June 2017 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

J U N E 2017

When To Include Modifiers on Medicare Claims P.16

This Just In: Medicare Orthotics and Prosthetics Improvement Act Arrives in 115th Congress P.20

The Latest in O&P Product Innovation P.34

Making the Case for VR in Rehab P.46

O&P Overseas: The Hong Kong Polytechnic University

Getting A

Grip LEVERAGING MYOELECTRIC TECHNOLOGIES TO IMPROVE FUNCTION

P.24

P.50

Check out the AOPA 2017 World Congress Preliminary Program

WWW.AOPANET.ORG

View at www.AOPAnet.org.

E! QU IZ M EARN

BUSINESS CE

CREDITS P.18

YOUR CONNECTION TO

EVERYTHING O&P

#AOPA2017

Registration is OPEN for this

HISTORICAL EVENT The second World Congress combined with AOPA’s 100th Anniversary Celebration will take place in Las Vegas, Nevada on September 6-9, 2017.

WHY YOU SHOULD ATTEND:

• Celebrate 100 years of the formalized O&P Profession in the United States. • Clinical Education so remarkable that it will be memorialized in an international scientificjournal. • The best speakers from around the world. Hear from physicians, researchers and top-notch practitioners. • The largest exhibit hall in the Western Hemisphere will feature devices, products, services, tools and the latest technology from exhibitors around the world. • Earn 40+ continuing education credits. • Participate in hands-on learning and demonstrations during workshops

THE PREMIER MEETING FOR ORTHOTIC, PROSTHETIC, AND PEDORTHIC PROFESSIONALS.

LAS VEGAS AOPAnet.org

• Preparation for the changes that U.S. Healthcare reform is sure to bring and its influenceonglobalhealthpolicy. • Networking with an elite and influential group of professionals. • Ideal Las Vegas location, chosen for its popularity, travel ease excitement. Register at www.opworldcongressusa.org.

contents

J U N E 2017 | VOL. 66, NO. 6

FEATURES

24 | Getting a Grip

COVER STORY

By Christine Umbrell

PHOTO: Handspring Clinical Services

Today’s upper-limb patients have more options than ever in choosing externally powered prostheses with a wide range of grip capabilities. The development of advanced myoelectric devices and control systems allows for more choice among users as well as increased opportunities for patients who were previously unable to take advantage of the technology. Here, clinicians offer their experiences fitting patients with advanced myoelectric technologies.

20 | This Just In Legislators Put Forth Bill To Improve Standards for O&P in Medicare

JUNE 2017 | O&P ALMANAC

PHOTO: AOPA

On the eve of the AOPA Policy Forum, legislators introduced the Medicare Orthotics and Prosthetics Improvement Act of 2017. Known as S. 1191 in the Senate and H.R. 2599 in the House of Representatives, the legislation would require Medicare and Medicaid to reimburse only qualified providers, recognize the prothetist’s and orthotist’s clinical notes, and more.

Sen. Bill Cassidy (R-Illinois)

34 | Exploring New Technologies Advances in O&P componentry and tools have proliferated throughout the past two years. From sockets, vacuum pumps, and braces to upperlimb prostheses and scanning technologies, several new products have hit the market recently, offering expanded options to O&P professionals and their patients. By Lia K. Dangelico

contents

SPECIAL SECTION

AOPA’S 100TH ANNIVERSARY AND WORLD CONGRESS PREVIEW

44 | Then & Now

46 | Bridge to the Future Virtual reality enhances O&P rehabilitation and research efforts

50 | The Global Professional Meet a clinician at The Hong Kong Polytechnic University

PHOTO: AOPA

AOPA Yearbooks and the centennial Who’s Who membership directory P.12 Rep. Brian Mast (R-Florida) and AOPA President Michael Oros, CPO, LPO, FAAOP

DEPARTMENTS Views From AOPA Leadership......... 4 Insights from AOPA Vice President Chris Nolan

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

Numbers......................................................... 8 At-a-glance statistics and data

COLUMNS

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

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

Research, updates, and industry news

Additional Information

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

Modifiers for O&P claims

Transitions in the profession

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

AOPA News...............................................56 P.16

Member Spotlight................................. 52 n n

AOPA meetings, announcements, member benefits, and more

Welcome New Members ..................58

Protosthetics

Ad Index......................................................58

Winkley Orthotics & Prosthetics

Calendar..................................................... 62

Marketplace..............................................59 Upcoming meetings and events

Ask AOPA.................................................. 64 Diabetic shoes, inserts, and more

P.42

O&P ALMANAC | JUNE 2017

VIEWS FROM AOPA LEADERSHIP

100 Years and Stronger Than Ever

OW! 2017 CELEBRATES 100 YEARS of AOPA’s support and service

to our noble profession. This is a milestone that many organizations never reach. I have had the privilege to be a part of three organizations that have either celebrated their centennial or will do so soon. When that milestone approaches, it is always fun to look back at how the world has changed in that span of time. In 1917, The United States (all 48 of them) was about to enter World War I, the Russian Revolution was beginning, and a young, quirky physicist named Albert Einstein published his first paper on cosmology. The U.S. federal budget was “only” $22.1 billion versus $3.65 trillion today. And, somewhere in Washington, DC, a fledgling organization pioneered by a dozen people founded the American Limb Manufacturers of America, which would one day become AOPA. I feel honored to be a part of AOPA’s storied history. Even though my time thus far has been short, I hope the impact is lasting. I have served as chair of the AOPA National Assembly—which is a World Congress this year—for the past four years and will be transitioning the conference to the next caretaker, who will continue to take our annual meeting to new heights. Today the AOPA National Assembly draws more than 2,200 attendees, and we are continuing to look for ways to expand our impact. In 2016, the Assembly in Boston closed with a ceremony that was the kickoff to a year-long celebration of AOPA’s rich history and our pathway to the future. All this year we are celebrating that history through social media and asking for your stories. If you haven’t shared your AOPA story with us, visit www.AOPA100.org and see how you can participate. You can join in the discussion by going to our social media pages and using #aopa100. Each Thursday we are featuring a Throwback Thursday picture to let you look back, remember, and perhaps crack a smile as you reflect on the fact that while some things change, many stay the same. An important part of the celebration will take place at the World Congress at the Mandalay Bay Resort and Casino September 6-9. The “Walk Through Time” display will feature items contributed by many of our members and will showcase the evolution of the devices we work with every day. We also will honor some of the great inventors who have contributed to the advancement of orthotics and prosthetics, and we will provide a world-class education program for our clinicians. This year, the first-ever “Technology Transfer” session will allow inventors to meet with potential investors to advance technology for the patients we serve. Finally, the climax of this year’s World Congress will be a “Party With a Purpose”—part party and part fundraiser for the O&P PAC, which is instrumental in influencing policy with lawmakers in Washington, DC, and ensuring innovation is available for our patients. I look forward to seeing you in Las Vegas, and seeing your stories online. Chris Nolan is vice president of AOPA.

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

Board of Directors OFFICERS President Michael Oros, CPO, LPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL President-Elect Jim Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO Vice President Chris Nolan, LPO Ottobock North America, Austin, TX Immediate Past President James Campbell, PhD, CO, FAAOP Hanger Clinic, Austin, TX Treasurer Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA DIRECTORS David A. Boone, PhD, MPH Orthocare Innovations LLC, Edmonds, WA Traci Dralle, CFm Fillauer Companies Inc., Chattanooga, TN Teri Kuffel, JD Arise Orthotics & Prosthetics Inc., Blaine, MN Pam Lupo, CO Wright & Filippis and Carolina Orthotics & Prosthetics Board of Directors, Royal Oak, MI Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Dave McGill Össur Americas, Foothill Ranch, CA Rick Riley Townsend Design, Bakersfield, CA Brad Ruhl Ottobock, Austin, TX

JUNE 2017 | O&P ALMANAC

It’s not endo or exo, it’s

Proximal Attachment with Open Distal End

Multiple Attachment Options

This feature allows easy access for pull-in designs and provides the amputee with a transfer of force proximal to the cut bone end.

The NEXO system offers two socket ring options: set screws for easy adjustment and adhesive for a lowprofile, cosmetic finish.

Flexible PEEK Rods The NEXO’s PEEK rods are lightweight and strong. Because of their flexibility, they reduce rotational and perpendicular vibration to the residual limb.

Quick Disconnect Wrist Included Simply change terminal devices with the USMCstyle quick disconnect wrist, previously only available for use in an exoskeletal system.

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

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 Carlson, CMP, senior director of membership operations and meetings, 571/431-0808, tcarlson@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

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@AOPAnet.org SPECIAL PROJECTS Ashlie White, MA, manager of projects, 571/431-0812, awhite@AOPAnet.org Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com

O&P ALMANAC Thomas F. Fise, JD, publisher, 571/431-0802, tfise@AOPAnet.org

Yelena Mazur, membership and meetings coordinator, 571/431-0876, ymazur@AOPAnet.org

Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com

Ryan Gleeson, meetings coordinator, 571/431-0876, rgleeson@AOPAnet.org

Catherine Marinoff, art director, 786/252-1667, catherine@marinoffdesign.com

AOPA Bookstore: 571/431-0865

Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

JUNE 2017 | O&P ALMANAC

Publisher Thomas F. Fise, JD

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Sheridan 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 landerson@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 © 2017 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. COVER PHOTO: Getty Images/Pobytov

Advertise With Us! Reach out to AOPA’s membership and more than 12,500 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac17 for advertising options!

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NUMBERS

Costs of Employer-Sponsored Health Insurance As costs grow, employers embrace alternative care options

Employer-sponsored health insurance covers more than half of the non-elderly population in the United States— approximately 150 million in total, according to the Kaiser Commission on Medicaid and the Uninsured. Costs related to employer-sponsored plans continue to grow.

ANNUAL PREMIUMS IN 2016

$6,435

Average annual premium for single coverage.

DEDUCTIBLES

TYPES OF PLANS OFFERED BY COMPANIES WITH EMPLOYER-SPONSORED PLANS

83 Percent

$1,221

15 Percent

Average deductible among all covered workers in 2016.

Percentage of companies that offered employees a choice between two types of health plans in 2016.

Percentage of companies that offered employees only one type of health plan in 2016.

ALTERNATIVE SITES OF CARE

39 Percent

73 Percent

63 Percent

Increase in average annual deductible for single coverage, all workers, since 2011.

Average annual premium for family coverage.

“Employers, particularly larger ones who employ most workers, continue to show interest in programs to improve health and in new delivery options…. Employers also are covering services through new venues, such as retail health clinics and telemedicine, sometimes providing financial incentives for employees to use these new options.” —“Employer Health Benefit Survey 2016,” Kaiser Family Foundation.

AVERAGE ANNUAL WORKER AND EMPLOYER CONTRIBUTIONS AND TOTAL PREMIUMS FOR FAMILY COVERAGE FOR PAST 10 YEARS 2007

$3,281

2008

$3,354

2009

$3,515

2010

$3,997

2011

$4,129

2012

$4,316

2013

$4,565

2014

$4,823

2015

$4,955

2016

$5,277

$8,824

$12,106

$9,325

Worker Contribution

$12,680 $13,375

$9,860

Employer Contribution

$13,770

$9,773

$10,944

$15,073 $15,745

$11,429

$16,351

$11,786 $12,011

$16,834

$12,591 $12,865

$17,545 $18,142

SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2016. NOTE: Not all totals tally, per survey report

JUNE 2017 | O&P ALMANAC

SOURCE: “Employer Health Benefit Survey 2016,” Kaiser Family Foundation.

Percentage of large firms that offered health benefits covering some type of telehealth services.

Percentage of large firms that offered health benefits covering services provided in retail health clinics, such as those found in pharmacies and supermarkets.

$18,142

Providing you with the comfort you need

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Happenings RESEARCH ROUNDUP

British Engineers Develop Prosthetic Hand With ‘Computer Vision’ Prototype of the hand that sees fitted with a 99p camera

Kianoush Nazarpour, MD

MD, a senior lecturer in biomedical engineering at Newcastle University. “Responsiveness has been one of the main barriers to artificial limbs. For many amputees the reference point is their healthy arm or leg so prosthetics seem slow and cumbersome in comparison.” The research was led by Ghazal Ghazaei, who carried out the work as part of her PhD work in the School of Electrical and Electronic Engineering. A team of researchers used neural

networks to show the computer numerous object images and teach it to recognize the grip needed for each type of object. “We would show the computer a picture of, for example, a stick,” said Ghazaei. “But not just one picture, many images of the same stick from different angles and orientations, even in different light and against different backgrounds, and eventually the computer learns what grasp it needs to pick that stick up.” This methodology was instrumental in teaching the computer to recognize objects and group them according to the appropriate grasp type. Several amputees are participating in clinical trials using the new technology, and it will soon be offered to patients at Newcastle’s Freeman Hospital. Related research has been published in the Journal of Neural Engineering.

Pilwon Hur, PhD, an assistant professor in mechanical engineering at Texas A&M University, is leading a research

JUNE 2017 | O&P ALMANAC

effort to develop robotic prostheses that can help balance users in the event of an unexpected slip or trip. Hur is creating customized algorithms that allow a device to learn from a human’s behavior to aid in fall prevention efforts. Hur and his team at Texas A&M’s Human Rehabilitation Group have developed the AMPRO prosthesis with the goal of predicting and reducing the number of falls. The device was designed using data gathered from test subjects with normal walking and balancing ability.

The test subjects were exposed to environments where they walked across an oily surface and experienced a controlled fall. Participants were outfitted with sensors attached to their muscles for data collection and muscle activity measurement purposes. The researchers are separating activities related to falls into subcomponents so they may program assistive devices to fit each individual’s walking habits. Hur is focusing on the rehabilitation side of robotics “so we can have better, more human-friendly, lightweight, and robust robotic prosthetics and exoskeletons,” he said.

PHOTO: Courtesy of the Department of Mechanical Engineering at Texas A&M University

Texas A&M Researchers Study Robotic Prostheses for Fall Prevention

PHOTOS: Newcastle University, UK

Biomedical engineers at the United Kingdom’s Newcastle University are testing an “intuitive” prosthetic hand that is designed to “react without thinking,” according to the researchers. The bionic hand is fitted with a camera that instantaneously takes a picture of the object in front of it and assesses its shape and size, which triggers an immediate series of movements in the hand. The prosthetic hand is unique in that it bypasses the traditional processes that require the user to see the object and physically stimulate the arm muscles to trigger a movement in the prosthetic limb. Instead, the technology relies on a camera and computer vision to recognize objects and select the proper grip. “Using computer vision, we have developed a bionic hand which can respond automatically—in fact, just like a real hand, the user can reach out and pick up a cup or a biscuit with nothing more than a quick glance in the right direction,” said Kianoush Nazarpour,

HAPPENINGS

VETERAN VIEWPOINTS

AOPA Testifies Before House Veterans Affairs Subcommittee

PHOTOS: Thomas F. Fise, JD

AOPA was invited to provide testimony during a hearing of the House of Representatives Veterans Affairs Subcommittee on Health on May 2. The hearing focused on the Department of Veterans Affairs’ (VA’s) ability to meet the need for high-quality clinical care and procurement of O&P devices for wounded warriors and veterans with limb loss and limb impairment. Jeffrey Brandt, CPO, founder and chief executive officer of Ability Prosthetics and Orthotics, represented AOPA at the hearing. Highlights of Brandt’s testimony included the need for the VA to ensure that both wounded warriors and veterans with limb loss and limb impairment have proper access to high-quality prosthetic and orthotic care within the VA health system as well as through partnerships with O&P facilities in the private sector. Brandt also spoke on the increasing demand for high-quality O&P care and the decreasing provider population, and the potential impact those trends may have on veterans’ access to care. In addition, he provided testimony regarding the need for increased funding to support O&P education through the passage of legislation such as the Wounded Warrior Workforce Enhancement Act. Visit www.AOPAnet.org to read a transcript of Brandt’s testimony.

Rep. Brad Wenstrup, DPM (R-Ohio), and Jeffrey Brandt, CPO

Meeting of the House Veterans Affairs Subcommittee on Health

CODING CORNER

RAC Removes Announcement of L5845 Audits Performant Recovery, the national recovery audit contractor (RAC), announced in April that it would begin performing an automated review on claims involving Health-Care Common Procedure Coding System (HCPCS) code L5845 billed in conjunction with specific prosthetic knee codes. AOPA reviewed the announcement and was immediately concerned that the RAC was not in compliance with its statement of work, which requires specific criteria before an automated review can be implemented. In an April 28 letter to the Performant Recovery medical director, AOPA expressed its

concern regarding Performant’s decision to initiate an automated review without meeting the specific criteria identified in its statement of work. AOPA has received a formal response from Performant Recovery addressing its concern, but the audit announcement for L5845 has been entirely removed from the “approved issues” section of the Performant Recovery website indicating that AOPA's concern was valid and that the issue was on hold pending further review. This was followed by a letter from CMS that indicated that the issue should not have been approved and was being removed from the Performant website.

CODING CORNER

Jurisdiction C Announces Prepayment Review of Microprocessor Knee Code On May 4, CGS Administrators LLC, the durable medical equipment Medicare administrative contractor (DME MAC) for Jurisdiction C, announced the initiation of a widespread prepayment review for HCPCS code L5856— Addition to lower-extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type. L5856 is used as an addition code to prosthetic knee components that incorporate the use of a microprocessor to control the knee during both swing and stance phase of the gait cycle. The prepayment review will begin on or around June 15, 2017, according to CGS. The DME MAC suggested that providers review the current Local Coverage of Determination and Policy Article for lower-limb prostheses and reference the CGS documentation checklist for lower-limb prostheses. AOPA members are encouraged to work with their physician partners to ensure that documentation regarding the need for a microprocessor-controlled prosthetic knee is present in the patient’s medical record. The documentation must address the need for a microprocessor knee over a conventional prosthetic knee and should support the need for K3 or higher functional-level components.

O&P ALMANAC | JUNE 2017

HAPPENINGS

ADVOCACY IN ACTION

Amputee Coalition Hosts Hill Day AOPA Hosts Policy Forum The AOPA Policy Forum was held May 24-25 in Washington, DC. More than 100 AOPA members and O&P stakeholders gathered to discuss the most important issues affecting O&P. Participants also met with legislators and their aides to share how the O&P profession restores lives and puts people back to work, and to discuss why O&P should be included as an essential health benefit in any new health-care legislation. Details of the Policy Forum will be featured in a future issue of the O&P Almanac.

io) Rep. Wenstrup (R-Oh

Amputee Coalition Hill Day participants

and Lisa Arbogast

Hill Day participant meets with Douglas Hill, defense legislative fellow for Sen. Johnny Isakson (R-Georgia).

Rep. Brian Mast (R-Florida) and Peter Thomas, JD

PHOTOS: Amputee Coalition

JUNE 2017 | O&P ALMANAC

PHOTOS: AOPA

Rep. Brian Mast Michael Oros, CP(R-Florida) and AOPA Preside nt O, LPO, FAAOP

On April 25-26, the Amputee Coalition hosted Hill Day as part of Limb Loss Awareness Month. A record-breaking 80 attendees participated in nearly 100 meetings with legislators and staff during the event. Many participants were first-time visitors to Capitol Hill. Attendees took part in an afternoon of preparation and training on Tuesday, April 25, followed by a day of meetings with senators and representatives across the Hill. Staffers were cordial and supportive, listening intently to the issues impacting the community, and took the time to help people with limb loss take the direct route to their next meeting, even if it involved traveling through the tunnels under the Capitol. The Amputee Coalition plans to follow up on the in-person discussions by continuing talks with legislators about the introduction of the Insurance Fairness for Amputees Act, co-sponsorship and passage of the Local Coverage Determination Clarification Act, and education about the importance of funding for research and programs that directly affect people living with limb loss and limb difference.

HAPPENINGS

TECHNICIAN TAKEAWAYS

ABC Publishes Certified Technician Practice Analysis The American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) has released the 2017 Practice Analysis of Certified Technicians in the Disciplines of Orthotics and Prosthetics. ABC’s Practice Analysis Task Force and Executive Director Cathy Carter worked with Professional Examination Services to create and implement a practice analysis of ABC-certified technicians. ABC last conducted a practice analysis study of technicians in 2011. In 2016, technicians were resurveyed to identify changes related to orthotic and prosthetic care, available componentry, and the technology in use today. The goal of the practice analysis is to determine current trends in the provision of prosthetic and orthotic services by technicians. “We wanted to get an idea of what current orthotic and prosthetic technician practice looks like in order to meet the ever-changing needs of the

profession,” said Robert Carlile, CPA, CTPO, chair of ABC’s Practice Analysis Task Force. The overall return rate for the survey was 30 percent, a high return rate for this type of survey, according to ABC. “The technicians who participated in the survey have provided a great service to their profession,” said Carlile. “Only those working within the profession can give us a comprehensive and contemporary look into their specific knowledge and skill sets.” ABC will use the results of the practice analysis survey to ensure that its orthotic and prosthetic technician credentialing exam is continually relevant for individuals entering the profession. The results also will be used to identify content for in-service and continuing education, as well as provide guidance for education programs in regard to curriculum review and program self-assessment.

O&P ATHLETICS

AOPA, ABC, and NCOPE Raise Funds for Youth Camp

PHOTO:

As part of Limb Loss Awareness month, staff members from AOPA; the American Board for Certification in Orthotics, Prosthetics, and Pedorthics; and the National Commission on Orthotic and Prosthetic Education joined together for a 3.5-kilometer walk to raise funds for the Amputee Coalition’s Paddy Rossbach Youth Camp. The Youth Camp provides a traditional summer camp experience—including swimming, boating, archery, and other activities—for children ages 10-17 with limb loss or difference, at no cost to participants. Funding the camp costs approximately $2,000 per child. The organizations exceeded their original goal and raised more than $4,900, which covers the costs for two children to go to camp.

O&P ATHLETICS

First Swim Returns to Charlotte

The Orthotic & Prosthetic Activities Foundation’s (OPAF’s) First Swim event returned to Charlotte, North Carolina, and Queens University for the third year in a row for an adaptive swimming training and clinic. Two-time World Champion triathlete Mabio Costa, a belowknee amputee, led the instruction, assisted by the Queens University Royals Swim Team. More than 20 individuals participated in the three-hour clinic in the pool at Levine Center, along with family and friends. Attendees included both amputees and spinal cord injury patients as well as visually impaired participants, ranging in age from 4 to adult. Each participant was matched with a personal swim coach and received one-on-one coaching from Costa on improving his or her skills in the water. The event was sponsored locally by Hanger Clinic, Paceline Advanced Medical Solutions, and Accessible Mobility Center.

O&P ALMANAC | JUNE 2017

PEOPLE & PLACES PROFESSIONALS

BUSINESSES

ANNOUNCEMENTS AND TRANSITIONS

Dennis Williams, CO, BOCO, has been named chief executive officer of Allard USA. Williams previously served as president and chief operating officer for Fillauer Companies, executive vice president and partner of Dennis Williams, Biomedical Horizons Inc., and director of CO, BOCO sales and marketing for Camp International, among other positions. Throughout his career, Williams has been actively involved in product development.

The Board of Certification/ Accreditation (BOC) has moved to www.bocusa.org a larger space, transitioning from a 3,600-square-foot office to a 5,183-square-foot office space. BOCâ&#x20AC;&#x2122;s new address, as of June 6, 2017, is 10461 Mill Run Circle, Ste. 1250, Owings Mills, Maryland 21117. The Orthotic Prosthetic Group of America (OPGA) has announced a partnership with Cypress Adaptive LLC. As an OPGA supplier-partner, Cypress Adaptive will offer its prosthetic products to more than 1,200 independent O&P facilities throughout the United States.

THE LIGHTER SIDE

BUILD A

Better BUSINESS WITH AOPA

Visit www.AOPAnet.org/join today! Learn how AOPA can help you transform your business into a world class provider of O&P Services with: Coding, Billing and Audit Resources Education, Networking, and CE Opportunities Advocacy Research and Publications Business Discounts

JUNE 2017 | O&P ALMANAC

REIMBURSEMENT PAGE

By DEVON BERNARD

E! QU IZ M

Modifiers: When and How to Use Them

EARN

BUSINESS CE

CREDITS P.18

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

HE FUNCTION OF A modifier is to provide additional information to the claims processor—information such as financial liability, pricing, or coverage. Not all claims or codes require the use of a modifier, but forgetting to include a modifier when one is required or misapplying a modifier could result in improper payments or denials, and an overall slowdown in the adjudication process of your claims. This month’s Reimbursement Page reviews some of the core modifiers and some of the more obscure modifiers, or those that are not routinely used or may be used incorrectly.

Policy-Specific Modifiers

JUNE 2017 | O&P ALMANAC

PHOTO: Getty Images/monkeybusinessimages

All of the Medicare medical polices include information regarding what modifiers may be needed in order for a claim to be processed and how the modifiers are to be used. Sometimes the policy includes information beyond the basic set of modifiers (LT, RT, GA, KX, etc.) and requires the use of a specific modifier. For O&P claims, three policies have their own unique set of modifiers: the spinal orthoses policy, the lower-limb prostheses policy, and the surgical dressing policy. For spinal componentry, Medicare has stated that devices constructed of primarily elastic or other stretchable/ flexible materials are not always rigid enough to provide sufficient support to a weakened or deformed body member, not meeting the definition of a brace, and therefore are noncovered. However, there are several codes that describe both flexible spinal orthoses that are elastic in nature and devices that are flexible but not made of elastic materials. Since these nonelastic items remain

eligible for coverage, providers have been advised to use the CG modifier to identify flexible spinal orthoses that are not made of elastic material. According to the lumbosacral orthosis (LSO)/thoracolumbosacral orthosis (TLSO) policy, only the following codes require the use of the CG modifier: L0450, L0454, L0455, L0621, L0625, or L0628. So, if you are providing a spinal brace described by one of the preceding codes and it is primarily constructed of inelastic material (e.g., canvas, cotton, or nylon) and/or has stays/panels, providing the required support, then be sure to include the CG modifier. Also, the Pricing, Data Analysis, and Coding contractor and the durable medical equipment Medicare administrative contractors have stated that a claim for the L3923 must include the CG modifier if it is to be considered eligible for payment. If you are providing elastic supports or compression garments, be aware of the surgical dressing policy. Traditionally, compression garments are considered statutorily noncovered by Medicare; however, they are covered under one narrow exemption. If the compression garments are used in the treatment of open venous stasis ulcers, and in conjunction with a surgical dressing, then they may be considered a benefit and covered. According to the surgical dressing policy, only three compression garment codes may fall into this exemption: codes A6531, A6532, and A6545. The AW modifier is used with these codes to indicate they are being provided in conjunction with a surgical dressing, and the patient has open venous stasis ulcers, rendering them eligible for payment.

REIMBURSEMENT PAGE

The most recognizable of these policy-specific modifiers are the functional level modifiers, or K-level modifiers. These modifiers are used with lower-limb prosthetic claims, and only with Health-Care Common Procedure Coding System (HCPCS) codes that describe prosthetic hips, prosthetic knees, prosthetic ankles, and prosthetic feet. Two outlier codes also require the use of a K-level modifier: codes for a polycentric hip joint (L5961) and a high-activity knee frame (L5930). When using the K-level modifiers, remember they should be used to describe the patient and not the componentry being provided, and your claim should reflect that distinction. In other words, if your patient is a K2 ambulator, but you wish to provide him or her with K3-rated componentry, you would still use the K2 modifier on the claim. Also remember that even though the policy states that bilateral amputees are not strictly bound by the functional levels, you are still required to assign a functional level to the patient and the claim.

of a KX modifier: AFO/KAFO, KO, orthopedic shoes, and therapeutic shoes for persons with diabetes. How the KX modifier is used and applied depends on the policy. For example, in the policy article for KOs, under “Policy-Specific Documentation Requirements,” the following statement is included: “Suppliers must add a KX modifier…if all of the coverage criteria…. have been met and evidence of such is retained

to ensure that the policy criteria for medical necessity have been met, that the KX modifier is required, and that specific requirements of the KX modifier usage also have been met. Note that when you include the KX modifier on your claim, you are attesting that everything required by policy is in place. Do not simply add the KX modifier because you know it will get your claim paid. This practice can lead to fraudulent billing.

in the supplier’s files.” Thus, you must physically have the documentation supporting the use of the KX modifier in your files—and if you don’t have this documentation, you should not attach the KX modifier. However, if you review the same section of the therapeutic shoes for persons with diabetes policy, you will not see such a statement. Instead, you will see the following statement: “Suppliers must add a KX modifier…only if criteria in the Nonmedical Necessity Coverage and Payment Rules section have been met. This documentation must be available upon request.” Thus, while you don’t have to have all the supporting documentation in your files, you must be able to provide the documentation if asked. So, before using the KX modifier, review current medical policies

The next commonly used liability or payment modifier is the GA modifier. The GA modifier informs Medicare that you expect the code or codes in question to be denied as not medically necessary (perhaps because policy coverage or documentation criteria have not been met and you cannot use the KX modifier); that you have discussed this possibility with the patient; and that the patient has signed a properly issued advanced beneficiary notice (ABN). The ABN is used to notify the patient that Medicare may deny the claim as not medically necessary, and the patient agrees to assume financial liability for the codes in question should Medicare deny the claim. Without a GA modifier, Medicare assumes that financial liability remains with you—the provider—if the claim is denied.

Liability/Payment Modifiers

PHOTO: Getty Images/Alvarez

Liability or payment modifiers are typically required to be included on your claims in order for the claims to be processed properly. For example, the ankle-foot orthosis (AFO)/kneeankle-foot orthosis (KAFO) policy and the knee orthosis (KO) policy require the use of the KX, GA, or GZ modifier; and the diabetic shoe policy states that each claim and claim line must include the KX, GA, GZ, or GY modifier. If one of these modifiers is not present on the claim, the claim will be rejected. These modifiers also help indicate if the items/services you are providing should be considered a Medicare benefit, considered medically necessary; and if the items/services should be paid and who will be responsible for the payment—you or the patient. The first of these modifiers is the KX modifier. The KX modifier means that the coverage and medical necessity requirements specified in a policy have been met. Currently, only four O&P medical policies require the use

O&P ALMANAC | JUNE 2017

REIMBURSEMENT PAGE

essential to ensure

If Medicare will never pay for the item, then why must you use the GY modifier and submit a claim? As a Medicare-approved supplier, you agree to submit claims on behalf of Medicare beneficiaries if the beneficiary requests that you do so. While it is not mandatory to submit a claim to Medicare for a statutorily noncovered service, if the beneficiary requests that you do so, then you must comply. The most common reason why a beneficiary may request that you submit a claim is if he or she has secondary insurance that requires a Medicare denial before the claim will be considered. Submitting a claim with a GY modifier will trigger a Medicare denial—a denial that holds the patient (and not you) financially liable, releasing it for consideration by the secondary insurer.

reimbursement at

Miscellaneous Modifiers

The GZ modifier also may be used to indicate that you believe that Medicare will deny a claim or a claim line item as not medically necessary. This modifier is to be used when you fail to have the patient sign an ABN or if the patient refused to sign the ABN. The GZ modifier will automatically cause your claim or the item to be denied, and you will have to appeal to demonstrate medical necessity, but the financial liability would rest with you as the provider and not the patient.

Correct coding continues to be

O&P facilities. So, the GA modifier does not cause your claim to be denied and Medicare may still pay the claim, but the GZ modifier will automatically cause the claim or claim line to be denied. Next is the GY modifier, which is used to indicate that the item or service you are providing is statutorily excluded from Medicare coverage, meaning there is no Medicare benefit and Medicare will never pay for the item or service. The GY modifier is most commonly associated with claims involving orthopedic shoes that are not attached to a brace, but it may also be used with AFOs used solely for off-loading and for diabetic shoes and inserts that exceed the number of allotted services in a year, or compression garments. In addition, the GY modifier is used with a select set of LSO/TLSO codes, when the CG modifier may not be used, when the brace is primarily made of elastic and doesn’t provide sufficient support. The GY is not used when an item does not meet coverage criteria and will be denied as not medically necessary. 18

JUNE 2017 | O&P ALMANAC

The EY modifier is used in those instances where you did not obtain an order prior to dispensing an item to a patient, perhaps because you thought one was on file, or because the patient chose a cash-pay option but later changed his or her mind and requested that you submit a claim to Medicare. The EY modifier signifies that no physician order or order from any other healthcare provider (nurse practitioner, physician assistant, etc.) is on file for this item. The EY modifier causes the claim to be denied as not medically necessary. This means that you do have appeal rights and you can appeal the denial and demonstrate the medical necessity of the item, or demonstrate that the patient waived his or her rights with the voluntary cash-pay option and you should not be held liable. The GW modifier is one that may prove useful if you have hospice patients. Hospices are paid under a prospective payment system (PPS), just like hospitals and skilled nursing facilities. When a patient elects hospice care, he or she is agreeing not to accept treatment for his or her terminal illness, and Medicare under the PPS will pay the hospice to cover all palliative treatments of the symptoms of the terminal disease for which the patient has

elected hospice care. Remember, however, that the patient has not agreed to waive all of his or her other Medicare benefits, or treatments not related to the terminal illness. In other words, treatments of conditions that are not directly related to the patient’s terminal disease will remain a covered Medicare benefit, and may be billed to Medicare. In order for Medicare to properly process these types of claims, you must include a GW modifier indicating that the service is unrelated to the patient’s terminal disease or illness, and that the hospice is not responsible for payment. Finally, the QJ modifier is used if you are providing items or services to a patient who is incarcerated, and you plan to bill Medicare for the item or service. Typically, if a patient is incarcerated, which could mean he or she is under arrest or imprisoned, under supervised release, under home detention, or on medical furlough, then the patient is responsible for payment and you may not bill Medicare. However, if the state requires the patient to repay all costs (associated with the care) and the state actively enforces the payment of the debt, then you could bill Medicare and use the QJ modifier. While this explanation of the modifiers is not exhaustive, understanding the modifiers discussed here is critical and could mean the difference between payment and nonpayment for your services. Correct coding continues to be essential to ensure reimbursement at O&P facilities. 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

Legislators Put Forth Bill To Improve Standards for O&P in Medicare Medicare Orthotics and Prosthetics Improvement Act introduced in 115th Congress

OW IN ITS FIFTH VERSION since 2009

and its original introduction in the 111th Congress, the Medicare Orthotics and Prosthetics Improvement Act of 2017 was introduced by co-sponsors Sens. Charles Grassley (R-Iowa) and Mark Warner (D-Virginia) as Senate Bill S. 1191 in the 115th Congress on May 22. Sens. Bill Cassidy (R-Illinois) and Tammy Duckworth (D-Illinois) have since joined as co-sponsors. The introduction of the bill brings O&P another step closer to accomplishing several major achievements for O&P patients and their providers. A companion bill has been introduced in the House of Representatives as H.R. 2599 by Reps. Glenn Thompson (R-Pennsylvania) and Mike Thompson (D-California). The bipartisan legislation would apply accreditation and licensure requirements to providers and suppliers for Medicare payment purposes. It would modify the designation of accreditation organizations for orthotics and prosthetics to recognize O&P suppliers as independent professional providers of medical care for Medicare beneficiaries. “Orthotics and prosthetics, like other medical equipment, is an area that attracts a lot of fraud,” Grassley said when introducing the bill. “The good actors in this industry want to distinguish themselves from the bad actors who cheat Medicare. Having accreditation and licensing will help weed out bogus products. This will benefit the people who rely on orthotics and prosthetics for their health and mobility, and it will protect the taxpayers at risk of paying for fraudulent equipment.”

JUNE 2017 | O&P ALMANAC

Sen. Bill Cassidy (R-Illinois) speaks at the 2017 Policy Forum.

“The Medicare Orthotics and Prosthetics Improvement Act puts in place needed reforms that will improve the quality of orthotic and prosthetic care for seniors on Medicare while reducing fraud,” said Warner. Bills cannot be carried over from one Congress to the next so new bills must be introduced in each new Congress, carrying new bill numbers.

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Enactment of provisions in the earlier S. 829 and H.R. 1530 versions in the 114th Congress came close to being included in a last-minute continuing resolution before Congress adjourned. Like the new versions, the legislation would have imposed the following requirements on CMS: • Require Medicare/Medicaid to reimburse only qualified providers meeting required licensure or accreditation standards according to Section 427 of the Benefits Improvement and Protection Act; • Recognize the prothetist’s and orthotist’s clinical notes as part of the patient’s medical record; • Distinguish the clinical activities of orthotists and prosthetists from those providing durable medical equipment and supplies; and • Clarify that “off-the-shelf orthotics” eligible for competitive bidding be limited to those devices that require minimal self-adjustment only by the patient and not another person in order to fit the patient.

Sen. Mark R. Warner (D-Virginia), left, and AOPA President-Elect Jim Weber

These long-sought objectives are reasonable requests that will help ensure timely delivery of O&P patient care and reduce opportunities for fraud and abuse in the Medicare and Medicaid systems. Over the years, with each re-introduction of the bill, AOPA members have cultivated a following in Congress that brings passage of provisions closer and closer. At the May 24-25 Policy Forum last month, more than 100 advocates for O&P—including nearly a dozen patients—took part in over 395

congressional visits. During their meetings, they topped their list of “asks” by urging legislators to sign on as co-sponsors for S. 1191 and H.R. 2599. AOPA will be making a further all-out push to enlist those AOPA members who did not attend the Policy Forum to urge their senators and representatives to join as co-sponsors of the legislation. The introduction of the Medicare Orthotics and Prosthetics Improvement Act of 2017 was announced right before the Policy Forum briefings. Seldom does a single piece of legislation do so much for a vital segment of patients and health-care providers as does the 2017 version introduced by Grassley and Warner in the Senate, and their counterparts in the House, Thompson and Thompson. These four members of Congress have sponsored versions of the bill in prior years and continue the bipartisan support this legislation has always generated. Visit www. AOPAvotes.org for a letter to send to your representatives.

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COVER STORY

Getting a GRIP

ADVANCES IN MYOELECTRIC TECHNOLOGIES ARE IMPROVING FUNCTION FOR UPPER-LIMB AMPUTEES

JUNE 2017 | O&P ALMANAC

By CHRISTINE UMBRELL

COVER STORY

NEED TO KNOW • Significant advancements in myoelectric-controlled prostheses have been made in recent years, with more choices in multiarticulating hands, a greater number of grip options, and improvements in battery life. • New control schemes, such as pattern recognition and targeted muscle reinnervation, are being used in conjunction with externally powered prostheses, enabling more functionality for those patients who are suited to their use. • With so many options available, it’s important for prosthetists to stay educated on new technologies and help guide patients to the most appropriate upper-extremity solution, by determining patients’ typical activities, work responsibilities, and medical needs, and by explaining how different devices function. • Training amputees in the proper use of myoelectric-controlled devices is critical. Patients benefit from exercises designed to strengthen the muscles and form isolated and independent contractions or patterns of activities. • A team approach to patient care, which may involve prosthetists, surgeons, physiatrists, and occupational and physical therapists, may facilitate optimal care and rehabilitation for upper-limb amputees using myoelectric devices.

PHOTO: Getty Images/Pobytov

harnessing or additional movements NE OF THE MOST impactful from the user to actuate the devices. advancements in the world of Dave Beachler, CP, prosthesis upper-limb prosthetics has been the development of myoelectric-controlled technology specialist in Orthotic & Prosthetic Services at Walter Reed prostheses. These externally powered National Military Medical Center artificial limbs are controlled by (WRNMMC), notes several recent electrical signals generated by muscles improvements, including more choices in the individual’s residual limb. As of multiarticulating hands and partial this technology matures, the devices hands (in both sizes and manufacare enabling more functionality for a greater swath of patients. turers), an increase in the number of “Myoelectric prostheses have grasp patterns available, and an evoluimproved tremendously in recent tion in the ways in which users access years,” says Levi Hargrove, those grasps or gestures. He PhD, director of the Neural also cites improvements in Engineering for Prosthetics battery life, as myoelectric and Orthotics Laboratory at componentry becomes more the Shirley Ryan AbilityLab complex and the degrees of in Chicago. The primary freedom increase, and the use benefit of myoelectric of flexible polymer batteries, devices is that they do which provide more choices Levi Hargrove, PhD not require additional for battery placement. O&P ALMANAC | JUNE 2017

COVER STORY

PHOTO: Handspring Clinical Services

Handspring clinician Chris Baschuk, CPO, MPO, FAAOP, works with a patient on his training with a pattern recognition system.

Like Hargrove and Beachler, Will Yule, CP, Hanger Clinic national upper-limb specialist, points to the emergence of newer multiarticulating hands as significant progress. He also notes that today’s hands offer multiple gripping patterns and features and are available in a broader range of sizes. “Previous versions of myoelectric hands had a C-shape with simple open-and-close options. New hands can have up to 21 grip options,” he explains. “What’s exciting is to see a previous user of a more traditional myoelectric hand start to use a multiarticulating hand that enables the patient to hold his hand in a way that he was not able to before—for example, turning a page in a book, turning a key in a lock, and putting a card in an ATM machine,” says Yule. With the advent of new technologies and new socket systems, more patients are trying myoelectric devices, and increased visibility in the media has prompted some upper-limb amputees to seek out myoelectric devices, says Yule. “Patients who may not have been enthusiastic about previous 26

JUNE 2017 | O&P ALMANAC

Most of the existing externally powered prostheses can be used in conjunction with a pattern recognition system to enhance control and function, says Blair Lock, MSc, Improving Control PEng, co-founder and chief As the devices improve, executive officer of Coapt, a so do the technologies company that offers myoelecthat enhance their use. Beachler cites new control tric pattern recognition control schemes, such as pattern systems. Coapt announced in recognition and the use of May that it has obtained the Blair Lock, MSc, PEng Food and Drug Administration’s targeted muscle reinnerClass II medical device clearvation (TMR), as crucial advancements. “All are targeted toward ance for its pattern recognition system, improved dexterity, more intuitive making it the only myoelectric pattern control, and overall function,” he says. recognition system to be cleared for Hargrove agrees, noting that some marketing in the United States. clinicians are pairing prostheses Lock describes the pattern recogwith control systems using pattern nition system as the “brains” of the recognition, which “provides an prosthesis, which works in conjuncunprecedented level of functionality tion with myoelectric prostheses. “All for transradial and transhumeral of the pre-existing devices use muscle amputees,” he says. “Pattern recogsignal information in a very basic way,” he explains. nition and targeted muscle Together, myoelectric devices and reinnervation are two improvements that have received widespread clinical pattern recognition control systems offer advantages for some patients, acceptance. These technologies allow says Thomas Passero, CP, founder users to safely and intuitively control and clinical advisor of Handspring their devices.” myoelectric devices are now willing to reconsider myoelectric prostheses as a good fit to meet their needs.”

COVER STORY

Lifetime Prosthesis User Shares Her Perspective

JUNE 2017 | O&P ALMANAC

PHOTO: Handspring Clinical Services

Debra Latour, MEd, OTR/L, has been a prosthesis user for the past 60 years, due to a congenital upperlimb difference. Latour Debra Latour, MEd, OTR/L works as a clinical therapy consultant for Handspring Clinical Services, an upper-limb company under the parent company of Prosthetic & Orthotic Associates, and is involved in prosthetic rehabilitation and training. She has worn all kinds of devices throughout her life, favoring a body-powered prosthesis. “In 1972, I tried a standard myoelectriccontrolled hand. I didn’t like it because it was a lot of work and not very natural, and it didn’t make any tasks any easier than my body-powered device did,” says Latour, who typically wears a prosthesis 16 hours a day. She tried a myoelectric prosthesis again in the late 1970s, but she still preferred her body-powered prosthesis. A couple of years ago, Latour tried pattern recognition control while attending a national conference. “When I tried it,” she says, “it was exactly what I perceived control should be—efficient and intuitive to each specific user.” She was fit with a myoelectric device paired with pattern recognition control nine months ago. Latour states that by using her new prosthesis, “I can do things with the externally powered, multiarticulated hand that help to preserve my natural hand.” But Latour also continues to rely on her body-powered device eight hours a day. “No one device takes the place of a hand. Each device is great for certain circumstances, but no one device is perfect for all circumstances. “For those of us who are active users, the prosthesis becomes a part of us,” she says. “Both of my devices are part of my body schema. I perceive myself as whole both with and without the device.”

Handspring clinician Laura Katzenberger, CP, works with a myoelectric patient.

Clinical Services, an upper-limb “With conventional technology, there company under the parent company was no signal we could find to use with of Prosthetic & Orthotic Associates. myoelectric prostheses.” Fortunately, For example, they allow for more the patient’s physician had conducted intuitive control, he says. “When you an EMG test and found trace signals think ‘open’ and ‘extend,’ that’s what coming out of his arm. Passero obtained happens.” In addition, the components a testing system from Coapt and found may require less occupational therapy a pattern in the patient’s arm “that fell and training, he says. below the threshold of conventional More amputees can take systems but was detectable advantage of myoelectric to the pattern recognition devices via pattern recognisystem,” he says. The patient has since been fit with a tion, too. For some patients myoelectric prosthesis with with residual limbs that have pattern recognition, which sustained injuries, conven“has meant the difference tional two-site myoelectric between a body-powered devices may not work—but Thomas Passero, CP versus a myoelectric device.” those same individuals may Similarly, Beachler recalls be able use myoelectric how a transhumeral patient, who had devices with pattern recognition not undergone TMR, struggled with control systems, says Passero. consistent surface EMG signals due He cites the example of a patient to involuntary muscle tremors. “With who was unable to use a conventional two-site myoelectric prosthesis because pattern recognition, we were able to isolate out the tremors that had the industrial accident that led to his no particular EMG patterns and use amputation had left him with a crushed voluntary EMG patterns for hand open/ elbow, grafted skin, and multiple close and wrist pronation/supination as surgical reconstructions. “He had a lot of tissue damage and no detectable elec- the control commands. This opened up the possibility to use a myoelectric with tromyographic (EMG) muscle signals more success,” he says. on his arm,” says Passero.

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Selecting an Appropriate Prosthesis

When deciding which device will be most appropriate for a given patient, it’s important to remember that while a natural hand can “do it all,” a prosthesis is more limited.

The Rise of TMR

Upper-limb amputees who undergo TMR and are subsequently fit with myoelectric devices controlled via pattern recognition may achieve improved function, according to Hargrove and Passero. Yule says more surgeons are becoming aware of advanced myoelectric devices and are performing amputations that allow individuals to benefit from them; however, Passero says the number of surgeons qualified to perform TMR surgeries remains relatively low. Those patients who do undergo the procedure and are Will Yule, CP fitted with an appropriate device usually experience more intuitive control— and “virtually all neuroma pain is eliminated,” he adds. Of course, TMR surgery is not required for patients to take advantage of the greater functionality available in newer myoelectric devices. “All of the technology available on the market is able to be controlled with as little as one electrode, with just one signal,” explains Yule. But having multiple muscle groups engaged after TMR surgery allows for greater functionality. “We can use sockets with 17 different sensors to be able to pick up all of the EMG activity; we’re using all of this fine fidelity of information,” says Yule. 30

JUNE 2017 | O&P ALMANAC

With so many new devices and control systems available, today’s upper-limb patients have more prosthesis options than ever. Consequently, prosthetists must be educated on all of the technologies to help guide patients to the most appropriate solution— myoelectric or not. When deciding which device will be most appropriate for a given patient, it’s important to remember that while a natural hand can “do it all,” a prosthesis is more limited. No myoelectric device, body-powered prosthesis, or activity-specific device can fully restore the function of a natural hand, says Passero. He suggests thinking of different types of prostheses as tools that can be used for different types of activities—and most patients need more than one tool. Determining how a patient wants and needs to use a prosthesis is critical to device selection, says Hargrove. “For example, certain users may need a very robust and waterproof device to return to work. A different patient may work in an office environment and require a multifunction hand. It really is patient-specific,” he says. Helping patients choose the most appropriate device is the most enjoyable part of Yule’s job. He starts by learning the patient’s typical activities of daily living (ADLs) and work responsibilities, and delves deep into the patient’s needs and abilities. He then describes all of the options: no prosthesis, passive, body-powered, hybrid, activityspecific, myoelectric, and combination. “I explain the pros and cons of each option.” He also shows patients samples of all of the devices. “I drill down to the patient’s medical needs, which helps provide justification for devices” and aids in ensuring reimbursement, he says. For example, if a below-elbow patient has a hand on the sound side that is greatly compromised, that could provide justification for a myoelectric device.

At WRNMMC, Beachler works closely with Josef Butkus, occupational therapy supervisor, to educate patients. They help patients determine the positives and negatives of each terminal device as it is related to a task. As a large facility, WRNMMC can allow patients to observe peers using prostheses to provide a clearer picture of how a device might or might not be used in their own life. “If possible, we try to have patients trial a particular device. If there are specific tasks they are wanting to achieve, like washing their vehicle and soldering onto a circuit board, we will try and find a solution that will not only fill those activities but also allow them to achieve their everyday tasks and ADLs,” says Butkus. “Therapists stimulate this active problem solving during activities by asking questions like, ‘Would this task be easier with a body-powered, a myoelectric, a standard or powered utilitarian hook, a standard hand, or a multiarticulating hand? In what position? What if you couldn’t use your intact arm?’”

"Certain users may need a very robust and waterproof device to return to work. A different patient may work in an office and require a multifunction hand. It really is patientspecific," says Levi Hargrove, PhD.

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Comprehensive Care

Progress in Myoelectric Bracing Options

HILE MYOELECTRIC PROSTHESES HAVE advanced in recent years, progress among myoelectric upper-extremity braces is allowing more individuals with weak and impaired upper extremities to return to important activities of daily life, says Jonathan Naft, CPO, general manager of Myomo and president of Geauga Rehab Engineering in Chardon, Ohio. “One who is an amputee is very similar in the need for assistance at home as one who has a limb but cannot use it,” says Naft. For example, carrying a laundry basket with one arm “is virtually impossible, but it’s also virtually impossible for someone who has an arm but can’t use it.” These individuals have fewer options for function-restoring devices than those with limb loss, he says. Myoelectric orthoses, introduced to the market about five years ago, provide more opportunities for limbimpaired individuals. These braces offer support to the weakened arm and also assist movement, explains Naft. “Static bracing offers support of the wrist and fingers in a fixed position. Myoelectric devices offer that support, plus they can help control movement in the same manner as existing lower-extremity braces.” Today’s myoelectric orthoses are being fit most frequently on stroke patients and brachial plexus patients, but Naft says they also are being used on brain injury patients as well as individuals diagnosed with amyotrophic lateral sclerosis, multiple sclerosis, and spinal cord injuries. Naft notes that the past year has seen significant advances for bracing technologies, allowing patients to achieve more than previous iterations. Published research about the devices, such as the paper “Giving Them a Hand: Wearing a Myoelectric Elbow-Wrist-Hand Orthosis Reduces UpperExtremity Impairment in Chronic Stroke,” is allowing developers to learn more and improve the efficacy of the devices, according to Naft. “We’re opening more doors and leaning into more patient populations,” he says. Myomo has sized down its original device for adolescent patients, and the company is developing smaller, lighter devices for younger children. “These are patients who are expecting the worst because they’ve been told by doctors that their function may never return,” he says. Once they try a myoelectric brace, they may find "they're able to support their arm, move their arm, and open and close their hand. So, they are very grateful. It’s nice to be a part of that.” PHOTOS: Myomo

JUNE 2017 | O&P ALMANAC

Proper device selection, fitting, and training all require a team approach to patient care. “The physiatrist, prosthetist, and occupational therapist have obvious roles in treating patients,” including prescribing the prosthesis, fabricating and fitting the prosthesis, and teaching the patient to become a proficient user, Hargrove says. In addition, several team members are less obvious but just as important. “Surgeons, for example, can be consulted to revise the residual limb or perform TMR. A reimbursement specialist can be helpful to clearly justify why a specific prosthesis was selected for the patient.” WRNMMC has an Amputee Care Team in place, designed to keep clinicians in close proximity to each other. Physical medicine and rehabilitation doctors, orthopedic surgeons, prosthetists, and occupational and physical therapists are all involved in patient care. “Each team member brings a different set of skills. It may be deciding the correct length of amputation needed for certain myoelectric devices or how a certain functional goal may be achieved,” Beachler explains. The contribution of the prosthetist should not be understated, says Hargrove. Prosthetists “are instrumental in device selection, configuration, fitting, and follow-up care. Based on their experience, they can suggest the best prosthesis for patients. The skill and experience of the prosthetist can also overcome very challenging fittings for successful outcomes.” Such a team of prosthetists, specializing in upper-extremity prosthetics, exists at WRNMMC. “Many of our amputees have complex cases to include multiple amputations,” says Beachler. “We need to be educated on all the different combinations of components available for our patients. What might work for a unilateral upper-extremity amputee may not work for a trilateral or quadrilateral amputee. With complex cases, our prosthetists have to take into consideration how to achieve basic ADLs,

COVER STORY

MYOELECTRIC

how to just don and doff all of their prosthetics/liners, and how to … plan for their return to active duty or other work and activities. These and many other factors help us decide what style of socket, type of suspension, and componentry are the most appropriate for each patient.” Training amputees to use their prosthesis is critical, says Hargrove. Patients benefit from exercises designed to strengthen the muscles and form isolated and independent contractions or patterns of activities. “The tools provided by the manufacturers are helpful to ideally locate electrode positions and verify good myoelectric signals,” he adds. “It is useful to transition to controlling a prosthesis as soon as possible so that the patient

help him, but hopefully the problemsolving skills that he learned with his medical staff may help him analyze and successfully complete whatever task that has to be performed,” he says. “Patient satisfaction is of utmost importance, because if we can’t remedy their issue then they are going to be less likely to wear the prosthesis.” Beachler also emphasizes the benefits of working closely with an occupational therapist: “Occupational therapists are an essential component of proper upper-extremity prosthetic care. The therapist focuses on ADLs and problem solving for appropriate inclusion of the prosthetic limb into any novel task,” he says.

With so many new technologies in place and on the horizon, prosthetists are encouraged to stay up-to-date on the latest research to understand the new externally powered devices and control options. The best informed prosthetists will lead their upperextremity patients toward optimal function and outcomes. Christine Umbrell is a staff writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@ contentcommunicators.com.

Patients benefit from exercises designed to strengthen the muscles and form isolated and independent contractions or patterns of activities.

PHOTO: Hanger Clinic

can receive appropriate occupational therapy and be trained to better perform activities of daily living.” Just by observing other prosthetic users in the clinic, WRNMMC patients pick up different tricks and techniques to achieve their desired goals, according to Butkus and Beachler. “This could be as simple as hand positioning before use or as complex as a technique they have developed for successful simultaneous control with a TMR transhumeral prosthesis,” says Beachler. Patients at WRNMMC are educated and coached until they have achieved a level of competence with all their prosthetic systems and terminal devices, says Butkus. “When the patient gets a flat tire in the middle of nowhere, his therapist and prosthetist aren’t going to be able to

The Future of Myoelectrics

As technology evolves, innovations will benefit upper-extremity amputees. According to Hargrove, “Implantable technologies are a very exciting emerging research area. These technologies range from osseointegration to implantable EMG sensing, and successful firstin-man demonstrations have been performed. Over the coming years, these technologies are likely to improve and see wider deployments.” Yule agrees that osseointegration is an emerging technology to get excited about and foresees a future that combines implants with “pretty cool stuff, like wireless Bluetooth telemetry signals.” He’s intrigued by other emerging technologies, such as osseointegration paired with myoelectric control.

Joan Lang, a patient of Will Yule, CP, uses a left transradial HCR silicone suction socket with an integrated humeral sleeve; dualsite control with a small bebionic hand and IBT flex cell batteries.

O&P ALMANAC | JUNE 2017

By LIA K. DANGELICO

EXPLORING New Technologies Unlocking the potential of patients and clinicians with the latest O&P devices and tools

NEED TO KNOW • With new technologies being introduced to the market at an accelerating pace, O&P manufacturers have released several new products in the past two years in an effort to assist clinicians in improving function for patients. • Developments in lower-limb products have centered on improved socket technology, vacuum systems, and knee and foot prostheses, as well as advanced ankle-foot orthoses, among other innovations. • New upper-limb technologies include smarter, sturdier products that more closely mimic the natural hand.

JUNE 2017 | O&P ALMANAC

PHOTO: Getty Images/Mattjeacock

• In addition to new componentry, manufacturers have introduced tools and technologies to aid clinicians in evaluation and fitting, including image capture devices and measurement and scanning systems.

IKE ANY GOOD SUPERHERO,

an O&P clinician must be armed with the right tools to help his or her patients overcome daily challenges. After all, where would Captain America be without his shield or Wonder Woman without her Lasso of Truth? The same goes for a clinician trying to get a young athlete back onto the soccer field or return an amputee handyman to his workshop. And while the latest items to hit the O&P market can’t unleash super-human strength or expel honesty, they do present unique solutions to the issues patients and clinicians face. The most recent batch of O&P products and tools were developed not only with patients in mind but also clinicians, according to manufacturers. Designers sought to help clinicians reduce costs and drive outcomes with simpler designs that boost efficiency while also allowing them to innovate and customize devices to patients’ needs. For patients, engineers and developers worked to control the body and ensure comfort and skin protection through a variety of settings and uses. They also identified ways to incorporate more patient feedback into overall care. O&P Almanac recently reached out to manufacturers from across the profession to discuss a sampling of their newest innovations from the past two years. These advancements fit into the larger trend of rising to meet future challenges in O&P, including the growth of 3-D and robotics technology and more.

Ottobock’s Dynamic Vacuum System (DVS)

that was designed by LIM Innovations to allow prosthetists and users to make the maximum adjustments for volume, function, and comfort. It is targeted to outcomes-oriented clinicians who are in need of a streamlined, mobile fitting process, as well as transfemoral and knee disarticulation users—levels K1 through K4, some of whom are highly active and may be prone to

Lower-Limb O&P

The latest developments in lower-limb O&P products serve a variety of patient populations and needs. While prosthetic and orthotic newcomers often get the most attention, the advancements in their smaller moving parts and the technologies that help them function properly are just as important. After all, everyone needs a good sidekick. Socket technology is just one area of improvement. The Infinite Socket TT is a custom-molded, modular socket

LIM Innovations’ Infinite Socket TT

discomfort or skin breakdown. With the use of LIM Capture technology, a 3-D digital version of the limb is generated using measurements and images, and from that a mold is created in the likeness of each patient’s distinct shape. The socket was designed to save time and to accommodate a truly custom fit—clinicians don’t need to create impressions or test sockets, and they can make tweaks up to the final fitting. “The Infinite Socket allows users to adjust the fit of their socket to their individual needs,” says Robert Spotswood, vice president of revenue at LIM Innovations, and an amputee who uses the device himself. “It enables amputees to increase function through improved comfort.” Another recent lower-limb innovation is Ottobock’s Dynamic Vacuum System (DVS), which features a low-profile design that works to reduce the amount of movement between the limb and socket associated with limb-volume fluctuations. “The DVS system makes it more accessible for practitioners to begin using vacuum and get away from some of the disadvantages of the pin system,” says Mark Edwards, MHPE, CP, director, professional and clinical services, North America, for Ottobock.

O&P ALMANAC | JUNE 2017

Ottobock’s 3R31 Prosedo modular knee joint, released earlier this year, also contributes to patients’ overall mobility and function. It uses hydraulic flexionresistant sitting assist to give users more control as they lower into the seated position, which can Ottobock’s 3R31 help eliminate strain Prosedo modular and improve balance knee joint for lower-mobility transfemoral patients. “Instead of unlocking the knee and creating instability, the user can safely sit without worrying about falling into the chair or the knee collapsing underneath them,” says Edwards. Some of the new lower-limb products are helping patients to walk, play, and run farther, faster, and more confidently. For example, Ottobock’s

Ottobock’s Meridium Foot 36

JUNE 2017 | O&P ALMANAC

Meridium Foot, introduced in 2016, is an intelligent, microprocessor-controlled foot that uses a four-axis design and real-time situation detection for users. While other designs use carbon feet as the base and place a microprocessor on top of it, “the Meridium houses the hydraulic unit in the foot itself, and it uses sensors to allow for real-time adaptation to adjust automatically to stairs, ramps, terrain, and speeds of walking,” says Edwards. On the orthotics side, two of the latest ankle-foot orthoses (AFOs) to hit the market take distinct approaches to lower-limb support. The Agilium Freestep AFO, released in 2016 by Ottobock, was designed to reduce force in the knee but uniquely applies to the patient’s ankle/foot. “Instead of being a traditional knee orthosis, which can migrate on the user and [can be difficult to wear under or over clothing], this design is placed on the lower part of the leg and foot to help alleviate knee pain and allow for increased comfort in walking,” says Edwards.

Ottobock’s Agilium Freestep AFO

The TayCo External Ankle Brace, developed by University of Notre Dame athletic trainer Michael Bean in conjunction with Surestep and team physicians, is a rigid, over-the-shoe, custom AFO designed to assist adult patients in returning to their active lifestyles more quickly. Patients can use the brace, introduced last year, with existing footwear and orthoses, reportedly without compromising stability, performance, or comfort. Available in athletic, worker, and medical versions, this custom AFO does not require any casting and can be ordered from any smartphone.

TayCo External Ankle Brace

Spiro Joint by Surestep

Not all new technologies are limited to adult users. Created in 2015, the Spiro Joint is a low-profile, lightweight joint manufactured with high-grade stainless steel that was meant for smaller bodies. It allows for the creation of durable and strong braces that can be easily adjusted to accommodate patients’ specific needs. “Our static-progressive Spiro Joint is perfect for pediatric patients,” says Bernie Veldman, chief executive officer of Surestep. “It can be used on any non-ambulatory upper- or lower-extremity orthosis.” Of course, protecting patients’ skin is a huge factor in any approach to foot care. Created for diabetic foot-care patients and amputees, GlideWear® Shear Protection Socks feature duallayer low-friction fabric technology that protects skin against breakdown. The silk-like fabric, initially introduced by Tamarack Habilitation

Tamarack Habilitation Technologies’ GlideWear® Shear Protection Socks 38

JUNE 2017 | O&P ALMANAC

Gesture control powered by i-mo™ technology from Touch Bionics by Össur

Technologies last year and released to the market in 2017, aims to wick moisture away from the skin and protect against pressure, friction, and shear forces, which can cause callusing, blisters, and diabetic foot ulcers. O&P practitioners who are trying to prevent breakdown or are treating patients with chronic wounds that resulted from breakdown may want to investigate these socks, which are available in forefoot and partial foot models. “One of the biggest points of confusion is that a lot of these wounds are purely pressure issues,” says Jason Pawelsky, sales and marketing manager for Tamarack Habilitation Technologies. “In literature and product development we’ve seen recently, more and more clinicians and manufacturers are realizing there’s more going on than just pressure… With the sock, it’s very intuitive. It doesn’t require you to use a secondary type of device that is foreign to somebody… [It] specifically addresses patients who have edema in their calves and feet, so that you’re not constricting the foot and reducing blood flow. It works nicely in conjunction with other therapies, like an ankle-foot orthosis, diabetic shoe and insole, or a total-contact cast.”

Upper-Limb O&P

In the realm of upper-limb products, there have been several advances in the design and functionality of prosthetic hands and fingers. In response to patient feedback, manufacturers have developed smarter, sturdier products that more closely mimic the abilities of a natural hand. With the release of its i-limb and i-digit bionic hands, Touch Bionics by Össur introduced gesture control powered by i-mo™ technology, which allows users to access up to four different grips with a simple gesture. i-mo uses gyroscopes and accelerometers to sense movement so users merely sustain an open signal, wait for their index finger to “twitch,” and move in the direction of a desired grip. “The multiarticulating hands on the market have the ability to do so much more than the two standard inputs that are provided to it,” says Nathan Wagner, CPO, LPO, OTR/L, director of clinical training for Touch Bionics by Össur. “Gesture control eliminates the problem of not being able to take full advantage of those hands,” and makes accessing grips more consistent and reliable. “Even though it’s an advancement in technology, it’s actually a

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simpler way for users and practitioners to program and access grips within the hand,” he says. “So the technology actually simplifies the process... For the user, that equates to more grips, more easily, more accurately. For the practitioner, less time spent explaining different methods by which to switch. They can use this one, intelligent motion to get four grips.” Toward a similar goal, the MCPDriver™ allows finger amputees to more simply complete the tasks that make up their daily lives, including hobbies, chores, and more. This custom-designed finger prosthesis from Naked Prosthetics was created for patients who have had an amputation in their proximal phalanx—specifically, those who have at least 1/2 inch of the proximal phalanx, at least 45 degrees flexion in the metacarpophalangeal (MCP) joint, and at least 10 degrees extension in the MCP joint. Using the joint, or knuckle, users can mimic the movements of a natural finger and complete ordinary tasks, such as buttoning a shirt or picking up a hammer. The design is meant to be both attractive and durable; it uses medical-grade nylon 12 and features stainless steel components as well as a silicone strap that anchors to the device. Pivot hinges help ease opening and closing of the component. “What sets us apart is how robust and intuitive our devices

MCPDriver™ by Naked Prosthetics

JUNE 2017 | O&P ALMANAC

Orthomerica’s SmartSoc® 3-D Capturing System

are to use,” says Brad Crittenden, lead engineer for Naked Prosthetics. “Each prosthesis is uniquely designed to suit the patient’s affected finger, which enables him or her to quickly return to a demanding lifestyle.”

O&P Tools

Beyond the technical aspects—the nuts and bolts that hold things together— several new tools and technologies have emerged to aid in O&P practitioners’ work and facilitate patients’ success. From software developments that allow for more accurate and custom designs, to workflow innovations that improve efficiencies and save trees, these O&P tools address the challenges clinicians face while creating devices and caring

for various areas of the body—from the head to the toes. The SmartSoc® 3-D Capturing System is part of Orthomerica’s U.S. Food and Drug Administration 510(k)-cleared line of image capture devices for the manufacturing of STARband® and STARlight® cranial orthoses. Developed with a team of researchers from the Massachusetts Institute of Technology, the system analyzes 2-D video images for optimal 3-D conversion in the Cloud without the use of structured light. It reportedly simplifies aspects of the process, from allowing for patient movement during the scan to showing real-time progress. Currently, it is only available on the Android operating system for the Samsung Galaxy S7, but an iOS version for the iPhone is expected this fall, as is a prosthetic module. “Because it’s based on a commercial mobile phone device, everyone is familiar with how to use it; there’s minimal or no learning curve,” says Chris Schulte, vice president of operations for Orthomerica Products. This system “leverages the advancements in mobile phone computing and photogrammetry to capture the patient shape without the use of projected light or lasers,” he says. “As a result, the SmartSoc™ system is not susceptible to light or scanning noise and is totally intuitive, capitalizing on the ergonomic design and programming researched by the cell phone manufactures.”

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Another development for smartphone-toting clinicians is the eCast™ app, a custom brace measurement system that was introduced by VQ OrthoCare last year. It uses advancements in digital photography, pattern recognition, and image processing to read the precise leg anatomy and generate a more accurate fit. Available for iPhone, iPod touch, iPad, and iOS 8 or greater, the app helps guide clinicians through the scanning process to ensure proper height, distance, and camera tilt before an image is captured. Clinicians can send orders directly from their phones, which may decrease the need for additional paperwork and measurements and reduce turnaround time. The iTOM-CAT also aims at a more accurate read of the lower limb. This fully functioning foot-and-ankle scanning system was developed by ComfortFit Orthotics last year in conjunction with TOM-CAT Solutions. Built for the iPad Air 2 platform, it allows clinicians to scan a foot or ankle using a structured sensor that captures a 3-D image with an accuracy within 0.2 mm. From there, they can complete the patient’s prescription form and send the data digitally, reducing paper

VQ OrthoCare’s eCast™ app

JUNE 2017 | O&P ALMANAC

ComfortFit Orthotics’ iTOM-CAT

flow and turnaround time. It also generates a digital history of each patient’s scanned data and prescriptions so casts can be easily altered based on changes in the patient’s physique or specific needs. According to Chief Executive Officer Howie Schorr, the system is designed to help foot specialists save time and money by eliminating the need for office casting with foam, plaster, or fiberglass socks, and shipping to the lab. Standard Cyborg’s custom iPadbased scanning app isn’t targeted to one specific area of the body; rather, it allows for a fully digital workflow in designing O&P devices. Introduced last year, the Cloud-based software generates a 3-D model that clinicians

can modify without the need for sending extra emails or cleaning edges. Clinicians can take scans offline or while connected to wifi, then log into the website to see their full digital file in color. Featuring its Structure Scanner and Design Studio software, the app is being adopted throughout the United States and beyond, with educational programs, including Baylor University, Northwestern University, and University of Hartford, using it in classrooms. “Driven and informed by clinician feedback and ideas, the Design Studio software makes 3-D design easy to learn and use, with typical users getting up to speed in a matter of weeks,” says Jeff Huber, co-founder of Standard Cyborg.

Standard Cyborg’s custom iPad-based scanning app

In addition to smartphone-enabled advances, some manufacturers are leveraging new technologies to develop innovative casting techniques. For example, the Symphonie Aqua System from Cypress Adaptive presents a new approach to the standard method of hand casting that enables clinicians to determine the burden of a stump within a prosthetic socket under actual conditions. With the use of hydrostatic pressure, one can reportedly generate a more specific and detailed impression that indicates prominent areas on the bone as well spots that may be scarred or more sensitive. “The Symphonie Aqua System facilitates excellent, reproducible outcomes with significant benefits for both the patient and practitioner,” says Lynn Snyder, PT, operations manager for Cypress Adaptive. The company is the exclusive North American distributor of the system, which was developed by a German firm, Romedis GmbH. “The sockets produced with the

Cypress Adaptive’s Symphonie Aqua System

Symphonie Aqua casting technique enhance patient satisfaction, as they are comfortable and well fitting. This translates to faster functional progression for patients and clinical efficiency and consistency for the practitioner.” From lower-limb to upper-limb technologies, the latest innovations in O&P have been designed to assist orthotists and prosthetists—the superheroes

of O&P—in returning patients to an improved quality of life. AOPA and the O&P Almanac do not endorse the products included in this article. Lia K. Dangelico is a contributing writer to O&P Almanac. Reach her at liadangelico@gmail.com.

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& NOW

THEN

AOPA’s Membership Directory Centennial Yearbook continues a long tradition of connecting members with important resources

Then & Now is a monthly department for 2017. As part of AOPA’s centennial celebration, O&P Almanac will feature a different AOPA product or service and discuss how it has evolved over the years. This month, we focus on the AOPA directory.

HE PUBLICATION OF THIS year’s Who’s Who 100th Anniversary Commemorative Membership Directory is a fitting way for AOPA to celebrate the association’s centennial. Serving as the 2017 AOPA Yearbook, the 200-plus page directory features photos, stories, timelines, and resources in addition to the expected member listings and contact information. The Who’s Who publication follows a long tradition of directories released by AOPA over the years with the purpose of connecting members with the information and contacts essential to running a successful O&P facility.

JUNE 2017 | O&P ALMANAC

THEN

Over the years, AOPA’s membership directories have served as a tool for members to share and learn from each other, for patient referrals, and for networking. These documents also have enabled AOPA to communicate the value of membership and AOPA products and services, and also allow the organization to celebrate its leaders and political action committee (PAC) donors. During AOPA’s early years—when the association was not as expansive as it is today—the association published much smaller directories, or “rosters.” They typically listed the names of each member company by location and via alphabetical order, and often included addresses. Looking through old directories offers a sense of how the organization has changed over the years. For example, the 1959 Roster—published when the association was called the Orthopedic Appliance and Limb Manufacturers Association (OALMA)—features a section delineating the 11 “Regions” of the association at that time, with names and contact information for each of the regional directors. As OALMA became AOPA and the directories became thicker, they evolved to include more comprehensive contact information as well as additional editorial articles. The publication came to be called the AOPA Yearbook, and typically included sections such as a message from the president, AOPA membership

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THEN & NOW

After the 2010 printing, the directory moved online to www.AOPAnetonline. org/membershipdirectory. The 2017 Centennial Directory represents the first printing in seven years.

NOW

This year, AOPA has published the Who’s Who 100th Anniversary Commemorative Membership Directory as part of the association’s centennial celebration. The publication celebrates AOPA members and their contributions to the O&P profession over the years—and serves the dual purpose of promoting members to case managers: AOPA plans to make an electronic copy of Who’s Who available to case managers for referral purposes. The comprehensive 2017 directory features more than 200 pages of both historical and current content. Sections include a message from 2017 AOPA President Michael Oros, CPO, LPO, FAAOP; a long history of the association and the profession; a

technology timeline; a list of current leadership; lists of AOPA past presidents and Lifetime Achievement award recipients; a key to titles, certifications, and abbreviations; a list of PAC supporters; AOPA membership highlights; AOPA resources; AOPA bylaws; a geographical listing of AOPA members; a list of AOPA suppliers; and indices.

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The Who’s Who is designed as a useful tool for networking, so that members can share and learn from each other and provide patient referrals. Each AOPA member will receive one copy of the directory, and additional copies will be available through the AOPA bookstore, at a cost of $75 for members and $185 for nonmembers. Members—and anyone associated with the O&P profession—will want to make sure they keep copies of Who’s Who at all of their locations, and take the time to read it, revisit it, recollect memories, and keep it on the shelves for future generations to reference.

Order the 2017 Who’s Who 100th Anniversary Commemorative Membership Directory today. Visit www.AOPAnetonline.org/store or call 571/431-0876.

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

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

O&P ALMANAC | JUNE 2017

BRIDGE TO THE FUTURE: THE INTERVIEWS

Virtual Rehabilitation O&P professionals are leveraging virtual reality technologies to enhance patient rehabilitation strategies By CHRISTINE UMBRELL

Bridge to the Future: The Interviews is a monthly column for 2017. As part of AOPA’s Centennial Celebration, O&P Almanac will look to the next 100 years—by interviewing noted experts in the O&P field to learn their vision for the future of O&P. This month, we speak with Christopher A. Rábago, PT, PhD, an expert in virtual reality technology with the Extremity Trauma and Amputation Center of Excellence at the Center for the Intrepid at Brooke Army Medical Center in San Antonio, Texas.

IRTUAL REALITY (VR) IS becom-

ing more mainstream each day. As VR technologies are increasingly incorporated in gaming and leisure activities, we also are seeing expanded uses of VR in the O&P health-care environment—with more patients leveraging these technologies during rehabilitation and outcomes assessment activities. During the past several years, researchers have begun using VR to facilitate motor retraining for O&P patients to help them refine motor pathways and improve movement and function. Several institutions across the country have dedicated lab space to house these technologies for use in research and clinical care. VR

JUNE 2017 | O&P ALMANAC

The VR Evolution

There are different types of VR technologies that O&P facilities may leverage, says Christopher A. Rábago, PT, PhD, a research physical therapist for the Extremity Trauma and Amputation Center of Excellence. Rábago works with a ComputerAssisted Rehabilitation Environment (CAREN) system at the Military Performance Laboratory at the Center for the Intrepid (CFI) at Brooke Army Medical Center in San Antonio, Texas. “There are large-scaled VR environments such as the CAREN, which have been used over the past 10 years

PHOTO: Lester Rosebrock, Creative Media Services

Christopher A. Rábago, PT, PhD

technologies create conditions where O&P patients can walk and maneuver in simulated environments, with the goal of improving gait. Many of these spaces are housed in military O&P facilities. But smaller—and less expensive—VR-based technologies also are being developed and used in clinical settings. Understanding how the technology is evolving and how it may be used to enhance patients’ rehabilitation experiences is important for clinicians who seek to use all of the tools at their disposal to help patients achieve optimal outcomes

BRIDGE TO THE FUTURE: THE INTERVIEWS

Christopher A. Rábago, PT, PhD, works with a team of scientists and physical therapists performing amputee, prosthetic, and limb injury clinical research in the Military Performance Laboratory at the Center for the Intrepid.

PHOTO: Lester Rosebrock, Creative Media Services

in Department of Defense military treatment facilities,” with examples including Brooke Army Medical Center, Walter Reed National Military Medical Center, and National Intrepid Center of Excellence, as well as in the research centers at Navy Health Research Center and MIT Lincoln Labs, says Rábago. “New mobile devices, tablets, head-mounted displays, and console gaming systems also have been incorporated into the virtual rehabilitation landscape.” The latter group of devices originated in the entertainment and gaming industry and were “not originally meant for use in health care,” explains Rábago. Yet advances in VR technologies are mostly driven by these entertainment industries, he says. In addition to the distinct types of hardware that support VR environments, the various systems are supported by a spectrum of applications and software. Applications can be designed for three purposes, says Rábago: simulating environments, providing real-time or summative feedback, and/or allowing for game play. “When gaming systems and their associated applications have a purpose

beyond entertainment, we call them ‘Serious Games.’ Some examples of Serious Games are virtual trainers or coaches that track task performance and allow users to practice certain tasks—for example, exercise games,” he says. There has been a long history of repurposing gaming technology, such as Wii, Kinect, and PlayStation systems, but “many Serious Games also have emerged in the marketplace and are undergoing trials at our facilities,” reveals Rábago.

VR and O&P

Systems such as the CAREN and the Gait Real-Time Analysis Interactive Lab (GRAIL)—which are both manufactured by Amsterdam-based Motekforce Link—engage multiple senses through the use of visual, audio, and ground movement. The CAREN at CFI features a 270-degree VR environment as well as 30 motion-capture cameras, which can track the movements of a wounded warrior while he or she interacts with elements in realistic and challenging scenarios created by a CAREN operator. Rábago and his colleagues can assess a service member’s biomechanics for adaptation

to a prosthesis and record information for comparison over time, among other evaluations. “The keys for us are the dynamic movements that patients can perform in the large-scale VR environments,” explains Rábago. “In general, we assess patients as they perform various tasks, such as walking while being perturbed to look at their stability. We also have patients perform a simulated patrol task complete with full gear and hostile engagements to determine if there are deficits associated with occupational duties. At times, we are assessing the patient, but the tasks performed in the VR environments can also help us assess the function of the orthotic or prosthetic devices used by the patient.” In addition to utilizing the CAREN system, Rábago also leverages VR-based Serious Games to assess and treat patients. He has used Serious Games to extend treatments beyond the clinic into patients’ homes as “telerehab.” CFI established partnerships with Blue Marble Health and Blitz Games studio in developing a prototype game called “Vitalize,” which delivers a home exercise program to patients with extremity injuries. “Great efforts were made to make the game accessible to patients who use prosthetic and orthotic devices and wheelchairs, and those with limb loss using no devices,” states Rábago. “This effort led to a current project with Levi Hargrove, PhD, of the Shirley Ryan AbilityLab, and Asim Smailagic, PhD, of the College of Engineering, Carnegie Mellon University, to develop a ‘Virtual Coach’ to aid in preprosthetic training for users of myoelectric prostheses."

The Value of VR

Rábago sees a number of benefits of leveraging VR technologies with the O&P patient population. First and foremost, “the simulation of real-world tasks is essential to rehabilitation as patients’ goals are often activity- and participation-centric,” he says. “VR environments allow for task simulation with realistic feedback” and support creation of optimal control schemes O&P ALMANAC | JUNE 2017

BRIDGE TO THE FUTURE: THE INTERVIEWS

for prosthetic devices to be determined during task simulation. In addition, “candidates for certain devices can be assessed using task simulation in VR environments,” says Rábago. Of course, the entertainment factors of many VR applications “can motivate users to comply with therapy programs and expand access to care via tele-rehab.” Some innovators are taking VR technologies even further, says Rábago. Researchers at Sheffield Hallam University in the United Kingdom have gone so far as to create “virtual prosthetic arms based on real devices that can be visualized and operated in a VR environment,” he says. “This allows user to virtually try out an arm, which can decrease costs and help clinicians and patients choose appropriate devices.” Because VR technology is currently being leveraged at a limited number of facilities, there are many O&P patients who are not yet benefiting from it. But the research being conducted at CFI and other military facilities will be advantageous to the entire O&P patient base. “Military and civilian populations in general have similar ‘return to’ goals, like returning to

community activities, returning to independent home mobility, returning to sport, and returning to occupational duties,” Rábago explains. As virtual rehabilitation techniques and protocols are developed and validated in the military, “the outcomes from this research are published and shared with the civilian sector,” he says. And if the research is conducted in collaboration with academic or industry partners, commercial products can show up on the open market, he adds.

Anticipating the Future

During the past few years, VR technology “has become more accessible to patients via handheld mobile devices and lower-cost, entertainment-based systems. Likewise, the public has continued to embrace the use of technology and their applications, thus making the use of virtual rehabilitation devices and applications more natural,” says Rábago. However, there are still limits to the use of some of the technology. “As more custom virtual rehabilitation devices and applications come to market, hopefully individuals with disabilities will find them more user-friendly.”

JUNE 2017 | O&P ALMANAC

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

PHOTO: Motekforce Link

Real-time gait analysis using the 3-D motion capture system and the instrumented dual-belt treadmill of the GRAIL system aids in prosthetic and orthotic fitting.

Rábago predicts that increasingly accessible VR technologies will enable more O&P patients without access to large VR systems to engage in telerehab. This could lead to improved rehabilitation experiences, as patients perform structured and monitored rehabilitation at home, and may allow patients to attempt tasks in simulated environments and with simulated devices “to focus and personalize the plan of care,” says Rábago. It also may facilitate socialization with peer groups “as people virtually rehab online or in a multiplayer setting.” With more U.S. clinicians and patients turning to VR to aid in rehabilitation efforts, Rábago warns that usability testing should take place to ensure the technology is not burdensome to either party. It also will be important that researchers and clinicians share their experiences and publish guides regarding how to use these VR technologies with different patient populations—whether using custom applications or off-the-shelf games, he says. As more data is collected via VR systems, there will be a “potentially accelerated time to select adaptive devices, speed up independence with devices, and demonstrate efficacy of techniques collectively supporting reimbursements,” says Rábago. Rábago cautions clinicians to become educated on any VR systems they choose to use with patients. “There are already several VR/Serious Game systems for use in health care. More will enter the market, with very little evidence to their efficacy or usability,” he says. “Clinicians and patients will need to be educated consumers, as with other aspects of their health care.” O&P professionals who explore and embrace VR technologies to enhance patient care may find their patients enjoy this additional rehab tool—and have a better overall feeling about their O&P patient-care experience.

Contact our team for your personal consultation.

877-811-6344

Function With Purpose.

THE GLOBAL PROFESSIONAL

Aaron Kam Lun Leung, CPO (HK), PhD Hong Kong SAR, China O&P instruction and research at The Hong Kong Polytechnic University

O&P ALMANAC: Please tell us a little

about your university, your position and responsibilities there, and the orthotics and prosthetics program at your institution.

AARON KAM LUN LEUNG, CPO (HK), PhD: The Hong Kong Polytechnic

As the O&P profession prepares for the Second O&P World Congress, to be held in conjunction with AOPA’s 100th anniversary celebration September 6-9, in Las Vegas, the O&P Almanac is featuring a question-and-answer section with international O&P experts. Each month, we spotlight an O&P professional from a different part of the world to find out how O&P is practiced across the globe.

China

JUNE 2017 | O&P ALMANAC

University, which was formerly The Hong Kong Polytechnic, was established in 1994. The university is composed of five faculties and two schools. I work in the Interdisciplinary Division of Biomedical Engineering, which is within the faculty of engineering. The Division offers a four-year BSc (Hons) degree program in biomedical engineering, which has three special concentrations: prosthetics and orthotics, clinical engineering, and medical imaging and sensors. The biomedical engineering program has a yearly intake of about 30 students. About one third of the students select the prosthetics and orthotics concentration during their third year of study The program has been accredited by the Hong Kong Institution of Engineers. The prosthetics and orthotics concentration has received additional recognition from the Hong Kong Society of Certified Prosthetist-Orthotists and the International Society for Prosthetics and Orthotics as a Category I P&O education program. Graduates of the P&O concentration are prepared to

work in clinical P&O positions or other biomedical engineering positions. I was responsible for planning and implementing the undergraduate (1995) and master’s (2011) programs in prosthetics and orthotics at the university. I am currently an associate professor of the Division and am responsible for teaching the undergraduate lower-limb prosthetics and orthotics subjects, as well as coordinating the clinical attachments in the summer semester for Year 3 and Year 4 students. I also contribute to the teaching of postgraduate courses and supervise master’s and PhD theses. O&P ALMANAC: Can you explain the

types of O&P research that you are involved in? What are you studying, and what are your expectations for future research projects?

LEUNG: My research interests include lower-limb biomechanics, human movement analysis, foot orthotics for various pathological conditions, ankle-foot orthotics for cerebral palsy and stroke rehabilitation, mobility of patients with spinal cord injury, prosthetics alignment and socket design, application of smart fiber, and obesity. O&P ALMANAC: How are new

orthotists and prosthetists being educated in your country? What are some of the new techniques or processes they are studying?

THE GLOBAL PROFESSIONAL

Hong Kong LEUNG: As mentioned above, ortho-

tists and prosthetists are educated through the P&O concentration of the BSc (Hons) degree program in biomedical engineering. Graduates of the program are required to complete a one-year, full-time clinical training under the supervision of a CPO before he or she can be fully qualified as a CPO. The university and the professional associations organize courses, seminars, conferences, workshops, and more to facilitate the graduatesâ&#x20AC;&#x2122; learning. The professional society has held world and regional congresses and also encourages members to attend international conferences. Traveling awards and scholarships are provided. There are frequent events on the introduction of new approaches and techniques. O&P ALMANAC: If there are any cirPHOTO: Getty Images/Nikada

cumstances where you see patients, please explain those circumstances, and describe how you provide O&P solutions for those patients. LEUNG: I offer clinical orthotic and prosthetic services to patients who require special attention and give

advice to junior colleagues through the Rehabilitation Engineering Clinic of the Division. I also serve as an expert witness to assess patients and recommend prosthetic and orthotic requirements. O&P ALMANAC: Can you share any

information about reimbursement for O&P services in your country? How are the devices you provide paid for?

LEUNG: More than 90 percent of prosthetic and orthotic services in Hong Kong are provided by the public sector through our Hospital Authority. The service has been heavily subsidized by the government. The patients are only required to pay part of the material cost. Thus, mainly standard or basic systems are offered by the Hospital Authority. Because the public health-care system in Hong Kong is heavily subsidized by the government, health-care insurance is not popular. If patients require more advanced models, most of them have to cover the costs by themselves or receive the service in the private sector.

O&P ALMANAC: Describe your own

educational background and any certifications you have. How do you keep your skills sharp?

LEUNG: I received my professional education and training in prosthetics and orthotics in Hong Kong. I am a CPO of the Hong Kong Society of Certified Prosthetist-Orthotists, an organization of which I was the founding president in 1991. I keep my skills sharp through patient contact, attending training workshops and other professional activities, and sharing with P&O colleagues. O&P ALMANAC: Whatâ&#x20AC;&#x2122;s the biggest

challenge you face in your position, and how do you deal with it?

LEUNG: As an O&P academic, my daily work includes teaching O&P theory and practice, conducting research, engaging in patient contact, and participating in academic administration as well as professional and community services. It is very challenging to be a good O&P teacher, researcher, and professional at the same time. O&P ALMANAC | JUNE 2017

MEMBER SPOTLIGHT

Protosthetics

By DEBORAH CONN

New Dimensions Entrepreneurs build contract manufacturing and 3-D printing central fab facility

Protosthetics’ Amphibian leg

FTER LAUNCHING PROTOSTHETICS in January

2016, founders Josh Teigen and Cooper Bierscheid celebrated their new company by making a 3-D printed myoelectric upperextremity prosthesis for a fouryear-old. They soon discovered that a larger market beckoned for lower-extremity devices, and the company pivoted to become a 3-D printing central fabrication supplier for O&P facilities.

Cooper Bierscheid

Josh Teigen

JUNE 2017 | O&P ALMANAC

COMPANY: Protosthetics OWNER: Josh Teigen and Cooper Bierscheid LOCATION: Fargo, North Dakota HISTORY: One year

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

PHOTOS: Protosthetics

Teigen and Bierscheid were new to the industry, so they sought input from orthotic and prosthetic clinicians and combined it with their backgrounds in business, engineering, and medical devices. Teigen is a serial entrepreneur: Protosthetics is his fifth venture. The company’s 3-D printing system is compatible with any 3-D scanner or software platform, says Teigen. He and Bierscheid were dissatisfied with their off-the-shelf printers, so they began to design and build all of their own equipment. “Our printers can print products up to four feet high,” says Teigen. “We can print in 30 different materials, including urethane, nylons, carbon fiber, and Kevlar, and in multiple materials simultaneously. Our print times and strength are best-in-class in the market, and we can print both check and definitive sockets.” Teigen says the company

faced some skepticism about its ability to 3-D print definitive sockets. “But we are so confident in our products that we are having them tested overseas to do one million walking cycles. We’ll have the results shortly,” he said. In addition to central fab, Protosthetics creates its own products, including the Amphibian leg, a durable, all-purpose water leg. “When we met with practitioners, their number one request from patients was a water or shower leg. We set out to build one, keeping in mind that the patient would likely have to pay out of pocket,” says Teigen. The result was a prosthesis that incorporates a definitive socket and an energy-return foot made from Dupont Engineering polymers. “The design allows for a smooth roll-over gait and heel impact dampening, which replicates a natural walking motion,” Teigen says. Cosmetic covers are available for the device, but if patients choose not to use one, the company can 3-D print a custom

overmold of the foot, place the foot in the mold, and cast urethane around the foot to create a nonslip surface and to fill in any cavities that might collect dirt. The socket also features an optional integrated custom gel liner that eliminates the need to unroll and reroll a liner. “We also incorporated the Boa system on the socket, so patients can easily take the leg on and off and adjust the fit,” Teigen says. The prosthesis is designed for use at the beach, in the shower, or “anywhere you don’t want your primary leg to get wet or dirty,” he says. “Our first Amphibian leg went to a snowmobiler.” Protosthetics recently moved into a new facility, increasing its square footage. “We finally have room for a ping-pong table and foosball,” jokes Teigen. The company has nine employees and hires contract workers as needed. While most marketing efforts have focused on word of mouth, the company is planning to launch several ad campaigns this summer, including videos and case studies presented on the company’s website and such social media sites as Facebook, YouTube, and LinkedIn. “We want to show the start-up, high-tech, cool 3-D printing side of the business,” says Teigen. Looking ahead, Teigen and Bierscheid plan to continue to increase their contract manufacturing and central fab services. “We want to scale up to offer a full suite of product lines,” says Teigen. “And since we design and build our own machines, we’ve thought about franchising the equipment to clinics, moving from central fab to a franchise model. Whatever happens, we want to continually be positioned as a thought leader in the industry.”

Already working for an O&P practice and want to take your career to the next level? Become certiďŹ ed as an ABC Orthotic and/or Prosthetic Assistant and get the recognition you deserve for your knowledge, training and experience.

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MEMBER SPOTLIGHT

Winkley Orthotics & Prosthetics

Landmark Care Fifth generation continues a family tradition at 129-year-old facility

HE HISTORY OF WINKLEY

Orthotics & Prosthetics added a new chapter in January when the fifth generation of family members took ownership. Alexander Gruman, CO, and his sister, Amalia Gruman Laird, CP, purchased the business from their father, Gregory S. Gruman, CP, who had served as president since 1983. Original Winkley facility

Alexander Gruman, CO, and Amalia Gruman Laird, CP

JUNE 2017 | O&P ALMANAC

OWNERS: Alexander Gruman, CO, and Amalia Gruman Laird, CP LOCATION: Headquarters in Golden Valley, Minnesota, with seven satellite offices in Minnesota and Wisconsin HISTORY: 129 years

Alex Gruman and Amalia Gruman Laird expect their technological contribution to involve an increasing use of advanced materials and processes in the clinical area. Winkley O&P uses CAD/CAM to design and fabricate devices and has recently adopted 3-D scanning and purchased a seven-axis robotic carver. “Using these tools will help us be able to do more, faster,” says Gruman. Like their father, Gruman and Laird became familiar with the family business at an early age. “We used to do odd jobs here as children,” says Laird. She and her brother both graduated from Century College in White Bear Lake, Minnesota, and joined the firm soon after. Headquartered in the Minneapolis suburb of Golden Valley, Winkley O&P has offices in Minneapolis, Coon Rapids, St. Paul, and Redwing, Minnesota, as well as Eau Claire and Rice Lake, Wisconsin. The Golden Valley facility handles the major share of custom fabrication for all of the Minnesota offices, while the Eau Claire site’s fabrication lab serves Rice Lake as well.

The company has about 60 employees, including 28 clinicians. Both Gruman and Laird plan to continue some clinical work as they shift into managerial positions. “Our general manager, Terry Woodman, CO, is retiring in a couple of years, and we are slowly taking over his responsibilities,” says Gruman. “But we still want some clinical interaction. It keeps us in tune with what’s going on, and we both enjoy it. No one wants to sit at a desk all day.” Winkley offers a full line of O&P services for adults and children, including upper- and lower-extremity devices. Laird estimates that orthotics accounts for about two thirds of the company’s business. “We have a sizable diabetic population in the area,” says Gruman, “and we see a large number of stroke and trauma patients as well.” Winkley has such a longstanding reputation that the company has never needed a dedicated marketing director. Gruman has begun to manage the company’s website and social media presence, including accounts on Facebook, Instagram, Twitter, Google, and Yelp. For many family businesses, transferring ownership can be fraught with complications. “It helps to have a good succession plan and good management team in place,” advises Gruman. “We definitely had that here, and the transition has been seamless.” The company’s longevity—it is the oldest privately owned O&P facility in the nation—also has something to do with its mission. “We provide the best quality patient care and products that we can,” says Gruman. “We always try to put the patient first. That’s why we have lasted as long as we have.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: Winkley Orthotics & Prosthetics

Winkley O&P was founded in 1888 by Albert Winkley, an amputee who invented the adjustable double-slip socket in 1888, and his partner, Lowell Jepson, who brought marketing expertise to the fledgling business. Winkley returned to horse farming after a few years, and Jepson—Alex and Amalia’s great-great-grandfather—ran the business with his brother from 1892 until 1938. The Winkley brand was well known by then, so the Grumans decided not to change the name of the company. As time passed, successive generations of Grumans took control: Del (A.P.), from 1938 to 1962; Robert, from 1962 to 1983; and Gregory, from 1983 to 2017. “My dad always said that each generation instituted some technological change in the company,” says Alex Gruman. “A.P. introduced carbon paper, Robert brought in dictation machines and photocopiers, and Dad introduced computers to the workplace.”

FACILITY: Winkley Orthotics & Prosthetics

Albert Winkley

By DEBORAH CONN

amp Seanâ&#x20AC;&#x2122;s an example of a successful fight for access to prosthetic care. To help create more stories like his, visit amplifyyourself.org for ways to write insurance executives and legislators, and to speak out on behalf of people living with limb loss and limb difference. The Amplify initiative is turning up the volume to make sure everyone has access to the care that they need.

Sean told his insurance company that no was not answer. Read his story at amplifyyourself.org and share yours today.

AOPA NEWS

JUNE 14

JULY 12

Internal Audits: The Why and the How of Conducting Self-Audits The best way to prevent external audits is by conducting self-audits. Increase your chances for a favorable reimbursement climate at your facility by taking part in the June 14 webinar, where experts will address the following topics: • How do you create an in-house audit/self-audit? • Where do you start when building a self-audit? • How often should you conduct self-audits? • What can self-audits tell you about your business?

AOPA members pay $99 (nonmembers pay $199), and any number of employees may participate on a given line. Attendees earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring at least 80 percent. Register at bit.ly/2017webinars. Contact Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0876 with questions. Register for the whole series and get two free webinars! The series costs $990 for members and $1,990 for nonmembers. All webinars that you missed will be sent as a recording. Register at bit.ly/2017billing.

JUNE 2017 | O&P ALMANAC

Know Your Resources: Where To Look To Find the Answers There is a vast array of O&P-related information available via manuals and on various websites, but it’s hard to know where exactly to go for answers to your questions. Find out how to narrow your search and locate the most relevant information by participating in the July 12 AOPA webinar. Experts will address the following topics: • Navigating the CMS website; • Understanding the website for Pricing, Data Analysis, and Coding; • Finding information on the websites of the durable medical equipment Medicare administrative contractors; • Understanding which Medicare manuals apply to O&P; and • Knowing where to go to find out about appeals. AOPA members pay $99 (nonmembers pay $199), and any number of employees may participate on a given line. Attendees earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring at least 80 percent. Register at bit.ly/2017webinars. Contact Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0876 with questions. Register for the whole series and get two free webinars! The series costs $990 for members and $1,990 for nonmembers. All webinars that you missed will be sent as a recording. Register at bit.ly/2017billing.

NEW!

Co-OP

An AOPA Member Benefit As an online reimbursement, coding, and policy resource, this site includes a collection of detailed information with links to supporting documentation for the topics most important to AOPA Members. Like a Wikipedia of all things O&P, the Co-OP incorporates a crowdsourcing component, which is vetted by AOPA staff, to garner the vast knowledge and experience of our membership body.

Resources include: • State-specific insurance policy updates, • L code search capability, • Data and evidence resources, and so much more!

Learn more and sign up at

www.AOPAnet.org/co-op. www.AOPAnet.org

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 publication, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership. At the end of each new facility listing is the name of the certified or state-licensed practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or state-licensed practitioner to be eligible for membership. At the end of each new supplier member listing is the supplier level associated with that company. Supplier levels are based on annual gross sales volume.

Epica Applied Technologies 2753 Camino Capistrano, Ste. A101 San Clemente, CA 92672 949/238-6323 Member Type: Supplier Level 1 Jerry Sherlock Home Care Orthotics Inc. 917 Dolly Parton Parkway Sevierville, TN 37862 865/774-9959 Member Type: Company Thomas Bonneville

International Orthotic Labs 6777 Fairmount Drive SE Calgary, AB T2H 0X6 Canada 403/236-8540 Member Type: International Jeff Ayotte Landis International 800 Rossiter Street St. Jean, QC J3B 8J1 Canada 450/359-8800 Member Type: Affiliate Prosthetics Laboratories Inc. Miami, FL

ADVERTISERS INDEX

Company

Page Phone

Website

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

703/836-7114

www.abcop.org

ALPS South LLC

800/574-5426

www.easyliner.com

Amfit

21 800/356-3668

Amputee Coalition

888/267-5669

www.amputee-coalition.org

Anatomical Concepts

800/837-3888, 330/757-3569

www.anatomicalconceptsinc.com

Cascade Dafo Inc.

800/848-7332

www.cascadedafo.com

Coapt LLC

844/262-7800

www.coaptengineering.com

College Park Industries

800/728-7950

www.college-park.com

ComfortFit Orthotic Labs Inc.

888/523-1600

www.comfortfitlabs.com

Custom Composite

866/273-2230

www.cc-mfg.com

Ferrier Coupler Inc.

810/688-4292

www.ferrier.coupler.com

Fillauer Companies Inc.

800/251-6398

www.fillauer.com

Hersco

1 800/301-8275

www.hersco.com

LIM Innovations

www.amfit.com

844-888-8LIM

www.liminnovations.com

Motion Control, a Fillauer Company

801/326-3434

www.UtahArm.com

Orthomerica

19 800/446-6770

www.orthomerica.com

Ottobock

C4 800/328-4058

www.professionals.ottobockus.com

Spinal Technology Inc.

800/253-7868

www.spinaltech.com

Touch Bionics

855/694-5462

www.touchbionics.com

JUNE 2017 | O&P ALMANAC

Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac17 for advertising options.

ALPS Anterior Posterior Tapered Liner ALPS’ new AP Tapered Liner is gradually tapered from the anterior to the posterior to provide superior comfort. This liner is available in a pin-andlocks system or suction suspension. The AP Tapered Liner features our black high-performance fabric with gel to assist in reducing bunching in the popliteal region. For more information, contact ALPS at 800/574-5426 or visit www.easyliner.com. ALPS is located at 2895 42nd Avenue N., St. Petersburg, FL 33714.

Custom Stealth Foot Orthotics Custom carbon-fiber foot orthotics—and boy, are they pretty. And strong. And lightweight. Trusted to protect the feet of our service members, this beauty goes more than skin deep. Fabrication available from foam boxes or Amfit digital files in two rigidities (firm or flex). Corrections and adjustments are molded into the carbon fiber to eliminate movement of pads and edges during wear. EVA heel counter maintains stability in the shoe or boot. Contact our customer service team to learn more today, orders@amfit.com or 800/356-FOOT(3668), x250.

Foam Box Lab Services for Diabetic, EVA, and Rigid Orthotics FootPrinter allows you to send your own boxes or use ours. Standard EVA orders manufactured in three to four business days; diabetic A5513, carbon fiber, and polypro in three to five days. PDAC-approved A5513 diabetic pricing includes shipping costs for bi-lam and tri-lam styles. EVA available in soft, medium, dual, firm, and cork blend. Carbon-fiber fabrication offered in flex or firm to best suit your patient. Milled polypropylene available in three widths and thicknesses for excellent fit and wear. Get started right away by emailing orders@amfit.com for an account form, or call 800/356-FOOT.

MARKETPLACE

Anatomical Concepts Inc. Elbow Orthoses We present a cost-effective, low-profile, quick and easy fit design with our elbow orthosis line that simplifies the fitting process and increases comfort for the patient while providing the necessary control and/or stability addressing various upperextremity and specific elbow etiologies. The elbow orthosis product line consists of the EMO™, QUAD™, and E-ROM™. The EMO provides immobilization for musculoskeletal injuries in a static, progressive positioning environment. The QUAD and E-ROM are joint systems that also provide immobilization for musculoskeletal injuries, and feature a ratchet-style positioning ability or variable range of motion technique. Suggested L 3760. For more information, contact Anatomical Concepts Inc. at 800/837-3888 or visit www.anatomicalconceptsinc.com.

Advanced Myoelectric Control The Complete Control system from Coapt is a powerful add-on enhancement to powered prosthetic arms. The controller provides more intuitive, natural control for prosthesis users and is specifically designed to work with commercially available prosthetic elbows, wrists, and terminal devices. Coapt’s advanced FDA-cleared pattern recognition technology works by using greater information from users' muscle signals and dramatically improves the function and adoption of the prosthesis. Other benefits include the elimination of mode switching, quick and easy recalibration, and better proportional control. For more information call 844/262-7800 or visit www.coaptengineering.com.

O&P ALMANAC | JUNE 2017

MARKETPLACE New Locking Shoulder Joint From College Park Formerly the LTI Locking Shoulder Joint, the new AXIS® has been re-engineered by College Park. With a patented friction hinge, the shoulder joint is operated with simple switches that simplify harnessing by eliminating the need for gross body movements. The AXIS is able to be integrated with all upper-limb control systems with a special channel to conceal and protect power cables. Unlike any product on the market, the AXIS provides better task control, a natural range of motion, and ease of use for the patient’s daily life. Learn more at www.college-park.com/axis-shoulder-joint.

NEXO™ by Fillauer® It’s not exo. It’s not endo. It’s NEXO—a simple, new alternative in upper-extremity socket technology. Featuring an adjustable socket adapter ring, PEEK rods, and a USMCstyle quick disconnect wrist, the NEXO is an easy-to-build upper-extremity socket system that is 50 percent lighter than existing sockets, allows quick access for pull-in socket designs, transfers the force proximal to the cut bone end, and reduces rotational and perpendicular vibration to the residual limb. Contact Fillauer to learn more today! For more information, contact Fillauer at 423/624-0946 or visit www.fillauer.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, call 800/301-8275 or visit www.hersco.com.

JUNE 2017 | O&P ALMANAC

Motion E2 Elbow From Motion Control

Motion Control, a Fillauer Company, is now distributing the former Hosmer E2 Electric Elbow. Renamed the Motion E2 Elbow, it is available in four colors and two sizes (large and medium). The Motion E2 Elbow is a lightweight electric elbow that can be used with simple switch control, or proportional myoelectric control. It is small enough to be used by adolescents or smaller adults. Forearms can either be prefabricated or custom fabricated from Fillauer Central Fabrication. For more information, contact Motion Control at 801/326-3434 or info@UtahArm.com.

New Greifer From Ottobock The powerhouse Greifer is now available in black. Adding to its already exceptional design and high-quality engineering is a new feature: an LED flashlight. Helping to spotlight work areas, it makes this terminal device an even more incredible and useful tool for users. Award-winning design: Greifer earned the prestigious “Red Dot: best of the best award” for the exceptional new design. Functional, stylish combinations: For a modern rugged look, the update also pairs well with the black Dynamic Arm or can be a sophisticated secondary device for bebionic users. Power and versatility: Greifer features a proportional gripping force of 0 to 160 N, and different gripping tips (wide, narrow, or rubber coated) allow adaptation for special tasks. Call your local sales rep at 800/328 4058 or go to professionals.ottobockus.com.

MARKETPLACE 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.

2017 AOPA Coding Products Get your facility up to speed, fast, on all of the O&P Health-Care Common Procedure Coding System (HCPCS) code changes with an array of 2017 AOPA coding products. Ensure each member of your staff has a 2017 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors. • Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers • CodingPro CD-ROM (single-user version): $185 AOPA members, $425 nonmembers • CodingPro CD-ROM (network version): $435 AOPA members, $695 nonmembers • Illustrated Guide: $185 AOPA members, $425 nonmembers • Quick Coder: $30 AOPA members, $80 nonmembers

design. dexterity. intelligent motion.

Order at www.AOPAnet.org or by calling AOPA at 571/431-0876.

AOPA Compliance Guide CD—Updated

• Smarter: Uses simple gestures to change grips. • Faster: Boost digit speed by up to 30 percent. • Smaller: New form-fitting anatomical design reduces profile in every dimension. For more information, contact Touch Bionics Inc. at (855)MY iLimb or visit www.touchbionics.com.

This Compliance Handbook helps patient care facilities follow the fraud and abuse prevention guidelines recommended by the Office of the Inspector General (OIG). This product will assist you in developing a compliance plan for your facility, including guidelines for developing a standard of conduct, billing policies and procedures and much more. With the help of the AOPA Compliance Handbook CD, you will be able to create an effective audit/quality assurance program to monitor compliance and conduct introductory training sessions for employees. • AOPA Compliance Guide CD—Updated: $159 AOPA members, $318 nonmembers Order at www.AOPAnet.org or by calling AOPA at 571/431-0876.

O&P ALMANAC | JUNE 2017

CALENDAR

2017

July 1

June 8-9

Michigan Orthotics & Prosthetics Association Continuing Education Seminar. DoubleTree by Hilton Hotel Bay Cityâ&#x20AC;&#x201D;Riverfront. Exhibitor and Sponsorship Opportunities Available! Attendees earn CE credits! For more information and registration, please contact Amy Shea at MichiganOPA@gmail.com or 810/733-3375.

June 14

Internal Audits: The Why and the How of Conducting Self-Audits. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Webinar Conference

PrimeFare East Regional Scientific Symposium 2017. Renaissance Hotel & Convention Center, Nashville. Contact Jane Edwards at 888/388-5243 or visit www.primecareop.com.

July 1

ABC: Application Deadline for September Certification Exams. Applications must be received by July 1 for individuals seeking to take the September ABC certification exams for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and orthotic and prosthetic technicians. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

ABC: Written and Written Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and technicians in 250 locations nationwide. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

July 12

Know Your Resources: Where To Look To Find the Answers. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

July 17-18

2017 Mastering Medicare: Essential Coding & Billing Techniques Seminars. Pittsburgh. The DoubleTree by Hilton Hotel and Suites Pittsburgh Downtown, One Bigelow Square, Pittsburgh. Register online at bit.ly/2017billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Coding & Billing Seminar

Apply Anytime!

Apply anytime for COF, CMF, CDME; test when ready; receive results instantly. Current BOCO, BOCP, BOCPD candidates have three years from application date to pass their exam(s). To learn more about our nationally recognized, in-demand credentials, or to apply now, visit www.bocusa.org.

Calendar Rates Let us

your next event!

July 10-15

Webinar Conference

June 16-17

www.bocusa.org

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

JUNE 2017 | O&P ALMANAC

Free Online Training

Cascade Dafo Institute. Now offering a series of seven free ABC-approved online courses, designed for pediatric practitioners. Earn up to 10.25 CEUs. Visit cascadedafo.com or call 800/848-7332.

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

CREDITS

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

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CALENDAR November 6-7

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

August 1

ABC: Application Deadline for ABC/OPERF Resident Travel Award. Four residents will be selected to present their Directed Study Research project at the 2017 Academy Annual Meeting and receive $2,500 plus complimentary meeting registration. For more info or to apply, go to operf.org.

August 4-5

The Texas Chapter of the American Academy of Orthotists and Prosthetists 2017 Annual Meeting. Westin Galleria, Dallas. For information and registration, visit www.txaaop.org.

August 9

What the Medicare Audit Data Tells Webinar Conference Us and How To Avoid Common Errors. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

September 6-9

100th AOPA National Assembly and Second World Congress. Las Vegas. Mandalay Bay. For exhibitors and sponsorship opportunities, contact Kelly O’Neill at 571/431-0852 or koneill@AOPAnet.org. For general inquiries, contact Betty Leppin at 571/431-0876, or bleppin@AOPAnet.org, or visit www.AOPAnet.org.

September 13

ABC Inspections and Accreditation. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Webinar Conference

October 11

AFO/KAFO Policy. Register online at Webinar Conference bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

October 26-27

International African-American Prosthetic Orthotic Coalition Annual Meeting. Atlanta Marriott Suites Midtown, 35 14th Street NE, Atlanta, GA 30309. For more info, visit www.iaapoc.org or contact Tony Thaxton Jr. at thaxton.jr@comcast.net or 404/875-0066.

November 5-11

Health-Care Compliance & Ethics Week 2017. AOPA will be celebrating Health-Care Compliance & Ethics Week and will be providing resources to help members celebrate.

2017 Mastering Medicare: Essential Coding & Billing Techniques Seminars. Phoenix. Sheraton Grand Phoenix, 340 N. 3rd Street, Phoenix. Book by October 13 for the $179 rate by calling 800/325-3535 or by calling the hotel directly at 602/262-2500. Register online at bit.ly/2017billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Coding & Billing Seminar

November 8

Gift Giving: Show Your Thanks and Webinar Conference Remain Compliant. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

December 13

New Codes and Other Updates for 2018. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Webinar Conference

2018 September 26-29

AOPA National Assembly. Vancouver, Convention Center. For general inquiries, contact Betty Leppin at 571/431-0876, or bleppin@AOPAnet.org, or visit www.AOPAnet.org.

2019 September 25-28

AOPA National Assembly. San Diego, Convention Center. For general inquiries, contact Betty Leppin at 571/431-0876, or bleppin@AOPAnet.org, or visit www.AOPAnet.org.

2020 September 9-12

AOPA National Assembly. Las Vegas, Mandalay Bay. For general inquiries, contact Betty Leppin at 571/4310876, or bleppin@AOPAnet.org, or visit www.AOPAnet.org. SUBSCRIBE

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

O&P ALMANAC | JUNE 2017

ASK AOPA CALENDAR

Coding Concerns Answers to your questions regarding diabetic shoes, 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, we’ll share several of these questions and answers from AOPA’s expert staff with readers. If you would like to submit a question to AOPA for possible inclusion in the department, email Editor Josephine Rossi at jrossi@contentcommunicators.com.

Will Medicare pay for a pair of diabetic shoes if the patient has a below-knee or above-knee amputation on one side?

Yes. The “therapeutic shoes for persons with diabetes” benefit is for a pair of shoes, not for each individual shoe. However, unless you can demonstrate a medical necessity, it would be unlikely that Medicare would cover a custom shoe on the amputated side, or inserts on the amputated side, as there would not be a need or benefit for these services.

JUNE 2017 | O&P ALMANAC

May we provide both an L5000 and a custom insert (A5513) or prefabricated insert (A5512) for the same patient, and for the same foot?

No. You may provide either the L5000 or the A5513 or A5512, but you may not provide both a toe filler and an insert. According to the durable medical equipment Medicare administrative contractors (DME MACs), the L5000 includes a rigid longitudinal arch support (designed to provide standing balance and toe-off support for the patient to improve his or her gait), and includes the addition of materials to fill the void of the missing digits, as well as the addition of softer materials in areas where the residual limb makes contact with the insert. The diabetic shoe inserts (A5512 and A5513) are designed with multiple layers of materials varying in density to provide a protective function for the foot as part of the diabetes management plan. So, if the patient does not need the extra rigidity and support provided by the L5000 because he or she is only missing toes, excluding the big toe (hallux), you should bill with the A5513. The customization of the A5513 would include the addition of materials to replace the missing toes. However, if the patient requires extra rigidity and support because he or she is missing the hallux or forefoot, you should bill with the L5000. The L5000 includes the addition of materials to create the protective function as part of the patient’s diabetes plan, and the materials to replace the missing toes and/or foot.

Can the L7499 code be used to describe the inclusion of features such as skin, veins, or hair on an upper-extremity terminal device?

No. The DME MACs and the Pricing, Data Analysis, and Coding contractor have stated that these cosmetic features are included in the codes for custom-fabricated gloves, like the L6895. These features cannot be separately billed using the not-otherwiseclassified code L7499.

When would I use the GL modifier?

The GL modifier is used when you are providing an upgraded item to a Medicare beneficiary but you are choosing not to bill Medicare or the patient for the upgrade. When using the GL modifier, your claim must include only the charge and the code for the non-upgraded item, along with the GL modifier. In the narrative field of your claim, you must provide a description of the item actually provided to the patient, the upgraded item, and why the item is an upgrade.

AOPA Celebrates

Healthcare Compliance & Ethics Week November 5-11, 2017

Why Should you Participate? • Demonstrate your company’s commitment to ethical business practices. • Create awareness of the Code of Conduct, relevant laws, and regulations. • Provide your staff with recognition for training completion, compliance, and ethics successes. • Reinforcement—of the culture of compliance for which your organization strives.

AOPA has developed tools and resources to assist you. Learn more about our products, special webinars, compliance tip of the day, how to win prizes and more at bit.ly/aopaethics.

www.AOPAnet.org

The bebionic hand expands our impressive portfolio of upper limb designs.

Embrace the everyday.

bebionic

AxonHook

Michaelangelo Hand

Ottobock US . P 800 328 4058 . professionals.ottobockus.com