122;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:

www.bocusa.org

Interchange or Disconnect

The Ferrier Coupler provides you with options never before possible:

Enables a complete disconnect immediately below the socket in seconds without the removal of garments. Can be used where only the upper (above the Coupler) or lower (below the Coupler) portion of limb needs to be changed. Also allows for temporary limb replacement. All aluminum couplers are hard coated for enhanced durability. All models are interchangeable.

Model A5

Model F5

Model P5

The A5 Standard Coupler is for use in all lower limb prostheses. The male and female portions of the coupler bolt to any standard 4-bolt pattern component.

The F5 Coupler with female pyramid receiver is for use in all lower limb prostheses. Male portion of the coupler features a built-in female pyramid receiver. Female portion bolts to any standard 4-bolt pattern component.

The Ferrier Coupler with an inverted pyramid built in. The male portion of the pyramid is built into the male portion of the coupler. Female portion bolts to any 4-bolt pattern component.

Model FA5

Model FF5

Model FP5

NEW! The FA5 coupler with 4-bolt and female pyramid is for use in all lower limb prostheses. Male portion of coupler is standard 4-bolt pattern.

Female portion of coupler accepts a pyramid.

Model T5

NEW! The FF5 has a female pyramid receiver on both male and female portions of the coupler for easy connection to male pyramids.

NEW! The FP5 Coupler is for use in all lower limb prostheses. Male portion of coupler has a pyramid. The Female portion of coupler accepts a pyramid.

The Trowbridge Terra-Round foot mounts directly inside a standard 30mm pylon. The center stem exes in any direction allowing the unit to conform to uneven terrain. It is also useful in the lab when tting the prototype limb.

The unit is waterproof and has a traction base pad.

O&P ALMANAC | APRIL 2016

45

MEMBER SPOTLIGHT

ComfortFit Orthotic Labs

By DEBORAH CONN

Focus on the Foot Company offers custom-made orthotic inserts and serves as a distributor for foot-related products

T

HOMAS CALAGNA HELPED ESTABLISH ComfortFit

46

APRIL 2016 | O&P ALMANAC

Chief Financial Officer Randee Husik, President Thomas Calagna, Chief Executive Officer Howie Schorr, and Chief Operating Officer Michael Mohring

COMPANY: ComfortFit Orthotic Labs Inc. OWNERS: Howie Schorr and Thomas Calagna LOCATIONS: Roselle, New Jersey, and Glendale, Arizona HISTORY: 16 years Plaster cast preparation

products for all sports activities, men’s and women’s dress shoes, adult and pediatric functional orthotic inserts, as well as accommodative, leather, and diabetic orthotic inserts, many of which are approved by Medicare.

In addition to fabricating custom-made orthotic devices, ComfortFit Labs is a distributor for several other products, including the Richie Brace line of custom ankle-foot orthoses, the Stabilizer Brace, and diabetic shoes manufactured by Ped-Lite, Drew, and Propét. Other products include night splints, walkers, and over-the-counter prefabricated orthotic inserts from partners such as Arch Angels, ProThotics, Redi-Thotics, PediFix, and Schein Orthopedic.

ComfortFit Labs accepts plaster, foam, and fiberglass molds of patient’s feet, as well as digital scans. The company offers an iPad scanning system called iTOM-CAT that allows clinicians to scan feet in their office, fill out an online form, and transmit the image to

PHOTOS: ComfortFit Orthotic Labs

Orthotic Labs in 1999. Shortly thereafter, Howie Schorr, a businessman who had been involved in the orthotic insert industry since 1987, joined the company.

He and Calagna thought they had some ideas to fill a need in the orthotic industry.

One of those ideas was flat-rate pricing. ComfortFit Labs began offering all of its custommade orthotic inserts at a price of $85, including shipping. “No matter how you order them—any length, any cover, any modifications—the price is the same,” says Schorr. “The only exceptions are graphite and full leather shells, which carry a $10 premium.

“We may be the only orthotic lab that does that,” he says.

“Customers love it. They know they will be charged the same every time, so they know what to charge their patients.” All ComfortFit Orthotic Labs shells carry a lifetime guarantee against breakage, and a six-month guarantee against workmanship defects on all other components.

In addition, ComfortFit refurbishes orthotics from other labs.

The company, which has 50 employees, is based in Roselle, New Jersey, with a regional office in Glendale, Arizona.

The New Jersey site comprises two company-owned buildings that house production and warehousing, as well as all administrative functions.

ComfortFit offers a full line of custom-made orthotic inserts, including rigid, semirigid, and flexible products. These include

ComfortFit Labs. Facilities that place orders for at least 12 pairs a month have access to the software at no charge and receive a free plug-in scanner.

The company’s primary customers are podiatrists, although the company serves hundreds of O&P facilities, according to Schorr. “O&P facilities are an up-and-coming market for us,” he says.

Schorr credits his company’s success not only to its products, but also to its commitment to superior service. “We’re easy to get along with,” he says.

“We don’t argue about credits or remakes. We just try to do the right thing and, as such, we are very accommodating.”

The company markets its products through ads in trade publications, an opt-in email list, and direct mail, and takes part in select foot-care conferences. Schorr says an additional direct-mail campaign aimed at O&P facilities is in the works.

As for the future, the company plans to incorporate technology “wherever it makes sense,” says Schorr. “We plan on expanding our new iPad-based scanning system, and other technology enhancements have already enabled us to provide our customers with lifetime cast storage for any type of cast— plaster, fiberglass, foam, and digital. It is our company’s goal to continue our growth in the podiatry and O&P markets.”

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

At last, an insurance program

you’ll feel good about.

AOPA’S INSURANCE PROGRAM— Practitioners trust us most because we know your business and we know insurance unlike any other program.

Call Cailor Fleming today and we’ll gladly customize a specific plan for you.

We’ve been a trusted insurance company for years, let our experience and lasting service speak for itself.

800-796-8495 http://cailorfleming.com/OandP.asp

An Endorsed Member of AOPA

PROFESSIONAL LIABILITY | GENERAL LIABILITY | PROPERTY

| AUTO | UMBRELLA | WORKERS COMP & MORE

MEMBER SPOTLIGHT

Bremer Prosthetics

By DEBORAH CONN

Transparent O&P Care Michigan facility offers open treatment rooms

S

COTT BARANEK, BOCP, CP,

48

APRIL 2016 | O&P ALMANAC

FACILITY: Bremer Prosthetics OWNERS: Scott Baranek, BOCP, CP, and Nathan Kapa, CP LOCATIONS: Flint and Saginaw, Michigan HISTORY: 18 years

Scott Baranek, BOCP, CP, owner and partner of Bremer Prosthetics, lost his leg below the knee as the result of a motorcycle accident in 1994.

A patient receives instruction at the Step Up amputee training program

equipment, such as stairs and a treadmill, the new location will include a feature that has been well-received in the Flint facility: an open treatment room.

“This has been very successful,” says Kapa. “Most of our patients like to be around others who share their challenges and successes. We have a separate treatment room for those who prefer privacy, but the majority want to be around other people.”

Many of those patients already know one another from their experience in Bremer’s Step Up Program, a free therapy clinic offered in three local rehabilitation and hospital settings. The monthly meetings focus on strength building and gait training with physical therapists and prosthetic specialists, and they are open to prosthetic patients from any O&P facility. Some participants travel more than 60 miles for the program, Kapa says.

Bremer Prosthetics fabricates all devices in house, at the Flint

PHOTOS: Bremer Prosthetics

and Nathan Kapa, CP, found their paths to facility ownership by serving separate stints as prosthetic technicians.

Baranek, a below-knee amputee since 1994, joined a prosthetic facility about a year after he lost his leg in an accident.

He started his O&P career in marketing and sales, became a technician, and eventually earned his prosthetic certification.

Kapa was a biomedical engineer who worked as a technician for two-and-a-half years before attending Northwestern University’s Prosthetics-Orthotics Center to become a prosthetist.

The two met at Bremer Prosthetics, founded by Thomas Bremer in the late 1990s, and eventually became business partners. When Bremer retired last year, Baranek and Kapa bought the company, and they haven’t looked back.

Although Bremer’s patients run the gamut in age and disability, the facility serves a high proportion of active amputees, including athletes, and fits both lower- and upper-extremity devices at all levels of amputation. Bremer Prosthetics has two offices, in Flint and Saginaw, Michigan. The company’s 11 employees include a resident, two prosthetic assistants, and two technicians, in addition to clinicians Kapa and Baranek.

The Saginaw location, once a satellite office, has seen such growth that it is being moved from a 1,000-square-foot space to a 4,000-square-foot facility.

As well as offering additional

location. The new Saginaw facility also will feature a full fabrication lab, says Baranek. The company relies on traditional plaster casting for most of its work, using computer-aided design only for initial transfemoral prostheses, which can be problematic to cast.

Kapa describes Bremer’s approach as patient centered, with a focus on details. He and Baranek pay particular attention to the first two years of their patients’ rehabilitation, often starting at the preoperative stage, as an amputee’s residual limb, and emotional state, adjust to using a prosthesis. “Even when a patient is successfully ambulating in a year, it can take longer than that to adapt to this new life,” Kapa says.

Kapa emphasizes that every device is made specifically for each patient. “We don’t just build a standard K2 transfemoral prosthesis, for example. We make sure we design and build the best prosthesis for every patient.

Every one is a custom device.”

So far, word of mouth has been sufficient to increase business, according to Baranek.

“Coming from a sales and marketing background, I was expecting to be more involved in activities like that. But it wasn’t necessary. Instead, our patient programs, like Step Up, increase our exposure to amputees, and that leads to new patients.”

Looking ahead, Kapa and Baranek are not ready for longrange plans at this point. They are settling in as owners and overseeing the expansion of the Saginaw facility. “Eventually,” says Baranek, “we’d like to expand our scope of care, but for now, we plan to focus on the present.”

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

AOPA NEWS

Understanding Shoes, Mastectomy, & Other Policies Register for the April 13 Webinar Don’t miss the April webinar on “Understanding Shoes, Mastectomy, & Other Policies.”

Participants in this webinar will complete the following: • Review the nuances of the Therapeutic Shoes for Persons With Diabetes Policy.

• Review the Orthopedic Shoe Policy and when the L3000 series of codes is covered.

• Review the External Breast Prostheses Policy.

• Learn when and how compression garments are covered.

• And much more.

AOPA members pay $99 (nonmembers pay $199), and any number of employees may participate on a given line.

Attendees earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring at least 80 percent. Register at bit.ly/2016webinars. Contact Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0876 with questions.

Register for the whole series and get three free webinars!

The series costs $990 for members and $1,990 for nonmembers. All webinars that you missed will be sent as a recording. Register at bit.ly/2016billing.

50

APRIL 2016 | O&P ALMANAC

When Things Go Wrong: Making Lemonade Out of Lemons Register for the May 11 Webinar Learn to make lemonade out of lemons and earn 1.5 credits during the hour-long webinar on May 11. AOPA experts will be on hand to explain how to handle the following situations: • When a patient refuses an item/service • When a patient returns an item • When you have a disgruntled patient • Other instances when things don’t go as planned AOPA members pay $99 (nonmembers pay $199), and any number of employees may participate on a given line.

Attendees earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring at least 80 percent. Register at bit.ly/2016webinars. Contact Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0876 with questions.

Register for the whole series and get three free webinars! The series costs $990 for members and $1,990 for nonmembers. All webinars that you missed will be sent as a recording. Register at bit.ly/2016billing.

ROBUST adjective; strongly or stoutly built.

INTUITIVE adjective; readily learned or understood.

TRUSTED verb; a belief that something is reliable, good, honest, effective.

FREE Scanner - Ask How Custom Diabetic A5513, EVA and Rigid Foot Orthotics in Days, not Weeks Use of Scanner with lab services agreement, terms and conditions apply. sales@amfit.com . +1-800-356-3668 . AMFIT.COM .

@Amfitinc

WELCOME NEW MEMBERS

T

HE OFFICERS AND DIRECTORS of the American Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an www.AOPAnet.org official member of AOPA if, within 30 days of publication, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership.

At the end of each new facility listing is the name of the certified or state-licensed practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or state-licensed practitioner to be eligible for membership.

At the end of each new supplier member listing is the supplier level associated with that company. Supplier levels are based on annual gross sales volume.

Garrison’s Prosthetic Services Inc. 17184 NE 19th Avenue North Miami Beach, FL 33162 305/949-1888 Category: Patient-Care Facility Kevin Garrison, CP, LP Innovative Prosthetic & Orthotic Professionals Inc. 1750 Humboldt Street, Ste. 102 Denver CO, 80218 303/832-1750 Category: Patient-Care Facility Paula Englander, JD

Is Your Facility Celebrating a Special Milestone in 2016?

O&P Almanac would like to celebrate the important milestones of established AOPA members. To share information about your anniversary or other special occasion to be published in a future issue of O&P Almanac, please email cumbrell@contentcommunicators.com.

Products & Services

For Orthotic, Prosthetic & Pedorthic Professionals

What are we doing?

Where are we going?

How do we survive?

2016 OPERATING PERFORMANCE REPORT FREE for AOPA members

Find the best practices to help you manage your business.

Participate in the annual O&P Operating Performance Survey to chart your course.

Contact Bleppin@aopanet.org to participate in the 2016 survey coming this spring.

52

APRIL 2016 | O&P ALMANAC

www.AOPAnet.org

MARKETPLACE ALPS Skin Reliever ENCP The ALPS Skin Reliever eliminates shear forces and friction, and prevents abrasions on the skin of the stump. It offers both superior comfort and durability while also accommodating for volume fluctuations over the life of the prosthesis. The ALPS Skin Reliever provides superior elongation for very little compression against the skin, reducing shearing and abrasion. There is no need to make a new socket for this product, as the ALPS Skin Reliever can be worn under silicone and gel.

For more information, contact ALPS at 800/574-5426 or visit www.easyliner.com. ALPS is located at 2895 42nd Avenue N., St. Petersburg, FL 33714.

Introducing Precise Insoles by Amfit Amfit is proud to announce a prefabricated, functional insole in 24 sizes. Confidently offer a noncustom orthosis with biomechanically engineered arch support built right in. Millions of unique foot shapes formed the basis for designing a ready-towear insole with true functional support and the widest size range on the market. Most high-quality premade insoles offer less than 10 shell sizes. Precise insoles were designed to bridge that gap so you can offer a high-quality, functional orthosis when full custom isn’t an option.

• 24 sizes • Integrated length, width, and arch height • Anatomically correct design • Functional shell with no crack guarantee • Forefoot comfort insert • Stabilizing deep heel cup • Tablet-style digital sizing guide Opt for the Starter Kit (36 pairs, digital sizer, mount, and display materials) or order by the pair.

Ask about introductory specials at sales@amfit.com or 800-356-FOOT (3668), x264.

Amfit: It’s Your Patient, Shouldn’t It Be Your Orthotic Design, Too? Take complete control for the ultimate in patient satisfaction with Amfit Lab Services.

• Carbon fiber (flex and firm) • Polypropylene (flex, semiflex, rigid) • Five EVA styles and densities • One- to four-day turnaround • Diabetic-specific program: three pair for $60, includes shipping • Foam box processing • Contact Digitizer 3D digital casting system • Equipment rental and lease programs available.

Thirty years specializing in custom foot orthotics and orthotic technology, we will help move your practice forward while saving time and money. Contact Amfit Inc. today at 800/356-FOOT(3668), email sales@amfit.com, or visit www.amfit.com.

Peak Scoliosis Bracing System Winner of the 2015 Spine Technology Award, the Peak Scoliosis Bracing System is a revolutionary new bracing system from Aspen Medical Products.

This innovative new concept in bracing is the only brace specifically designed for adults with scoliosis and has been shown to: • Significantly reduce pain • Increase mobility • Promote better posture • Improve the quality of life.

Code L1005 approved.

Visit www.aspenmp.com.

O&P ALMANAC | APRIL 2016

53

MARKETPLACE

Feature your product or service in Marketplace.

Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net.

Visit bit.ly/aopamedia for advertising options.

New Multiaxial Stubbie Feet: Sidekicks™ College Park’s Sidekicks are the first adjustable stubbie feet for bilateral, above-knee amputees.

With natural anatomical ankle motion, Sidekicks flex and plant in real-world environments for the ultimate balance and stability.

The feet encourage muscle activity to assist in the rehabilitation process, which can be especially helpful when the goal is a transition to microprocessor knees. Also sold as a single unit and certified safe for water use, the Sidekicks can be used by unilateral amputees for adaptive sports, like surfing or rock-climbing. The robust multiaxial ankle and small, treaded platform provide unlimited possibilities.

See the Sidekicks in action at www.youtube.com/CollegeParkInd.

New Shoes from Apex: The Spring Collection Consummate style, superior comfort, and industry-leading construction showcase this new collection of Apex footwear. Each pair is meticulously crafted with the highest quality materials and designed for agility and ultimate durability.

Apex is proud to offer this new collection while continuing its long tradition of manufacturing the finest foot health products available on the market.

For more information, contact Apex at 800/252-2739 or visit apexfoot.com.

Socket-less Socket Transfemoral—Kids We’ve re-invented sockets from the ground up, for kids too. No more static socket shape. No more hard ischial seat.

No more loss of suction.

Using our NASA-based hammock-fit technology, the Socket-less Socket truly conforms to the user, providing a customfit socket every time you put it on.

Fitting a socket is now micro-adjustable in real-time, eliminating the need for the antiquated casting, modification, and iterative test socket fitting methods from the past.

View the free Socket-less Socket training at MartinBionics. com. Contact Martin Bionics at 844-MBIONIC. 54

APRIL 2016 | O&P ALMANAC

Bikini Socket—One Third the Size, One Third the Weight, Three Times the Comfort Instead of encapsulating the pelvis with a bucket, our patented, lightweight Bikini Socket and Iliac Crest Stabilizers provide a direct biomechanical link between the device and its user, resulting in superior control, comfort, and functional outcomes.

Fitting a hip or hemipelvectomy level has never been so simple. The Bikini Socket Hammock Casting Stand allows you to microadjust the socket shape using our NASA-based mesh fabric hammock—eliminating point-specific ischial loading and providing an ultracomfortable hammock fit. The casting shape becomes the final socket shape. It’s that simple.

View the free Bikini Socket Hammock Casting Stand training at MartinBionics.com. Contact Martin Bionics at 844-MBIONIC.

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 at 800/301-8275 or visit www.hersco.com.

New KS Sure Stance Knee by DAW This ultralight, multiaxis knee is the world’s first four-bar stance control and stance flexion knee. The positive lock of the stance control activates up to 35 degrees of flexion.

Unlike single-axis knees, there is no need to shorten the pylon, which produces undue strain on the lower spine. All of the above, combined with the reliability of toe clearance at swing phase, makes this knee the choice prescription for K2 patients.

For more information, call DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

Products & Services For Orthotic, Prosthetic & Pedorthic Professionals

AOPA MASTERING MEDICARE:

ESSENTIAL CODING & BILLING TECHNIQUES SEMINAR

SAN ANTONIO

EARN

JUNE 13-14 | 2016

AOPA Coding Experts Are Coming to San Antonio The world of coding and billing has changed dramatically in the past few years. The AOPA experts are here for you! The June 13-14 Coding & Billing Seminar will teach you the most up-to-date information to advance the coding knowledge of O&P practitioners and billing staff.

The seminar features hands-on breakout sessions, where you will practice coding complex devices, including repairs and adjustments. Breakouts are tailored specifically for practitioners and billing staff. Take part in this seminar and to better your business, your staff, and your patients!

Don’t miss the opportunity to experience two jam-packed days of valuable O&P coding and billing information. Learn more and see the rest of the year’s schedule at bit.ly/2016billing.

In this audit-heavy climate, can you afford not to attend?

14 CEs

Top 10 reasons to attend: 1.

Get your claims paid.

2.

Increase your company’s bottom line.

3.

Stay up-to-date on billing Medicare.

4.

Code complex devices

5.

Earn 14 CE credits.

6.

Learn about audit updates.

7.

Overturn denials.

8.

Submit your specific questions ahead of time.

9.

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 2016 Coding & Billing Seminar!

Register online at bit.ly/2016billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. .

www.AOPAnet.org

MARKETPLACE

Feature your product or service in Marketplace.

Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net.

Visit bit.ly/aopamedia for advertising options.

EZ ACCESS DAWSKIN The New MegaStretch DawSkin is the most durable tear-free skin in the world.

The New MegaStretch DawSkin provides the vertical ankle stretch required for multiaxis feet and energy restitution feet. “Heat-shrink” skins limit the ankle movement and will tear; not so with the New MegaStretch DawSkin.

DawSkin New EZ-Access dons on and off just like a sock yet provides all the benefits of the New MegaStretch DawSkin.

For more information, call DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

DAW’S DGEL RESIN II Tubular Braid: • 38 million Modules Fiber means way stronger than the market best!

• Two layers lay-up is all you need for 75 percent of your patients.

• Double its strength when used in conjunction with DGEL Fiber Beam.

• Available in 4-, 5-, 6-, 7-, and 8-inch diameters to fill all your lay-up needs.

Epoxy Resin: • Half the resin—double the strength.

• So safe it can ship overnight.

• The “no smell” resin.

• Ultralight, ultrastrong, and ultrathin.

• Twice as strong as acrylic resin, “You can stand on it.”

For more information, call DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

56

APRIL 2016 | O&P ALMANAC

Introducing the Fuzion™ Family of Orthoses Patients experience greater fit, function, and freedom with Orthomerica’s new Fuzion line of custom orthoses. The Fuzion’s design and materials ensure greater patient compliance for a variety of challenging clinical indications. Available for both select adult and pediatric patients.

Key benefits: • Proprietary heat-adjustable plastic makes patient management much easier vs. traditional orthoses • New treatment options for patients historically not candidates for orthotic intervention & management • Fuzion’s compression design holds the patient in a secure comfortable position while assisting with spasticity management • Accommodates volume changes.

Call 877/737-8444 or visit www.orthomerica.com.

Silicone, Urethane, and Copolymer Liners The Skeo family of silicone liners includes an internal matrix to reduce pistoning plus a slick outer surface to aid in donning and doffing.

Choose from a variety of options that include preflexed for enhanced fit, and SkinGuard protection to reduce odor. Our copolymer liners are ideal for lower-activity patients, and our Anatomic 3D Urethane liner is preferred for Harmony vacuum or valve systems. Whether your patients need a silicone, urethane, or copolymer solution, Ottobock can help you find the right fit.

Call your local sales rep to find out more.

For more information, call Ottobock at 800/328-4058 or visit www.professionals.ottobockus.com.

MARKETPLACE Ottobock: 28U90 Ankle-Foot Orthosis The 28U90 ankle-foot orthosis from Ottobock blocks foot drop during swing phase. Its thin-walled polypropylene construction has been optimized for increased resilience, providing effective support in an incredibly lightweight orthosis. The long sole provides precise foot guidance and good pressure distribution. New calf pads and closure straps are included and ensure a high level of wearer comfort. These can be adapted without additional tools.

Ask your sales rep at 800/328-4058 about how the 28U90 can help your patients.

• CodingPro CD-ROM (network version): $435 AOPA members, $695 nonmembers • Illustrated Guide: $185 AOPA members, $425 nonmembers • Quick Coder: $30 AOPA members, $80 nonmembers Order at www.AOPAnet.org or by calling AOPA at 571/431-0876.

Enjoy the Freedom and Flexibility of Natural Wrist Movement! +40 degrees

-40 degrees

Spinal Technology Spinal Technology Inc. is a leading central fabricator of spinal orthotics, upper- and lower-limb orthotics, and prosthetics. Our ABC-certified staff orthotists/prosthetists collaborate with highly skilled, experienced technicians to provide the highest quality products and fastest delivery time, including weekends and holidays, as well as unparalleled customer support in the industry.

Spinal Technology is the exclusive manufacturer of the Providence Scoliosis System, a nocturnal bracing system designed to prevent the progression of scoliosis, and the patented FlexFoam™ spinal orthoses.

For information, contact 800/253-7868, fax 888/775-0588, email info@spinaltech.com, or visit www.spinaltech.com.

2016 AOPA Coding Products Get your facility up to speed, fast, on all of the O&P HCPCS code changes with an array of 2016 AOPA coding products.

Ensure each member of your staff has a 2016 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors.

• Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers • CodingPro CD-ROM (single-user version): $185 AOPA members, $425 nonmembers

The unlocking flexion wrist allows for better positioning during functional tasks such as: • Sweeping • Cleaning tabletops • Pushing a shopping cart • Opening doors • Stabilizing objects during cooking tasks For more information, contact Touch Bionics Inc. at (855)MY iLimb or visit www.touchbionics.com.

Regulate Heat and Reduce Sweat With the WillowWood Alpha SmartTemp® Liner WillowWood’s Alpha SmartTemp® Liner brings temperature control to prosthetic liners with Outlast®, the original heat management technology developed for NASA. An Alpha SmartTemp Liner absorbs heat generated by an amputee’s residual limb (as illustrated) and reduces sweating and the amount of moisture within a liner. When skin temperature drops, stored heat is then recycled back to a limb to prevent chilling. A comfort level is achieved when the skin temperature and the liner temperature are balanced.

Alpha SmartTemp Liners are available for transtibial and transfemoral use and retrofit with Alpha Hybrid and Silicone Liners.

For information, contact WillowWood at 800/848-4930.

O&P ALMANAC | APRIL 2016

57

AOPA NEWS

CAREERS

Opportunities for O&P Professionals

North Central

Job location key:

Job Opportunity

Central Indiana A highly respected leader in O&P in Central Indiana is looking to grow. We need highly motivated and experienced individuals to help grow our practices, while maintaining the high quality of services and products we provide. Excellent pay and benefits commensurate with experience and performance.

For more information, please contact:

- 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 landerson@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.

Mid-Atlantic

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

Nonmember $678 $830

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

Job Board

Member Nonmember $85 $150

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

SUBSCRIBE

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.

58

APRIL 2016 | O&P ALMANAC

Keon Mansoori Advanced OrthoPro Inc. Phone: 317/924-4444, ext. 124

CPO/BOCPO

Louisville, Kentucky At Center for Orthotic & Prosthetic Care (COPC), our staff of orthotic and prosthetic professionals is committed to our mission of providing the highest level of patient care possible. COPC is a private partnership that enjoys the privilege and challenge of serving in leading and renowned medical centers in Kentucky, Indiana, North Carolina, New York, and Pennsylvania. Due to an opening at one of our patient-care facilities in Louisville, Kentucky, we are seeking a CPO, or Kentucky-licensed BOCPO, with a minimum of five years’ clinical experience. Candidates must possess excellent communication, organizational, and interpersonal skills, and the demonstrated ability to provide the highest-quality patient care. This position offers a competitive salary, relocation assistance, and excellent benefits including medical, dental, disability, 401K, certification and licensure fees, and continuing education expenses. If you meet these requirements and have an interest, please submit your résumé, in confidence, to:

Center for Orthotic & Prosthetic Care (COPC) Fax: 502/451-5354 Email: dkoch@centeropcare.com

CAREERS

Pacific CO/CPO

BUILD A

Sacramento, California Established in 1987, Pacific Medical Prosthetics and Orthotics has become a tenured company in the industry for patient-care products and services. With the heart of the company dedicated to helping and serving others, we are currently seeking an orthotist or prosthetist/orthotist in Northern California that is a seasoned practitioner with experience in practice management, clinical expertise in outpatient and inpatient settings, organization and maintenance of an O&P facility, fabrication, fitting, and a willingness to supervise and work within a dynamic team. This position is an excellent opportunity for a candidate who is self-driven/motivated with an entrepreneurial spirit who is looking to produce results in an expanding market. Competitive salary, benefits, and profit sharing offered based on experience.

Interested candidates should email inquiries/résumé to:

Better BUSINESS WITH AOPA

Visit www.AOPAnet.org/join today!

Learn how AOPA can help you transform your business into a world class provider of O&P Services with: Coding, Billing and Audit Resources Education, Networking, and CE Opportunities

Pacific Medical Prosthetics and Orthotics Email: careers@pacmedical.com Fax: 209/834-0690

Advocacy Research and Publications Business Discounts

EXTRAORDINARILY SIGNIFICANT FINDINGS: Medicare data proves the economic value of an O&P intervention.

O&P CARE is COST EFFECTIVE The Study that Started MobilitySaves.org

5

Reasons to visit MobilitySaves.org

Learn about the study proving orthotic and prosthetic care saves money

1.

Find ads and videos on Medicare’ costcutting to share on your website or social media

A major study, commissioned by the Amputee Coalition with support from the American Orthotic & Prosthetic Association, shows that Medicare pays more over the long term in most cases when Medicare patients are not provided with replacement lower limbs. Mobility Saves Lives And Money!

See healthy lives affected

by O&P care

2.

Follow us on social media!

Find resources to share with your patients

3.

4.

Learn how much Medicare has saved this year by providing O&P care

5.

Visit MobilitySaves.org.

“Search Mobility Saves” on Facebook, Twitter, and LinkedIn O&P ALMANAC | APRIL 2016

59

CALENDAR

2016

April 22-23

PrimeFare Central Regional Scientific Symposium 2016.

Southern Hills Marriott, Tulsa, OK. Contact Jane Edwards at 888/388-5243, jledwards88@att.net, or visit www.primecareop.com.

April 4-5

Orthomerica Whole Limb Solutions Seminar. Las Vegas. Earn 14 CEUs and increase your referral sources as a Certified OWLS Practitioner by attending this ABC-accredited seminar in Las Vegas. Tuition is $495. Each attendee receives a $200 coupon. For more information, visit www.orthomerica.com/education and register today as seating is limited.

April 7-9

Texas Association of Orthotists & Prosthetists.

Dallas/Addison Marriott Quorum by the Galleria, Dallas.

For more information, visit www.TAOP.org.

April 11-12

AOPA Mastering Medicare: Essential Seminar Coding & Billing Techniques Seminar.

Doubletree Hotel, Portland, OR. Register online at bit.ly/2016billing.

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

April 13

Understanding Shoes, Mastectomy, & Other Policies. Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

April 26-27

AOPA Policy Forum. Washington Marriott at Metro Center, Washington, DC. For more information, visit bit.ly/policyforum2016 or contact Ryan Gleeson at rgleeson@AOPAnet.org.

May 1

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

May 9-14

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 250 locations nationwide. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

May 11

When Things Go Wrong: Making Lemonade Out of Lemons. Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

No Application Deadlines BOC offers year-round testing for all of its exams and has no deadlines. Candidates can apply, test when ready, and receive their results instantly for the multiple-choice and clinical-simulation exams. Apply now at http://my.bocusa.org. To learn more about our nationally recognized, in-demand credentials, visit www.bocusa.org or emailcert@bocusa.org.

www.bocusa.org

SHARE

your next event!

60

Cascade Dafo Inc. Cascade Dafo Institute. Now offering a series of six free ABC-approved online courses, designed for pediatric practitioners. Visit www.cascadedafo.com or call 800/848-7332.

CE For information on continuing education credits, contact the sponsor.

Questions? Email landerson@AOPAnet.org.

Calendar Rates Let us

Online Training

CREDITS

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 landerson@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.

APRIL 2016 | O&P ALMANAC

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

CALENDAR June 24-25

May 11- 13

New York State Chapter Annual Meeting. Albany Marriott, Albany, NY. For information, email Marx4NYSAAOP@aol.com, or visit www.NYSAAOP.org

PrimeFare East Regional Scientific Symposium 2016. Renaissance Hotel & Convention Center, Nashville. Contact Jane Edwards at 888/388-5243, jledwards88@att.net, or visit www.primecareop.com.

May 19-20

Orthomerica Whole Limb Solutions Seminar. Dallas. Earn 14 CEUs and increase your referral sources as a Certified OWLS Practitioner by attending this ABC-accredited seminar in Dallas. Tuition is $495. Each attendee receives a $200 coupon. For more information, visit www.orthomerica.com/education and register today as seating is limited.

May 19-21

International African-American Prosthetic & Orthotic Coalition.

Memphis, TN. For more information, visit www.iaapoc.org.

June 1

ABC: Practitioner Residency Completion Deadline for July & August 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.

July 13

Strategies and Levels: How To Play the Appeals Game. Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

August 10

The Supplier Standards: Are You Compliant? Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

August 11-12

Orthomerica Whole Limb Solutions Seminar. Milwaukee. Earn 14 CEUs and increase your referral sources as a Certified OWLS Practitioner by attending this ABC-accredited seminar in Milwaukee. Tuition is $495. Each attendee receives a $200 coupon. For more information, visit www.orthomerica.com/education and register today as seating is limited.

June 8

Physician Documentation: How To Get It & How To Use It. Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

June 9-10

MOPA: Michigan Continuing Education Meeting.

DoubleTree by Hilton Bay Cityâ&#x20AC;&#x201D;Riverfront, Bay City, MI. Now offering pedorthic continuing education credits. Contact 517/784-1142 or visit www.mopa.info.

June 13-14

AOPA Mastering Medicare: Essential Coding & Billing Techniques Seminar.

Grand Hyatt, San Antonio. Register online at bit.ly/2016billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Seminar

June 23-24

Orthomerica Whole Limb Solutions Seminar. Newark, NJ. Earn 14 CEUs and increase your referral sources as a Certified OWLS Practitioner by attending this ABC-accredited seminar in Newark, NJ. Tuition is $495. Each attendee receives a $200 coupon. For more information, visit www.orthomerica.com/education and register today as seating is limited.

Ottobock 360Ë&#x161; Education and Events

Select from a range of upper and lower limb prosthetic courses as well as orthotic training. Courses are offered around the country and at our North American Headquarters in Austin, TX. Go to our site, find the Education menu, and select Classroom Training to see the full list of options. www.professionals.ottobockus.com www.professionals.ottobock.ca

O&P ALMANAC | APRIL 2016

61

CALENDAR

August 12-13

Texas Chapter of the American Academy of Orthotists and Prosthetists: Annual Meeting.

Grand Hyatt on the Riverwalk, San Antonio. Contact Leslie Gray at 214-648-1006, email secretary-treasurer@txaaop.org, or visit www.txaaop.org.

October 12

KO Policy: The ABCs of the LCD and Policy Article. Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

November 9

August 18-20

Virginia Orthotic & Prosthetic Association. Hyatt Regency Reston, Reston, VA. For more information, visit www.vopainfo.com.

Don’t Miss Out: Are You Billing for Everything You Can? Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

September 8-11

99th AOPA National Assembly. Boston.

For exhibitors and sponsorship opportunities, contact Kelly O’Neill at 571/431-0852 or koneill@ AOPAnet.org. For general inquiries, contact Betty Leppin at 571/431-0876, or bleppin@AOPAnet.org, or visit www.AOPAnet.org.

December 14

New Codes and What Lies Ahead for 2017. Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

September 14

Fill in the Blanks: Know Your Forms.

Register online at bit.ly/2016webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Webinar Conference

ADVERTISERS INDEX

Company

Website

ABCOP - American Board for Certification in Orthotics, Prosthetics & Pedorthics Inc.

49

703-886-7114

www.abcop.org

ALPS South LLC

21

800-574-5426

www.easyliner.com

Amfit

51

800-356-3668 www.amfit.com

Aspen Medical

29

800-295-2776

www.aspenmp.com

Cailor Fleming Insurance

47

800-796-8495

www.cailorfleming.com

Cascade Dafo Inc.

13

800-848-7332

www.cascadedafo.com

Charleston Bending Brace Foundation

19

843-577-9577

www.cbb.org

College Park Industries

23

800-728-7950

www.college-park.com

Custom Composite

37

866-273-2230

www.cc-mfg.com

DAW

1

800-252-2828 www.daw-usa.com

Ferrier Coupler Inc.

45

810-688-4292

Hersco

2

800-301-8275 www.hersco.com

Martin Bionics

27

844-BIONICS

www.martinbionics.com

OHI - Apex

7, 9

877-780-8382

www.ohi.net

Orthomerica

5

www.ferrier.coupler.com

800-446-6770 www.orthomerica.com

Ottobock

C4

800-328-4058 www.professionals.otobockus.com

Touch Bionics

15

855-694-5462

www.touchbionics.com

Spinal Technology

31

800-253-7868

www.spinaltech.com

800-848-4930

www.willowwoodco.com

WillowWood

62

Page Phone

APRIL 2016 | O&P ALMANAC

Insert

The premier meeting for orthotic, prosthetic, and pedorthic professionals.

#AOPA2016

AOPAnet.org

LIGHTING the FUTURE SEPTEMBER 8-11, 2016 | BOSTON

Earn more than

32 CE

SAVE THE DATE

CREDITS

Join us September 8-11, 2016, for the 2016 AOPA National Assembly at the Hynes Convention Center in Boston, MA.  PLOT A COURSE FOR FUTURE SUCCESS with 5 concurrent sessions for Orthotists, Prosthetists, Pedorthists, Technicians, Business Owners and Managers

The O&P community has experienced stormy seas for the past several years with legislative challenges, rising costs, and reimbursement pressures. If you are looking for a lighthouse in the storm—join us at the 2016 Assembly.

Our goal is to bring our profession together to build a strong future through clinical and business education, networking and the support of a strong supplier community.

 Cruise through the stormy seas of REGULATORY RULES with answers you can only get from AOPA  Navigate the country’s LARGEST O&P EXHIBIT HALL  Sail through spectacular general sessions with inspiring KEYNOTE PRESENTERS

 Partake in FUN NETWORKING EVENTS  Enjoy exciting and HISTORIC BOSTON BACK BAY  Catch up with the ALUMNI CONNECTION  Maneuver your way with CASE STUDIES AND SYMPOSIA  GET ONBOARD with MDs, PhDs, Wound Care Specialists, Research Scientists, Attorneys, Business Experts and Top-Notch Practitioners.

Questions?

Contact AOPA at 571/431-0876 or email at info@AOPAnet.org.

For information about the show, scan the QR code with a code reader on your smartphone

Visit www.AOPAnet.org to learn more, submit a paper, or to exhibit.

ASK AOPA CALENDAR

Office FAQs Answers to your questions regarding sequestration, office hours, and more

AOPA receives hundreds of queries from readers Q 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.

Are Medicare Advantage plans allowed to apply the 2 percent sequestration to our final payments?

Q/

The answer is yes and no; the answer depends on whether you have a contract with the Medicare Advantage plan and how that contract is worded or written.

A/

If you are noncontracted with the plan, Medicare has stated that a “noncontract provider must accept, as payment in full, the amount that it could collect if the beneficiary were enrolled in the Medicare feefor-service program.” This means the plan may apply the 2 percent sequestration to your final payment.

If you are a contracted provider with a Medicare Advantage plan, then typically the plan may not apply the 2 percent reduction to your final payment because Medicare “may not require any Medicare Advantage organization to… require a particular price structure for payment under such a contract….” In other words if your contract does not address the issue of sequestration or your contract does not indicate that your payment is based on Medicare payments (not fee schedule amount but payments), then the 2 percent sequestration could not be applied.

More information can be

found in a CMS memo available at www.cms.gov/Medicare/MedicareAdvantage/Plan-Payment/Downloads/ PaymentReductions.pdf.

Q/

Are we required to be open for at least 30 hours a week?

Medicare Supplier Standard 30 states that certain suppliers must be open to the public for a minimum of 30 hours a week. However, as an O&P provider you may be exempt from this requirement. If you are providing some custom orthoses and prostheses, and only orthoses and prostheses, then you are exempt.

However, if you are providing any type of durable medical equipment (DME) items, even if you are providing custom orthoses and prostheses as well, then you are not exempt and you are required to be open at least 30 hours a week.

A/

What is Medicare’s reasonable useful lifetime (RUL) for orthotics and prosthetics?

Q/

The RUL for orthotics and prosthetics 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 orthotics and prosthetics, but in no case may a RUL be longer than five years. In other words, if Medicare does not establish a RUL for an item, the DME MACs may create a RUL through policy—but if the DME MACs do not create a policy, the RUL for an item is set at five years.

A/

APRIL 2016 | O&P ALMANAC

PHOTO: iStock.com/Johnny Greig

64

The Source for Orthotic & Prosthetic Coding

Marketing Opportunity Enhanced Listing

AOPA members ONLY $1,000 per year!

An enhanced listing on LCodeSearch.com, enables you to add as many products as you wish, with descriptions, images, and links to your website.

What if you had a chance to reach a potential of

10,000

O&P buyers

with product info, a link to your website, and your ordering information?

The Source for Orthotic & Prosthetic Coding

Included in Search Product Name Manufacturer Name

Basic Listing (Free)

Enhanced Listing ($1000)

✓ ✓ ✓

✓ ✓ ✓ ✓ ✓ ✓

Up to 2 Photos Description Link to website

*This offer is only available for current AOPA members. It is offered independently of the Supplier Plus program.

In a typical year, AOPA’s LCodeSearch.com reaches:

10,000+ UNIQUE USERS

55,000+ VISITS

2,000+

HOURS OF SEARCH TIME

Don’t miss out on this great opportunity for buyers to see your product information! Contact Betty Leppin for more information at 571-431-0876. www.AOPAnet.org

C-Brace

Up and out of his wheelchair

Promote more natural walking without a locked knee

Supports you even when your knee is flexed

www.ottobockus.com www.ottobock.ca