July 2015 O&P Almanac by AOPA

2015 AOPA NATIONAL ASSEMBLY PREVIEW: SAN ANTONIO P.30 The Magazine for the Orthotics & Prosthetics Profession

J U LY 2015

Midyear Updates to Medicare’s O&P Policies P.16

Why Tech Innovations Matter

REINVENTING

P.36

CONTROL AND PRODUCTION

How To Write Valid ABNs

HOW BMI, TMR, AND 3D PRINTING COULD BE GAME-CHANGERS FOR THE DELIVERY OF PATIENT CARE P.24

P.40

E! QU IZ M EARN

BUSINESS CE

CREDITS

WWW.AOPANET.ORG

P.18 & 42

Exclusive: The Battle To Distinguish O&P From DME P.20

YOUR CONNECTION TO

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R EG American Orthotic & Prosthetic Association

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The premier meeting for orthotic, prosthetic, and pedorthic professionals

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Register Today! The 98th Annual AOPA National Assembly in conjunction with the Texas Academy Chapter Meeting October 7-10, 2015 The Henry B. Gonzalez Convention Center On the Riverwalk in San Antonio, TX Experience an ideal combination of top-notch education, exhibits, and entertainment at the 98th AOPA National Assembly in San Antonio, Texas. We look forward to seeing you!

Earn over

35 CE Credits For information about the show, scan the QR code with a code reader on your smartphone or visit www.AOPAnet.org.

O&P Almanac readers are invited to tour the AOPA National Assembly Exhibit Hall on Saturday, October 10, at the Henry B. Gonzalez Convention Center in San Antonio. You may choose to pre-register online at bit.ly/aopa2015 and use the promocode OPALMANAC (Be sure to select the registration category, Exhibit Hall Only, and then Saturday, Oct. 10) or you may choose to bring the adjacent coupon to the registration desk in San Antonio.

AOPAnet.org

Valid for Admission to the AOPA National Assembly Exhibit Hall Only on Saturday, October 10, 2015 Henry B. Gonzalez Convention Center San Antonio, Texas

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contents

J U LY 2015 | VOL. 64, NO. 7

FEATURES

DEPARTMENTS | COLUMNS

COVER STORY

President’s View....................................... 4

Insights from AOPA President Charles Dankmeyer Jr., CPO

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

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

At-a-glance statistics and data

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

24 | Reinventing Control and Production New technologies that serve as industry disruptors are impacting not only the type of devices O&P professionals provide, but also the way practitioners provide patient care. Find out how the advent of targeted muscle reinnervation, brain-machine interface technologies, and 3D printing is changing the O&P profession.

P. 20

Why and how should you integrate new technologies into your practice? Senior O&P executives explain why it’s important to consider innovative devices despite the reimbursement challenges, and offer suggestions to smooth the transition when fitting patients with advanced componentry.

Compliance Corner.............................. 40

Writing Valid ABNs

CE Opportunity to earn up to 2 CE credits by taking the online quiz.

CREDITS

Member Spotlight................................ 44 n

P. 30

With three months to go until the 2015 National Assembly, it’s time to start planning for AOPA’s can’t-miss annual meeting. Visiting San Antonio’s historic sites and riverside attractions will round out this year’s premier networking events and expert educational sessions.

Technology Smarts

Midyear Updates

Recently announced updates to Medicare’s O&P policies

Section-by-section breakdown of advanced beneficiary notice requirements

AOPA and the O&P Alliance have voiced their concerns regarding a rulemaking proposal that would expand the Bundled Payment for Care Initiative and include orthotics and prosthetics in the 90-day period of acute care bundling.

36 | O&P Almanac Leadership Series

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

CREDITS

The Battle To Distinguish O&P From DME

30 | Texas Charm and Hospitality

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

Transitions in the profession

CE Opportunity to earn up to 2 CE credits by taking the online quiz.

By Christine Umbrell

20 | This Just In

Research, updates, and industry news

Medical Center Orthotics and Prosthetics Myomo

AOPA News............................................... 48

AOPA meetings, announcements, member benefits, and more

Welcome New Members ................... 51

P. 36

Marketplace.............................................. 52

Careers......................................................... 56

Professional opportunities

Ad Index........................................................57 Calendar...................................................... 58

Upcoming meetings and events

Ask AOPA.................................................. 60

Expert answers to your questions about diabetic inserts, breast prostheses, and more O&P ALMANAC | JULY 2015

PRESIDENT’S VIEW

Pull the Plug on TV Braces

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

AVE YOU EVER WATCHED those late-night commercials

hawking back braces? You probably know what I’m talking about. They start out with a question like, “Are you on Medicare, and do you suffer from back pain? Do you use a cane, a walker, or a wheelchair, scooter, or power wheelchair? If any of these examples apply to you or a loved one who is on Medicare, we’ve got great news. You could qualify to receive a pain-relieving, comfortable back brace at little or no cost to you.” Substitute knee brace for back brace and the ad is the same. You get the picture. I don’t need to ask whether you’ve silently cursed these overthe-top messages to the unwary. Have you asked yourself what can be done to do curb this misleading—and most likely harmful—sale of “braces” by these charlatans? Have you or a patient ever written a letter, sent an email, or made a phone call to a state or federal watchdog agency expressing concern? There’s some solid data that suggests maybe you should. The experiences of my colleagues and myself tell me these “braces in a box” may result in no relief from pain, but of more immediate concern is whether the inappropriate use of a back brace that has not been properly fit causes more pain, not less. It may well lead to harmful consequences that could involve more costly medical care. Have there been any Medicare or Medicaid audits for those television-pitched back braces? Consider this: A likely television-pitched device may be an L0631 back brace or an L1832 knee brace. In 2012, Medicare allowed a total of $175,087,438 to all providers for these two devices, of which $24,822,122 was paid to O&P providers, or 15 percent of the pie. Those numbers compare to the 2011 allowed payments of $125,821,640, of which O&P received $23,167,833, or 19 percent of the pie. In that period, all other providers saw their dollars jump from $102,633,757 to $150,245,316—a $47 million jump, nearly a 50 percent increase! Durable medical equipment providers received the lion’s share of the increased revenues. Snake oil sells. The obvious conclusion: Those TV ads must be diagnosing a growing number of back pain and knee pain sufferers and account for most of the 50 percent jump in Medicare payouts. It’s hard to believe the usual law of supply and demand prevails here. It seems a little rigged—maybe fraudulently so. That’s the question. There is a lot of unnecessary patient suffering and a lot of Medicare money wasted. I hate to say it, but let’s hope none of these phony medicine men carry a credential from the American Board for Certification in Orthotics, Prosthetics, and Pedorthics or the Board of Certification/Accreditation. If they do, it needs to be revoked. The Federal Trade Commission (FTC) has the primary responsibility for misleading advertising complaints, but your state consumer agency also may have an oar in that stream. There’s no reason you can’t complain to the FTC, but a patient’s voice will be more telling. Encourage them to write to www.ftccomplaintassistant.gov or call 877/382-4357. Yes, CMS has its fraud and abuse reporting system for your patients as well, and they should absolutely complain. It is time to stop 1-800-ORTHOTICS. If nothing else, triggering a complaint can get the frustration from those late-night ads off of your chest. There’s nothing like a good vent to clear the air. What’s your view? Email info@AOPAnet.org.

Board of Directors OFFICERS

President Charles H. Dankmeyer Jr., CPO Dankmeyer Inc., Linthicum Heights, MD President-Elect James Campbell, PhD, CO, FAAOP Becker Orthopedic Appliance Co., Troy, MI Vice President Michael Oros, CPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Immediate Past President Anita Liberman-Lampear, MA University of Michigan Orthotics and Prosthetics Center, Ann Arbor, MI Treasurer Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA DIRECTORS Maynard Carkhuff Freedom Innovations, LLC, Irvine, CA Eileen Levis Orthologix LLC, Trevose, PA Pam Lupo, CO Wright & Filippis Inc., Rochester Hills, MI Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Dave McGill Össur Americas, Foothill Ranch, CA Chris Nolan Endolite, Miamisburg, OH Scott Schneider Ottobock, Austin, TX Don Shurr, CPO, PT American Prosthetics & Orthotics Inc., Iowa City, IA

Charles H. Dankmeyer Jr., CPO AOPA President 4

JULY 2015 | O&P ALMANAC

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, 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

JULY 2015 | 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 © 2015 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 15,000 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/aopamedia for advertising options!

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Mobile Health Health-care providers are implementing mobile strategies to meet patients’ increasing digital needs.

As patients increasingly “go mobile,” O&P professionals must understand how patients access health information and be prepared to offer mobile solutions. More Americans are relying on their smartphones to research health conditions, communicate with health-care providers, participate in remote monitoring, and access mobile health apps.

U.S. SMARTPHONE USE

ACCESSING HEALTH DATA

INTEREST IN E-HEALTH

64 Percent

Nearly two thirds of adults own a smartphone.

79 Percent: Wearable Device

18- to 29-Year-Olds 77 percent of young adult smartphone owners have used their phone to get health information.

Almost 80 percent would be willing to use a wearable device to manage their health.

88 Percent: Willing to Share Data Nearly nine out of 10 would be willing to share their personal information for the sake of improving care and treatment options.

Health-Care Providers’ Adoption of Mobile Health Have no plans to use mobile in health-care delivery Have plans to incorporate mobile into health-care delivery

9% 18%

Use mobile health in some way SOURCE: “The State of Mobile in Health-Care Delivery,” Modern Healthcare Custom Media and Verizon.

JULY 2015 | O&P ALMANAC

73%

“Roughly six in 10 smartphone owners have used their phone to get information about a health condition in the past year, similar to the percentage who say they’ve used their smartphone for online banking.” —Pew Research Center’s “U.S. Smartphone Use in 2015”

SOURCES: Fifth Annual Makovsky/Kelton “Pulse of Online Health” Survey; Pew Research Center’s “U.S. Smartphone Use in 2015.”

Almost two thirds would use a mobile app to manage health-related issues.

62 percent of adult smartphone owners have used their phone to get health information.

One quarter of adults rely “solely” or “usually” on their smartphones for Internet access.

66 Percent: Mobile App

18 & Up

A survey of health-care professionals across disciplines found a majority have adopted mobile strategies to some extent:

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Happenings CODING CORNER

RESEARCH ROUNDUP

Prosthetic Leg Enables Lifelike Foot Sensations

CMS Names NSC Contractor CMS has announced the final PHOTO: Samuel Kubani/AFP/Getty Images

award of the National Supplier Clearinghouse (NSC) contract to NCI Information Systems Inc., a Reston, Virginia-based information technology firm. NCI will administer the contract through AdvanceMed, a wholly owned subsidiary that also holds several CMS contracts to serve as regional zone program integrity contractors. The $52 million contract is for one base year and up to four additional option years.

NCI based its proposal on its

ability to provide streamlined provider enrollment with increased focus on keeping questionable suppliers from enrolling in the Medicare program. CMS has not provided any specific information regarding the timing of the transition of the NSC contract from Palmetto GBA, which previously held the NSC contract, to NCI.

JULY 2015 | O&P ALMANAC

Professor Hubert Egger (L) of Linz University, who created the world’s first “feeling” leg prosthesis, works with Wolfgang Rangger (R)

Austrian scientists are developing a sensory-enhanced prosthesis that allows amputees to feel lifelike sensations from their feet. The technology is designed to prevent slips and falls on different surfaces and limit phantom limb pain. The first clinical trial was conducted on patient Wolfgang Rangger, who lost his right leg in 2007 after suffering a blood clot caused by a cerebral stroke. Surgeons first rewired nerve endings in Rangger’s residual limb to the healthy tissue in the thigh, placing them close to the skin surface. The researchers attached six sensors to the sole of a lightweight prosthetic foot, stimulating nerves at the base of the residual limb to measure the pressure of heel, toe, and foot movement. Those signals are relayed to a microcontroller, which relays them to stimulators

inside the shaft where it touches the residual limb. Vibrations stimulate the nerve endings under the skin. When Rangger takes a step or applies pressure, the sensors send signals to his brain. “The sensors tell the brain there is a foot, and the wearer has the impression that it rolls off the ground when he walks,” says Hubert Egger, professor at the University of Linz and project lead. Rangger, who has been using the prosthesis for the past six months for walking, running, cycling, and climbing, says that the technology makes him feel as if he has a foot again. He also reports a reduction in phantom limb pain now that his brain receives real data rather than searching for information from the missing limb. Details of the study are featured in the June 2015 issue of Science Translational Medicine.

HAPPENINGS

British Engineers Develop Pressure Casting Technique Researchers in the department of biomedical engineering at Glasgow’s University of Strathclyde have developed an innovative technique for building lower-limb prosthetic sockets. The procedure employs a patient’s body weight to simulate walking pressures, with the goal of reducing stress and discomfort and ensuring securely fitting prostheses. The technology is being used to develop a “leg bank” to provide prostheses to lowincome amputees. To cast using the new system, known as Majicast, the residual limbs of amputees are immersed in a tank of water one at a time with a membrane wrapped around them. Pressure casting deforms the soft tissue under a uniform load using the amputee’s body weight. Using this method, the soft tissue is positioned in its stiffest form for load transfer, limiting vertical movement of the limb in the socket and reducing deep shear stresses.

The new method “gives uniform loading to the soft tissue,” says Arjan Buis, MD, project lead. Because the technique is simple to perform, it is being considered for use in low-income countries. The research team is working with members of ProPortion to help people in Colombia acquire high-quality artificial legs.

FSU Partners With VA To Improve Prosthetic Socket Systems The U.S. Department of Veterans Affairs (VA) has awarded Florida State University’s (FSU’s) HighPerformance Materials Institute (HPMI) with a two-year, $4.4 million contract to address the shortcomings of current prosthetic socket systems. FSU researchers will develop, test, and deliver sockets optimized for comfort with advanced techCarbon nanotube model nology (SOCATs) as part of the VA Innovation Initiative project. Led by Changchun “Chad” components, such as auxetic materiZeng, an assistant professor and principal investigator, the research team als (which have the unique property will deliver prototypes that feature a of getting fatter when stretched) and combination of advanced composite carbon nanotube buckypaper, will be materials and technology. These used to develop an intelligent prosthetic

socket system that monitors the socket environment and self-adjusts. The system will record pressure, temperature, and moisture for transmission to prosthetists to facilitate patient care. “This transformative project will leverage the latest advances in innovative materials and advanced manufacturing technologies to build the next-generation prosthetic socket system with significantly improved comfort,” says Ben Wang, a key researcher on the project and executive director of the Georgia Tech Manufacturing Institute. “These advanced materials can improve the fit, pressure points, humidity, and temperature of the prosthesis so that the patient can wear it longer and much more comfortably.” O&P ALMANAC | JULY 2015

HAPPENINGS

FRAUD FINDER

#ICYMI

What Does the King v. Burwell Decision Mean for O&P? NE

CMS To Develop Fraud-Tracking Website CMS will soon launch a system to track enforcement actions against Medicare providers over questionable claims. The agency is seeking a contractor to build and maintain a provider compliance reporting system that will be accessible on the ProviderMedicare.gov website, which is in development. CMS currently contracts with several private companies to protect the Medicare trust fund against fraud by taking a second look at claims. However, none of the existing reporting mechanisms allow for a comprehensive view of Medicare’s activity with CMS and its contractors, according to a solicitation notice published by CMS. The new system will be designed to allow contractors and CMS staff to view provider profiles. The provider profiles will capture information such as when a provider received one-on-one education and which claims have been flagged for review. The system will ensure the same topic is not being reviewed by two contractors for the same provider at the same time. Providers will have access to the new web resource. CMS plans to award the two-year contract by September 30.

JULY 2015 | O&P ALMANAC

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their own state-based exchanges. Individuals residing in states that rely on CMS to operate federally facilitated exchanges (FFEs) on the state’s behalf would not be eligible for premium tax credit subsidies. Overall, CMS operates FFEs in 34 states that together account for a significant portion of the enrolled population. Experts estimate that if the court had sided with the petitioners in King v. Burwell and invalidated premium tax credit subsidies in states with FFEs, roughly 7.5 million individuals would have lost tax credit subsidies and as many as 10 million fewer people would obtain individual market health insurance coverage through the health insurance exchanges. Bottom line? Regardless of political viewpoints, the risk of substantial chaos in the insurance market has been averted.

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PEOPLE & PLACES PROFESSIONALS ANNOUNCEMENTS AND TRANSITIONS

Kevin Carroll, MS, CP, FAAOP

Hanger Clinic Vice President of Prosthetics Kevin Carroll, MS, CP, FAAOP, delivered the undergraduate commencement address to students of Quinnipiac University’s School of Health Sciences and School of Nursing on May 17. The university also awarded Carroll an honorary doctor of humane letters degree during the commencement ceremony.

Greg Crouse, a Loma Linda University Health PossAbilities member, made the Team USA World Cup paracanoe team and competed in the Paracanoe World Cup Games May 20-24 in Greg Crouse was on the waters of Newport Duisburg, Germany. Crouse Beach in April training for the Team USA was on the Paracanoe race trials. World Championship teams in 2010, 2012, and 2013, and is hoping to compete in the 2016 Paralympics in Rio de Janeiro. A U.S. Army veteran, Crouse lost his left leg while serving overseas in 1988. He has been a part of PossAbilities since 2008.

IN MEMORIAM

C. Michael Schuch, CPO, FISPO, FAAOP Charles Michael “Mike” Schuch, CPO, FISPO, FAAOP, passed away on June 9 at the age of 60 in Chapel Hill, North Carolina. He served C. Michael the O&P field for more than 40 years, and was Schuch, CPO, FISPO, president of AOPA during the 1999-2000 term. FAAOP Schuch played baseball at the University of North Carolina at Chapel Hill while an undergraduate in orthotics and prosthetics. He attended University of California—Los Angeles (UCLA) for postgraduate education and training in O&P. He accepted a government-funded fellowship in the comprehensive management of pediatric amputees at the Child Amputee Prosthetics Project at UCLA following his graduation. In addition to clinical work in university and private practice settings, Schuch gave more than 100 clinical, scientific, and educational presentations throughout the United States and internationally. He wrote and published educational texts and atlases as well as numerous peer-reviewed journal articles. He was on

JULY 2015 | O&P ALMANAC

Jeff Erenstone, CPO, president of Mountain Orthotic & Prosthetic Services in Lake Placid, New York, recently travelled to Nepal to provide orthopedic and rehabilitation care to survivors of the 2015 earthquakes. He has founded Jeff Erenstone, Operation Namaste to provide training and CPO support services to the local O&P clinics, and has developed a plan to conduct a needs assessment; provide postoperative, fracture, contracture management, and limb health services; and offer ongoing education and services to provide a continuum of care. More information is available at www.operationnamaste.org.

David de Magtige

David de Magtige has joined College Park Industries as the company’s international sales development manager. He will reside in the United Kingdom and provide education, sales training, and marketing support to current international distributors and assist College Park in developing new business relationships and opportunities.

the editorial board of both the Journal of Prosthetics & Orthotics (JPO) and Prosthetics & Orthotics International, and spent four years as chair and editor in chief of JPO. Schuch served as board director, officer, and president of both AOPA and the American Academy of Orthotists and Prosthetists (AAOP), as well as for the U.S. International Society for Prosthetics and Orthotics. He also served as commissioner of the National Commission for Orthotic and Prosthetic Education. He served as chair and organizer of clinical education programs for AOPA and AAOP. He was chair of the AOPA National Assembly Clinical Education Workgroup for several years. He also served as chair of the Orthotic and Prosthetic Education and Research Foundation Advisory Board. Some of his more unique contributions include serving as an expert witness for cases involving amputation-related litigation and serving as an expert advisor to Walt Disney World and Universal Studios in Orlando with the goal of enhancing the safety of amputees and other physically challenged persons wishing to participate in theme park rides. He also was a consultant and advisor to state Medicaid programs from 1992 to 2004 and for regional or state BCBS insurance programs from 2000 to 2009.

PEOPLE & PLACES

Sarah Katchpole, CO

Riley Quinn

Sarah Katchpole, CO, has joined the staff of Orthotic Solutions of Fairfax, Virginia. Katchpole graduated from the University of Pittsburgh in 2013 with a master’s of science in prosthetics and orthotics, and returned to the Washington, D.C., area to complete her orthotic residency at Orthotic Solutions. She has now become a full-time orthotist at the company. Riley Quinn of San Carlos, California, has been awarded the Amputee Coalition’s Christina Skoski, MD, Scholarship for 2015, which provides a $1,000 scholarship to a full-time undergraduate student who has congenital limb difference or an amputation. He will be attending the Massachusetts Institute of Technology this fall.

BUSINESSES ANNOUNCEMENTS AND TRANSITIONS

The Amputee Coalition has announced that two of its certified peer visitors/peer review advocates participated in research evaluation reviews for a $10 million O&P research project undertaken by the Department of Defense (DoD). Robert Haas of Columbus, Ohio, and Tom Coakley of Canton, New York, both of whom are transtibial amputees, consulted in the evaluation of research applications submitted to the DoD’s Orthotics and Prosthetics Outcomes Research Program. Haas, Coakley, and a team of scientists reviewed more than 100 research applications. The Amputee Coalition also has announced that two National Limb Loss Resource Center staff members have earned their Certified Information and Referral Specialists certifications. Resource Center Manager Christina Johnson and Resource Center Specialist Keith Canady were certified by the Alliance of Information and Referral Systems, a professional credentialing program. Fourroux Prosthetics has launched a full-service patientcare facility in Atlanta. The facility has additional offices in Huntsville and Birmingham, Alabama, as well as in Memphis, Tennessee.

Össur has introduced mind-controlled bionic prosthetic lower limbs. The devices have been designed for use with implanted myoelectric sensors (IMES) that have been surgically placed in patients’ residual muscle tissue. The IMES, which were provided by the Alfred Mann Foundation, trigger the desired movements via a receiver located inside the prosthesis. This process occurs subconsciously, continuously, and in real time, according to Össur. “Mind-controlled bionic prosthetic legs are a remarkable clinical breakthrough in next-generation bionic technology,” says Jon Sigurdsson, president and chief executive officer of Össur. “By adapting not only to the individual’s intentional movements but to intuitive actions, we are closer than ever to creating prosthetics that are truly integrated with their user.” Two amputees have participated in the company’s initial First-in-Man research. Both were implanted with the IMES and have been living with Össur’s mindcontrolled bionic prostheses for more than one year. Otto Bock HealthCare GmbH has announced plans to raise money for acquisitions and investments with an initial public offering, according to the Wall Street Journal. Owner and Chief Executive Officer Hans Georg Näder says he will list on the Frankfurt stock exchange in 2017. The German company could be worth more than $2 billion when listed, according to financial experts. Näder and his family plan to retain a majority stake in the business through their company Otto Bock Holding. The company’s headquarters will move from the central German town of Duderstadt to Berlin, where it recently opened a research and development facility. A large part of the workforce, currently about 6,500, will remain in Duderstadt. Physiotherapy Corporation has unveiled a new brand identity, featuring a new logo and tagline. The Physiotherapy Associates brand has become Physio, and the company’s O&P clinics have officially changed their name to Physio O&P. Prosthetic Orthotic Solutions Inc. will continue and is positioned as the Physio O&P division center of excellence. Wright & Filippis, a Michigan-based O&P facility, has relocated to a larger Dearborn location, near Garrison. The grand opening was celebrated May 18 with an open house that included a ribbon-cutting ceremony with Mayor Jack O’Reilly.

O&P ALMANAC | JULY 2015

REIMBURSEMENT PAGE

By DEVON BERNARD

Midyear Updates

E! QU IZ M

Medicare has announced a number of O&P policy changes

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were relatively slow regarding updates to Medicare’s orthotic and prosthetic polices, but that changed in May when a series of changes was suddenly announced, published, and put into effect. Some of these changes should not come as any surprise, as the information is not new but is now being published and/or placed into policy. However, some of the changes may have a direct impact on O&P businesses, and may require you to update or change your policies and practices. This month’s Reimbursement Page examines some of these changes and explains the impact they may have on your business.

New Standard Language

The beginning section of each Medicare medical policy includes an introductory statement about coverage indications, limitations, and medical necessity. This paragraph usually outlines the general criteria of what is needed for an item to be covered by Medicare; now, the paragraph includes the following statement as well: 16

JULY 2015 | O&P ALMANAC

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare fee-for-service (FFS) program. When a beneficiary receiving a DMEPOS item from another payor (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding, and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary may be required upon request of the durable medical equipment Medicare administrative contractor (DME MAC). This added language makes it clear that Medicare will not automatically provide payment for any item that was covered by a different payor before the beneficiary became eligible and enrolled in the Medicare program. If Medicare is to make a payment in these scenarios, you must demonstrate that the patient meets all of the

appropriate coverage criteria and the previously delivered item meets all of the coding criteria in existing policies.

Continued Need and Continued Use

All of the DMEPOS policies—not just orthotic and prosthetic policies—now include identical sections and wording relating to continued medical need and continued use. These sections apply more to DME items, supplies, and other rental items, but there is some important information located in these sections, and they will become very important when we cover the changes to the documentation required for repairs. For any DMEPOS item, the medical need is created at the time of initial order, so any documentation supporting the medical need of the item must be made prior to or at the time of the issuing of the initial order. However, any information that can be used to justify payment and demonstrate compliance with policy-related coverage criteria must be entered into the patient’s medical record prior to or at the time of delivery (the date of service).

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If you are to provide any supplies on a routine or continued basis, you must be able to demonstrate a continued medical need—in other words, you must show that the item for which the supplies are needed is still medically necessary for the patient, and you must document and demonstrate continued use, or show that the patient is still using the item for which the supplies are needed. To document and demonstrate continued need or medical necessity, you may use any of the following: a new order from the treating physician for refills, a recent change in order, or timely documentation in the patient’s medical record showing usage of the item. The policy defines “timely documentation” as a record entry in the preceding 12 months, unless otherwise specified in a policy. So, as long as the patient has been seen by the treating/referring physician within the last 12 months, and the physician has documented that the patient still has the underlying condition and still requires the item, then the criteria for continued medical need have been met. To document and demonstrate continued use of an item by a patient, there must be documentation either in the medical record (i.e., physician’s record) or in your records that the patient continues to use the item in question, and this documentation must be “timely documentation.”

Proof of Delivery Changes

As stated in the beginning of the policy, the patient and item must meet all coverage, coding, and documentation requirements in order for it to be covered by Medicare, even if it was provided and delivered before the patient was eligible for Medicare. One of the requirements is that you must have a valid proof of delivery (POD) on file. To meet this requirement you have two options: First, you may obtain or create a new POD that meets all of Medicare’s requirements for a valid POD. Second, you may have the patient sign and date a statement indicating that you have reviewed the item, that it is in good shape/working order, and that it meets Medicare requirements.

The revised policies also include a clarification to the POD as it relates to the delivery date information included on the form. The delivery date on the form must be the date the patient receives the item, and this date does not have to be entered by the patient when he or she signs the POD. The date may be entered by you or included on the form. However, if you have entered the delivery date on your POD form and the patient signs and dates the form, then the date entered by the patient becomes your date of service, even if it is different than the date you entered.

For prosthetics, the revised policy focuses on replacements. Previous policies have always stated that Medicare payments for the replacement of a prosthesis or prosthetic component could be made, without regard to continuous use, if an ordering physician determines that the replacement prostheses/components are reasonable and necessary. The reason for replacement must be documented by the physician. The new policy now clearly indicates that the need for the replacement can be documented on the order/prescription or in the official medical record.

Miscellaneous Codes

Repairs and Replacements

The revisions in the orthotic policies focus on repairs—in particular, the type of documentation requirements. When conducting a repair, you must have two key pieces of documentation. First, the treating physician must document that that the item being repaired continues to be reasonable and necessary. This means there must be “timely documentation” in the treating physician’s record showing that the patient still needs the item that is being repaired. Second, either the physician or you must document that the repair is necessary. This should not be anything new because you have always had to document the need for the repair, including a detailed explanation of the need and the time involved with the repair.

When billing for a miscellaneous code, Medicare has always required you to submit or provide additional information with your claim. This additional information includes providing a narrative description of the miscellaneous item if it was custom fabricated, including what makes it unique, and a breakdown of charges (or you may provide the manufacturer’s name and product information if it was prefabricated). This requirement has not changed, but the policies now require you to provide one more piece of information when submitting a claim for a miscellaneous code: “justification of patient’s medical necessity for the item.” In other words, you must include information that will support the medical necessity for the item coded with the miscellaneous code. It is very unlikely that you will be able to provide all of the required information within the narrative fields of an electronic claim form, as you are typically only allotted 80 characters. However, when the electronic claims forms were updated in 2011, Medicare introduced the paperwork (PWK) segment. The PWK allows you to submit additional information for a given claim ahead of time, instead of waiting for an additional documentation request. For more information about the PWK segment, review the Medicare Claims Processing Manual, Chapter 24. For information on how to use the PWK segment, visit your DME MAC’s website or contact them directly. O&P ALMANAC | JULY 2015

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Off-the Shelf Coding Update

The DME MACs, along with the Pricing, Data Analysis, and Coding (PDAC) contractor, released a joint publication on April 30, 2015, that revised a previously published announcement released in March 2014 titled, “Correct Coding—Definitions Used for Off-theShelf (OTS) Versus Custom-Fitted Prefabricated Orthotics (Braces).” The announcement was designed to provide additional guidance on how to code for items that may have a split code and can be provided as an OTS item or as a custom-fitted item. The revised announcement featured several pieces of information that are included in the revised policies. First, it clarified that an OTS orthosis is an orthosis that requires only minimal self adjustment at the time of delivery, and it doesn’t require the services or skills of a certified orthotist or any other individual with specialized training. The announcement and the policy also clearly define “minimal self adjustment” as an adjustment the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and does not require the services of a certified orthotist or an individual who has specialized training. It is important to point out that neither the announcement nor the revised policies list or define who “any other individual with specialized training” may include so there is still some uncertainty as to whether state-licensed orthotists or certified fitters would be considered “individuals with specialized training.” Second, the revised announcement and subsequent policy revisions officially expanded the classification of custom-fitted orthoses to include those orthoses that require substantial modification for fitting at the time of delivery in order to provide an individualized fit, and explained that these modifications go well beyond minimal self adjustment and require the expertise/services/knowledge of a certified orthotist or an individual with specialized training in the provision of orthoses. “Substantial modification”

JULY 2015 | O&P ALMANAC

has been defined to mean any changes made to an orthosis to achieve an individualized fit through the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, occupational therapist, or physical therapist in compliance with all applicable federal and state licensure and regulatory requirements. This means that you must document not only the type of orthosis provided, but who provided the orthosis and what type of modifications were done to the orthosis, especially those modifications done at the time of fitting. Third, the revised announcement and revised policies reinforced the notion that the need for the type of orthosis provided (custom fabricated or prefabricated) must be found in the referring physician’s records, and you must document that you are providing the item that has been requested by the physician. The physician’s order should indicate whether a prefabricated item or a customfabricated item is to be provided. The revised announcement also included information that was not included in the revised policies; however, this doesn’t mean you get to ignore the information. You are required to follow its guidance since it has been released and made available via a joint DME MAC and PDAC publication. It becomes de facto policy. The announcement stated that if you are providing/delivering an item described by a custom-fitted code and the item doesn’t have a corresponding OTS split code, and you didn’t substantially modify the orthosis or if it was not provided or modified by a certified orthotist or other individual with specialized training, it then must be billed with the appropriate miscellaneous code. Be sure to follow the rules for submitting miscellaneous codes, but also indicate that you are providing an OTS version of a custom-fitted code. For example, if you are providing an L1620, a custom-fitted hip orthosis, and you didn’t substantially modify the item, you would have to bill it as an L2999, because the L1620 doesn’t have an OTS

version. Then when you submit the claim for the L2999, you would include a narrative that says OTS version of L1620.

Policy-Specific Revisions

The information for lumbosacral and thoracolumbosacral orthoses (LSOs and TLSOs) was revised to expand the list of codes by one, which requires the use of a CG modifier. The CG modifier is used to provide an orthosis that may be both rigid and semirigid in construction and that meets the definition of a brace, or when the brace may be constructed out of primarily elastic material and does not meet the definition of a brace. The policy indicates that the following codes may be provided either as a brace, rigid or semirigid in construction, or as a noncovered elastic garment: L0450, L0454, L0455 (the newly added code), L0621, L0625, or L0628. If you are providing an item described by any one of these codes and it is made from primarily nonelastic materials or it includes a solid posterior panel, then you must use the CG modifier. If you are providing an item described by one of these codes and it does not contain a solid posterior panel or is not constructed of primarily nonelastic materials, then you must use the code A4466. Be sure to review the revised policies and correct coding bulletins in more detail to make sure you understand all of the changes. Update your office’s policies and procedures to keep in line with these changes. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@aopanet.org. Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:

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This Just In

The Battle To Distinguish O&P From DME AOPA and the O&P Alliance continue the fight to exclude O&P services from bundled postacute care payment systems

MS ANNUAL RULEMAKING

Rep. Ryan Costello (R-Pennsylvania)

Rep. Tammy Duckworth (D-Illinois)

JULY 2015 | O&P ALMANAC

proposals seldom raise serious concerns for the O&P community, but two published this past April sounded alarm bells. The troublesome proposal involving Medicare’s hospital inpatient annual payment revisions included a recommendation for expanding the Bundled Payment for Care Initiative (BPCI) and the potential inclusion of orthotics and prosthetics in the 90-day period of post-acute care bundling under the direction of the providing hospital.

CMS rulemaking continues to hold danger for O&P because there is still no clear separation of durable medical equipment (DME) from O&P as sought by the O&P Medicare Improvement Act (S. 829 and H.R. 1530), numerous letters to Congress from influential members, and several other pending legislative proposals. The recent letter written by Reps. Ryan Costello (R-Pennsylvania) and Tammy Duckworth (D-Illinois) to Sylvia Mathews Burwell, secretary of the Department of Health and Human Services (HHS), called upon CMS to issue regulations implementing BIPA 427, which does create a recognized separation of O&P from DME, and urged resolution of the 15-year implementation delay regarding who is considered a “qualified provider” for purposes of the provision of O&P care to Medicare beneficiaries. The O&P community continues to be exposed to rulemaking proposals that have harmful patient consequences because of the one-size-fits-all approach by CMS and other payors. These entities fail to see the distinction from the clinical care provided by O&P professionals, as contrasted with the many commodity-type products delivered by DME suppliers requiring no special services.

This Just In

2015 Services & Medicaid Services Medicare man Centers for t of Health and Hu en Departm 1632–P S– CM : Attention 8013 1) 4–1850 P.O. Box 0938–AS4 , MD 2124 ov (RIN– Baltimore ulations.g ms for www.reg ent Syste yment ically via tive Paym Pa d electron t Prospec ital Prospective Submitte ty Inpatien l sp ita Ho sp re s of Quali Ho Ca the Program; d the Long-Term 06 Rates; Revision ges Related to are dic ls an Re: Me Year 21 ing Chan re Hospita d Fiscal ers, Includ Acute Ca licy Changes an ific Provid ec Sp Po m nts for System quireme rd Incentive Progra Re ing report Reco ic Health Electron to take this ncern: ) would like yment rates It May Co pa on (AOPA To Whom g-term Associati e regarding 2016 te and lon d Prosthetic sed rul for both acu 15 Federal Orthotic an nts on the propo tem can sys t eri 20 , en me that ril 30 paym The Am to offer com e facilities spective d in the Ap opportunity spital inpatient pro ich was publishe ation for patient caror orthopedic wh ho s , oci los the -P) ass 1632 tient under h limb trade 2,000 pa tals (CMS g national ces to patients wit ximately care hospi PA is the leadin ts of appro pedic bra AO sis ho . ort con ter d an Regis ership ificial limbs Its memb . (H)(4) provide art logic problems. ited States Section (II) ents uro ym out the Un visions of and/or ne to the pro g the Bundled Pa es through relevant care faciliti expandin yments for to those pa on ited nt led lim me nd bu any l be com ments wil sthetics in concept of icits public AOPAʼs comsed rule which sol cally regarding the of orthotics and pro cifi po inclusion of the pro iative (BPCI), spe potential the Init d re an sed es for Ca often discus care servic post acute ve. ces), while nt as their hopedic bra differe etic such initiati bs and ort (DME) are very and prosth tificial lim nt r orthotic hotics (ar medical equipme es; rathe s and ort diti le etic mo rab sth Pro as du of com e breath tribution in the sam not simply the dis is provision

June 15,

Sylvia Mathews Burwell, secretary of the Department of Health and Human Services (HHS)

This BPCI proposal is a good example of a proposition that could have slipped under the radar screen unnoticed with serious repercussions. In responding to the threat, AOPA’s prepared comments objected to the potential inclusion of O&P in bundling by noting: “The precedence for exclusion of O&P services from existing bundled payment systems was established with passage of the Balanced Budget Refinement Act of 1999 (BBRA), which provided a specific exclusion of customized prosthetic devices from the bundled prospective payment to skilled nursing facilities (SNFs). Through this legislation, Congress clearly signaled its intent that inpatient facilities could not be reasonably expected to absorb the cost of providing orthotic and prosthetic services to patients, and therefore provided a pathway by which O&P providers could provide quality services to Medicare beneficiaries at a reasonable reimbursement rate.” The law provided for exemptions for low-utilization, high-cost items. Many prosthetic and orthotic devices meet those criteria. A further problem, particularly with prosthetic devices, is the often lifelong relationship established by a patient with his

care involves an ongoing series of clinical services provided by licensed and/or certified professionals resulting, through the use of devices, in the ability to regain or maintain ambulation and full function. Under the present Medicare structure, beneficiaries with limb-loss or limb-impairment are permitted to choose the licensed and/or certified health care professional with whom they establish a patient care relationship. Importantly, as limb-loss is a permanent condition, this relationship is generally established for the patientʼs entire life. The patient has the right to choose a provider with whom they are comfortable and who best addresses their mobility needs. This clearly is a relationship that needs to be based on the long term needs of the patient, well beyond the limited time period immediately following a Medicare covered inpatient stay. Post acute care bundled payments are poorly suited for the delivery of custom orthotic and prosthetic (O&P) care because the devices and related clinical services are of a unique nature that is not appropriately captured by a system that relies on a comparison between what may seem to be similar or substitute items and services. In addition, in the inpatient setting, O&P devices represent a relatively high cost, low utilization category of service that, if included as part of a bundled payment, may represent an unusual financial hardship to the inpatient facility responsible for providing care during the acute inpatient stay as well as the post acute follow up period. Precedence for exclusion of O&P services from existing bundled payment systems was established with passage of the Balanced Budget Refinement Act of 1999 (BBRA), which provided a specific exclusion of customized prosthetic devices from the bundled prospective payment to skilled nursing facilities. Through this legislation, Congress clearly signaled its intent that inpatient facilities could not be reasonably expected to absorb the cost of providing orthotic and prosthetic services to patients, and therefore provided a pathway by which O&P providers could provide quality services to Medicare beneficiaries at a reasonable reimbursement rate. There are currently two bills that have been introduced in the House of Representatives that create a legislative requirement for post acute care bundled payments. Representative McKinley, of the House Ways & Means Committee introduced H.R. 1458 on March 19, 2015 and Representative Black, a member of the House Energy and Commerce Committee introduced H.R. 2502 on May 21, 2015. Both of these bills, drafted independently, contain specific exclusions for orthotic and prosthetic devices from post acute care bundling provisions. H.R. 1458 clearly recognizes that neither the government nor Medicare ought to engage in anything to abrogate the long-established patient-health care professional relationship, nor limit in any way the right of the patient to select the health care professionals who will be engaged in any long-term patient care relationship with patients. Therefore, H.R. 1458 provides for an exclusion from the bundle for a range of patient care providers including:

(i) physiciansʼ services; (ii) hospice care; (iii) outpatient hospital services; (iv) ambulance services;

AOPA appreciates the opportunity to provide public comment on such an important issue.

(v) outpatient speech-language pathology services; and

Sincerely,

(vi) the items and services described in section 1861(s)(9) which are defined as leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the patientʼs physical condition. H.R. 2502 contains a similar exclusion for items and services described in section 1861 (s) (9) from post acute care bundling. The recognition of O&P services as patient care services rather than commodity items in both of these bills establishes the grounds necessary to exclude them from bundle post acute care payment systems. To include orthotic and prosthetic services in an acute care bundling payment system would be a radical change to the Medicare system, and catastrophic for limb-impaired individuals, especially if adoption of post acute care bundling modified existing patient care relationships or denied Medicare beneficiaries the right to choose their prosthetist/orthotist. Fortunately, Congress has previously addressed this issue very appropriately when, in 2003, Congress established that CMSʼ authority to apply competitive bidding in orthotics would be limited only to "off-the-shelf orthotics," which Congress further defined as devices which could be used by the patient with "minimal self-adjustment" and which do not require any expertise in trimming, bending, molding, assembling, or customizing to fit to the individual. This congressional action, limiting the scope of competitive bidding to only the simplest of orthotic devices, further reinforces the importance of protecting patient choice and affirming the patient-provider relationship with their orthotist or prosthetist, as well as and on the same basis as in the other five patient care areas enumerated above. Congress, through its action on the BBRA in 1999, its action on DMEPOS competitive bidding, and recently through the introduction of the two post acute care bundling bills, clearly understands the value of the relationship between a patient and their orthotist or prosthetists as well as the fact that the cost of the provision of orthotics and prosthetics cannot be absorbed by the inpatient facility without creating a serious and undue financial hardship on the facility and a threat to patient choice of those providing their care. AOPA recommends that any changes to the BPCI as a result of the proposed rule contain specific provisions that follow the precedent of H.R. 1458 and H.R. 2502 in excluding O&P services from any bundled post acute care payment systems.

or her prosthetist to modify treatment and prosthetic devices as mobility needs change over the years. AOPA’s comments also noted, “There are currently two bills that have been introduced in the House of Representatives that create a legislative requirement for postacute care bundled payments. Rep. David McKinley (R-West Virginia) of the House Ways & Means Committee introduced H.R. 1458

Charles H. Dankmeyer, Jr., CPO President American Orthotic and Prosthetic Association The following interested parties/non-profit organizations concur in the above comments and so they have decided to sign-on in support of these comments:

David McGill President National Association for the Advancement of Orthotics and Prosthetics

Phillip M. Stevens, Med, CPO, FAAOP President American Academy of Orthotists and Prosthetists

James H. Wynne, CPO, FAAOP President American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.

James L. Hewlett, BOCO Chair, Board of Directors Board of Certification/Accreditation (BOC)

on March 19, 2015, and Rep. Diane Black (R-Tennessee), a member of the House Energy and Commerce Committee, introduced H.R. 2502 on May 21, 2015. Both of these bills, drafted independently, contain specific exclusions for orthotic and prosthetic devices from postacute care bundling provisions.” The comments concluded with, “AOPA recommends that any changes to the BPCI as a result of the proposed O&P ALMANAC | JULY 2015

The

ground rules will

never be the same. Coming Fall 2015

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This Just In

The proposed rule encourages suggestions for any additional HCPCS codes that are not currently on the exclusion list but meet the requirements for exclusion under the provisions of the Act.

15 Services & Medicaid Services Medicare man Centers for t of Health and Hu en rtm pa –P De 22 CMS–16 Attention: 16, 80 4–8016 P.O. Box 38–AS44) , MD 2124 v (RIN 09 Baltimore ulations.go www.reg stem and yment Sy 2016, SNF onically via ctr Pa ele ve d cti Submitte ; Prospe Fs) for FY Program ram, and cilities (SN : Medicare illed Nursing Fa ty Reporting Prog 2-P 62 F Quali g for Sk Re: CMS-1 ted Billin ogram, SN Consolida d Purchasing Pr se Value Ba ta Collection Da s Staffing to take thi ncern: ) would like It May Co tion (AOPA ing the Prospective To Whom s c Associa rule regard Nursing Facilitie Prostheti d d se an po tic d PA is the on the pro can Ortho for Skille The Ameri to offer comments nsolidated Billing deral Register. AO artificial y e Fe Co opportunit stem (PPS) and the April 20, 2015 that provid d/or facilities Sy blished in tient care hopedic an Payment ich was pu association for pa h limb loss or ort ly 2,000 patient wh F), wit (SN ate de tional tra to patients nsists of approxim leading na hopedic braces ership co ort . Its memb limbs and tes. n IV ic problems out the United Sta s of Sectio neurolog gh provision 1888 (e) (2) ou the thr to es t relevan section care faciliti sed rule, services d to those l be limite ssed in the propo st, low probability es are wil ts en cu co vic mm dis c de high AOPAʼs co ated Billing. As prostheti provision of s certain olid t exclude stomized (B): Cons curity Ac under the d Certain cu Social Se SNF PPS that is updated an system. (A) of the F PPS payment s ded from ces exclu ded HCPCS code SN sion of clu ex from the categories of servi clu ed list of ex orts the continu inclusion ir the among the are identified in a pp as an undue system d AOPA su uld create SNF PPS the Act an nually by CMS. from the yment wo an .. published prosthetic devices der a SNF PPS pa they serve d un ze nts mi red tie ve sto pa co s cu services d limb los among the rdship on SNFs an ha financial

20 June 15,

In response to the CMS request in the proposed rule, AOPA suggests that two Healthcare Common Procedure Coding System (HCPCS) codes be added to the list of codes excluded from the SNF PPS Consolidated Billing program. AOPA believes the following HCPCS codes meet the statutory requirements for exclusion from SNF PPS and therefore should be added to the list of excluded codes.  

L5969- Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s) L5987- All lower extremity prosthesis, shank foot system with vertical loading pylon

According to the proposed rule, for a code/service to be considered for exclusion from the SNF PPS, it must meet the criteria set forth in section 103(a) of the Balanced Budget Refinement Act (BBRA). AOPA believes the HCPCS codes listed above meet the established criteria. First, the service/code must fall within one of the four established exempt categories under the BBRA. These four categories are chemotherapy items, chemotherapy administration services, radioisotope services and customized prosthetic devices. The above codes, which are used to describe a component of an artificial limb, fall into the customized prosthetic device category as described in Section 1888 (V) of the Social Security Act. Second, the code must be a high cost item/service, which would put an undue burden on the SNF because the cost of the item/service would exceed the SNFʼs payment under the PPS. In calendar year 2012, the most recent data available, the average daily Medicare payment to a SNF was $402. Based on 2012 Medicare Part B claims processing data, the average Medicare allowable for L5987 was $6,635. The average allowable for L5987 is on par with other currently excluded customized prosthetic devices, which have been deemed to have an undue burden on the SNF, and therefore meets the criteria of being a high cost item/service. L5969 was added to the HCPCS code set on January 1, 2014. While no Medicare allowable has been established for this code, the Local Coverage Determination for Lower Limb Prostheses limits its use to describe additional features of HCPCS code L5973 which describes a microprocessor controlled foot that is excluded from SNF PPS and, in 2012, had an average Medicare allowable of $16,030. Based on this data, L5969 also meets the criteria of being a high

cost item/service, especially since it may only be used with a currently excluded high cost item. Also, in order to be considered for exclusion a code must have a low frequency, or provided to patients infrequently in a SNF. According to the 2012 Medicare Part B claims processing data, these codes were provided to patients on an infrequent basis. In 2012, L5987 was covered for Medicare beneficiaries 4,379 times. AOPA understands that Part B data will not reflect codes/services provided to a patient in a Part A SNF setting, but the number of Medicare beneficiaries receiving services in a SNF will be considerably lower than those in the Medicare population receiving Part B benefits. In 2012, the most recent year available for SNF data, there were approximately 49.4 million people enrolled in the Medicare program. These people were eligible for Hospital Insurance (Part A) and/or Part B (Supplemental Insurance), and approximately 2.5 million of these individuals were admitted to a SNF. In 2012, 2.2 million prosthetic services codes were paid by Medicare. L5987 represented approximately 0.2% of these prosthetic services. The frequency with which this code is provided to Part B beneficiaries is comparable with currently excluded customized prosthetic devices, which have been deemed to be provided infrequently in SNFs, so L5987 code meets the criteria of having a low probability of being provided in a SNF. Lastly, the proposed rule states that CMS has the “statutory authority to identify additional service codes for exclusion as essentially affording the flexibility to revise the list of excluded codes in response to changes of major significance that may occur over time (for example, the development of new medical technologies or other advances in the state of medical practice)”. This describes the situation of L5969 perfectly. The HCPCS code L5969 was established in 2014 specifically for the BiOM iWalk ankle system, and its new unique power assisted functions or its newly developed technology. L5969 is currently paid on an individual consideration basis; so there is no reliable Medicare average allowable data available at this time. However, according to the Medicare Pricing, Data Analysis and Coding (PDAC) contractor the iWalk must be coded and billed using the HCPCS codes L5969 and L5973. In 2012 the average Medicare allowable for the L5973, a prosthetic HCPCS code which is on the SNF PPS exclusion list, was $16,030 and was paid for by Medicare 495 times. Using these figures, since L5969 cannot be billed for or provided separately from L5973, the L5969 would meet the criteria of being a high cost item/service and having a low frequency of usage in SNFs. We thank you for the opportunity to formally request the addition of codes to the SNF PPS exclusion list and we believe L5969 and L5987 should be added to the list. These two codes meet all the criteria for being excluded as put forth in section 103(a) of the BBRA and subsequent regulations, they are customized

rule contain specific provisions that follow the precedent of H.R. 1458 and H.R. 2502 in excluding O&P services from any bundled postacute care payment systems.” The second, less troubling, CMS rulemaking proposal is the annual revision of the SNF prospective payment system, which offers an opportunity to update the Healthcare Common Procedure Coding System (HCPCS)

prosthetic devices which are high cost and infrequently provided in SNFs and/or represent the development of new medical technologies. . Sincerely,

David McGill President National Association for the Advancement of Orthotics and Prosthetics

Phillip M. Stevens, Med, CPO, FAAOP President American Academy of Orthotists and Prosthetists

James H. Wynne, CPO, FAAOP President American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.

James L. Hewlett, BOCO Chair, Board of Directors Board of Certification/Accreditation (BOC)

codes that should be on the exclusion list that meet the statutory requirements but are not currently on the list. AOPA recommended the following two HCPCS codes be added to the exempt list: • L5969—Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s) • L5987—All lower-extremity prosthesis, shank foot system with vertical loading pylon.

Both codes meet the criteria for one of the four established exempt categories and a high-cost item, which would place a burden on the SNF provider if it were not excluded. AOPA’s comments further observed, “Lastly, the proposed rule states that CMS has the statutory authority to identify additional service codes for exclusion as essentially affording the flexibility to revise the list of excluded codes in response to changes of major significance that may occur over time (for example, the development of new medical technologies or other advances in the state of medical practice). This describes the situation of L5969 perfectly.” AOPA shared its draft comments on these two rulemaking proposals with the other members of the O&P Alliance for further suggestions. The final document, reflecting those revisions, was reviewed, approved, and signed by all members of the O&P Alliance: the American Board for Certification in Orthotics, Prosthetics, and Pedorthics, the American Academy of Orthotists and Prosthetists (AAOP), the Board of Certification/ Accreditation (BOC), and the National Association for the Advancement of Orthotics and Prosthetics (NAAOP), in addition to AOPA. This is another example of the collaborative work advocated by AOPA President Charles H. Dankmeyer Jr., CPO, in his May President’s Page column, “Working Toward a Common Goal.” While Dankmeyer’s message pointed toward progress with AAOP and AOPA’s coordination of research activities, it is certainly equally important for the O&P community to join together as “one voice” in responding to the regulatory and legislative issues confronting our patients and the O&P community. O&P ALMANAC | JULY 2015

COVER STORY

REINVENTING AND

CONTROL PRODUCTION IN THIS FIRST OF A TWO-PART SERIES ON DISRUPTION, LEARN HOW BMI, TMR, AND 3D PRINTING COULD BE GAME-CHANGERS FOR THE DELIVERY OF PATIENT CARE By CHRISTINE UMBRELL

JULY 2015 | O&P ALMANAC

COVER STORY

NEED TO KNOW: • Using EMG signals from residual muscles, or reinnervated muscles through TMR procedures, is already making a

significant clinical impact in the clinic, says one expert. • New classes of bionic limbs are becoming commercially available. Improvements in control will allow users to take full

advantage of their capabilities, which will in turn provide better functional outcomes for patients. In the future, implantable sensors will allow users to “feel” their prosthetic limbs. • Several O&P manufacturers currently use 3D printers for protoyping and making machine parts, but this

technology is not yet being used for traditional fabrica-

tion. Others are using 3D technology to offer prosthetic covers and other customized products to patients.

• Some practitioners predict that 3D technology may change the manufacture of certain orthoses once

the printers can work with polypropylene or equivalent materials, because it could reduce costs.

• AOPA has written a policy statement that acknowledges the

emerging 3D technology but expresses caution for the absence of approvals for 3D hands as a medical device by the FDA.

NNOVATION IS TRANSFORMING the U.S. health-care arena, and

perhaps nowhere is this more apparent than in the orthotics and prosthetics profession. Myoelectric arms and microprocessor feet, ankles, and knees are becoming much more commonplace. But it is the evennewer technologies that promise to change the way O&P professionals restore function to patients. From targeted muscle reinnervation surgeries and brain-machine interface breakthroughs, to the advent of 3D printing, the possibilities are almost endless. Many practitioners are asking: Is it really necessary for today’s prosthetist/orthotist—faced with treating larger numbers of patients and preparing ever-increasing volumes of documentation—to understand all of these new technologies? The answer is yes. While not every practitioner will be implementing all of the new technologies tomorrow, it’s important to have a basic understanding of the advances in the O&P industry and comprehend how they may impact patient treatment in the next five to 10 years. In this first of a two-part series, we’ll explore several of the most promising industry disruptors and examine how these innovations may affect the O&P profession in the not-too-distant future.

Brain-Machine Interface and TMR

A number of recent clinical trials involving targeted muscle reinnervation (TMR) and brain-machine interface technologies are demonstrating that more intuitive prosthetics are the next step in the O&P evolution. O&P ALMANAC | JULY 2015

COVER STORY

PHOTO: Jen Owen

“Using advanced decoding, such as pattern recognition recently released by Coapt Complete Control System, allows us to decode neural intent and intuitively control advanced prosthetic limbs. As brain-machine interface technologies are refined and released to the market, they have similar disruptive potential.” Hargrove made headlines in June when news of a first-of-its-kind clini“Measuring directly from the brain using implanted electrodes holds great cal trial was reported in the Journal of promise for certain individuals; however, the American Medical Association. He this technology is still in the research led an RIC research team in developphase and has yet to disrupt traditional ing a system to use neural signals practice of O&P,” says Levi Hargrove, PhD, to safely improve limb control of a bionic leg. Seven lower-limb ampudirector of the Neural Engineering for Prosthetics and Orthotics Laboratory at tees participated in the randomized the Rehabilitation Institute of Chicago trial demonstrating applications of and assistant clinical professor in the first thought-controlled bionic leg prosthesis that did not require nerve the Department of Physical Medicine redirection surgery or implanted & Rehabilitation at Northwestern sensors. Instead, a computer team University. at RIC analyzed EMG signals from “However, using electromyographic sensors on a robotic leg, which (EMG) signals from residual muscles, allowed the movements the user was or reinnervated muscles through TMR trying to perform to be decoded and is already making a significant clinical sent as commands to the prosthesis’s impact in the clinic,” Hargrove says. motorized knee and ankle to produce coordinated movements. “This leg’s intuitive thought control appears to work as well without nerve redirection surgery and does not require implants to be placed into the body,” says Hargrove. O&P experts believe brainmachine interface and TMR technologies will have a significant impact on the future of prosthetics. “New classes of bionic limbs are becoming commercially available. Several multiarticulating hands are already on the market, and powered legs manufactured by BiOM and Össur are available,” notes Hargrove. “Improvements in control will allow users to take full advantage of their capabilities, which will in turn provide better functional outcomes for patients. “In the next five to 10 years, I believe we will see a migration toward implantable sensors that provide cleaner signals for control,” adds Hargrove. “This will also provide a portal to provide sensory feedback to allow users to ‘feel’ e-NABLE’s Jon Schull, PhD, and Ivan their prosthetic limbs.” Owen examine a 3D-printed hand. 26

JULY 2015 | O&P ALMANAC

3D Printing

Perhaps one of the most talked-about industry disruptors to emerge over the past few years is 3D printing. 3D printers make use of additive manufacturing; the process starts with a blueprint created in a 3D digital modeling program, which is programmed into the printer. The printer then builds the design by laying down super-thin layers of the materials, which can range from metal to plastic and more. Several O&P manufacturers currently have 3D printers on premises and use the technology for research and development in protoyping and making machine parts, but this technology is not yet being used for traditional fabrication. So far, 3D printers cannot print strong enough materials to build components that meet the durability and strength needs of traditional O&P devices. While some engineers outside the O&P profession—such as those involved in the e-NABLE organization—have developed low-cost 3D-printed hands for short-term, largely cosmetic, use by children and individuals in developing countries, those devices simply do not compare to the components provided by traditional industry manufacturers, say experts.

COVER STORY

“The 3D-printed hand, in its present stage of development, certainly fills a need for many around the world, especially for children, and I, for one, hope these e-NABLE volunteers continue their good work,” says AOPA President Charles Dankmeyer Jr., CPO. “My personal view is to applaud this 3D effort but at the same time do everything possible to correct any misleading

comparisons to what traditional prosthetists do.” Dankmeyer notes that it’s important to distinguish between an organization like e-NABLE—“a group of volunteers providing an assistive device at no charge to folks in need”—and individuals who position 3D-printed hands as similar devices to traditionally manufactured prostheses. “And neither group has gone through

the medical device approval process by the Food and Drug Administration (FDA), so distribution by professional prosthetists would be a questionable practice at this time.” AOPA has written a policy statement that acknowledges the emerging 3D technology but expresses caution for the absence of approvals for 3D hands as a medical device by the FDA.

The Debut of More Responsive Prosthetics A number of clinical trials are indicative of the advances being made both domestically and abroad. Here is a sample of some of the devices being developed and tested using targeted muscle reinnervation and brain-machine interface technologies.

• Bionic-Reconstruction Prostheses. Early in 2015, surgeons in Austria performed voluntary amputations on three men with poorly functioning limbs, then fit the patients with the first “bionic-reconstruction” prostheses. The patients tested mind-controlled prostheses designed so that nerve and muscle transfers provide signals that are translated into mechatronic functions to animate the devices. “The scientific advance here was that we were able to create and extract new neural signals via nerve transfers amplified by muscle

JULY 2015 | O&P ALMANAC

transplantation. These signals were then decoded and translated into solid mechatronic hand function,” says Oskar Aszmann, director of the Christian Doppler Laboratory for Restoration of Extremity Function at the Medical University of Vienna. • Brain-Machine Interface for Prosthetic Grasping. University of Houston researchers have created an algorithm designed to harness an amputee’s thoughts to enable grasping with a prosthetic hand. The study, funded by the National Science Foundation, demonstrates for the first time an electroencephalogram (EEG)-based brain-machine control of a multifingered prosthesis for grasping. The research team designed a brain-machine interface that captured a subject’s intentions, enabling the subject to successfully grasp objects such as a water bottle and credit card using a prosthetic hand. • Peripheral Nerve Interface for Prosthetic Hands. Washington University researchers have developed a macro-sieve peripheral nerve interface to stimulate the nerves in the upper arm and forearm. The device is intended to be used in conjunction with motorized upper-limb prostheses to allow users to “feel” various sensations through the prosthesis, which would send sensory signals to the brain. The goal is for users to receive hot and cold sensations, as well as a sense of touch to enable them to adjust the pressure when handling different items with their prostheses.

PHOTO: Johns Hopkins University Applied Physics Laboratory

• Thought-Controlled Upper-Extremity Devices. Late last year, Colorado’s Les Baugh became the first bilateral shoulder-level amputee to wear and control two modular prosthetic limbs in a clinical trial conducted at the Johns Hopkins Applied Physics Laboratory. After surgeons reassigned Les Baugh nerves that once controlled his arms and hands, Baugh underwent extensive training on the use of the modular prosthetic limbs, which were attached via a custom socket for his torso and shoulders. The socket made the neurological connections with the reinnervated nerves. During testing, Baugh performed a variety of tasks, and was able to perform a combination of motions across both arms at the same time.

COVER STORY

PHOTO: Jen Owen

The policy, which is available at www. AOPAnet.org/media, recommends that members encourage media to fact check when comparing costs of 3D devices with traditional prostheses. “Often the comparisons are woefully amiss citing advanced upper-extremity prosthetics costing between $40,000 and $80,000 when traditional prosthetic hands are available in the $1,500 to $5,000 range,” says Dankmeyer. The question remains whether 3D technology will evolve to the point that materials are strong enough to use in manufacturing prostheses and orthoses. Some practitioners predict that the technology may change the manufacture of certain orthoses once the printers can work with polypropylene or equivalent materials, since it could reduce costs. Most O&P professionals are taking a wait-and-see attitude. Jeff Erenstone, CPO, owner of Mountain Orthotic & Prosthetic Services, is one practitioner who has taken an interest in 3D printing and its applications both overseas and at home. He serves on the Medical Matching Advisory Board for the e-NABLE organization, helping advise and answer questions about safety. “I want to help bridge the gap between prosthetists and these printers,” says Erenstone. He views 3D technology not as revolutionary but as evolutionary: “This is just one more technology we need to understand.” Erenstone notes that while 3D-printed components are nowhere near equivalent in strength to traditionally manufactured devices, they do allow people to prototype in small batches and may fill a niche: “Giving a kid a ‘robot hand’ can have a ‘cool

factor’ that offers a self-esteem boost, and can lead to patients requesting more information about traditional prostheses when they want a better device,” he says. He also notes that 3D printers in developing countries could limit supply chain costs, shift costs toward labor, and ultimately allow more individuals to receive prostheses. Regardless of how you view 3D printing, it is definitely a technology to watch: “We’re just at the beginning of the 3D printing evolution,” says Brad Mattear, CPA, CFo, central U.S. and national strategic account manager for Cascade Orthopedic Supply Inc. “The only thing slowing us down from taking 3D printing to the next level is the materials science. Once the materials science catches up to the rotational stress forces and can withstand forces applied with traditional devices, businesses will begin to incorporate 3D printing,” he adds. In fact, some O&P professionals are finding ways to take advantage of 3D printing technologies to increase offerings to patients. Ottobock, for example, recently partnered with UNYQ, a manufacturer of lower-limb fairings that offers 3D-printed prosthetic covers. Through the partnership, UNYQ will begin offering a line called “UNYQ designed for Ottobock,” which will allow for more personalization of some devices.

Erenstone also is venturing into the 3D-printing arena; he recently started a company, createprosthetics.com, where amputees can express themselves using prosthetics. The company will focus on the cosmetic side of O&P, and will make hands and coverings using lightweight, flexible materials. Erenstone recommends that all practitioners, at a minimum, become educated on how the 3D process works. “I suggest every O&P practice should buy an inexpensive 3D printer, just to experiment and get to understand them,” he says. Mattear believes that 3D printing has the potential to decrease the amounts of hazards, promote safety in the lab, decrease costs, and increase revenues. “If you don’t think 3D printing is the future, then you’re way behind.” “My guess is that 3D is here to stay as it plays an increasingly important role in what we do for patients,” adds Dankmeyer.

Get Ready

The traditional practice of orthotics and prosthetics is evolving, and practitioners who keep an eye on new technologies and consider how industry innovations may eventually alter the O&P landscape are the ones who will prosper in the years to come. Those who refuse to alter their standard operating procedures are at risk of getting left behind. Says Erenstone, “When a new technology comes along and it’s disruptive, but you’re smart about it and embrace it, you can be very successful.” Christine Umbrell is a staff writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@ contentcommunicators.com. EDITOR’S NOTE: Learn more about industry disruptors— such as Big Data and wearable technologies and their roles in value-driven care—in the August issue of O&P Almanac.

O&P ALMANAC | JULY 2015

Texas Charm AND HOSPITALITY

San Antonio Welcomes the 2015 AOPA National Assembly

JULY 2015 | O&P ALMANAC

NOWN FOR ITS RICH history, tem-

perate climate, and scenic riverside attractions, San Antonio will welcome O&P professionals from around the world to the 2015 AOPA National Assembly, October 7–10, at the Henry B. Gonzalez Convention Center. For the orthotic, prosthetic, and pedorthic community, this dynamic four-day event offers unparalleled education, networking, and development opportunities—in one of the country’s most culturally rich cities. The Assembly Planning Committee is honored to have the participation of the Center for the Intrepid Military Medical Center at the Brooke Army Medical Center in this year’s program. Speakers include John Fergason, L/CPO; Andrea Ikeda, MS, CP; Riley Sheehan, PhD; Robert Kuenzi, MS, CP; Elizabeth Russell Esposito, PhD; Jason Wilken, PT, PhD; and Christopher Rábago, PT, PhD. They will discuss a wide range of critical business-, clinical-, and research-focused topics to elevate the knowledge and practical experience of the profession. Although attendees will come to San Antonio to hear from highlevel researchers and experts and to develop career-building connections, they should stay for the city’s many cultural hot spots, historic sites, and other attractions.

A River ‘Walks’ Through It

While you are planning your stay and session schedule, be sure to build in time to visit one of the country’s oldest and most notorious battle sites for freedom: The newly named UNESCO heritage site, the Alamo Mission. Located downtown on Alamo Plaza, the 4.2-acre complex is most remembered as the site where 200 Texans held their ground for 13 days against more than 1,000 of Gen. Antonio López de Santa Anna’s troops in 1836. Although the Alamo fell during the early hours of March 6, the overpowering sense of victory—memorialized by Sam Houston’s cry, “Remember the Alamo!” as his troops defeated Santa Anna one month later—resonates with visitors even today. (If you are in the mood to learn more about the Alamo, don’t forget to download your discount ticket to the Alamo IMAX Theater, which is screening a documentary on its history, at bit.ly/1nQIWXt.).

O&P ALMANAC | JULY 2015

NEW Special Events Planned for 2015

Whether you’re participating in the Manufacturers’ Workshops or waiting for exhibitors to show off their Texas Pride during the Welcome Reception, Texas Style on October 7 at 5:15 p.m., this year’s special events are a can’t-miss opportunity to revive old relationships and build new ones.

JULY 2015 | O&P ALMANAC

Celebrate a Full Day of Learning Join your O&P colleagues for a happy hour reception, October 8, at 5:15 p.m., in the exhibit hall. The mixing and mingling is hosted by exhibitors and included in your full-conference registration.

PHOTOS: The San Antonio Convention & Visitors Bureau

Closer to the convention center is San Antonio’s unique River Walk. This below-street-level urban sanctuary winds 5 miles along the San Antonio River and is accessible by walking, biking, or taking one of the city’s guided river taxi tours. Extending from South Alamo Street to convention center, the River Walk is host to fine dining, historic sights, and exciting nightlife—not to mention the state-of-the-art accommodations for Assembly attendees. The first iteration of River Walk was completed in March of 1941, with further revitalization completed for the Hemisfair of 1968 to celebrate the city’s 250th anniversary. Developed to create a strong downtown for visitors and residents alike, Hemisfair Park is home to the Magik Theatre, Institute of Texan Cultures, Instituto Cultural de México, Universidad Nacional Autónoma de México, and several historic structures—all with access to the River Walk. It also includes the 750-foot-tall Tower of the Americas, which provides guests the most spectacular view of the Alamo City and boasts a gorgeous panorama from the Tower’s revolving Chart House Restaurant, an Observation Deck, and 4D Theater Ride.

Alumni Connection

Include your graduating school and year on your Assembly registration to be invited to connect with fellow alumni. Use the mobile app to find your school’s networking group; wear the school button; find your school’s table and message board at the AOPA Welcome Reception; and meet your friends at informal social gatherings on October 10.

8th Annual AOPA

WINE TASTING

& AUCTION

Wine Tasting & Auction

O&P PAC Challenge It wouldn’t be San Antonio without a little bull riding— so in the spirit of the ALS ice bucket challenge, challenge your peers to either ride the mechanical bull or make a donation to the O&P PAC!

Support the O&P PAC while sampling wines and enjoying an open bar on October 8 at 6:30 p.m. Registration is $150, but you’ll receive a $100 credit toward your first winning bid, which is not limited to wine! Previous events included jewelry, Tiffany’s crystal, cigars, a vacation, bourbon, and more.

Topgolf

Technician IN THE WEST

Fastest Technician in the West Got what it takes to be the best technical fabricator in O&P? Prove your proficiency by properly assembling an articulating AFO joint in a timed exhibition on the show floor!

PHOTOS: The San Antonio Convention & Visitors Bureau; Top Golf photos: Dror Baldinger

Fastest

Support two great causes, AOPA’s Capitol Connection and OPAF, October 9 at 6:30 p.m. for a new twist on the Golf Classic at Topgolf entertainment complex. Players hit micro-chipped golf balls at targets on an outfield. Just picture a largerthan-life-sized outdoor dartboard—but for golf! Tickets are $125 and include transportation, food, bar, and more.

Henry B. Gonzalez Convention Center

O&P ALMANAC | JULY 2015

Self-Guided River Walk Tour Plan to stroll the River Walk? Keep an eye out for these notable buildings, and don’t forget to “show your badge” to get discounted meals and admissions at attractions. • Most of the caliche block and stucco structures in La Villita Historic Arts Village, a collection of boutiques, art galleries, and restaurants, date back to the mid-1800s when European immigrants lived and worked there. • The city’s Carnegie Library, built along the river on Market Street in 1930, became the Hertzberg Circus Museum in 1968. Today, it’s being renovated for the Dolph and Janey Briscoe Western Art Museum. • Robert H. H. Hugman, architect and visionary of the River Walk, maintained a river-level office in the Clifford Building, constructed on Commerce Street in 1893 and designed by Bexar County Courthouse architect James Riely Gordon. • The Drury Plaza Hotel on South St. Mary’s Street is in the former Alamo National Bank Building, an art-deco skyscraper built in 1929. • Overlooking the San Antonio River in the King William Historic District, the private residence of Carl H. Guenther, founder of the Pioneer Flour Mill, was built in 1860 and remodeled in 1917. The Guenther House restaurant, a popular destination for breakfast and lunch, opened at the location in 1988. The restaurant, museum, and store are owned by C.H. Guenther & Son Inc., the oldest continuously operating milling company in the United States.

• Two former breweries built along the San Antonio River—Pearl and Lone Star—are now accessible on the Museum Reach section of the River Walk. The Pearl Brewery complex on E. Grayson is a mixed-use commercial and residential development that is also home to the Culinary Institute of America—San Antonio, along with acclaimed restaurants and specialty stores. It was founded in 1881 as the J. B. Behloradsky Brewery and the City Brewery, and the first Pearl Beer was bottled there in 1886. The Lone Star Brewery on Jones Street was completed in 1904 and remained in operation until 1918, when Prohibition was enacted and the buildings were then used for storage and warehouses until 1957.

JULY 2015 | O&P ALMANAC

PHOTOS: The San Antonio Convention & Visitors Bureau

Source: The San Antonio Convention & Visitors Bureau

Something To Savor

PHOTO: The San Antonio Convention & Visitors Bureau

Meanwhile, Bella on the River (106 River Walk Street, 210/404-2355; www. bellaontheriver.com; $$$) serves southern European, mostly Mediterranean, food. Chef Sean Fletcher offers a small and intimate dining room and wine bar, with natural limestone rock walls, candle-lit tables, and a cozy and comfortable atmosphere. Honored as the 2012 and 2013 San Antonio Express News Critics’ Choice for The Best River Walk Dining, one TripAdvisor. com reviewer says it’s “slightly hidden, which is part of its charm. Great food, attentive service, good range of dishes, and all delicious.” If steak is more to your liking, you won’t want to miss Bohanan’s Prime Steak and Seafood (219 E. Houston Street; 210/472-2600; www.bohanans. com; $$$$). “At Bohanan’s, we’ve blended Texas spirit with Old World charm, creating a space that pays tribute to the traditions of the past with a sense of pride,” says Chef/Owner Mark Bohanan, and TripAdvisor.com reviewers agree, commenting, “Simply the best in town. Either steak or seafood, you can’t go wrong.”

Easy-To-Reach Hotels

Attendees are responsible for making their own hotel reservations. AOPA has reserved a block of rooms (room rate: $229) at the Grand Hyatt, the Marriott Riverwalk, and the Westin Riverwalk.

Grand Hyatt San Antonio

600 E. Market Street San Antonio, TX 78205 210/224-1234 www.grandsanantonio.hyatt.com Distance from Convention Center: 0 Blocks

San Antonio Marriott Riverwalk

The Westin Riverwalk San Antonio

889 E. Market Street San Antonio, TX 78205 210/224-4555 Toll Free: 800/648-4462 http://marriott.com/SATDT Distance from Convention Center: 1 Block

420 W. Market Street San Antonio, TX 78205 210/224-6500 Toll Free: 888/627-8396 www.westinriverwalksanantonio.com Distance from Convention Center: 2 Blocks

O&P ALMANAC | JULY 2015

PHOTO: The San Antonio Convention & Visitors Bureau

San Antonio’s rich history isn’t limited to the battle of the Alamo or its placement on the San Antonio River. It’s also arguably the birthplace of chili con carne, a dish that gained public attention in 1895 when Stephen Crane, author of Red Badge of Courage, wrote, “…upon one of the plazas, Mexican vendors with open-air stands sell food that tastes exactly like pounded fire-brick from Hades—chili con carne, tamales, enchiladas, chili verde, frijoles.” These “vendors” were San Antonio’s Chili Queens—women who cooked or reheated chili and other Mexican specialties over mesquite fires, and joked, bantered, and flirted with customers from dusk until dawn in the central plazas of San Antonio. Although chili may be the city’s signature dish—and proclaimed the state dish in 1977—San Antonio has something for everyone’s taste buds. What’s more, many of the city’s cafés, restaurants, and bistros are within walking distance from the Assembly group-rate hotels and the convention center. Serving a variety of contemporary American cuisine and seafood, Bliss Restaurant in Southtown (926 S. Presa Street; 210/225-2547; www.restaurantsan-antonio.com; $$$$) offers a fine selection of charcuterie and artisanal cheeses in addition to is entrees and small plates. It also boasts an eclectic

selection of beers, and the wine list is designed to suit a variety of preferences. Reservations aren’t required, but are recommended, according to TripAdvisor.com. Specializing in the art of breadmaking, Jose and David Cáceres of La Panaderia (8305 Broadway, 210/375-6746; http://lapanaderia.com/ our-story/; $$) have a unique, long fermentation process for their breads. Their bakery aims to give visitors a taste of “the type of bread that was experienced by all when Mexico was in its Golden Era (Epoca de Oro) of breadmaking.”

LEADERSHIP SERIES

Technology

Smarts

Today’s orthotists and prosthetists must keep a watchful eye on the latest technologies and related reimbursement trends

The O&P Almanac’s Leadership Series shares insights and opinions from senior-level O&P business owners and managers on topics of critical importance to the O&P profession. This month, we investigate the topic of new technologies in the O&P industry.

VERY TIME YOU LOOK up, it seems there’s a new O&P component,

designed to offer patients improved function, comfort, or cosmesis. Keeping up with all of the latest technologies and deciding which new devices to offer patients can be difficult for the modern O&P professional— especially because reimbursement for new prostheses and orthoses is rarely a given. Despite the challenges, it’s essential for orthotists and prosthetists to stay educated about the newest innovations and consider whether each new device is something that could be beneficial in their facilities. This month, three O&P professionals with experience in new technologies explain why the profession should view O&P innovation as an opportunity and offer suggestions for integrating new products into both large and small O&P practices.

Meet Our Contributors

DAVID BOONE, PHD, MPH, is chief executive officer and co-founder of Orthocare Innovations, a company that focuses on technology research and development for orthotics and prosthetics. He also is a partner and director at Modus Health. Boone has spent the past 30 years as an innovator, developer, researcher, and instructor in rehabilitation and bioengineering.

JULY 2015 | O&P ALMANAC

JAN SAUNDERS, CPO, is corporate senior vice president/chief clinical officer of Level Four Orthotics & Prosthetics Inc., a provider of orthotics, prosthetics, and cranial remolding orthoses with 36 locations in eight states—North Carolina, South Carolina, Georgia, Florida, Texas, Maryland, New Jersey, and Pennsylvania— and a corporate center in Winston Salem, North Carolina.

STEPHEN BLATCHFORD is executive chairman of Chas. A. Blatchford & Sons Ltd. in the United Kingdom, a company that has been making artificial limbs and prosthetic components since 1890. Endolite is a part of Blatchford Inc. Blatchford also is chairman of the British Healthcare Trades Association and a nonexecutive board member of the National Centre for Training and Education in Prosthetics and Orthotics.

O&P ALMANAC: How does the O&P profession typically view new technologies? DAVID BOONE, PHD, MPH:

Technology is a conundrum for the field. Our goal is to improve function of people who have a disability. We apply technology with novel designs and new materials in order to improve function. The conundrum is that the reimbursement systems are focused on the thing—the prosthesis or orthosis—and not the function. The L codes are focused on the devices. JAN SAUNDERS, CPO: The O&P profession views new technologies positively, but with trepidation. Although newer technologies may be best for patients, pressures on reimbursement from insurance companies make it difficult to restore people’s lives. More and more practitioners are getting skittish about providing new technologies because there’s a lot of risk that you might not get paid. The answer to this risk is to do all of your paperwork up front, to get approvals done ahead of time. Manufacturers are starting to assist practitioners with this task. It’s a little easier for bigger companies—smaller companies may be much more timid about supplying new products as they can’t afford to take the financial hits of having to return money if a device gets rejected.

I believe that while there is a range of reactions from people who want to use new technology as soon as it is released to those who do not want to change from what they are used to, that overall the O&P profession views new technologies and innovations favorably as they will help them to provide a better outcome for their patients. O&P ALMANAC: Are new technolo-

gies threats or opportunities for O&P practitioners?

BOONE: New technologies are both an opportunity and a threat. With new technologies, practitioners have more options, and patients do their research and come in with a lot more demand. But how do you convince the payors that the improved function is worth more money? Technology can get in the way of personal delivery of patient care; we must not lose sight of providing good care. Technology should augment the up-to-date clinician, not replace him or her. We perhaps shouldn’t ask whether advanced technology poses a threat or opportunity as much as it is vital that we consider how to best use the technology that is coming.

SAUNDERS: New technologies are an

opportunity. When someone asks O&P professionals what we do, we should not say we make legs or braces. We should say we restore function; we restore people’s lives functionally. It is essential to continue to embrace technologies to maximize functionality. BLATCHFORD: I think they are a bit of

both—opportunities because they give the possibility for serving our patients better by providing more functional prostheses and orthoses for better rehabilitation and, if the reimbursement is there, then they also give the opportunity to increase the facility’s business for the future. They also are potential threats: There is the danger of raising expectations and failing to deliver on those expectations. There also is the potential threat that if clinicians do not adopt new technology and others do, then [the clinicians] could potentially be left behind. One of the big changes over the past few years is how much information is available to the general public on the Internet. This means that more and more patients have researched their situation and have clear views about what they want. These views may not always be correct or even take account of all of the relevant factors of

STEPHEN BLATCHFORD: We are liv-

ing in a time where new technologies and innovations are being introduced at a faster rate than ever before. In the broader environment, you just need to look at the evolution of the smartphone, the Internet, autonomous vehicles, and so on to see this in practice. Within O&P, we also are seeing the same with the ongoing development of the microprocessor knee, the introduction of microprocessor feet, hydraulic ankles, liner developments, elevated vacuum, powered prosthetics, integrated limb systems, and so on. O&P ALMANAC | JULY 2015

their situation, but it does mean that patients are seeking facilities that will provide the high-tech solutions they are looking for. O&P ALMANAC: What are some of the specific new technologies that will have an impact on the O&P profession? BOONE: Advanced technology has many forms—first, there are components and materials. Second, there is data technology. We can create prostheses and orthoses that are smart enough to help them work better, that include sensors to improve function, or that track performance and outcomes. Data technology has a lot of value because it doesn’t necessarily cost a whole lot more. And outcomes can quantify how much improvement is made by using the technologically advanced devices. Finally, there are practice systems—the clinical control of technology. Advances here augment knowing when and how to apply technology to which patients. Unfortunately, payors really have control of this right now. Many people are talking about 3D printing, and these discussions can be very polarizing. In general, younger practitioners are very positive about beginning to have the ability to use 3D printing. Those of us who are more familiar with the regulations are a little more cautious about the applications of 3D printing to structural components, except for sockets. Because the materials used for 3D printing are not strong enough, 3D printing is not something that’s going to be happening soon for high-stress components. There is a disconnect between popular exposure and the reality of the state of the technology. The fact is, many of us are already using 3D printing for prototyping and to make a part that is integral for testing. There’s a place for 3D printing in prototyping and development. But in production,

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machinists can actually make parts in bulk much cheaper. And the material qualities are much better with traditional manufacturing methods. We need to maintain very high standards for the strengths of O&P devices. More revolutionary is the advent of data technology; this is far more important. 3D printing may eventually replace something we already do, but data technology is bringing us to a point where we can do something new—diagnose gait and diagnose function and optimize them. We need to use data to change the way orthotists and prosthetists see ourselves working. SAUNDERS: Microprocessors are

the greatest technologies right now. They’re being used not only for prosthetics; we now have microprocessors used in orthotics. We are very close to high technology allowing quadriplegics and paraplegics to be able to walk. The military is developing exoskeletal frames. Orthotics has gone way beyond the usual plastic and metal joint. 3D printing is being used to help in the manufacture of some of these components. The technology is very

valuable, but we are still very far away from using it in our manufacturing. BLATCHFORD: Over the next few

years, the introduction of microprocessor feet and biomimetic and moving (hydraulic) ankles will have a huge benefit for amputees. They allow for better adaption of the prosthesis to the ground and hence less compensation on the sound side and a far more natural gait. There are studies in progress that also seem to show that these devices enable the amputee to walk further; have equal loading of both limbs, which reduces the risk of degradation of the sound limb; and have faster walking and with less energy so that overall mobility is greatly increased. At the moment, I am still not fully convinced by current powered prosthetics as they are bulky, make a noise, and the batteries don’t last very long, which means that they do not benefit all amputees. However, in time these teething problems will be overcome and will result in another very significant step forward. Another very interesting technology to watch is the whole question of osseointegration where the prosthesis is directly connected to the patient’s skeletal system. This seems to give the possibility for elimination of socket

discomfort on suitable amputees and greater control and awareness of what the prosthesis is doing by the amputee—but as yet it seems to need further work on failsafe mechanisms (to prevent damage to the bone if the amputee were to fall) and control of infection where the abutment goes through the skin. There is then the more speculative research into direct interfacing with the neural system—mind-controlled prostheses—which seems to be a veritable Pandora’s box. I can see that ultimately this will have great benefits for upperlimb amputees although I am less sure about most lower-limb amputees as the lower-limb prosthesis should be able to work out what to do from all of the other data inputs that it gets. O&P ALMANAC: How should prosthetists and orthotists integrate new technologies into their practices? BOONE: We need to focus on the fact that technology should be used to improve function for patients. We need to make sure technology is in a form that’s affordable so patients have access to it. If a patient doesn’t have access to technology, then it’s not improving function. So we really need to think about how technology solutions are fitting into the market. SAUNDERS: Remember that not every-

body needs the highest level of technology. We owe it to our payor sources not to over-utilize technology for profit. For example, patients in nursing homes do not need microprocessor knees. We have a fiduciary responsibility to payor sources to put their money to best use. Practitioners must use proper documentation and scrutinize patients for newer expensive technologies, and understand that they will be required to prove outcomes. As we move forward with accountable care organizations, we’re going to have to be able to prove that what we do is effective.

For example, if we have a patient who’s diabetic, and we can prove that what we do will make him more ambulatory, his health will improve, that it will lead to more activity that may bring down his blood pressure, and may reduce his insulin intake, then we can prove we are providing value. We no longer can say, “I know what I do works because I’ve been doing it for years.” We need to have evidence-based practices in order to get reimbursements. BLATCHFORD: I think that they need

to do this in a step-by-step manner. First, use the new technology in a limited or controlled manner and carefully monitor how it goes and the understanding of clinical benefits or issues arising from the technology. You can then modify your approach based on the learning from this and gradually adopt the new technology more fully.

O&P ALMANAC: What is your advice to O&P professionals who are hesitant to adopt new technologies? BOONE: Fifty years ago, cardiologists used stethoscopes to diagnose heart problems. Today, they have EKGs, 3D imaging, and a number of other advanced tools to help diagnose heart problems and do a better job of treating their patients. Like cardiologists, O&P professionals need to learn to embrace and apply new technologies for the benefit of our patients. Yes, it will change the way we do things—but we have to overcome the challenges inherent in using new technologies. SAUNDERS: I have heard so many

people say they won’t use an expensive component because they don’t want to fight for reimbursement. But that’s wrong—we need to fight for our patients and we need our patients to fight for themselves, get them involved. So we need to document well to get the payors on board. Make sure you’ve done proper evaluations. And get lots of documentation—for gait-related devices, consult with a physical therapist to build your documentation. Take videos to show what the patients looked like before and after using the new device. BLATCHFORD: I am very mindful of

the Charles Darwin quote, “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” I believe that change from the introduction of new technologies is inevitable, and we must work hard to welcome this change so that we all can get positive benefits from it. This does not mean to rush headlong into using new technologies heedlessly, but to introduce them in a step-by-step and controlled manner. O&P ALMANAC | JULY 2015

COMPLIANCE CORNER

By DEVON BERNARD

Writing Valid ABNs Learn the rules before asking patients to sign advanced beneficiary notices

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 42 to take the Compliance Corner quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

CREDITS

CREDITS P.42

ITH MORE DENIALS OCCURRING on a regular basis because of

increased audit activity, facilities are searching for ways to protect their investments and their bottom lines. Some are relying more heavily on advanced beneficiary notices (ABNs) to possibly shift financial liability to the patient in case a claim is denied due to medical necessity. But ABNs are not a cure-all, and having a patient sign an ABN form doesn’t guarantee that you are protected. For an ABN to be useful, it must be valid in the eyes of Medicare. If it is considered invalid, then you would be held financially liable for any claim denial due to medical necessity. This Compliance Corner article examines the ABN form and offers tips to help you fill out the ABN, deliver it, and issue it so that it will be considered a Medicare-compliant and valid ABN.

There is only one valid ABN form for O&P services: the CMS-R-131 (03/11) form (see the lower left corner of the form to validate the form number). If your ABN does not contain this document number, your ABN is invalid. Each ABN form also includes a disclaimer statement, which is found under the patient’s signature box. The disclosure statement is required to be included on your ABN forms and cannot be removed. Following is a section-by-section breakdown of the different parts of the ABN. Section A: Notifier. This section indicates who is providing the ABN to the patient. To be considered valid, this section must include your company’s name, address, and telephone number, and you also may include an email address or website address. Customization of the ABN to include your logo or multiple facility locations is JULY 2015 | O&P ALMANAC

EARN

BUSINESS CE

Preparing Valid and Proper Forms

E! QU IZ M

acceptable as long as the form contains the required information (name, address, and telephone number). If you include multiple facility locations in the Notifier section, clearly mark the facility where the services are being provided so the patient can contact the correct location if he or she has any issues or questions. The key is to provide enough information so that the patient or his or her representative knows who provided the ABN and who will be providing the items/services, as well as how to contact you with questions or concerns. Section B: Patient’s Name. Include the patient’s full name, and make sure it matches exactly the name printed on his or her Medicare ID card. If an ID card includes a middle initial, you should include the middle initial on the ABN form. Although the ABN will not become invalid if you misspell the patient’s name or if you forget to include a middle initial, it’s important that you and the patient or

COMPLIANCE CORNER

his or her representative recognize and understand that the name listed on the ABN is that of the patient in question. Section C: Identification Number. This section is optional; if you choose not to use it, your ABN will not be considered invalid. This section is primarily used by you for record keeping or tracking purposes. The key to this section is that you do not use the patient’s Social Security number or Medicare ID number as the identification number.

Section D: Title Unfilled. Here, list what item(s)/service(s) you believe will be denied. It’s important to use language the patient can easily understand, so avoid listing only the Health Care Common Procedure Coding System code. Consider providing the manufacturer’s name and model number, if available. Once again, customization of this section of the ABN is acceptable in certain circumstances and will not invalidate the ABN. This section may be prefilled out to include the items you provide on a regular basis, and it is acceptable to use check boxes in this section as long as the item you are providing is clearly identified. Section E: Reason Why Medicare Will Not Pay. Explain why you believe the items/services you are providing may be denied and why Medicare may not

pay. Provide a detailed explanation in friendly terms; use everyday language and don’t quote Medicare policy or use technical jargon. Provide a reason the patient can easily understand. For the ABN to be valid, it must clearly identify the particular item or service being provided (Section D) as well as the specific reason why you believe Medicare will deny the item/ service, so there must be at least one reason for the possible denial for each of the items mentioned in Section D, and the same reason can be used for multiple items. Be careful when listing or providing reasons. Simply listing a whole series of possible denials, without indicating which one may apply to your patient, could cause the ABN to be invalid. It is acceptable for you to provide multiple reasons, if multiple reasons apply. Remember to be specific because if the item or service is denied for a reason that is different from what is stated on the ABN, then the ABN is not valid. This section may be customized with information prefilled out, with check boxes to include some of the more common reasons you issue an ABN (for example, possible same/ similar denials)—as long as the reason for possible denial is clearly identified. Section F: Estimated Cost. You must provide a good faith estimate of the amount the patient may be liable for if/and when the claim is denied. You do not have to provide the exact amount; CMS and the durable medical equipment Medicare administrative contractors usually expect the estimate to be within $100, or 25 percent, of the actual costs, or whichever is greater. Section G: Options. For the form to be valid, the patient must choose from one of the three “options” listed on the ABN form. You can’t make the choice for the patient, so you may not provide the patient with a customized ABN form with options prechecked. However, if a patient requests that you select the box for them (perhaps because he or she is unable to mark the form), then you may do so.

Section H: Additional Information. This is another optional section, and your ABN will not be considered invalid if you don’t put any information in this section. You may use this section to provide more detailed information about the reason for the denial (e.g., quoting policy) or any other information you feel the patient may need to know. Sections I and J: Signature and Date. The patient must sign and date the form in these sections. If the patient cannot sign, you may request the signature of a patient representative (i.e., someone with power of attorney, spouse, adult child, etc.). This representative must have the best interest of the patient in mind and cannot have a financial interest in the claim. If someone other than the patient signs, you should document who signed and why the patient could not sign, and indicate on the ABN that the signature is that of a representative.

ABN Length

To be considered valid, the ABN cannot exceed one page. This does not mean you have to squeeze all of the information onto one page. Instead, it means that the Sections A through J must appear on one page; in other words, you may not have your company’s name and the items being delivered appear on page 1 and the patient’s signature appear on page 3. Attachments are permitted, and you may include phrasing such as “See attached” in Section D, for example. If you are using attachments, there must be a clear and easy way to match the items being provided to the reason why an item will be denied and the amount the patient may be responsible for paying. O&P ALMANAC | JULY 2015

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EXPERIENCE THE VALUE

Finally, for an ABN to be considered Valid Delivery Methods ORTHOTICof & PROSTHETIC andAMERICAN Provision ABNs ASSOCIATION (AOPA) valid, it must be presented to the benefi-

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Deciding when an ABN should be ciary far enough in advance of providing provided or issued to a patient is the the item or service that the beneficiary first step in ensuring that you are has time to make an informed decision compliant with Medicare rules for on whether to receive the service. liability protections and ABNs. The ABN Providing an ABN in person is the may only be issued when you believe ideal method of delivery. Be sure to the item/service you are providing is provide it as early as possible to ensure normally covered under an established the patient has time to review it and Medicare benefit, but you have a make an informed decision. If possible, documented reason to believe that it should not be provided at the time Membership has its benefits: Join the World’s Leading Medicare may deny the service due to of delivery. Providers of O&P Services as If you must request that BUILD A medical necessity or coverage issues. a patient sign an ABN at the time You Enter a New and Challenging Providing an ABN to every single of delivery, document the time you World of Health Care patientBUSINESS for every single item is considprovided the ABN to the patient and WITH AOPA Coding, Billing and Auditthe patient signed the ABN. the time ered by Medicare to be “blanket Learn more at www.AOPAnet.org/join When in-person delivery of the usage,” which invalidates theResources ABNs ABN is not possible, it is acceptable you are providing. Medicare also Education and CE Opportunifor you to use alternate methods such considers generic and routineties uses as mail (email or regular mail), fax, or of ABNs to be invalid—for example, Advocacy direct telephone contact. If using one it is unacceptable to provide ABNs Research and Publications of these alternate methods, document to patients when there is no specific Business in your records that you contacted reason to believe Medicare may not Discounts the patient (or his or her representapay or deny a claim, or to simply state on the ABN that Medicare may pay. tive), and wait for a response from the

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Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz. Earn CE credits accepted by certifying boards:

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AOPA’s Mission Is To Serve YOU! The mission of the American Orthotic and Prosthetic Association is to work for favorable treatment of O&P businesses in laws, regulations and the media; to help members improve their management and marketing skills; and to raise awareness and understanding of the industry and the association. AOPA membership is one of the best investments you can make to assure the future of your O&P business. Just ask the world class providers whose membership makes AOPA possible and the world of O&P and better place for you and your patients.

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Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@aopanet.org.

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beneficiary (or his or her representative) to validate the delivery of the ABN. To learn more about the proper use of an ABN, review Chapter 30 of the Medicare Claims Processing Manual located on the CMS website, cms.hhs. gov/manuals/IOM, or attend one of AOPA’s coding and billing seminars.

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MEMBER SPOTLIGHT

Medical Center Orthotics and Prosthetics LLC

By DEBORAH CONN

Serving the Nation’s Capital Facility treats military and civilian patients at Walter Reed and beyond

HORTLY AFTER LAUNCHING Medical Center Orthotics and

Prosthetics LLC (MCOP) in 2002, owners Michael Corcoran, CPO, and Mark McVicker, CPO, bid on a contract to supply lowerextremity prosthetic services to Walter Reed National Military Medical Center, then located in Washington, D.C. MCOP won that bid, and since 2005 has been the exclusive contractor providing lower-extremity prosthetics to wounded military personnel at Walter Reed, which moved to Bethesda, Maryland, in 2011. That relationship has given MCOP clinicians exposure and expertise with the most advanced prosthetic technology and complex cases, far beyond most other O&P facilities, according to Clinical Development Manager Ian Fothergill, BOCP. “We have a nationally recognized skill set in higher-level amputations, including hip disarticulations, complex bilateral amputations, and hemipelvectomy amputee

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rehabilitation,” he says. “We also see far more of these cases than the average practitioner. FACILITY: For example, to date we have Medical Center used 50 Helix hip systems from Ottobock—at one point it was Orthotics almost a weekly occurrence.” and Prosthetics Fortunately, war injuries are on the decline as the United LOCATIONS: States has reduced its forces in Headquarters Iraq and Afghanistan. But the in Silver Spring, experience MCOP practitioners Maryland; offices in have gained while treating Annapolis, Maryland, military amputees over the past and Washington D.C. 10 years has benefited all of the facility’s patients. “It has made us OWNERS: challenge ourselves to become the best we can be with any Michael Corcoran, amputee that trusts us with his CPO, and Mark or her care,” says Fothergill. McVicker, CPO MCOP has 11 clinicians, including certified prosthetists, HISTORY: certified prosthetist-orthotists, 13 years and prosthetic assistants. Four are dedicated full time to Walter Reed, while the others serve communities in the metropolitan D.C. area. The facility’s headquarters occupies 4,500 square feet in Silver Spring, Maryland, in

addition to a 5,000-square-foot lab where MCOP fabricates nearly all of its devices. “The scale of our operation is somewhat unusual, but it resulted in part from the need for fast turnaround times for hospitalized military amputees at Walter Reed,” explains Fothergill. In addition to technical expertise, MCOP’s experience at Walter Reed has transferred in other ways to the facility’s nonmilitary patients. “We have been working hard to emulate the services that are available to military amputees,” says Fothergill. “We work very closely with physical therapists in local rehabilitation hospitals and have built partnerships with physical therapy (PT) sites in or closely associated with our offices. As a result, we can provide true multidisciplinary care. Patients can make a single appointment to get a prosthetic adjustment and receive PT services.” MCOP clinicians noted another aspect of care at Walter Reed: the camaraderie developed among military personnel, as well as a tendency to group themselves by the level of their injury. As a result, MCOP offers peer networks to new patients and tries to schedule appointments that place similar-level amputees in the waiting room at the same time. “We have a large number of bilateral amputees, so we set up specific clinic days and schedule patients together to give them a chance to connect,” says Fothergill. MCOP takes advantage

PHOTOS: Medical Center Orthotics and Prosthetics LLC (MCOP)

Michael Corcoran, CPO

MCOP technicians work with a patient.

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MCOP’s amputee training center

of both word-of-mouth and digital marketing to highlight its services. The MCOP website has a blog that features special events, technology, and tips for patients. “We try to get new and better information out there,” says Fothergill. “As amputees gain knowledge, the questions that come in through our website get more sophisticated.” Like every other O&P facility, MCOP faces regulatory and reimbursement challenges. “Private insurers are coming up 20 to 40 percent lower than Medicare,” says Fothergill, “and this is

leading our industry down a path where we are significantly compromising the type of devices and the time spent with each patient. Although it has become increasingly difficult to offer the highest level of care, we have been very persistent in not accepting this shift to lower payments and ensuring we can operate a business that ensures amputees get the service and devices they need,” he says. “When you work with the military, you can’t be anything other than compassionate when you see men and women come home injured and

Mark McVicker, CPO

return to active lives. It’s a continual reminder of what we need to do and do better: speed up rehab times, apply technology where it’s needed, and give enough time to each patient.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

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PHOTOS: Medical Center Orthotics and Prosthetics LLC (MCOP)

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MEMBER SPOTLIGHT

Myomo

By DEBORAH CONN

Power Bracing Massachusetts firm offers upper-limb orthoses for support and function

YOMO, WHICH DEVELOPED the MyoPro myoelectric

JULY 2015 | O&P ALMANAC

Myomo brace

COMPANY: Myomo LOCATION: Cambridge, Massachusetts OWNERS: Privately held HISTORY: 9 years

motion,” explains Gudonis. The MyoPro displays patients’ EMG signals to a tablet computer provided to clinicians, who can adjust settings for each individual. The orthosis also uses Bluetooth technology to allow patients to play computer training games to learn how to control it. While myoelectric technology has been used in prosthetic devices for decades, Myomo was the first to commercialize it in upper-extremity orthoses, says Gudonis. “And now, with lighter-weight materials, advanced sensors, better computer processing, and greater life, lighter batteries, we can have a portable unit.” Myomo has about 25 employees, including several certified prosthetist-orthotists and an occupational therapist, who provide training and support to O&P facilities. Its corporate headquarters, across the street from MIT in Cambridge, house research

and development, marketing, and administrative functions. A product development and central fabrication facility is located in the Cleveland area, and the company has sales and clinical support reps nationwide. In addition to its business development team, Myomo’s marketing efforts include forming partnerships with patient advocacy groups, including the Paralyzed Veterans of America and the United Spinal Association. “We also attend a number of medical conferences across the country, like the American Occupational Therapy Association, the American Academy of Physical Medicine and Rehabilitation, and, of course, the AOPA meeting this fall,” says Gudonis. More than a dozen Department of Veterans Affairs (VA) hospitals have fit veterans with the MyoPro, and a number of major O&P providers are fitting the device. Myomo representatives offer demonstrations and training

PHOTO: Myomo

upper-limb orthosis, was named by a stroke survivor testing one of its early devices. “It feels like my own motion,” she said, and the term “Myomo” stuck. The company was spun out from the Massachusetts Institute of Technology (MIT) in 2006, where researchers developed its original technology. They recognized a large, unmet need among patients who had lost the use and support of their arms as a result of stroke, spinal cord injury, brachial plexus injury, and other neurological disabilities, according to Chief Executive Officer Paul R. Gudonis. “The conventional wisdom was that if a patient’s deficit remained after six months of therapy, they just had to live with it. Now we’re demonstrating that people can use their arms again—sometimes decades after an injury—and function independently,” he says. The company’s first devices, the e100 System and the mPower 1000, were primarily intended for use in hospitals and rehab centers. Its most recent product, the MyoPro myoelectric upperlimb orthosis, is custom molded for each user and designed to support the arm for use at home or work. The powered brace has electromyographic sensors in its cuff that pick up trace electromyography (EMG) signals. “The signals aren’t strong enough to allow patients to move muscles on their own, but the device amplifies them and translates them into

MEMBER SPOTLIGHT

to their O&P partners, and the company’s website features training modules, outreach programs, marketing, and reimbursement information. The company recently announced a sales partnership with Össur, in which Össur’s U.S. sales team is offering the MyoPro product line to its extensive customer base. Myomo recently released a new feature, the MotionW multiarticulating wrist orthosis that integrates with the MyoPro. It can be set manually to three degrees of freedom: wrist flexion/ extension, pronation/supination, and radial/ulnar deviation, allowing users to accomplish such tasks as opening a refrigerator door, holding a cookie sheet, and pushing a shopping cart with both hands, says Gudonis. Looking ahead, Myomo will continue to focus on

upper-extremity powered orthoses: “This area still has large, unmet needs, while a number of alternatives exist for lower-extremity mobility,” says Gudonis. Clinical efficacy and patient outcome studies are underway at the Rehabilitation Institute of Chicago, Northwestern University, the Mayo Clinic, and the Cleveland Clinic, as well as several VA hospitals. “Our mission is to enable individuals to overcome their paralysis and function more independently,” says Gudonis. “Seeing one of our nation’s veterans who was paralyzed from a gunshot wound in Afghanistan move both arms again is a reminder of why we do this.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

The Source for Orthotic & Prosthetic Coding

Myomo brace

Morning, noon, or night— LCodeSearch.com allows you access to expert coding advice—24 hours a day, 7 days a week.

HE O&P CODING EXPERTISE the profession has come to rely on is available online 24/7! LCodeSearch.com allows users to search for information that matches L Codes with products in the orthotic and prosthetic industry. Users rely on it to search for L Codes and manufacturers, and to select appropriate codes for specific products. This exclusive service is available only for AOPA members.

Log on to LCodeSearch.com and start today.

PHOTO: Myomo

Need to renew your membership? Contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org.

NEW

Manufacturers: for 2015! AOPA is now offering Enhanced Listings on LCodeSearch.com. 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

O&P ALMANAC | JULY 2015

AOPA NEWS

Who’s on First? Medicare as a Secondary Payor

Mastering Medicare Webinar, July 8

Not knowing the rules and provisions surrounding Medicare can make for a headache when it comes time for billing and collecting money. That headache becomes even bigger when there are multiple payors involved. Do you understand how the Medicare secondary payor provisions work? Join AOPA for the July webinar and discover how to ensure you submit claims to the appropriate payors. Learn all about the Medicare secondary payor provisions—and prevent your claims from being held and your payments from being delayed. AOPA experts will cover the following topics: • Which payors are primary to Medicare • How to determine if Medicare is a secondary or primary payor • How to calculate payments from Medicare when it is a secondary payer • What are conditional payments? 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 online at bit.ly/aopawebinars. Contact Devon Bernard at dbernard@AOPAnet. org or 571/431-0854 with content questions. Contact Betty Leppin at bleppin@ AOPAnet.org or 571/431-0876 with registration questions.

JULY 2015 | O&P ALMANAC

Congratulations to the 2015 AOPA National Assembly

Thranhardt Award Contenders

Launched by a gift from J. E. Hanger in memory of Howard R. Thranhardt, CP, the Thranhardt Award series has become one of the most distinguished honors in the orthotics and prosthetics profession. Attend the 2015 AOPA National Assembly to see the “best of the best” at the award-winning Thranhardt Lecture Series. The session will take place Thursday, October 8, at the Henry B. Gonzalez Convention Center at 8:45 a.m. This year’s award contenders include the following: Can Individuals With Transtibial Amputation Reduce the Metabolic Demand of Walking Using Real-Time Visual Feedback? Elizabeth Russell Esposito, PhD, is a researcher at the Center for the Intrepid at Brooke Army Medical Center. She specializes in lower-extremity biomechanics with a focus on prosthetic technology and secondary injury prevention. Balance-Confidence May Help Explain Physical Function and Community Integration Among Individuals with Unilateral Transfemoral and Transtibial Amputations J. Megan Sions, PhD, DPT, PT, OCS, specializes in evaluation and treatment of muscle and joint dysfunction and vestibular disorders with special interest in the management of spinal pain and disorders. High Prevalence of Cranial Asymmetry May Exist in Infants With Neonatal Brachial Plexus Palsy Megan Tang, MS, is a graduate of Georgia Institute of Technology. She completed her orthotics residency at University of Michigan O&P Center and is currently working as a prosthetics resident with Georgia Orthopedic Resources. Immediate Postoperative Prosthesis, a Comparative Analysis Art Shea, CPO, has 23 years of experience in O&P and has worked with New England Orthotic & Prosthetic Systems for 13 years. His education includes a bachelor of arts in physics and a certification in prosthetics from Florida International University in 1992.

AOPA NEWS

Congratulations to the 2015 AOPA National Assembly

Hamontree Award Contenders

The Sam E. Hamontree, CP(E), Business Education Award was created to recognize the best business paper submitted for presentation at the AOPA National Assembly. This award is envisioned as a counterpart to the Thranhardt Award given each year to the best clinical abstract(s). The audience will be invited to cast their vote for the award winner, and the winner will be announced at the Saturday morning General Session. Attend the 2015 AOPA National Assembly and take part in the October 9 session at 9 a.m. to see this year’s Hamontree Lecture Series contenders: Make Your Online O&P Presence Unforgettable… in Every Way Christina Throndson, web marketing manager, oversees all content produced by VGM Forbin for websites, social media, and online advertising. She is Google Ad Words certified, a certified Yahoo ambassador, and professionally trained in both new media marketing and search engine marketing. Control Your Marketing Message by Controlling the Medium Thomas McGovern is the managing partner of Clinical Education Concepts, a company that specializes in marketing platforms for O&P patient-care facilities and manufacturers. He has been involved with sales and marketing in O&P for 20 years. He has taught O&P practitioners throughout the country how to market their practices by positioning them as subject matter experts. Managers of Health Care Are Not Trained To Succeed in Business Tyler Ritchey, MBC, CP, ACM, is an area clinic manager for Hanger Clinic in Arizona, overseeing both clinical and marketing operations for the Southwest Region. Ritchey got involved in the industry following the loss of his left leg below the knee in a motor vehicle accident in 2000. He has earned his certification in prosthetics and his MBA, and is currently finishing his doctorate of business administration. Stick around for the Saturday general session to see who the audience chooses as the winner! See the 2015 AOPA National Aseembly Preliminary Program for the full education schedule. For more information, visit bit.ly/2015assembly or contact info@aopanet.org.

The AOPA Coding Experts Are Coming to Philadelphia July 13-14 The world of coding and billing has changed dramatically in the past few years. The AOPA experts are here for you! The Coding & Billing Seminar will teach you the most up-to-date information to advance the coding knowledge of both O&P practitioners and O&P billing staff. The seminar will feature hands-on breakout sessions, where you will practice coding complex devices, including repairs and adjustments. Breakouts are tailored specifically for practitioners and billing staff.

Top 10 Reasons To Go to Philadelpha

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. Benefit from more than 70 years of combined experience from AOPA coding and billing experts.

EARN CREDITS

14 CE

PER SEMINAR

Don’t miss the opportunity to experience two jam-packed days of valuable O&P coding and billing information. In this audit-heavy climate, can you afford not to attend? Register at bit.ly/2015billing.

O&P ALMANAC | JULY 2015

AOPA NEWS

Encourage Your Patients To Enter the Mobility Saves Testimonial Contest

8th Annual AOPA

WINE TASTING

& AUCTION

Become part of an important public relations campaign that proves cost effectiveness for orthotics and prosthetics. Create a video testimony and become eligible to win $500!

Why Participate?

• • • •

Help patients obtain medically necessary devices. Support the O&P profession. Become part of a major public relations campaign. Help spread the word that orthotic and prosthetic devices not only restore lives but are cost effective, too. • Receive a T-shirt. • One grand prize winner ($500), one second-place winner ($250), and one third-place winner ($100) will be awarded. • All entries must be received by 11:59 p.m. EST on Sept. 30, 2015.

It’s as easy as

1•2•3!

O CE T

WIN0

H AC

$50

1. Create your video testimony by using your smartphone or video camera. 2. Complete the online entry form at bit.ly/MobilitySavesContest. 3. Upload your video testimony or email video from your smartphone.

Questions?

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

JULY 2015 | O&P ALMANAC

Donate to AOPA’s Wine Tasting & Auction AOPA’s 8th Annual Wine Tasting & Auction will take place this October during the 2015 AOPA National Assembly in San Antonio. This exciting event provides attendees with a unique opportunity to mingle, network, and learn about and taste a variety of wines—but most importantly, it raises awareness of and funds for AOPA’s government relations outreach programs. Let’s keep the tradition of success alive and make this year’s event the best ever. Please join this great cause and add to the continued success of the Wine Tasting & Auction by donating today. Your special donations are what make this event unique and successful. Your attendance is what makes it fun! Your donation may be one of the gems from your cellar, jewelry, artwork, wine glasses, a bottle of your favorite spirit, cigars, craft beer, etc. We also have a team of personal shoppers who can locate that perfect item for you if you would prefer to make a monetary donation. Contact AOPA’s Devon Bernard at dbernard@ AOPAnet.org or 571/431-085 with questions, or access the donation form at bit.ly/aopawine.

AOPA NEWS

Sign Up for the Next AOPA Webinar AOPA’s monthly webinar series is the regulatory and business education that you can count on. No one in the O&P profession knows the ins and outs of Medicare, coding, billing, or Veterans Administration contracting like AOPA. Sign up for all 2015 webinars for only $990 for members, which includes two free webinars. If you missed one, we will send you the recording. The monthly webinars are a great way to bring your staff together for lunchtime learning by AOPA experts. Don’t miss any of the important topics in the webinars planned for the rest of the year.

July 8

Who’s on First? Medicare as a Secondary Payor

August 12

Off the Shelf Versus Custom Fit: The True Story

September 9

Prior Authorization, How Does It Work?

October 14

Understanding the LSO/TLSO Policy

November 11

Make a Good Impression: Marketing Yourself to Referrals

December 9

Bringing in the New Year: New Codes and Changes for 2016

WELCOME NEW MEMBERS

HE OFFICERS AND DIRECTORS of the American Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an official member of AOPA if, within 30 days of publiwww.AOPAnet.org cation, 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.

Is Your Facility Celebrating a Special Milestone in 2015? 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.

Active Prosthetics and Orthotics PC 1119 Fresno San Antonio, TX 78201 210/614-3000 Category: Patient-Care Facility David Gerecke Breg 2885 Loker Avenue E. Carlsbad, CA 92010 877/250-7951 Category: Supplier Affiliate Parent Company: Orthotic & Prosthetic Group of America, Waterloo, IA

Luke Prosthetics 117 E. Wallace Street Findlay, OH 45840 419/422-5009 Category: Patient-Care Facility Jeffrey A. Luke, CPO, LP Shamrock Prosthetics 825 King Avenue Athens, GA 30606 706/850-4544 Category: Patient-Care Facility Tom Karr Sound Limbs Orthotics & Prosthetics 39 S. Lisbon Road Lewiston, ME 04240 207/784-4345 Category: Patient-Care Facility Roger D. Park, CO

O&P ALMANAC | JULY 2015

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.

Aqualeg With New Soft Shell Technology The Aqualeg soft shell cover has an exact fit and is self-supporting without the need for foam underneath. This allows the cover to be used in and around water. It has flexibility modeled after real limbs and is available in a precise 3D custom fabrication. Every cover is produced to fit perfectly on the socket. The covers are intended to be used everyday and provide a solution for active people who have lifestyles that include getting into water or harsh environments. They offer the perfect solution for prosthetic devices that are traditionally difficult to cover, including those with electronic components or vacuum assistance. For more information, contact Aqualeg Inc. at 855/955AQUA (855/955-2782) or visit www.aqualeg.com.

DawSkin New Mega Stretch

DawSkin New MegaStretch is the most durable tear-free skin in the world. It is the ideal skin for your patient to shower on both legs (definitely the safer way). DawSkin MegaStretch provides the vertical ankle stretch required for multiaxis feet and energy restitution feet. “Heat-shrink” skins limit the ankle movement and will tear. DawSkin New EZ-Access dons on and off just like a sock yet provides all of the benefits of the DawSkin New MegaStretch. For more information, contact DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

JULY 2015 | O&P ALMANAC

ePAD: The Electronic Precision Alignment Device The ePAD shows precisely where the point of origin of the ground-reaction force (GRF) vector is located in sagittal and coronal planes. The vertical line produced by the self-leveling laser provides a usable representation of the direction of the GRF vector, leading to valuable weight positioning and posturing information. For more information, contact DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

New Sure Stance Knee by DAW This ultralight, true-variable cadence, multiaxis knee is the world’s first four-bar stance control knee. The positive lock of the stance control activates up to 35 degrees of flexion. The smoothness of the variable cadence, together with the reliability of toe clearance at swing phase, makes this knee the choice prescription for K-3 patients. For more information, contact DAW Industries Inc. at 800/252-2828, email info@daw-usa.com, or visit www.daw-usa.com.

Maximum Shock ValueWith the New Freedom Agilix™ The Freedom Agilix is a multiaxial, shock-absorbing, flexible foot system designed to manage loading impacts, reduce socket shear forces, and improve comfort while walking on nearly any terrain. The ultra-lightweight design offers low-impact K3 ambulators shockingly comfortable performance at a value like no other. Learn more about the Agilix at Freedom Innovations LLC by calling 888/818-6777 or visiting www.freedom-innovations.com.

MARKETPLACE Fit, Finish, and Roll ... with the New Freedom DynAdapt™ The Freedom DynAdapt Foot is a slim-profile, carbon-fiber foot system with a slender, anatomic design for easy fit and finish. Its multiaxial function provides maximum comfort, and the uninterrupted strands of carbon fiber in the full-length heel provide patients with effortless rollover and a more natural gait. The new EnduraCore™ Technology composite laminate delivers up to three times the fatigue life of a standard laminate in a design that also returns more energy. The result is a highly durable product that preserves users’ energy so they can do more with confidence. Learn more about the Freedom DynAdapt Foot at Freedom Innovations LLC by calling 888/818-6777 or visiting www.freedom-innovations.com.

Dynamic Chopart Gait Stabilizer This unique ankle-foot orthosis (AFO) has been designed for Chopart amputees who wish to remain active. Often a traditional full-length AFO for this patient will be stiff, feeling unnatural. Using a hinged ankle and flexible foot plate with a segmented dynamic filler allows flexion before providing a “stop” that protects the residuum and prevents shoe vamp collapse. The PTB design and the anterior shell redistribute groundreaction forces up the lower extremity. For more information, contact at 800/301-8275 or visit www.hersco.com.

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

Orthomerica’s Prosthetic Custom Fabrication Orthomerica Products Inc. is pleased to introduce Prosthetic Custom Fabrication. First-stage and secondstage sockets. Check, BK, and AK sockets are available with a three- to five-day turnaround time. All modifications and fabrications available. Most scans and casts accepted. For more information, visit www.orthomerica.com.

Ottobock: 300-lb Weight Limit on New Aluminum Components Our new line of aluminum pylons, adapters, and tube clamps are designed and tested to support up to a 300-lb weight limit while providing you with a costeffective, high-quality solution. The line includes double adapters at various lengths, a 30-mm pylon, a 30-mm tube clamp, and a pyramid adapter. For more information, contact your sales representative at 800/328-4058 or visit ottobockus.com.

O&P ALMANAC | JULY 2015

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.

Ottobock’s New 3R78 Polycentric Pneumatic Knee The 3R78 Polycentric Prosthetic Knee Joint with pneumatic swing-phase control offers reliable stance-phase security for users with moderate activity levels. In the swing phase, it supports a moderate range of walking speeds. The development of the 3R78 focused on a robust design that is durable enough to support a variety of patients. For more information contact your sales representative at 800/328-4058 or visit ottobockus.com.

Ottobock’s New 3R106 Pro Polycentric Pneumatic Knee The key element of the new 3R106 Pro is the servo-pneumatic control unit. Its powerful dual-chamber pneumatic unit with progressive damping has a flexion valve set for the patient’s normal walking speed. At faster walking speeds, the flexion resistance increases, which prevents too much knee flexion. This helps provide more consistent swing phase even during fast walking. With three options for the proximal connection (pyramid, threaded connector, and lamination anchor) and a 275-lb weight limit, the 3R106 Pro offers you great fitting options. For more information, contact your sales representative at 800/328-4058 or visit ottobockus.com.

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.

2015 AOPA Coding Products

• • • • •

Get your facility up to speed, fast, on all of the O&P HCPCS code changes with an array of 2015 AOPA coding products. Ensure each member of your staff has a 2015 Quick Coder, a durable, easyto-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. 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.

JULY 2015 | O&P ALMANAC

Are You the Best at What You Do?

Can you prove it?

eet the standards of ABCâ&#x20AC;&#x2122;s new voluntary Central Fabrication Accreditation program and prove to your customers that you have met the same high standards they have when it comes to running your business.

the 60 standards that youâ&#x20AC;&#x2122;ll be measured against promote best business practices and process improvement.

ABC is now accepting applications for its Central Fabrication Accreditation program! Details available at abcop.org.

Central Fabrication Standards cover areas such as:

H H H H H

Custom device tracking system Accurate record keeping Appropriately trained personnel Device recall and failure procedures Quality assurance programs

abcop.org â&#x20AC;˘ 703.836.7114

AOPA NEWS

CAREERS

Opportunities for O&P Professionals

Pacific

Job location key:

Certified Prosthetist-Orthotist, Certified Prosthetist, and Certified Orthotist

- 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. O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Nonmember $678 $830

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

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

Member Nonmember $80 $140

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

Orange County, Riverside County, and San Bernardino County, California Here we grow again: A reputable, well-established, multioffice, Southern California O&P company is looking for energetic and motivated individuals who possess strong clinical skills and experience to provide comprehensive patient assessments to determine patient needs, formulate and provide treatments, perform necessary protocols to ultimately deliver the best orthotic/prosthetic services, and provide follow-up patient care. Candidates must have excellent communication, patient-care, and interpersonal interaction skills, and always abide by the Canons of Ethical Conduct instilled by ABC. We offer competitive salaries and benefits. Salary is commensurate with experience. Local candidate preferred. Send résumé to:

Attention: Human Resources Inland Artificial Limb & Brace, Inc. Fax: 951/734-1538

Certified Orthotist or Certified Orthotist/Prosthetist

Tacoma, Washington Competitive western United States O&P business is seeking an ABC-certified orthotist/prosthetist or certified orthotist in Tacoma, Washington. We are seeking a seasoned practitioner with a minimum of five years’ experience and clinical expertise in both outpatient and inpatient settings with a willingness to work within a dynamic team. Unlimited business opportunities are available in an expanding local market. Competitive salary and benefits. Interested parties should email inquiries and résumé to: Email: jwiley@pacmedical.com

Discover new ways to connect with O&P professionals. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/aopamedia for advertising options.

JULY 2015 | O&P ALMANAC

CAREERS

Southeast

North Central

Certified Prosthetist-Orthotist

Certified Orthotist or Certified Orthotist/Prosthetist

Johnson City, Tennessee Well-established multioffice ABC-certified O&P company is looking for certified individual with excellent orthotic and prosthetic skills to provide comprehensive treatment of patients. Excel offers competitive salary and bonus opportunity with full benefits package. Salary to be determined on experience. Send résumé to:

Akron, Ohio We are looking to hire an ABC-certified CO or CPO to work in the Northeast Ohio area. Yanke Bionics is a privately owned facility that has been servicing Ohio for more than 30 years with 14 offices and offers a competitive salary and compensation package including health insurance, 401K, and vacation time. If you are interested in joining our team of experienced, dedicated practitioners, please submit your résumé to:

Email: sethwalters@excel-prosthetics.com

Supervising Engineer 303 West Exchange Street Akron, OH 44302 Email: resume@yankebionics.com

Northeast Certified Prosthetist-Orthotist, Certified Orthotist

Central New Jersey and Southern New Jersey

O&P Technician Southern New Jersey

AlliedOP is a well-established and growing full-service prosthetic and orthotic company with multiple offices in New Jersey and Pennsylvania. We are looking for hardworking and self-motivated individuals with strong clinical and technical skills to help continue our growth. We offer a very competitive compensation/benefits package. Contact:

Howard Brand Phone: 856/273-6400 Fax: 856/273-0506

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.

ADVERTISERS INDEX Company ABCOP - American Board for Certification in Orthotics, Prosthetics, & Pedorthics Inc. Ability Dynamics Aqualeg Inc. Cailor Fleming Insurance Custom Composite DAW Industries Dr. Comfort Freedom Innovations Hersco Orthomerica Ottobock Spinal Technology Inc.

Page Phone 55 27 13 7 5 1 43 22 2 19 C4 9

Website

703/836-7114 www.abcop.org 855/450-7300 www.abilitydynamics.com 855/955-2785 www.aqualeg.com 800/796-8495 www.cailorfleming.com 866/273-2230 www.cc-mfg.com 800/252-2828 www.daw-usa.com 877/713-5175 www.drcomfort.com 888/818-6777 www.freedom-innovations.com 800/301-8275 www.hersco.com 800/446-6770 www.orthomerica.com 800/328-4058 www.professionals.ottobockus.com 800/253-7868 www.spinaltech.com O&P ALMANAC | JULY 2015

CALENDAR

2015

July 30-31

July 6-11

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. For more information call 703/836-7114, or send email to certification@abcop.org, or visit www.abcop.org/certification.

July 8

Who’s on First? Medicare as a Secondary Payor. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

July 13-14

AOPA: Mastering Medicare Essential Coding & Billing Techniques Seminar. Philadelphia. Register online at bit.ly/2015billing. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

July 31

ABC: Resident Travel Award Application Deadline. Current residents, or those who finished their residency in the last three years, who chose the research and development track and are interested in presenting their directed study report at the 2016 Academy Annual Meeting are encouraged to apply. For an application and more details, visit operf.org.

Orthomerica Wound & Limb Salvage Seminar, Northern California. Earn 14 CEUs and increase your referral sources as a Certified OWLS Practitioner by attending this ABC-accredited seminar in Sacramento, CA. Tuition is $495; each attendee receives two free OWLS products (a $750 value). For more information, visit www.orthomerica.com/education or call Isora Purvis at 877/737-8444.

August 1

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

August 12

Off the Shelf vs. Custom Fit: Webinar Conference The True Story. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

August 13-14

Orthomerica Wound & Limb Salvage Seminar, Chicago. Earn 14 CEUs and increase your referral sources as a Certified OWLS Practitioner by attending this ABC-accredited seminar in Schaumburg, IL. Tuition is $495; each attendee receives two free OWLS products (a $750 value). For more information, visit www.orthomerica.com/education or call Isora Purvis at 877/737-8444.

Year-Round Testing

Online Training

BOC Examinations. BOC has year-round testing for all of its exams and no application deadlines. Candidates can apply and test when ready and receive their results instantly for the multiple-choice and clinical-simulation exams. Apply now at my.bocusa.org. For more information, visit www.bocusa.org or email cert@bocusa.org.

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.

www.bocusa.org

Calendar Rates Let us share your upcoming event! Telephone and fax numbers, email addresses, and websites are counted as single words. Refer to www. AOPAnet.org for content deadlines.

JULY 2015 | O&P ALMANAC

CE For information on continuing education credits, contact the sponsor. Questions? Email landerson@AOPAnet.org.

CREDITS

BONUS! Listings will be placed free of charge on the “Attend O&P Events” section of www.AOPAnet.org.

Words/Rate: Member Nonmember Color Ad Special: Member Nonmember 25 or less 26-50 51+

$40

$50

1/4 page Ad

$482

$678

$50

$60

1/2 page Ad

$634

$830

$2.25/word $5.00/word

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.

CALENDAR September 9

Prior Authorization, How Does It Work? Webinar Conference Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

Orthomerica Wound & Limb Salvage Seminar, Orlando. Earn 14 CEUs and increase your referral sources as a Certified OWLS Practitioner by attending this ABC-accredited seminar in Orlando. Tuition is $495; each attendee receives two free OWLS products (a $750 value). For more information, visit www. orthomerica.com/education or call Isora Purvis at 877/737-8444.

The Foot and Ankle: From Athletic to Decrepit. Wake Forest, NC. 16 credits. Support a good cause. Register at footcentriconline.com.

September 25-26

POMAC (Prosthetic and Orthotic Management Associates Corporation) Fall Continuing Education Seminar. LaGuardia Airport Plaza Hotel, New York. Contact Jon Shreter at 800/946-9170, ext. 108, or email jshreter@pomac.com.

October 1-3

SUPERCOURSE FALL 2015 AUGUST 19-22, 2015 AUGUST 19-22, 2015 TN Fillauer Headquarters, Chattanooga, Fillauer Headquarters, Chattanooga, TN

• In-depth training of Utah • In-depth of Utah Arm 3+ /training Hybrid Arm / Arm 3+ TDs / Hybrid Arm / ProPlus and Wrist ProPlus TDs and Wrist • Hands-on training with • Hands-on UI softwaretraining with UI software

September 10-11

September 12-13

Motion Control Motion Control SUPERCOURSE FALL 2015

• Casting/fitting/socket design • Casting/fitting/socket design for SD/FQ, T-H, T-R levels; for SD/FQ, T-H, provided T-R levels; patient subjects patient subjects provided

• Latest MC components, • integrating Latest MC components, with i-limb, integratingand with i-limb, bebionic, others bebionic, and others • Convenient Wednesday • Saturday Convenient Wednesday schedule Saturday schedule

Plus training in the NEW Plus training the NEW F.L.A.G. (ForceinLimiting Auto F.L.A.G. (Force Auto Grasp) feature forLimiting ETD & Hand Grasp) feature for ETD & Hand

The 4-day SuperCourse fee is $1,350.00 The 4-day SuperCourse fee is $1,350.00 CEUs: 28 (estimated) ABC/BOC CEUs: 28 (estimated) ABC/BOC For more information or to register for more information or to register for the For SuperCourse, email: info@UtahArm.com the SuperCourse, email: info@UtahArm.com

115 N. Wright Brothers Dr. • Salt Lake City, UT 84116 115 N. Wright Brothers Dr. •• Fax: Salt 801.978.0848 Lake City, UT 84116 Phone: 801.326.3434 Phone: 801.326.3434 • Fax: 801.978.0848 Toll Free: 888.MYO.ARMS • www.UtahArm.com Toll Free: 888.MYO.ARMS • www.UtahArm.com

2015 NC-SC Annual Meeting. The Ballantyne, Charlotte, NC. More information online at www. ncaaop.com/joinrenew-membership. For exhibitors and sponsorship opportunities, contact Jennifer Ingraham, jingraham@spsco.com or 800/767-7776, x1173, or contact Skyland Prosthetics at 828/684-1644.O&P Almanac Calendar Ad SuperCourse Fall 2015.indd

1 O&P Almanac Calendar Ad SuperCourse Fall 2015.indd 1

October 7-10

98th AOPA National Assembly. The Henry B. Gonzalez Convention Center, San Antonio. More information at bit.ly/2015assembly. For exhibitors and sponsorship opportunities, contact Kelly O’Neill, 571/4310852, or koneill@AOPAnet.org. General inquiries, contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org.

Children and Their Feet. FootRx Asheville and Boston, MA. 16 credits. Support a good cause. Register at footcentriconline.com.

November 9-10

AOPA: Mastering Medicare Essential Coding & Billing Techniques Seminar. The Flamingo, Las Vegas. Register online at bit.ly/2015billing. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

October 10-11

Children and Their Feet. FootRx Asheville and Boston, MA. 16 credits. Support a good cause. Register at footcentriconline.com.

October 14

Understanding the LSO/TLSO Policy. Register online at bit.ly/ aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org.

5/13/15 1:27 PM 5/13/15 1:27 PM

November 7-8

November 11

How To Make a Good Impression: Marketing Yourself to Your Referrals. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

Webinar Conference

November 4-6

NJAAOP. The New Jersey Chapter of AAOP presents the 21st Annual Continuing Education Seminar. Harrah’s Atlantic City, NJ. For more information contact Lisa Lindenberg at 973/6092263, or email director@njaaop.org, or visit www.njaaop.com.

December 9

Bringing in the New Year: New Codes and Changes for 2016. Register online at bit.ly/aopawebinars. For more information, contact Betty Leppin at 571/431-0876 or email bleppin@AOPAnet.org. Webinar Conference

O&P ALMANAC | JULY 2015

ASK AOPA

Coverage Q&A Deciphering Medicare reimbursement for compression garments, diabetic inserts, and more

AOPA receives hundreds of queries from readers and members who have questions about some aspect of the O&P industry. Each month, weâ&#x20AC;&#x2122;ll share several of these questions and answers from AOPAâ&#x20AC;&#x2122;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.

When does Medicare provide coverage for compression garments?

According to the Medicare medical policy for surgical dressing, Medicare will cover some compression garments, but only when certain criteria have been met. Medicare will cover A6531, A6532, and A6545 when they are being used in conjunction with a surgical dressing and are being used to treat an open venous statis ulcer. Any other compression garments or any other use of a compression garment is considered noncovered by Medicare. To demonstrate that the A6531, A6532, or A6545 code is being used to treat an open venous stasis ulcer, and is eligible for coverage, your claim must include the AW modifier.

JULY 2015 | O&P ALMANAC

Can we provide diabetic inserts to patients, if we did not provide the original pair of shoes?

Yes, you may provide inserts or modifications for a pair of shoes even if you did not provide the shoes originally. However, you must obtain a statement in writing from the original provider of the shoes indicating that the shoes meet the coding and coverage criteria set forth in the policy. If you provide inserts or modifications to a pair of shoes you did not provide, you should determine if the patient has already received any inserts or modifications within the calendar year, because a patient is only eligible to receive a certain amount of inserts/modifications per year.

If there is not a policy for upper-extremity orthoses or upper-extremity prostheses, how can we determine if Medicare will cover the items?

If there is no set policy to govern coverage for a certain item or service, Medicare will default to the standard coverage criteria for Medicare items. Those standard coverage criteria include the following: The item must be from a defined Medicare benefit category; it must be

medically necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; and it must meet all other applicable Medicare statutory and regulatory requirements. Upper-extremity orthoses and prostheses do fall within a defined Medicare benefit category, so they are covered on that front. You must document and show that the item is medically necessary for the condition being treated, and that all other Medicare rules have been met (i.e., documentation for the need of a custom item over a prefabricated item, substantial modification, etc.).

Does Medicare cover custom breast prostheses, L8035?

The external breast prosthesis policy states that L8305 will be considered not medically necessary if billed because there is not an established need for the custom features over those features found in prefabricated silicone breast prostheses. This doesnâ&#x20AC;&#x2122;t mean Medicare will not pay for an L8035; however, you will have to demonstrate that there is an established need for the custom prostheses. If you are to provide an L8035, consider asking the patient to sign an advance beneficiary notice of noncoverage.

Have you Heard the News That Mobility Saves?

A major new study has proven that prosthetic and orthotic care saves money for payers and improves lives for patients.

The Study A major new study shows that Medicare pays more over the long term in most cases when Medicare patients are not provided with replacement lower limbs. The study was commissioned by the Amputee Coalition and conducted by Dr. Allen Dobson, health economist and former director of the Office of Research at CMS. The study used Medicare data to compare patients with similar conditions who received prosthetics with patients who needed but did not receive prosthetics, over an 18 month period. A CHANCE TO

The Results Lower Limb Prosthetics

The prosthetic patients could experience better

WIN $500

The Contest Become part of an important public relations campaign that proves cost effectiveness for orthotics and prosthetics and perhaps win $500 just by submitting your testimony.

Why Participate?

It’s as easy as 1•2•3

•

Help patients obtain medically necessary devices

patients who did not receive

•

Support the O&P profession

1. Create your video testimony by using your smartphone or video camera.

the prosthesis at essentially

•

Become part of a Major Public Relations Campaign

no additional cost to

•

Help spread the word that orthotic and prosthetic devices not only restore lives but are cost effective too!

•

All entrants will receive a t-shirt

•

One (1) Grand Prize Winner ($500), one (1) Second Place Winner ($250), and one (1) Third Place Winner ($100) will be selected.

quality of life and increased independence compared to

Medicare or to the patient.

To learn more about the campaign, visit www.MobilitySaves.org.

•

All entries must be received by 11:59 PM EST on September 30, 2015

2. Complete the online entry form at http://bit.ly/MobilitySavesContest 3. Upload your video testimony or email video from your smart phone.

Questions? Contact us at at (571) 431-0876 or ymazur@AOPAnet.org

Video and add your own experiences like Queen’s story!

Make Sure the Insurance Companies and Health Care Providers Know This Too! Get Involved and Submit Your Testimony to the Public Relations Campaign Spreading the Word.

Upload your 1-3 minute video or write your story about how your prosthetic has improved your life, like helping you get back to work, take care of your family, rejoin the community, etc. Scan the QR code on left for the Testimony Contest Entry Form.

Michelangelo is the natural choice Natural design and incredible freedom of movement Give your patients the intuitive, responsive functionality of Michelangelo that brings them closer to a natural hand than any other myoelectric. The Michelangelo difference is more than cosmetic. It offers seven different hand positions and a powerful grip function. Along with its flexible wrist, unique fingertips, and electronically movable thumb, Michelangelo can open up a whole new world of possibilities for your upper limb patients. Ask your local sales rep to trial a Michelangelo today and see how it has become the natural choice.