November 2018 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

N OV E M B E R 2018

This Just In: New Threats to Coverage of Lower-Limb Prostheses P.22

Delivery Dates for Inpatient and Hospice Stays P.16

AOPA National Assembly: Progress in O&P Outcome Measures P.34

Research Advancing the Interests of Service Members and Veterans P.44

Sensing the Future ORTHOTIC PATIENT CARE EVOLVES WITH ADVANCES IN SENSOR TECHNOLOGIES P.24

E! QU IZ M EARN

BUSINESS CE

CREDITS

WWW.AOPANET.ORG

P.20

YOUR CONNECTION TO

EVERYTHING O&P

TH E P R E MI ER M EE TIN G FOR ORTHOTIC, PROSTHETIC, AND P EDO RTHIC PRO FESSIO NALS.

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contents

NOVE M B E R 2018 | VOL. 67, NO. 11

COVER STORY

FEATURES

24 | Sensing the Future Incorporating sensors into orthotic technology is a trend that is set to take off, as sensors will provide data that can be leveraged in clinical decision making and in capturing outcome measures. Learn how the new technology may change the provision of orthotic services, and find out about a new diagnostic ankle-foot orthosis that will enable orthotists to make more objective decisions when treating new patients. By Christine Umbrell

22 | This Just In

Pushing Back Against Restrictions in Coverage Health Care Services Corp., which operates Blue Cross Blue Shield (BCBS) of Illinois, Texas, Montana, New Mexico, and Oklahoma, recently issued a draft policy governing coverage of lower-limb prostheses, including microprocessor-controlled prostheses. If enacted, this policy would significantly reduce access to advanced prosthetic technology for BCBS subscribers in those states.

NOVEMBER 2018 | O&P ALMANAC

34 | AOPA National Assembly:

Finding Meaning in Measurement

Early adopters of evidence-based O&P practice spoke at the 2018 AOPA National Assembly in Vancouver, sharing their experiences with implementing outcome measures. Several presenters discussed the need for more O&P professionals to collect data to measure efficacy of practice and devices, benchmark patient outcomes and practitioners' success rates, and inform research hypotheses and clinical decision making. Plus, see photos and highlights from special events during the AOPA National Assembly. By Josephine Rossi

contents

PRINCIPAL INVESTIGATOR

DEPARTMENTS

Ignacio Gaunaurd, PT, PhD, MSPT ......................................................................44 Meet a research health scientist whose work includes developing outcome measures and improving the quality of life for injured service members and veterans.

Views From AOPA Leadership......... 4 Michael Oros, CPO, FAAOP, recaps AOPAâ&#x20AC;&#x2122;s 2018 accomplishments

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

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

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

COLUMNS

Research, updates, and industry news

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

Delivery Decisions

Responsible parties and delivery dates in three special circumstances CE Opportunity to earn up to two CE credits by taking the online quiz.

CREDITS

P.10 People & Places........................................14

P.16

Transitions in the profession

Member Spotlight................................ 50 n

AOPA News...............................................54

American Orthotic & Prosthetic Center

AOPA meetings, announcements, member benefits, and more

Motion Medical

PAC Update............................................... 57 Welcome New Members................... 57 Careers.........................................................58 Professional opportunities

Ad Index......................................................59 Marketplace............................................. 60 Calendar..................................................... 62 Upcoming meetings and events

Ask AOPA.................................................. 64

P.50

P.52

Diabetic shoes, orthotic replacement rules, and more

O&P ALMANAC | NOVEMBER 2018

VIEWS FROM AOPA LEADERSHIP

Looking Back at a Productive 2018

last month of the AOPA fiscal year, I thought it only fitting to reflect upon 2018. It’s no secret that when working in a niche profession such as O&P, the uncertainties can add to hardships for practitioners and businesses. AOPA is reminded of this daily with nervous, sometimes incredulous, calls from our members concerning changes in medical policy as well as coverage determinations that ultimately lead to claim denials and diminished access to care. These issues, mixed with a precarious health-care system, present challenges to providing optimal patient care. With that as a backdrop, I believe it’s imperative to have both a strong local business model and an association that can coalesce those many voices into a singular impactful message and action plan. At AOPA, our mission statement—“Through advocacy, research, and education, AOPA improves patient access to quality orthotic and prosthetic care”—guides our every effort. In 2018, Congress recognized the orthotist’s and prosthetist’s notes as being part of a patient’s medical record. This is a confirmation that orthotist and prosthetist notes must be considered by CMS to be officially part of the patient’s medical record for purposes of medical necessity. In the summer of 2018, the House Veterans Affairs Health Subcommittee voted unanimously to approve legislation to create competitive grants to expand or create accredited master’s degree programs in O&P. In June, the durable medical equipment Medicare administrative contractors released a joint publication announcing the retirement of the draft Local Coverage Determination and Policy Article on lower-limb prosthetics. Of course, there remain uncertainties regarding the complete withdrawal of the Section 427 proposed rule that could have threatened provider groups to continue to provide services within their scope of practice. In all cases, AOPA has emphasized that orthoses and prostheses must remain Essential Health Benefits, and any action by CMS that restricts or reduces access to O&P services is not in the best interest of quality patient care. AOPA remains committed to funding and developing the O&P body of knowledge. Without credible and viable research, patient care will ultimately suffer. AOPA partnered with the Center for O&P Learning & Evidence-Based Practice (COPL) and awarded grants for six O&P topics in addition to Orthotics 2020 grants. We also introduced research opportunities for osteoarthritis, stroke, traumatic spinal injuries, and plagiocephaly. A workgroup was created for scoliosis, with a request for proposals for this category’s grant. Finally, AOPA provided support to David Boone, MPH, PhD, and students from the University of Washington for developing the beginning stages of the Outcome Assessment Reporting System, an application that models a guided outcome measure instrument for clinicians. With the 101st National Assembly, AOPA provided 40+ CE credits in stellar education, featuring programs in clinical, technical, and business concentrations. Many of these courses will be posted and available for viewing through our online platform, AOPAversity, which hosts varying educational courses. The AOPA Co-OP continues to serve as an online resource for reimbursement, coding, and policy needs. This month, AOPA hosts Health-Care Compliance and Ethics Week— the perfect opportunity for your business to reaffirm its core principles for a viable business model and its dedication to your mission statement. We know you’ve had a busy year as well—and that’s why this month we’re reaffirming our mission statement to you. Know that we hear and value your concerns. Your AOPA membership ensures that we can continue to advocate, provide research, and educate the O&P profession. It is an honor and privilege to continue to serve the O&P community. We will continue to strive for collaborative success in 2019 and beyond. Michael Oros, CPO, FAAOP, is immediate past president of AOPA.

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

HEN ASKED TO WRITE the Views From AOPA Leadership column for the

NOVEMBER 2018 | O&P ALMANAC

Board of Directors OFFICERS President Jim Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO President-Elect Chris Nolan Ottobock, Austin, TX Vice President Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Immediate Past President Michael Oros, CPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL Treasurer Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA DIRECTORS David A. Boone, MPH, PhD, BSPO Orthocare Innovations LLC, Edmonds, WA Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics Inc., Exton, PA Mitchell Dobson, CPO, FAAOP Hanger Clinic, Grain Valley, MO Traci Dralle, CFM Fillauer Companies, Chattanooga, TN Teri Kuffel, JD Arise Orthotics & Prosthetics Inc., Blaine, MN Dave McGill Össur Americas, Foothill Ranch, CA Rick Riley Thuasne USA, Bakersfield, CA Brad Ruhl Ottobock, Austin, TX

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AOPA CONTACTS

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

Publisher Thomas F. Fise, JD Editorial Management Content Communicators LLC Advertising Sales RH Media LLC

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

Printing Sheridan

EXECUTIVE OFFICES

REIMBURSEMENT SERVICES

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

Eve Humphreys, MBA, CAE, executive director, 571/431-0807, ehumphreys@AOPAnet.org

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

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

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

Copyright © 2018 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.

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

Tina Carlson, CMP, chief operating officer, 571/431-0808, tcarlson@AOPAnet.org MEMBERSHIP & MEETINGS Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, kelly.oneill@AOPAnet.org

SPECIAL PROJECTS

Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org

Ashlie White, MA, manager of advocacy, outreach, and special projects 571/431-0812, awhite@AOPAnet.org

Yelena Mazur, communications specialist, 571/431-0835, ymazur@AOPAnet.org

O&P ALMANAC

Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0836, rgleeson@AOPAnet.org

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

Kristen Bean, membership and meetings coordinator, 571/431-0876, kbean@AOPAnet.org

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

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NOVEMBER 2018 | O&P ALMANAC

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Advertise With Us! Reach out to AOPA’s membership and more than 11,400 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac18 for advertising options!

NUMBERS

Company Profits and Profit Leaders O&P facilities saw varying profit margins last year

REVENUES PER NONOWNER PRACTITIONER

Net profit margins at O&P companies averaged 6.8 percent last year, rising to 15.2 percent among the “profit leaders,” defined as the top 25 percent of respondents to AOPA’s annual Operating Performance Survey. The “2018 Operating Performance Report,” based on 2017 data, captured the financial facts from 90 companies representing 1,022 full-time facilities and 191 part-time facilities. The report details net profit margins—net profit before taxes as a percentage of sales—as well as many other financial, profitability, and operational numbers from participating facilities.

NET PROFIT BEFORE TAXES AS A PERCENT OF TOTAL ASSETS

$551,641 Median revenue generated per nonowner practitioner, up from $547,238 in FY2016.

SALES GROWTH

3.5 Percent

Average return on assets for all respondents.

Average sales growth among all respondents.

66.7 Percent

4.7 Percent

Average return on assets for profit leaders.

Average sales growth among profit leaders.

Owner practitioners

Practitioner assistants/extenders

Nonclinical owners/ managers

FY2017

14%

NOVEMBER 2018 | O&P ALMANAC

40% Office

administration/ marketing staff

35%

Nonowner practitioners

8.5% 5.1% 8.5%

6.9%

$2 to $5 Million

Other job titles

FY2016

$1 to $2 Million

Over $5 Million

Technicians

O&P FACILITY NET PROFIT MARGINS

Up to $1 Million

Median revenue generated per nonowner practitioner among profit leaders.

EMPLOYEE MAKEUP

16.7 Percent

Company Size

$832,930

7.6% 7.8% 6.0% 6.1%

EDITOR’S NOTE: The “2018 AOPA Operating Performance Report” is now available through the AOPA bookstore. Visit www.aopanet.org.

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Happenings RESEARCH ROUNDUP

University Researchers Explore Brain-Interfaced Prosthetic Limbs A team of researchers from the University of Chicago, University of Pittsburgh, and the University of Pittsburgh Medical Center (UPMC) have been awarded a $7 million grant by the National Institutes of Health to develop robotic arms that patients can control with their minds, using sensory feedback from attached prosthetic hands. The grant will allow the research team to continue its work in the area of brain-controlled prosthetics. In 2016, the team demonstrated how a clinical trial participant from the Pittsburgh area was able to control a robotic arm with his mind

PHOTO: Courtesy of Pitt/UPMC

Nathan Copeland, who was paralyzed from the chest down in a car accident, controls a prosthetic arm and hand at the University of Pittsburgh Medical Center.

and regain the sense of touch through the prosthesis. With the additional funding, the clinical trial will be expanded to the University of Chicago, where the project will be led by Sliman Bensmaia, PhD, and Nicha Hastopoulos, PhD. The team has developed a robotic neuroprosthetic system that works by implanting arrays of electrodes in areas of the brain that control movement and process the sense of touch. The electrodes are designed to detect activity in neurons as a patient thinks about moving his or her arm to direct a robotic arm to move accordingly. The team is working on developing a prosthetic hand equipped with sensors to detect sensations of touch and to generate electrical signals that stimulate the brain. While past brain-control interface research has focused on moving limbs in free space, this team’s project attempts to solve the challenge of controlling the hand when it comes in contact with and manipulates objects, according to the researchers. “Our goal is to create a prosthesis that has the same dexterity and functionality as the natural human hand,” Bensmaia said. “UChicago has the benefit of years of experience with both motor neuroscience and somatosensory research, and we look forward to continuing that work with our partners at Pitt and UPMC.”

Patients With Immobilized Limbs Should Exercise Their Healthy Side, Say Canadian Researchers

NOVEMBER 2018 | O&P ALMANAC

muscles. Strength preservation was localized to the wrist flexor muscles of the casted arm, and not the extensors. Those who completed the exercises also preserved their muscle size, while the nonexercise group lost 3 percent of muscle, on average. “The strength preservation likely comes from a phenomenon related to how exercising one side of the body affects information exchange between the two sides of the brain, and then influences the nontrained side of the body,” said Andrushko—findings that could be useful to orthotists as well. The researchers posited that exercising may trigger a connection between the nervous system and a protein balance mechanism that helps maintain muscle size. “We do not know much about the causes of muscle size preservation, so we need to dig deeper,” said Farthing. “This was an initial study on healthy, young people. There may be unknown factors at play when applying this to injured people, and the results could change.”

PHOTO: Getty Images

Researchers at the University of Saskatchewan have conducted a study into loss of strength during casting and have concluded that individuals should exercise their opposite sides to keep their casted limbs strong. Researchers Justin Andrushko and Jonathan Farthing, PhD, from the university’s College of Kinesiology, believe that strength training of the healthy limb could one day be included in standard practice for recovery. Sixteen healthy subjects participated in a study, wearing casts that immobilized their wrists for one month. Half of the participants took part in wrist-flexion training on their noncasted arm while the other half did not undergo training. At the end of the study period, the researchers compared changes in muscle strength and size in the wrists that had been casted. Subjects who had participated in the strengthening exercises preserved the strength of their wrist muscles within their casted arms, but the nonexercise group experienced a 20 percent decrease in the strength of their wrist

HAPPENINGS

DOCUMENTATION DIRECTIVES

DME MACs Release Revised ‘Dear Physician’ Letter Regarding Documentation The four durable medical equipment Medicare administrative contractors (DME MACs) have released a revised version of the “Dear Physician” letter that addresses the need for prescribing physicians to support the medical necessity of the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) services they prescribe through proper clinical documentation in the patient’s medical record. While the revisions to the latest Dear Physician letter were not significant from previous versions, the revision provides a reminder that for DMEPOS items or services to be covered, they must always be supported by physician documentation. When Section 50402 of the Bipartisan Budget Act of 2018 was enacted in February, the clinical notes of orthotists and prosthetists were recognized as part of the medical record for purposes of

medical necessity determinations. The legislative change essentially reversed the now-retired 2011 Dear Physician letter advising that O&P notes were not considered part of the medical record. However, Section 50402 did not convey to O&P prescribing rights and did not eliminate the need for physician notes supporting the medical need for O&P services they prescribe. Section 50402 specifically indicates that while orthotist and prosthetist notes are now part of the medical record, they are corroborative, and cannot, standing alone, trigger a finding of medical necessity.

ASSOCIATION LEADERSHIP

AOPA Welcomes New Executive Director

Eve Humphreys, MBA, CAE, has Eve Humphreys, MBA, CAE assumed the role of AOPA executive director effective Nov. 19, 2018. Humphreys previously served as executive director of the Society for Healthcare Epidemiology of America (SHEA). “We are very pleased to welcome Eve Humphreys, whose experience and expertise include strategic organizational development, building and maintaining positive organizational culture, domestic and international partnerships, and navigating the complexities of legislative and regulatory advocacy,” says AOPA President Jim Weber, MBA. Humphreys has a master’s degree in business administration from the

University of Maryland University College and a bachelor’s degree in political science from Randolph-Macon College. Prior to her work at SHEA, Humphreys served as senior director of membership at the American Academy of Otolaryngology—Head and Neck Surgery. Her experience and expertise include navigating the complexities of legislative and regulatory advocacy and working with volunteer leaders to create policy and position statements, practice guidelines, and continuing medical education content. AOPA’s previous executive director, Thomas Fise, JD, has successfully led AOPA since 2007 and will continue to assist with the transition through the end of this year.

AUDIT ANSWERS

Custom-Fabricated Knee Orthoses Targeted for RAC Audits

Performant Recovery, the national home health, hospice, and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) recovery audit contractor (RAC), announced in September that it will initiate a postpayment complex medical review for custom-fabricated knee orthoses described by Health-Care Common Procedure Coding System codes L1844 and L1846. Providers whose claims are selected for review will receive a letter from Performant Recovery requesting relevant documentation to support medical necessity for the orthosis that was provided. Recipients of additional documentation requests (ADRs) from Performant Recovery should respond quickly, as failure to do so will result in automatic claim denial and recovery of any payments previously made. As with all RAC reviews, specific rules limit the number of ADRs that O&P providers may receive to a maximum of 10 ADRs per tax identification number every 45 days, and the lookback period for reviews is three years. The RAC audit for custom knee orthoses is the third O&P-specific approved issue since the award of the RAC contract to Performant Recovery.

O&P ALMANAC | NOVEMBER 2018

HAPPENINGS

CODING CORNER

AOPA Submits Comments on the Medicare Gap-Filling Process In September, AOPA submitted formal comments to CMS regarding suggestions on how to improve the “gapfilling” process that is currently used to establish Medicare fee schedule amounts for new Health-Care Common Procedure Coding System (HCPCS) codes. The opportunity to provide comments was the result of the annual proposed rule regarding Medicare coverage of end-stage renal disease (ESRD) and competitive bidding for durable medical equipment, prosthetics, orthotics, and supplies. The proposed rule requested suggestions from interested parties for improving the gap-filling process. Gap filling is used to establish Medicare fee schedules for new HCPCS codes. Current statutory requirements

mandate that when a new code is issued, CMS must establish a base price for the device, deflate the price to 1986-1987 rates by applying the annual consumer pricing index for urban areas (CPI-U), and then reinflate it by applying the annual update to the Medicare O&P fee schedule. Since the O&P update has not always equaled the CPI-U, gap filling results in a slightly lower price than the base price that was established for the device. The gap-filling process is considered by many to be an outdated process that does not consider important factors such as professional service and clinical expertise when calculating Medicare fee schedules. AOPA provided comments and made several suggestions toward improving the current system.

AMPUTEE ATHLETICS

O&P Facilities Host First Clinics

First Stride Training and Clinic, hosted by Prosthetic Center for Excellence

NOVEMBER 2018 | O&P ALMANAC

about prosthetic componentry and evidence-based outcome measures. They also received instruction on a reverse chaining method for getting patients off of the floor, as well as safe falling First Volley Adaptive Tennis methods. During the Clinic, hosted by Celerity Prosthetics afternoon session, amputees joined the clinic to work on the fall-prevention techniques. Also in October, Celerity Prosthetics hosted a First Volley Adaptive Tennis Clinic at Hidden Trail Golf and Tennis Club in Oklahoma City, attended by participants and volunteers with a variety of challenges. Darren Kindred, First Volley director and founder, provided instruction, assisted by volunteers from Hidden Trails and U.S. Tennis Association—Missouri Valley. Select Medical PT provided refreshments, and representatives from Canine Companions for Independence brought some of their dogs and puppies in training for the event.

PHOTOS: First Clinics

First Things First Training and Clinic, hosted by Bionic Prosthetics & Orthotics

Las Vegas; Merrillville, Indiana; and Oklahoma City, Oklahoma, were the sites of several recent First Clinics, hosted by O&P companies in those cities and assisted by OPAF. In early October, Prosthetic Center for Excellence hosted a First Stride Training and Clinic on the campus of the University of Las Vegas. Local therapists and practitioners as well as physical therapy students from two local programs attended the morning session, led by Chris Doerger, PT, CP, and focusing on evidence-based outcomes measures as well as an overview of prosthetic componentry and personal experience. In the afternoon, more than 20 lower-limb amputees took part in a gait training clinic. Participants were evaluated and taught exercises to improve balance, core, step length, and more. On October 8, Bionic Prosthetics & Orthotics, in coordination with Össur Americas, hosted an OPAF First Things First Training and Clinic at Indiana Wesleyan University. Doerger led instruction on falls and recovery during the morning session, attended by more than 20 therapists and practitioners. Participants learned more

HAPPENINGS

AMPUTEE ATHLETICS

Athletes Compete at Invictus Games in Sydney

PHOTO: www.invictusgames2018.org

Nearly 500 competitors from 18 countries took part in the 2018 Invictus Games in Sydney, Australia, last month. Athletes who had been injured, both physically and mentally, while serving their countries competed over a seven-day period in adaptive sports, including archery, athletics, indoor rowing, power-lifting, road cycling, sitting volleyball, swimming, wheelchair basketball, wheelchair rugby, and sailing. Seventy members of Team U.S. took part in the event. The U.S. athletes trained in Port Hueneme Naval Base in California prior to the competition. Brant Ireland, Team U.S. co-captain, explained that participating in the Invictus Games is a “big part of returning to life.” For many of the athletes, it's their first time competing after being injured. “I’ll admit when I first got injured and I was encouraged to participate in the adaptive sports, I thought it was just a chance to recover and it wasn’t going to be competitive,” said Ireland. “As soon as you step on the court, you realize what amazing athletes they are. It is absolutely the epitome of competitiveness.” Participants who experienced problems with their equipment during the competition visited a “workshop” sponsored by Ottobock, where 25 technicians were on hand to assist with prosthetic, orthotic, and wheelchair repairs. The volunteers noted a significant disparity in FAST FACT

Data Security Compromises Continue

how sophisticated the prostheses were, depending on the home country. “Not every country has proper funding Caption for their athletes and often they are self-funded so they have to pay for their own equipment. … They buy what they can afford, so we see a wide variety of products,” said Thomas Much, managing director of Ottobock Australia. During the Closing Ceremonies, Prince Harry, the Duke of Sussex and founder of the Invictus Games, told the competitors that their “magnificent” example “goes beyond the military community. … It is about more than your inspiring stories of recovery from injury and illness.” He called the competitors “ordinary people doing extraordinary things.” The Invictus Games were founded in 2014 by Prince Harry after he attended the 2013 Warrior Games in Colorado Springs, Colorado. The next Invictus Games will take place in May 2020 and will be hosted in The Hague, The Netherlands.

THE LIGHTER SIDE

In the second quarter of 2018,

3.15 MILLION PATIENT RECORDS

were compromised in 142 health-care data breaches in the United States, according to the Protenus Breach Barometer. Approximately 30 percent of privacy violations involved repeat offenders. “Insiders” were responsible for 31 percent of breaches in the second quarter.

O&P ALMANAC | NOVEMBER 2018

PEOPLE & PLACES PROFESSIONALS ANNOUNCEMENTS AND TRANSITIONS

Hanger Inc. has announced the promotions of Mitchell Dobson, CPO, FAAOP, and James Campbell, PhD, CO, FAAOP, and their subsequent appointments to Hanger’s senior leadership team, reporting to Hanger Chief Executive Officer Vinit Asar. Dobson has been named senior vice president and chief compliance officer. He has been with Hanger for 24 years and most recently served as the vice president and compliance officer for the company’s patient-care segment. Throughout his tenure with the company, Dobson has held various compliance and regulatory-related roles, and also practiced as a clinician for more than a decade. Campbell, the newest member of Hanger’s senior leadership team and an AOPA past president, has been promoted to senior vice president and also will continue to serve in his role as chief clinical officer, where he leads the Clinical and Scientific Affairs Department. Campbell joined Hanger in 2015, and during his time with the company has made an impact in the areas of outcomes and research. He and his team have developed “Clinical Practice Guidelines” for major medical conditions and have focused on capturing medical outcomes for patients and translating that information into value for payors.

Charlie Huizinga

Josh Seelye

Ray Speelman, CP, COF

John Robertson

Several individuals have received promotions at WillowWood. Charlie Huizinga, who has been promoted to corporate sales manager, has been at WillowWood since 2012 and most recently served as the company’s sales manager. As corporate sales manager, he will broaden his focus on international sales by expanding the company’s global distribution network into new market territories. Josh Seelye has been promoted to the sales manager position. He will continue serving customers in Ohio and Michigan, assume personnel management of the company’s regional account managers, and oversee WillowWood's domestic sales growth and activities. Ray Speelman, CP, COF, will take on a new role on WillowWood’s education team as a clinical support practitioner. He will apply his clinical skills and knowledge toward assisting and educating clinicians at national, regional, and state trade shows; customer facilities; and educational webinars. In addition, John Robertson has joined WillowWood as its new chief technology officer. Robertson has experience in the development of U.S. Department of Food and Drug

NOVEMBER 2018 | O&P ALMANAC

Administration Class 1 and Class 3 medical technology devices as well as leadership in engineering and operations. He recently worked as senior vice president of research development at Freedom Innovations, where he was active in the development of advanced technology lower-extremity prosthetics. In his new role, Robertson will focus on developing technology-based prosthetic products that demonstrate improved outcomes for patients and clinicians. Oksana Masters of Team USA has been named the Individual Sports Woman of the Year by the Women’s Sports Foundation. In 2018, Masters was awarded five medals in sitting ski events at the Paralympic Games in PyeongChang: two Gold medals and one Bronze medal in cross-country skiing and two Silver medals in biathlon. During the 20172018 World Para Nordic Skiing World Cup Circuit, she finished with eight Gold and two Silver medals. A multisport athlete who also rows and cycles, Masters participated in previous Paralympic Games in 2012, 2014, and 2016. Masters is currently ranked No. 1 in the women’s sitting classification in both cross-country skiing and biathlon by the International Paralympic Committee and was nominated for the 2018 ESPY Award for Best Female Athlete With a Disability.

BUSINESSES ANNOUNCEMENTS AND TRANSITIONS

Fillauer has been awarded the 2018 Spirit of Innovation Award by the Chattanooga Chamber of Commerce for its design and execution of the NEXO system, a lightweight upper-extremity prosthesis. The award honors businesses that originated in the Chattanooga region and have potential to impact many people and inspire change either within one industry or across a broader spectrum. Michael Fillauer, president and chief executive officer of Fillauer, said, “We are excited to be recognized for our efforts to make innovative products available for the upper limb loss community. … We look forward to continuing to offer better products for our patients and clinicians.” VGM Insurance Services has been named one of Business Insurance magazine’s Best Places To Work for 2018. The program recognizes employers for their outstanding performance in establishing workplaces where employees can thrive, enjoy their work, and help their companies grow. “We are humbled to be recognized among the more than 1,000 Managing General Agencies nationwide as one of the Best Places To Work,” said Mike Kloos, president of VGM Insurance. “It’s a testament to our team of employee owners that foster a culture encouraging collaboration and professional growth, which ensures exceptional work for our customers.”

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REIMBURSEMENT PAGE

By DEVON BERNARD

Delivery Decisions Location is key to determining delivery dates and responsible parties

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 20 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

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OME DELIVERY SCENARIOS CAN

cause confusion among suppliers— for example, confusion regarding the proper delivery date on a delivery slip and billing sheet, or in understanding who is responsible for payment and who should be billed. This confusion can be alleviated by understanding the rules based on delivery location. This month’s Reimbursement Page delves deeper into three scenarios to explore delivery date and responsible party determinations: delivery in a hospice, delivery using a delivery service, and delivery to an inpatient facility when items are ordered prior to admission.

Treating Hospice Patients

When a Medicare beneficiary elects hospice care, he or she is declining treatment for a specific terminal illness and is electing to receive only palliative care for that illness. Any item or service provided to the patient to meet those purposes is included in the prospective payment system (PPS) of the hospice and cannot be billed separately to Medicare.

With the election of hospice care, the patient does not give up his or her rights for care of illnesses or injuries not associated with his or her terminal illness, or any of his or her other benefits under Medicare Part B coverage—including orthotics and prosthetics. So, if you are providing a hospice patient with an orthosis, prosthesis, shoes, or related items for treatment of a condition or illness not related to the patient’s terminal illness or reason he or she elected hospice care, those items are eligible for payment by Medicare and must be billed to the durable medical equipment Medicare administrative contractors (DME MACs). To notify Medicare that the items you are providing are not related to the hospice stay and are eligible for separate payment, your claim must include the GW modifier. Inappropriate use of the GW modifier—or failure to include the GW modifier—can lead to claims being incorrectly paid by the hospice or by the durable medical equipment Medicare administrative contractors (DME MACs), resulting in overpayments.

What Is a PPS?

NOVEMBER 2018 | O&P ALMANAC

PHOTO: Getty Images

A prospective payment system (PPS) is a system of reimbursement whereby Medicare makes a daily payment or per diem to a facility—hospital, skilled nursing facility, hospice, etc.—to provide all medically necessary care under any Medicare Part A hospital insurance benefit period or inpatient stay. The PPS payment amount will vary depending on the type of facility and the level of care or treatment required. No matter how much each facility’s PPS rate is, the payment is the same whether the facility provides the services on its own or provides them through a vendor relationship with an outside provider. If the facility uses an outside provider, the facility must pay that outside provider for its services, since that facility has already received payment in full for the patient’s care under the PPS. In addition, the facility has the right to use the vendor of its choice and may have a sole contract with an outside supplier/provider.

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That is why Performant Recovery, the recovery audit contractor for durable medical equipment, prosthetics, orthotics, and supplies; home health; and hospice claims nationwide, has begun an automated review for items and services that were provided during a Medicarecovered hospice benefit period. When dealing with hospice billing, it’s also important is to know how to handle patients covered under a Medicare Advantage plan instead of traditional fee-for-service or Part B Medicare. Typically, if a patient has coverage through Medicare Advantage, you will not bill Medicare directly; you will deal with the Medicare Advantage plan provider. However, if a Medicareeligible beneficiary elects hospice care and has Medicare Advantage, the Medicare Advantage plan provider is not responsible for payments. Federal regulations require that traditional Medicare retain payment responsibility for all hospice- and nonhospice-related claims, beginning on the date the patient/beneficiary chooses hospice care. In this scenario, Medicare remains the payor, and you would have to seek payment from the DME MACs and use the GW modifier, if appropriate.

Rules for Shipping Services

NOVEMBER 2018 | O&P ALMANAC

items to beneficiaries, the key is to remain consistent. Consider creating an office policy on how to handle proof of delivery when shipping—and make sure the policy is followed.

Determining the delivery date, or date of service, can be more confusing when using a shipping service. Traditionally, the date you mailed the item(s) or the date the shipping labels were created—rather than the date or the anticipated date of delivery or when the patient receives the shipment—would be considered your date of service or date of delivery for billing purposes. However, a recent update to the Local Coverage Article: Standard Documentation Requirements (SDR) for All Claims Submitted to the DME MACs now lists two additional methods for determining date of service. First, you may now use the actual date the shipping service delivers the item. Second, you also may use a return-postage, physically signed proof-of-delivery form from the patient or his or her representative, and the date entered by the patient or his or her representative becomes the date of service. Whichever method you use to establish date of service when shipping

If an orthosis (custom or prefabricated) or a prosthesis is ordered before a patient is admitted to the hospital and it is delivered in the hospital, the hospital remains responsible for the payment. The hospital is responsible because the need and use of the item is occurring during the stay, and the hospital is being paid to provide all necessary care under its PPS. The same logic applies when you are providing an item prior to an admission, but it is not required until after the admission occurs, such as a spinal brace following back surgery. If you provide an item to be used by a patient prior to his or her hospital admission, you should document that the medical necessity and need are occurring prior to the inpatient hospital stay. For example, if you are providing a spinal brace to a patient prior to a hospital stay for spinal surgery because the referring physician wants to stabilize the patient, be sure the physician has documented that he or she wants the patient to wear the brace prior to surgery.

Ordering Items Prior to Inpatient Stays

PHOTO: Getty Images

The use of a delivery service, such as UPS, FedEx, DHL, or the U.S. Postal Service, for O&P items is uncommon, as most items and services are provided directly to the patient. However, a shipping service may be used for delivery of consumables and supplies— for example, socks, shrinkers, etc. If you are using a shipping service for certain O&P items, your proof-of-delivery form or documentation will have some additional features beyond those found on a traditional proof-of-delivery slip. Both types of delivery slips require the inclusion of the patient’s name, the delivery address, a detailed description of the item(s) being delivered, and the delivery date; but the proof-of-delivery documentation for the shipping service also requires two additional components: • Documentation that links your

delivery records to the records of the shipping/delivery company’s records, such as a package identification number or a tracking number; and • Evidence of delivery—for example, confirmation from the delivery company.

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REIMBURSEMENT PAGE

Items ordered prior to admission to a skilled nursing facility (SNF) stay follow a different set of rules, especially when the items are custom. If a customfabricated brace or prosthesis was ordered for a patient while he or she was still in the hospital but, due to the fabrication time associated with a custom item, it is not delivered until after that patient is admitted to the SNF, who pays for it? In this case, the hospital remains responsible for payment for the item because the medical necessity for the custom device was established while the patient was in the hospital, not in the SNF, so the SNF should not be billed. In addition, the two-day rule would not apply because the patient is not being discharged to his or her home—which is a primary requirement of the two-day rule. Also, if the medical necessity for a custom device occurs while the patient is at home, but delivery does not occur until after an SNF-covered admission, the item may be billed to the DME MACs. To avoid receiving a denial when billing for a custom item in this situation,

make sure your start date is the date of service and not the actual delivery date. This exemption for billing for items ordered prior to an SNF stay only applies to custom-fabricated orthoses and prostheses and does not apply to prefabricated (off-the-shelf or custom-fitted) items or to any type of therapeutic shoes or inserts. Prefabricated items would follow the same rules as those discussed for a hospital stay—meaning if the item is delivered and used in a facility, then the facility is responsible for payment, even if the item was ordered prior to the admission. As with hospice, when a hospital or SNF requires the services of an outside supplier for items subject to

the Medicare Part A PPS system, it is the facility's responsibility to make arrangements with the outside supplier. It is always in your best interest to negotiate the terms of payment prior to delivering your services. While the absence of a contractual agreement does not in any way relieve the facility from its responsibility to pay for such items, making such an agreement prior to providing services will help avoid any misunderstandings. 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

Pushing Back Against Restrictions in Coverage AOPA challenges draft lower-limb prosthesis policy released by Blue Cross Blue Shield in several states

N OCTOBER 1, AOPA submitted

comments on a draft policy governing coverage of lower-limb prostheses, including microprocessorcontrolled prostheses, that had been issued by Health Care Services Corp. (HCSC); HCSC operates Blue Cross Blue Shield (BCBS) of Illinois, Texas, Montana, New Mexico, and Oklahoma. The draft policy, as written, would significantly reduce access to advanced prosthetic technology for BCBS subscribers in these five states. AOPA strongly believes that the draft policy is unreasonably restrictive and will preclude access to advanced prosthetic technology for the majority of BCBS subscribers in the states covered by this policy. The policy is arbitrary at best, with no reference to scientific studies

NOVEMBER 2018 | O&P ALMANAC

that support the proposed restrictions. AOPA expressed its concerns regarding the draft policy in its comments. The first concern is that HCSC published the draft policy on Sept. 15, 2018, with comments due no later than Oct. 1, 2018. Fifteen days was not sufficient time to perform a complete review of the draft policy and provide informed comments; AOPA suggested a minimum 60-day comment period to allow stakeholders adequate time to comment on the draft policy. The 21st Century Cures Act requires not only a reasonable comment period when Medicare issues a draft local coverage determination (LCD) but also requires Medicare contractors to hold public meetings to allow stakeholders to provide input on the impact the draft LCD may have on Medicare beneficiaries. While the 21st Century Cures Act does not apply to private insurance companies, a 15-day comment period for such a drastic policy change is completely unreasonable and should be expanded to a minimum of 60 days. Despite the unrealistic deadline, AOPA submitted comprehensive comments regarding the draft policy and the negative impact it will have on BCBS subscribers. In further comments, AOPA expressed its opinion that the draft policy is unnecessarily restrictive and

The 21st Century Cures Act requires not only a reasonable comment period when Medicare issues a draft local coverage determination (LCD) but also requires Medicare contractors to hold public meetings to allow stakeholders to provide input on the impact the draft LCD may have on Medicare beneficiaries. will limit access to advanced technology, especially to BCBS subscribers who may be classified as limited community ambulators (K2) but may benefit from receiving microprocessorcontrolled prosthetic knees. AOPA referenced studies published by RAND Corp., Dobson-DaVanzo, and the Mayo Clinic that showed that the use of microprocessor-controlled

This Just In

knees by limited community ambulators reduced the rate of falls and fall-related injuries. While provision of microprocessor-controlled prosthetic knees may represent a slightly higher cost to a health insurance company, it is likely to lead to significant cost savings over time due to fewer falls and fewer injuries. The draft policy would effectively eliminate BCBS coverage of microprocessor-controlled prosthetic knees except among patients who were assessed as high-functioning community ambulators (top percentage of K3 patients). Based on higher functional level test scores cited in the draft policy, AOPA estimates that only 10 percent of BCBS subscribers in the states affected by the draft policy will be able to receive microprocessorcontrolled prosthetic knees as a covered benefit. This unnecessary

restriction in coverage is contradictory to the information that is being reported through all of the major studies that examined the clinical and financial benefits of microprocessorcontrolled prostheses. AOPA’s comments also referenced the recent report from the Interagency Workgroup that was convened to provide a consensus statement on Medicare coverage of lower-limb prostheses after the Medicare draft LCD was released several years ago. The Interagency Workgroup recommended the potential creation of a National Coverage Determination that would address Medicare coverage of microprocessor knees for K2 patients. This consensus statement is especially valuable because it was generated by a group of individuals who have no vested interest in payment for

microprocessor-controlled prostheses. The Interagency Workgroup was formed to provide a truly objective consensus statement and developed a statement that clearly recognizes the value of microprocessor-controlled prostheses across multiple functional level categories. AOPA’s comments expressed concern that restricting access to advanced prosthetic technology was not in BCBS’s best interest, nor in the best interest of its subscribers, as it was contradictory to the consensus statement of the Interagency Workgroup and the overall health of BCBS’s subscribers. AOPA is hopeful that HCSC will seriously consider AOPA’s comments before publishing the final version of the policy revision. AOPA’s complete comments may be viewed at www.AOPAnet.org.

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COVER STORY

Sensing

the Future

Increased use of sensors in orthoses, may lead to more objective orthotic assessments and optimized componentry By CHRISTINE UMBRELL

NOVEMBER 2018 | O&P ALMANAC

PHOTO: Clinical Biomechanics Lab, Georgia Tech

including an in-clinic diagnostic AFO,

COVER STORY

NEED TO KNOW Using technology to better define the parameters and measure the efficacy of orthotic treatment is becoming more important as payors expect to see outcome measures and proof of the value of O&P intervention. As sensor technology becomes more advanced and less expensive, more orthotic devices will incorporate sensors as an objective means to determine treatment criteria and patient compliance.

Sensors also will play a role in diagnostic tools for orthotists; researchers at the Georgia Institute of Technology have developed an instrumented ankle-foot orthosis (iAFO), tested so far on healthy subjects, that is equipped with sensors to capture diagnostic data.

The iAFO, which will be tested on subjects with drop foot next, has been designed as a wearable and portable passive exoskeletal device comprising an orthotic control feature that enables the clinician to modulate ankle joint stiffness, study the wearer’s biomechanical response to such a perturbation, and ultimately identify and prescribe an optimal orthosis stiffness on a patient-specific basis.

In the coming years, as the baby boomers age and the use of lower-limb orthoses for stability rises, it is expected that more sensors will be incorporated into conventional AFOs to capture real-time ambulatory information While sensors and other forms of advanced technology will be critical, orthotic decision making will continue to rely, to some extent, on the experience and expertise of certified orthotists.

N RECENT YEARS, stronger and

more lightweight materials have contributed to advances in orthotic componentry. But it’s the integration of sensor technology into orthoses that may be one of the biggest game-changers. The use of sensors is in its infancy in the field of orthotics, with a few manufacturers incorporating sensors for data collection purposes and advanced walking systems leveraging sensors in conjunction with microprocessors to adapt to changing walking speeds. But the sensor trend is set to take off—with researchers embracing the technology and a new diagnostic ankle-foot orthosis (AFO) currently under development.

Ripe for Innovation

“Orthotic patient evaluations have evolved tremendously in recent years,” says Julie McCulley, MPO, MS,

CPO, ATC/L, a clinician at Ability Prosthetics & Orthotics. Outcomebased research initiatives and manufacturing innovations are leading to new technologies that better aid patients. “We have turned the corner from being brace-makers that help a limb function better to practicing as orthotists that complete full and comprehensive evaluations in coordination with the patient’s medical team to develop treatment plans that will increase a patient’s mobility and quality of life,” says McCulley. O&P ALMANAC | NOVEMBER 2018

COVER STORY

measures. “Sensors and smart devices,” he says, “will benefit the field and go beyond ‘good enough’ to get optimal outcomes.”

A New Approach to AFO Evaluations

needed to correct the prominence. Using technology to better define Data generated from sensors in this the parameters of orthotic treatment study and others “helps motivate is instrumental to elevating the O&P profession, according to Chrysta Irolla, patients and inform clinicians,” she says. “As we develop more and more MS, MSPO, CPO, clinical manager at devices to better the University of measure our California—San treatments and Francisco (UCSF) Chrysta Irolla, communicate with Orthotic and MS, MSPO, CPO our patients, we Prosthetic Center. improve our care.” And leveraging “Sensors give you the ability to technology to provide more effective capture what the naked eye cannot,” treatments is essential. “Devices in explains Amira Mouad, CPO, a cliniour field,” explains Irolla, “are often over-designed in order to ensure we cian and cranial remolding specialist achieve the treatment goals in the at Ability P&O. Sensors are becoming absence of objective tests [that] define increasingly accessible and less the minimum necessary material, wear expensive, and offer a more holistic time, pressure, etc.” By more clearly approach to gait analysis that allows defining the criteria for a treatment, clinicians to see what’s going on in O&P professionals can avoid overeach phase, she explains. What sensors designing devices and only maintain bring to the orthotics the areas of contact necessary to profession is an achieve the device goal, she says. objectivity that aids “Sensor technology provides an in clinical decision objective means to determine treatmaking. “The old way ment criteria and assess patient of doing things—the compliance with those guidelines,” mentality of, ‘It’s good enough,’—is says Irolla, who is leading a research changing,” says Nicholas Bolus, a gradproject at UCSF that relies on sensors. The project focuses on pectus cariuate student with the Bioengineering Graduate Program at Georgia Institute natum patients and involves using of Technology (Georgia Tech). temperature sensors to measure Clinicians are relying less on qualitacompliance to a wear schedule and pressure sensors to measure the force tive information and more on objective 26

NOVEMBER 2018 | O&P ALMANAC

In an effort to move the orthotics field toward more optimal outcomes, Bolus and Geza Kogler, PhD, director of the MSPO program at Georgia Tech, are working with a team of researchers in creating an “instrumented AFO,” or “iAFO,” to be used as a diagnostic tool in treating AFO patients. During the AOPA National Assembly in September, Kogler and Bolus introduced the iAFO and explained why and how it will be used. Typical orthotic evaluations rely on experiential estimates of an AFO’s stiffness by manually deflecting the orthosis, thereby assessing whether a brace offers the requisite corrective forces to overcome a motor deficiency, such as foot drop. “As a clinician, I was always frustrated in not knowing for sure whether the devices I was fitting were really the most appropriate,” explains Kogler, who practiced O&P for 25 years and now is part of the Clinical Biomechanics Lab at Georgia Tech. “We need to start quantifying what we do in the clinic and start making decisions based on that information.” Kogler says that while Nicholas Bolus AFOs have been shown to improve gait velocity, stride length, walking efficiency, and balance, studies have shown that orthoses that are not designed or fit properly can cause discomfort and even compromise gait mechanics—perhaps leading to muscle disuse and reduced patient acceptance.

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COVER STORY

PHOTOS: Clinical Biomechanics Lab, Georgia Tech

Developing a useful orthotic diagnostic instrument—such as Kogler and Bolus’s iAFO—would provide a more objective way to determine the most appropriate device and fit and would serve as an additional tool during patient evaluations. “I don’t think that AFOs are a stranger to the multimodal sensing approach,” says Bolus. “A lot of them already use simple angle sensors, for example.” But sensors in most current research-oriented AFOs “are being used as a means to an end—as inputs to a control scheme for actuating a device.” The iAFO features an extensive set of sensors that are “intended not so much to aid in control, but rather to serve as diagnostic measures, to capture diagnostic data.” The diagnostic AFO has been designed as a wearable and portable passive exoskeletal device featuring an orthotic control that enables the clinician or researcher to modulate ankle joint stiffness with a series of interchangeable extension springs, study the wearer’s biomechanical response to such a perturbation, and ultimately identify and prescribe an optimal orthosis stiffness on a patient-specific basis. The design of the AFO imposes rotational resistance in only one direction at a time and preserves the critical functions of a clinically prescribed AFO, according to Kogler. 28

NOVEMBER 2018 | O&P ALMANAC

Healthy study participants tested the iAFO on varying terrains. The device could report gait parameters such as ankle range of motion, peak torque applied by the device, biomechanical “power” lost to the device across a gait cycle, time spent in single-limb support on the affected limb, changes to gait symmetry, peak impulse applied at the device-to-user interface, training/motor-learning effects over time, and ankle angle and amount of “shock” at initial contact— information that cannot be obtained via observational gait analysis alone.

The iAFO is “in-clinic friendly,” meaning it’s a wireless system that allows clinicians to see the sensor readings on their tablets as the user walks. A comprehensive sensor suite monitors a patient’s sagittal plane ankle kinematics, kinetics, muscle activity, plantar pressures, and orthotic interface pressures between the device and the user. The “system” works in conjunction with a desktop computer to store and display data, and allows users to participate in tasks other than normal walking level, including sloped walking, stair walking, and uneven terrain/obstacle evasion tasks, with the potential to be used outside the confines of a gait analysis lab. Clinicians can use the information from this system to make informed decisions about how best to modify device geometry and “dose” orthotic stiffness, says Kogler.

Changing the Paradigm

Using sensor technology to develop a diagnostic device for AFO patients is a “game-changer,” according to Kogler, because the iAFO will not only help clinicians treat patients with different underlying issues in determining how to improve their gait, but also optimize outcomes in a way that hasn’t been seen before. Currently, determining the best device and best fit in an AFO is a “crude” process, says Kogler. “We

COVER STORY

determine the strut just based on feel, then put the orthosis on the patient, and often have no idea whether the device can be optimized,” he says. “With drop foot, for example, a simple AFO is so effective at improving the user’s ability to walk that everyone can see the improvement,” he says. But the AFOs currently prescribed may be “overengineered for stiffness,” according to Kogler. “So, the user can’t get their foot flat on the ground, and step length is compromised,” he says. “If I can optimize an AFO to get to a clearance but only get limited stiffness to optimize walking,” that would be an improvement, he suggests. “To me, every AFO should optimize for walking—not just for level walking, but for stairs and sloped walking” as well, says Kogler. To date, the research team has completed a proof of concept, and the iAFO has been tested on healthy subjects. “By testing first with healthy subjects, we’ve learned a lot about how the healthy body responds when the ankle is constrained,” says Kogler. Next, they’ll be testing the iAFO with the drop foot population and then redesign some of the elements to look at different measurements, and make it less bulky. “Within about four to five

years, we will have a device ready for quickly,” he says. Of course, putting prime time.” the data to use is another question. Given time, the iAFO could be used “Just to collect data is one thing—you in conjunction with more sophistihave to understand what the data means to help clinicians. That could cated machine learning, says Bolus. happen in the next two years.” Researchers or clinicians could gather Kogler predicts that the data the data they collect from sensors, aggregated from diagnostic sensors then use the data to identify optimal embedded in AFOs will lead to the stiffness for a given individual, given development of better orthoses. “I their goal, he says—applying machine believe stiffness should be different learning to determine optimal stiffness between plantarflexion and dorsion a patient-by-patient basis. “As we collect flexion,” Kogler says. more data and add “But an AFO that sensors to capture could be optimized different types of doesn’t exist yet.” He Geza Kogler, PhD information, we’ll hypothesizes that be able to see how AFOs will soon be muscle dynamics engineered differchange at the lower limb, how much ently: After they’re fabricated, a small harder a person has to work in a given suite of sensors will be embedded, device, or even how much more oxygen along with a microchip, and informaa person needs to consume” using a tion will be able to be downloaded particular orthosis, suggests Bolus. and sent back to clinicians to report on how orthotic patients are doing. As such devices come to market, Growth of Sensor Technology Kogler believes that the data generIn the next few years, sensors will become commonplace not just in ated will be helpful when dealing diagnostic devices, but in standard with payors and other health-care braces including knee orthoses, AFOs, providers. “If a clinician is trying to bid and thoracolumbarsacral orthoon a contract, having data that proves [that facility’s] devices perform better” ses, suggests Kogler. “Developing will aid that facility in rising above the something for an orthosis just to competition, he says. collect data—that may happen pretty

DIAGRAM: Courtesy of Clinical Biomechanics Lab, Georgia Tech

Diagram of the iAFO

O&P ALMANAC | NOVEMBER 2018

COVER STORY

Outcome Measures Take On Larger Role in Orthotics Outcome measures have been in the spotlight with regard to prosthetics, but they also are “essential to substantiating our plan of care” in orthotics, says Amira Mouad, CPO, a clinician and cranial remolding specialist at Ability Prosthetics & Orthotics. Using tools such as the timed-up-and-go (TUG) test and the activities-specific balance confidence (ABC) scale is becoming increasingly important—not only to objectively demonstrate the efficacy of orthotic intervention but also to show patients their personal capabilities. In addition to assessment tools, Mouad notes comparative scans and X-ray analysis also serve as useful tools in measuring outcomes when treating patients with cranial and spinal deformities. “Comparison scans are taken at regular intervals during cranial remolding treatment showing the effectiveness of cranial remolding orthoses Lindsey Madden, who wears bilateral ankle-foot orthoses, works to parents. X-rays are compared with Julie McCulley, MPO, MS, CPO, ATC/L, to perform a TUG test at a at regular intervals for patients follow-up appointment. receiving treatment for scoliosis. Measurements are taken at each visit for both of these patient populations to regularly “I’ve experienced overwhelmingly positive feedback monitor growth and changes in condition.” from patients who have been given the opportunity to be For lower-limb patients, “we track various outcome involved in treatment that involves outcome measures,” measures … dependent on which tests are most approshe says. “The patient feedback gets them more involved in their care, and improves compliance and brings more priate for the patient,” says Julie McCulley, MPO, MS, CPO, awareness to the relevancy of what we’re doing.” ATC/L, also a clinician at Ability P&O. In addition to the In an effort to grow the data pool at Ability, Mouad and TUG and ABC tools, “Ability P&O has created an application McCulley are currently leading a unique project aimed at that enables our data to be collected and sorted automatstudying cranial remolding treatments for plagiocephaly ically so that we can analyze results at any time. We also and brachycephaly patients, both pre-treatment and use video analysis for some of our more challenging cases, post-treatment. They are using data, including concrete so we are able to measure angles, step length, compare gait scan overlays and several different severity scales, to deterto previous appointments, and collaborate with patients’ medical teams.” mine the level of severity. The goal is to establish future During appointments, outcome measure instruments protocols to help determine the best time to begin treathelp patients visualize their potential for success and ment and discharge the patient. ultimately achieve their goals, says Mouad. “From a clinical “We have been recording our outcomes for cranial perspective, measuring outcomes dictates my plan of care, remolding helmets in order to review and assess our perfortreatment timeline, and appropriate device selection. This mance,” explains McCulley. “Using this information, we allows the patient to receive a device that is suitable for have established best practices in the monitoring of patient their needs.” outcomes [that] we continuously review and improve. We All in all, patients seem to appreciate being more plan to continue our work to implement changes in the way involved in outcome measures testing, says Mouad. we practice in order to improve our outcomes.” 30

NOVEMBER 2018 | O&P ALMANAC

COVER STORY

While reimbursement can be a challenge with new technologies, Kogler is optimistic. “In cardiology, someone came up with an EKG, and they found value in that, and [payors] started [reimbursing] for it,” he says. That same model could be relevant to O&P, says Kogler. “If you can show that, using the iAFO, the outcome for the user will be better than an outcome that a clinician guessed at, then the payors will cover it,” says Kogler. “It will have to be demonstrated through research.”

In the future, “every orthosis and prosthesis we fit is going to be embedded with sensors. We will have performance values and target values.” —GEZA KOGLER, PhD

Amira Mouad, CPO

Mouad describes the orthotics space as “ever-evolving,” and suggests that clinical outcomes will likely be required to be supported via outcome measures or scanning in the future. “Payors are holding us accountable for our work,” she says. “If we want to continue to be respected as health-care professionals, we need to be able to demonstrate the efficacy” of orthotic intervention. Sensor technology incorporated into orthoses could be beneficial in securing reimbursement going forward, Irolla agrees, so clinicians should become more familiar with the technology. “Without a concerted effort on the part of practitioners, the use of sensors will not become pervasive, and denials from insurance may increase in the absence of objective measures,” she says. “There will need to be a deliberate effort on the part of our leadership to encourage the use of sensors and addition of L codes to reimburse for the additional expense and added value of these tools.”

A Data-Driven Future

In the coming years, as the baby boomers age and the use of lower-limb orthoses for stability rises, it will become “easier and almost unavoidable” for sensors to be incorporated into conventional AFOs, “to get real-time, longterm ambulatory information—even for something as simple as how many steps a person is taking per day,” says

Bolus. “That’s an extremely important parameter—how much a person is engaging with their device.” Fortunately, the “next generation” of orthotists will be prepared for the challenges involved in fitting advanced orthotics. “For the most part, orthotists have been aware of the limitations we have as clinicians,” says Kogler. “Now, we have a new generation of MSPO professionals—these younger clinicians [automatically think of ] solutions that involve technology and have a drive to use new technologies” such as the iAFO. “Within the next five years, everything is going to be ‘smart,’” predicts Kogler. “Every orthosis and prosthesis we fit is going to be embedded with sensors. We will have performance values and target values.” But even with sensors, advanced technology, and a movement toward more objective evaluation and measurement tools, orthotic decision making will continue to rely, to some extent, on the experience and expertise of certified orthotists. “I wouldn’t discount the subjective factor in setting realistic goals and expectations for the patient,” says Mouad. Optimal

treatment plans are made in collaboration with the entire health-care team to address the patient’s primary concerns or mobility challenges. “This plan is tested with the use of subjective feedback and outcome measures,” she says. Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

Kogler and Bolus offered a discussion of the iAFO at the AOPA 2018 National Assembly in Vancouver. They also published the early results of their study, which was funded by grants from the U.S. Department of Defense, in the article, “Instrumented AnkleFoot Orthosis: Toward a Clinical Assessment Tool for Patient-Specific Optimization of Orthotic Ankle Stiffness,” which appeared in the December 2017 issue of IEEE/ASME Transactions on Mechatronics.

O&P ALMANAC | NOVEMBER 2018

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Finding Meaning in

MEASUREMENT Top minds in O&P discuss outcomes and evidence-based practice at the 2018 AOPA National Assembly

NEED TO KNOW Several high-profile speakers at the 2018 AOPA National Assembly discussed the need for O&P professionals to gather large-scale outcomes data—data related to a patient’s health status, variables related to intervention and outcomes, and patient satisfaction. Although the profession is starting to publish this kind of data and share it with policymakers, efforts are still very limited. More data is needed to measure efficacy of practice and devices, benchmark patient outcomes and practitioners’ success rates, and inform research hypotheses and clinical decision making. Some facilities are already capturing outcome measures at specified points throughout each patient’s care process; this data is being used in some cases to develop clinical practice guidelines and to partner with larger entities in more comprehensive studies. Initial steps are underway, via a partnership between the Mayo Clinic and National Institutes of Health, to create a national Limb Loss and Preservation Registry to collect data and ultimately improve prevention, treatment, and rehabilitation for individuals with limb loss.

NOVEMBER 2018 | O&P ALMANAC

ALKING THE AISLES OF the

exhibit hall, attending a clinical or business educational session, discussing a poster presentation, or listening to a general session talk, attendees of the 2018 AOPA National Assembly were hard pressed not to hear the terms “outcomes measures” or “evidence-based practice” in conversation. While many organizations have made strides in identifying and documenting clinical outcomes in recent years, views on how the profession collects, validates, secures, and applies this data in the future are coming into focus. Addressing these critical aspects, seven experts gathered in Vancouver for a symposium to present current examples of routine outcomes measurements in clinical practice and examine how data collected can be used to demonstrate value, support reimbursement efforts, and direct policymaking in the years to come.

Brian Hafner, PhD, professor in the Department of Rehabilitation Medicine and an adjunct professor in the Departments of Bioengineering and Mechanical Engineering at the University of Washington, kicked off the conversation with a high-level discussion of large-scale outcomes data—data related to a patient’s health status, variables related to intervention and outcomes, and patient satisfaction—and how it can benefit the profession. This information can be used individually or en masse to examine practices and the O&P profession. Among its many uses, the largescale data can measure efficacy of practice and devices, benchmark patient outcomes as well as practitioners’ success rates, and inform research hypotheses and clinical decision making, Hafner explained. More broadly, he emphasized how data can be used to both form and revise health-care policy. “This data could really prompt a critical review of reimbursement policies and hopefully change some of those policies for the betterment of our patients,” he said. “We could use this data to form new policies as new types of P&O interventions come on the market, and we need new policies to support their provision. And ultimately CMS and the other insurance providers might use this information to appropriately allocate resources in the best way possible.” Although the profession is starting to publish this kind of data and share it with policymakers, efforts are still very limited in terms of data sets, despite the fact that millions of people are living with limb loss worldwide. “If you look at that relative to the numbers of people that are in even our biggest studies, if you look at retrospective cross-sectional or longitudinal studies, they’re just dwarfed in comparison,” Hafner explained. “We have access to all these patients, all of this information, and all of this data. We should be trying to use that if we possibly can.” From a clinical standpoint, Hafner suggested one of the most valuable uses of the large-scale data is to monitor the effects of O&P

“When we look at life outcomes, it’s equally important we think of things like quality of life, we think of pain, we think of employment, and independence.” — JAMES CAMPBELL, PhD, CO, FAAOP

intervention over long periods of time. Secondary conditions, such as osteoarthritis, take “decades to develop,” and typical grants or studies do not usually span that length of time. Data collected and generated in real time can also keep pace with technological advances and help clinicians “better look at incidence and prevalence of various conditions” with up-to-date information and establish normative data. Still, challenges abound with collecting “biomedical big data.” It can be unwieldy, disorganized, and poorly collected and secured, which can spur data mining rather than thoughtful investigation. “This leads to inference rather than using logic and reasoning to accomplish the aims of the study. Poor data leads then to bad evidence. Bad evidence then leads to poor policy. And that’s certainly not where we want to go,” he concluded, calling upon the O&P community to collectively decide on industry-wide standards for data collection, validation, access, and usage to be “data informed” rather than “data driven.” During his presentation, James Campbell, PhD, CO, FAAOP, chief clinical officer, Hanger Clinic, echoed this same call to action, particularly the need for validated outcome instruments and the ability to identify

and categorize the elements of best practice. He described how Hanger Clinic disseminates clinical practice guidelines based on evolving outcomes evidence: “As we integrate that guideline into our patient-care activities, as we gather individual patient outcomes and population outcomes, we can then use the information and the evidence that we’re securing to further drive, modify, and change our clinical practice guidelines.”

Choosing Variables

Campbell’s talk also tackled the correlation between life outcomes and mobility, which is of great interest to the profession. “When we look at life outcomes, it’s equally important we think of things like quality of life, we think of pain, we think of employment, and independence,” he said. Because research in this area was limited, Hanger conducted its own investigation and found that mobility is positively correlated to quality of life and general satisfaction. Having this demonstrative link is important, said Campbell, because “when you look at a peer community … there is a tremendous emphasis in place around quality of life. There’s a tremendous emphasis being placed around interaction in the community.” O&P ALMANAC | NOVEMBER 2018

“From using outcome measures in our care, we have found five benefits. …They improve our evaluation of treatment, our clinical decision making, our motivation of patients, our ability to set and measure goals, and our communication.” — BRITTANY POUSETT, CP(C), MSc

Hanger took this examination further by also investigating the impact of comorbidities on mobility in patients with lower-limb prostheses. The results showed that comorbidities do not appear to inform on a patient’s mobility. “Essentially within the peer community, the impact of comorbidity on prosthetic limb users’ mobility has been significantly and greatly overestimated,” said Campbell, adding that “… decreased mobility is really not synonymous with lack of mobility.” In his presentation, “The Use of Health Economic Measure in P&O,” Andreas Hahn, PhD, MSc, corporate vice president of clinical research for Ottobock, described industry practices for expressing the benefit of O&P intervention in terms of cost effectiveness by measuring gait speed, distances, time, and more. “That is something we have become really, really good at over the past years,” he explained. “And it is very important to specifically distinguish interventions within a certain discipline.” Now, the process has evolved to measure specific health status of O&P patients as it relates to quality of life and societal expectations. A number of generic instruments can be used to measure this, said Hahn, including the EQ-5D-5L, a five-dimensional questionnaire for patients that gauges 36

NOVEMBER 2018 | O&P ALMANAC

their health states related to mobility, self-care, usual activity, pain and discomfort, and anxiety and depression. Ottobock has been applying this instrument at 15 workshops in five countries with about 375 patients at various amputation levels to ascertain utility values and effectiveness of interventions. Results showed improvement in each of the five dimensions. Hahn says this kind of measurement instrument could be implemented at a larger scale for greater data samples. “It could have economical meaning, and it is very sensitive, very simple to apply, and is very supportive for our case.” Similarly, Scott Sabolich, CP, owner of Sabolich Prosthetics & Research, also provided perspective on how his facility is collecting data on lower-limb prosthetic users. What started out as a concerted effort to make the business “audit proof” and to justify the use of higher-level componentry has turned into a consistent evaluation process, administered by a trained medical assistant. “Every single person— whether K1 or K4—goes through the same three or four outcome tests and the same three PROMs [patient reported outcome modules] at every piece of the puzzle,” he explained. “Typically, [Sabolich Prosthetics & Research] does outcomes and

baselines prior to fitting, and initial assessment sometime, maybe two to three weeks after that, at six months, and then every year after,” said Russell Lindstrom, director of clinical research and services for Ottobock, who partnered with Sabolich on a retrospective chart review and data analyses. Lindstrom detailed the organization’s multiyear data collection process and offered insights on how he analyzed data sets and their results. About half of the patients showed clinically meaningful improvements based on outcomes. Outside of K level, however, “no clear predictors have emerged for clinical improvement” due to multiple limitations with the information, he explained. Additional work is needed to shore up data gaps, standardize data entry, and more. Still, Lindstrom emphasized the power of the work: “There is value to patients, prescribers, and payors in routine clinical outcomes that could be critical for your practice to prepare you for the future, differentiate your brand, guide care coordination across the health-care system, and eventually make advanced technology more accessible to patients.”

Changing Conversations

Collecting and evaluating outcomes also offers quantitative value to everyday conversations, according to presenters. Brittany Pousett, CP(C), MSc, head of research for Barber Prosthetics Clinic in Vancouver, shared her experiences implementing routine outcome measures with lower-limb patients: “From using outcome measures in our care, we have found five benefits. …They improve our evaluation of treatment, our clinical decision making, our motivation of patients, our ability to set and measure goals, and our communication,” she explained. Take, for example, the new transtibial amputee who complained of debilitating pain in her distal interior tip that prevented her from walking. After various adjustments and alignments did not help, Pousett asked the patient to rate her pain on a scale of one to 10. The patient described it as “0.5 out of 10.”

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“A registry tells us about effectiveness—how well does the device perform in the general population, in the general chaos of clinical practice.” — KENTON KAUFMAN, PhD, PE

That completely changed the conversation, said Pousett. “Now we can talk about maybe if the pain scale gets to a three, or a four, or a five, then we’ll address it. But for now, this is something that [the patient] might have to get used to. It's a new feeling for [her] limb.” In another example, by taking preand postsurgical assessments, Pousett was able to demonstrate to an individual who had an amputation for a bilateral club foot that his balance and mobility improved as a result of the surgery. “That's something that they can show their family and friends … something tangible that says, ‘Look at what I’ve done.’” Outcome measures also can improve intraoffice communications, according to Pousett. At Barber, clinicians must use outcome measures on every patient at set intervals. What they initially described as “daunting” is now seen as “quantification to complement the subjective information already obtained,” she reported.

Coming Up

The need for transparent, value-based evidence in O&P is just beginning, according to the presenters. 38

NOVEMBER 2018 | O&P ALMANAC

Professionals should expect that efforts currently focused on function, recorded patient outcomes, morbidity and mortality, and cost will be changing in the near future—and so should the profession’s mindset. Kenton Kaufman, PhD, PE, W. Hall Wendel Jr. Musculoskeletal Research professor, professor of Biomedical Engineering, director of Motion Analysis Laboratory, and consultant for the Departments of Orthopedic Surgery, Physiology, and Biomedical Engineering at the Mayo Clinic, points to changes at the U.S. Food and Drug Administration as one example. The agency has announced it will be using “real-world” data—including electronic health records, claims and billing activities, in-home use settings, and data gathered from mobile devices—to monitor postmarket safety. “I think the focus has to shift from measures that occur in a laboratory setting to measures that focus [on] when nobody’s watching,” said Kaufman. Wearable devices offer another opportunity for data collection and real-world observation, as do patient registries. Whereas a randomized clinical trial establishes a protocol and

criteria for inclusion and exclusion, registries are inclusive of all patients. “The randomized control trials give you information about efficacy, that is, how does the device perform in a carefully selected group of patients under a carefully controlled protocol,” Kaufman explained. “A registry tells us about effectiveness—how well does the device perform in the general population, in the general chaos of clinical practice. “What we really need to do is develop a registry for collecting real-world data of the patients that everybody treats. So, if you look at clinical care, if we collect that data and put it in a registry, we can then analyze the data … and look at performance of improvement and the best practice guidelines based on the practice of the entire nation,” said Kaufman. To that end, he used the presentation to announce the Mayo Clinic’s partnership with the National Institutes of Health (NIH) to develop a national patient registry to “evaluate resource utilization from interventions across the United States, and then identify provider and hospital variables associated with quality outcomes.” Data will be sourced from patients in hospitals at the time of amputation, from prosthetists, and from patients postamputation and stored in the repository. “The research data would require a written protocol reviewed by a committee, and that protocol would either be approved or disapproved, and there would be very tight controls on this data,” Kaufman explained. Leaders also are working with security experts to assure data is properly secured. Expected to be operational in 2020, the Limb Loss and Preservation Registry will be the first national registry of people who have lost limbs and promises to collect data that will improve prevention, treatment, and rehabilitation efforts for this population, according to NIH. Josephine Rossi is editor of O&P Almanac. Reach her at jrossi@contentcommunicators.com.

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AOPA NATIONAL ASSEMBLY

SPECIAL EVENTS Attendees of the 2018 AOPA National Assembly take time to enjoy networking opportunities in Vancouver

Poster Sessions Attendees explore the new e-learning lounge.

Welcome Reception Grand Opening Reception: Musqueam, “People of the River Grass,” welcome attendees with a traditional dance at the ribbon-cutting ceremony.

Exhibit Hall Activities Slap Shot Hockey

Thranhardt Golf Classic Furry Creek 40

NOVEMBER 2018 | O&P ALMANAC

THE EDWIN AND KATHRYN ARBOGAST AWARD 2018 Award Winner: “An Analysis of Internal Consistency Within OPUS in UpperExtremity,” Katherine Ching, University of Pittsburgh

THE OTTO AND LUCILLE BECKER AWARD 2018 Award Winner: “Self-Efficacy Related to Education Level in O&P,” Peter Zenger, University of Pittsburgh

AOPA Collaborates With Professionals From India At the 2018 AOPA National Assembly, the Orthotic and Prosthetic Association of India (OPAI) thanked AOPA for recent collaborative efforts that allowed members of the organization to participate at the National Assembly. OPAI leaders formally honored AOPA after the morning general session on September 29 by presenting leaders and staff with glass plaque keepsakes. The gesture is in response to a multiyear endeavor between the two organizations to increase awareness of O&P-related opportunities and challenges in India, and to enhance information sharing with Indian professionals. Among other efforts, AOPA has named OPAI President Neeraj Saxena as AOPA’s coordinator for India for future collaborations. OPAI currently counts around 1,400 O&P professionals as members, whose credentials range from a diploma to a master’s degree, according to Saxena. The organization is involved in efforts to raise the educational requirement needed to practice in the country in order to elevate the professional stature of O&P in the Indian health-care community and among citizens. OPAI Chairman of International Relations Rakesh Jain, CPO, LPO, describes the O&P environment in India as “challenging,” given the country’s size, diverse population, and vast wealth inequality. To navigate these issues, OPAI offers its members certifications, continuing education, legislative updates, networking with allied health-care organizations, advocacy work, and other benefits. Leaders hope that through the collaboration with AOPA, OPAI can glean best practices and insights for promoting the profession. They also aim to learn more about advanced technologies and partner with suppliers to bring more affordable and effective devices to India’s low-income communities.

“The profession is becoming very prominent [in India], and people are understanding the importance of prosthetics and orthotics [and] how they can play a vital role in improving the lives of … people around the country and lead them to live a dignified life,” says Jain. O&P ALMANAC | NOVEMBER 2018

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O&P ALMANAC | NOVEMBER 2018

PRINCIPAL INVESTIGATOR

Boosting Research To Aid Injured Service Members Ignacio Gaunaurd, PT, PhD, MSPT, works to improve quality of life for wounded military members—and the greater amputee population

O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and health-care professionals who have carried out studies and gathered quantitative and/or qualitative data related to orthotics and prosthetics, and find out what it takes to become an O&P researcher.

Ignacio Gaunaurd, PT, PhD, MSPT, works with amputees during prosthetic research studies.

NOVEMBER 2018 | O&P ALMANAC

decision-making process for a service member who lost their lower limb but who wants to continue serving in the military,” says Gaunaurd. In November 2013, the Journal of Rehabilitation Research and Development published the results from Gaunaurd’s CHAMP study in a single-topic issue. It was a proud moment for Gaunaurd: “We produced seven manuscripts and three editorials for that single-topic issue. [It] was an amazing, true team effort and has probably been my most significant work to date in physical therapy (PT)/O&P research.” Gaunaurd, who currently serves dual roles as a research health scientist at Bruce W. Carter Veterans Affairs Healthcare System in Miami (Miami VAHS) and a voluntary assistant professor in the Department of Physical Therapy at UM, was inspired to join the PT/O&P profession after seeing firsthand how targeted rehabilitation can have an immediate and significant impact on the quality of movement and function, the use of the prosthetic limb, confidence, and overall well-being of someone with lower-limb loss. “I was drawn to the team approach, with the CPO and PT working together for a common goal of optimizing the prosthetic fit, choosing the right components, and teaching the patient to maximize the use of their prosthesis,” he says.

PHOTOS: Ignacio Gaunaurd, PT, PhD, MSPT

GNACIO GAUNAURD, PT, PhD, MSPT,

has spent much of his career advancing the interests of amputee service members and veterans. In fact, his dissertation at the University of Miami (UM) focused on the development of the Comprehensive High-Level Activity Mobility Predictor (CHAMP), which is a “reliable and valid performance-based outcome measure that assesses highlevel mobility and readiness to return to high-level activity and duty in service members and veterans with traumatic lower-limb loss,” explains Gaunaurd. “It was an honor to develop a measure that could assist in the

PRINCIPAL INVESTIGATOR

Applying PT Expertise to O&P Rehabilitation

Gaunaurd earned both a bachelor of science degree in dietetics and nutrition and a master of science degree in physical therapy from Florida International University. He got involved in PT/O&P research soon after, when given the “opportunity of a lifetime” to work under Robert Gailey Jr., PT, PhD. Gaunaurd had been a research coordinator with Miami Research Associates for two years before beginning his master’s and had served as a research/graduate assistant to Neva Kirk-Sanchez, PT, PhD, throughout his master’s studies. After Gaunaurd completed his master’s, Kirk-Sanchez connected him with Gailey, who offered him a position as a research physical therapist at the Miami VAHS on a Merit Review RR&D grant exploring the benefits of a new prescription-based exercise program for veterans with unilateral below-knee amputation. Gaunaurd concurrently began his PhD studies at UM. Gaunaurd found rehabilitation research to be a perfect fit. “I really enjoy trying to develop and answer a research question. It is not easy, definitely not perfect—and what you find may surprise you—but it will always help you grow as

The University of Miami team a researcher, clinician, and person,” he says. He also appreciates the opportunity to interact with study participants: “They give an enormous amount of time out of their daily lives to try to help us solve a problem and address a need. They are paying it forward, giving back, and trusting us in the process.” In his current role at Miami VAHS—which partners with UM to house the Functional Outcomes Research and Evaluation Center, led by Gailey—Gaunaurd develops, guides,

NOVEMBER 2018 | O&P ALMANAC

PHOTOS: Ignacio Gaunaurd, PT, PhD, MSPT

Gaunaurd and his team at a live public demonstration at the Smithsonian Museum of American History, Washington, DC, October 2017

and implements innovative research to help improve the function and quality of life of veterans and service members. “I have been lucky to be involved in every aspect of the research process to develop new outcome measures, implement innovative rehabilitation interventions, examine the contribution of prosthetics to function and mobility, and introduce mobile technology in the home and community for veterans and service members with lower-limb amputation,” he says. Gaunaurd’s team, in collaboration with military, academic, and industry partners, has helped to develop outcome measures and metrics such as the CHAMP, the Bilateral Amputee Mobility Predictor (BAMP), the Component Timed-Up-and-Go Test (cTUG), the Prosthetic Limb Users Survey of Mobility (PLUS-M), the Comprehensive Lower-Limb Amputee Socket Survey (CLASS), and the Symmetry of External Work (SEW) metric. He and his team also have developed prescription-based exercise programs, such as the Evidence-Based Amputee Rehabilitation Program (EBAR); prosthetic gait training programs, such as the Standardized Functional Prosthetic Training; and mixed-method outcome measure education programs for CPOs. “We have published on the contribution of microprocessor ankle-foot components and foot design to everyday

PRINCIPAL INVESTIGATOR

Gaunaurd discusses early postsurgical intervention for patients with lower-limb loss during Federal Advanced Amputation Skills Training.

PHOTO: Ignacio Gaunaurd, PT, PhD, MSPT

activities such as walking, sit-tostand, stair climbing, and ascending and descending ramps,” he says. More recently, Gaunaurd’s team has implemented a mobile sensor system for home and community use for amputee veterans and service members that provides real-time gait assessment and correction through auditory biofeedback: the Mobile Device Outcomes-based Rehabilitation Program (MDORP). This program is a collaborative effort among the Miami VAHS, UM Department of Physical Therapy, UM Department of Music Engineering at the UM Frost School of Music, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, and Henry Jackson Foundation. The MDORP project incorporates the use of a mobile sensor system called “ReLOAD” to provide the patient with a self-management program through auditory biofeedback for real-time gait deviation detection and correction in the home and community and a prescription-based home exercise program that targets their most prominent gait deviations. “We

like to say that MDORP participants have a ‘PT in their pocket’ when they are home walking, identifying a gait deviation and immediately giving them a verbal cue to improve the way they walk,” explains Gaunaurd. Preliminary results have exceeded expectations, demonstrating that those who used the system as recommended demonstrated significant improvement in gait symmetry and prosthetic mobility. For future projects, Gaunaurd and his team plan to shrink the equipment needed for MDORP, to “transition from a mobile tablet to a mobile phone and eventually just have a downloadable app,” he explains. “We are working on auditory biofeedback for higher-level mobility for active people both with and without lower-limb amputation and for a prescription-based exercise program for higher-level agility and balance exercises.”

Leading the Next Generation

In his work at UM, Gaunaurd teaches foundational didactic courses for Doctorate of Physical Therapy (DPT) students and helps guide them through their research practicum.

He also has acted as a mentor and course master for current and past PhD students within the university’s Department of Physical Therapy who are currently enrolled in the amputee rehabilitation and prosthetics track. He enjoys introducing graduate DPT and PhD students, clinicians, and novice researchers to the research process in the field of PT/O&P, and he advocates for very hands-on training. “We had 22 UM DPT graduate students travel with our team and help us collect data for the development of CHAMP,” he recalls. “We have collected data at three of the last four Amputee Coalition meetings, bringing with us well over 25 graduate students and PhD students.” Gaunaurd, in his role at UM, recently joined in two collaborations with the University of Washington supported through National Institute of Health (NIH) and Department of Defense (DoD). The goal of the NIH project is to “develop a new performance-based measure of prosthetic mobility that we envision to be quicker and easier to administer in the clinic and more sensitive for assessment of function,” he explains. The goal of the DoD project is to add items to the PLUS-M that assess higher-level activity performance. While most of his collaborations are purely professional, Gaunaurd’s partnership with his wife of 11 years, Annabel Nunez-Gaunaurd, PT, PhD, is an example of the power of shared interests. Gaunaurd and NunezGaunaurd completed their PhDs together at UM; her expertise is in childhood and adolescent obesity and wellness, and she now serves as an assistant professor with the Department of Physical Therapy at Nova Southeastern University. “We were blessed and bit crazy to have both of our kids while in the PhD program,” Gaunaurd recalls—the couple have a 9-year-old son and 7-year-old daughter. In his spare time, he enjoys playing sports with his kids, exercising, riding his bike, fishing, and cooking. “I secretly always wanted to attend culinary school,” he says. “I get to live out my culinary fantasies when I cook for my family and friends.” O&P ALMANAC | NOVEMBER 2018

PRINCIPAL INVESTIGATOR

Expanding the Reach

While much of Gaunaurd’s research is centered around military members and veterans, his work has implications for men and women of all ages who are functioning at levels K1–K4 who have lost their lower limb due to trauma, dysvascular disease, and cancer. “We have helped develop outcome measures to assess basic and high-level mobility through survey and physical performance that will help clinicians measure the value of their rehabilitation and prosthetic intervention for third-party payors,” he says. “We have demonstrated the importance of a targeted rehabilitation program to help improve prosthetic mobility and function and minimize gait deviations. If not addressed, those gait deviations could lead to long-term secondary co-morbidities such as osteoarthritis, low back pain, inactivity, cardiovascular disease, obesity, and future amputation.” The work of Gaunaurd and his team also has shown how lower-functioning people with lower-limb amputation and

dysvascular disease can demonstrate improved walking symmetry using J-shaped dynamic response feet for everyday activities. “We recently published the CLASS, which is a survey that can be given to the patient during the prosthetic fitting process that provides the CPO with more detailed information about the patient’s socket stability, suspension, comfort, and appearance during sitting, standing, walking, and stair ascending and descending,” he says. The CLASS can help the patient communicate to the CPO his or her socket comfort during different everyday activities and justify to third-party payors the need for a new prosthetic socket, thus justifying the need for their intervention. Gaunaurd has seen a significant shift in the O&P profession over the past 10 years, with the implementation of several outcome measures during prosthetic interventions. “These measures, if administered at the time of patient evaluation, administered throughout the intervention periodically, and at the end of your intervention, can demonstrate

how your patient has improved, justifying your intervention,” he explains. “The key to implementation of outcome measures into your daily clinical routine is recognizing that you do not have to administer every single outcome measure.” He suggests choosing one or two self-report and performance-based outcome measures to administer, depending on the patient’s impairment or limitation—“and consistently administer them at key points in clinical time.” He also encourages O&P professionals interested in research to attend national conferences and to contact authors of research articles that interest them. “If you read a manuscript that inspires you, and you want to learn more about the topic or see if there is an opportunity to work with the individual, send them an email,” he recommends. “Do not be afraid to reach out. The majority of those who are part of the research community in PT/O&P want to give back and share their expertise, and educate the next generation of clinician scientists.”

Make Your First Impressions Count With Customized Polo shirts, Scrub tops and Lab Coats for your O&P staff

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NOVEMBER 2018 | O&P ALMANAC

AOPA Polo Shirts–Now for Sale Celebrate AOPA’s Centennial with us by ordering AOPA polo shirts for your office! The shirts are black with a white AOPA logo. Moisture wick, 100 percent polyester. Rib knit collar, hemmed sleeves, and side vents. The polos are unisex but the sizes are men’s M-2XXL. $25 plus shipping. Order in the bookstore at bit.ly/aopastore.

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MEMBER SPOTLIGHT

American Orthotic & Prosthetic Center

East Coast Action Virginia facility contracts with U.S. Department of Veterans Affairs and engages in volunteer efforts

ICHAEL SMITH, CPO, grew up around prosthetics and has always been fascinated by the profession. His father, Aubrey Smith, CP, owned a practice in Canton, Georgia, that began as a central fabrication facility and expanded into patient care. “In high school, I knew this is what I wanted,” he says. Smith attended the O&P program at the University of Washington and completed his residency in Topeka, Kansas. Once certified, he moved to Richmond, Virginia, where he opened and managed Hanger’s Newport News office. He returned to work with his father for a time, and in 1990 decided to launch his own practice, American Orthotic & Prosthetic Center, in southeast Virginia.

Michael Smith, CPO, fits a hip disarticulation prosthesis.

FACILITY: American Orthotic & Prosthetic Center OWNER: Michael Smith, CPO LOCATIONS: Several Offices in Virginia HISTORY: 28 years

Michael Smith, CPO, right, and his father, Aubrey Smith, CP, travelled together on a mission to Jamaica.

NOVEMBER 2018 | O&P ALMANAC

Smith worked with bilateral amputee Lillie Evans to help her get up and walking.

before seeking formal education in the field. “I’ve introduced O&P to many high school and college students,” he says. “I enjoy teaching. This is a unique field, and I like telling people about it.” Smith’s educational efforts do double duty as a marketing tool. The facility also leverages periodic social media posts and an active website to raise awareness of its brand. The website offers several resources for patients and professionals, including a password-enabled section that gives physicians and physical therapists access to research and information on orthotic and prosthetic components. In addition, physicians can complete an online form that serves as a detailed written prescription with complete information to meet requirements for billing under Medicare and most private insurers. Smith has a strong commitment to volunteer work. He began with a Norfolk group called Physicians for Peace and now works with Montero Medical Missions. The group set up an O&P clinic at a government hospital in Manila and is expanding to Mindanao, the second-most populated area in the Philippines. “We’re training local people to fabricate devices,” Smith says. “In the beginning, I had a Filipino tech come here to work with me for a month. Now we travel there twice a year.” American O&P also offers services at a local free clinic. Smith has no plans to expand his business outside of his Virginia offices. Instead, he says, he’d like to focus on additional volunteer work, teaching clinicians and technicians in underserved areas. “The more we can show them how things are done, the more limbs we can get to people who need them.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: American Orthotic & Prosthetic Center

Today, the company has 10 employees, with offices in Chesapeake, Richmond, and Hampton. A satellite office in Belle Haven serves patients on Virginia’s Eastern Shore, and one in South Hill offers services to the south/central part of Virginia. Smith’s wife of 30 years, Cynthia, handles payroll and accounts payable—key responsibilities within the practice. “She understands the hectic pace of the profession and keeps me informed on day-to-day operations, which

allows me to focus on patient care and keep the business running smoothly,” Smith says. While the facility offers a full range of upper- and lowerextremity orthoses and prostheses for adults and children, the majority of its work is in prosthetics. The Tidewater area of Virginia has a strong military presence, and American O&P has contracts with the U.S. Department of Veterans Affairs in Hampton and Richmond. The Chesapeake facility has a central fabrication lab that handles work from all offices. Technicians use computer-aided design and recently moved to a new system that allows clinicians to use a tablet to create patient scans. Education is important to Smith, and he often lectures and offers in-services to physical therapists (PTs). “We got our lectures accredited by the Virginia Physical Therapy Association, so PTs who attend earn continuing education credits,” explains Smith. Many students have passed through American O&P, where they received preliminary training

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Motion Medical

By DEBORAH CONN

Purpose-Driven O&P Company embraces team approach and leverages clinician partnerships to distribute orthopedic braces

OHN DEAN AND RUSS SMITH

NOVEMBER 2018 | O&P ALMANAC

John Dean works with a patient.

COMPANY: Motion Medical OWNERS: John Dean and Anne Dean LOCATION: Birmingham, Alabama HISTORY: 29 years

A Motion Medical product in use on a patient

System (HCPCS) codes and verification of benefits; and processes insurance claims for patients. A subsidiary of the company, The Orthopedic Marketplace, uses a cloud platform to help practitioners manage inventory and automate restocking orders. The system is designed to ensure accuracy and a streamlined ordering process, according to Anne. Another side to Motion Medical is business consulting. The company’s billing specialists will work with practices on proper procedures and keep up with any changes in Medicare and insurance reimbursement strategies. “We try to be their eyes and ears” in the durable medical equipment, prosthetics, orthotics, and supplies industry, says Anne. “If someone calls because they keep getting rejected for a particular code, we’ll dig down to find out why and help them work through it.” Most practices don’t have time for that kind of intensive work, she notes. Motion Medical occupies a 5,000-square-foot warehouse where the majority of its inventory

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

PHOTOS: Motion Medical

launched Motion Medical in 1989 to distribute orthopedic braces to customers in Alabama. A few years later, the company expanded its offerings and Dean became a certified orthotic fitter. Anne Dean joined the company early on, and she and John married in 1988. Today, the two own and run the company, which serves orthopedists, clinics, hospitals, and orthotic and prosthetic practices throughout most of the state. Motion Medical is the exclusive distributor for several orthopedic product manufacturers, emphasizing those that produce quality products in the United States. “We look for top-notch manufacturers who continue to reinvest in America by maintaining jobs in the U.S.,” says Anne. Motion Medical is not “just another company that sells braces from a catalog,” Anne notes. “We’ve expanded our services so that we can partner with physicians and O&P practitioners and help them grow their business. We believe in the importance of comprehensive patient care, and we as a company set ourselves apart by offering quality products and services to connect O&P practitioners with physicians in order to deliver this level of care.” Among its offerings are inventory management and stock-and-bill services. Motion Medical places orthopedic braces in physicians’ offices, O&P facilities, hospitals, and surgery centers; provides manufacturer-suggested Health-Care Common Procedure Coding

is held, which reduces delivery time to customers. “Sometimes in emergency situations, we will hop in the car to deliver a brace within hours,” says Anne, “and a number of our customers stop in to pick things up on their way to the hospital.” The facility features a patient exam/fitting room, so if physicians need an adjustment on a specialty brace, one of Motion Medical’s certified brace fitters can take care of it. John emphasizes the company’s tight-knit culture and the long tenure of its employees. “We all operate under a set of principles we call PAARE, which stands for purpose, attitude, awareness, relationships, and enthusiasm.” Another acronym in use is TIPS, for the company’s core values of teamwork, integrity, passion, and service. Regular weekly team meetings keep everyone connected and up to date on news and changes in the industry. In addition, the company hosts employee cookouts, fun nights out, go-cart racing, and other events to bring the team together, according to Anne. “We also sponsor service projects for employees and their families to help people in the community and overseas. “Each of our team members is so important to our success. We enjoy being around each other, and it makes a big difference. We work hard, but we have fun, too,” adds Anne. Looking ahead, John and Anne are open to exploring new partnerships and co-marketing relationships—and perhaps expanding beyond the state of Alabama. Any changes, they say, would have to relate to the company’s core purpose: helping people. “It’s the most important thing we do,” says Anne.

Realize the facts. O&P care improves quality of life and is cost effective! Learn more at MobilitySaves.org. The Study that Started MobilitySaves.org A major study, comparing patients using prosthetics versus patients without prosthetics had these findings: • They will have lower or comparable Medicare costs than patients who need, but do not receive, these services.

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See how amputees rallied when their prosthetic care was threatened

The Results Lower Limb Prosthetics Prosthetic patients experienced better quality of life and increased independence compared to patients who did not receive the prosthesis at essentially no additional cost to Medicare (or other payers).

O&P CARE IS A SAVER, NOT AN EXPENSE TO INSURERS! Visit MobilitySaves.org. Follow us on social media! “Search Mobility Saves” on Facebook, Twitter, and LinkedIn

AOPA NEWS

AOPAversity: Webinar Series Subscription During the one-hour monthly Webinars, AOPA experts provide the most up-to-date information on a specific topic. Webinars are held the second Wednesday of each month at 1:00 PM Eastern. One registration is all it takes to provide the most reliable business information and CE Credits for your entire staff. If you’ve missed a Webinar, AOPA will send you a recording of the webinar and quiz for CE credits, so you can still take advantage of the series discount and the valuable learning opportunities. Per Seminar Sign Up for the 2018 Full Year Series & SAVE! AOPA Members $99.00* $990.00 Non-Members $199.00* $1990.00 AOPA members use code “member” when registering for the $99 price. *Includes an unlimited number of participants per telephone line. Earn 1.5 Business CEs each by returning the provided quiz within 30 days and scoring at least 80%. All webinars begin at 1 p.m. Eastern. Webinar registration fees are non-refundable. AOPA can provide the webinar recording if registrants cannot make the scheduled webinar.

DECEMBER 12

2019 WEBINARS

2019 Webinar Topics Announced Mark your calendars for AOPA’s 2019 monthly webinars. These informative sessions take place on the second Wednesday of each month at 1 p.m. Eastern time. 2019 Webinars • January 9: Understanding the Knee Orthoses Policy • February 13: Patient Outcomes: Best Practices & How To Use Them • March 13: Advanced Beneficiary Notice (ABN): Get To Know the ABN Form • April 10: Shoes, External Breast Prostheses, Surgical Dressings, and Other Policies • May 8: Are You Compliant? Know the Supplier Standards • June 12: Documentation—Understanding Your Role • July 10: Target, Probe, Educate—Get To Know the Program & What the Results Are Telling You

New Codes, Medicare Changes, & Updates Prepare for the new year by getting a head-start on the Health-Care Common Procedure Coding System (HCPCS) coding changes for 2019. Take part in the December 12 webinar, where you will: • Learn about new HCPCS codes that will take effect Jan. 1, 2019 • Find out which codes will no longer be used as of Jan. 1, 2019 • Discuss verbiage changes to existing codes and how they may affect O&P businesses • Hear AOPA’s interpretation of why the changes are taking place • Look at other pertinent policy and legislative changes of which O&P facilities should be aware in order to succeed in 2019.

• August 14: Are You Ready for the Worst? Contingency Planning • September 11: Veterans Affairs Updates: Contracting, Special Reports, and Other News • October 9: Performance Reviews: How Is Your Staff Doing? • November 13: The Holiday Season— How To Provide Compliant Gifts • December 11: New Codes for 2020, Other Updates, and Yearly Roundup During these one-hour sessions, AOPA experts provide the most up-to-date information on a specific topic. Webinars are perfect for the entire staff—they’re a great team-building, money-saving, and educational experience! Sign up for the entire series and get two conferences free. Entire Series ($990 Members/$1,990 Nonmembers). Register at bit.ly/2019webinars.

NOVEMBER 2018 | O&P ALMANAC

AOPA NEWS

NOW AVAILABLE:

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

AOPA Announces 2019 Call for Papers Submissions Due March 25

NOVEMBER 2018 | O&P ALMANAC

Copies of the “2018 Operating Performance Report” are available electronically or print in AOPA’s bookstore: • “2018 Operating Performance Report” (Electronic)—Member/Nonmember: $185/$325

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

O&P PAC UPDATE

HE O&P PAC UPDATE provides information on the activities of the O&P PAC, including the names of individuals who have made recent donations to the O&P PAC and the names of candidates the O&P PAC has recently supported. The O&P PAC would like to thank the following AOPA members for their contributions to the O&P PAC:

• • • • • • • • • • • • • • • • •

Vinit Asar, MBA Devon Bernard Dale Berry, CP David Boone, PhD, MPH, BSPO Frank Bostock, CO Jeffrey Brandt, CPO Luke Brewer, CPO Jim Campbell, PhD, CO, FAAOP Tina Carlson, CMP Don DeBolt Tom Fise, JD Rick Fleetwood, MPA Brian Franklin Elizabeth Ginzel, CPO, LPO Ryan Gleeson, CMP Denise Hoffman Betty Leppin

• • • • • • • • • • • • • • • • •

Eileen Levis Sam Liang F. Daniel Luitjohan, CP Pam Lupo, CO Jeff Lutz, CPO Ann Mantelmacher Stuart Marquette, CO Brian Mayle Yelena Mazur Dave McGill Joe McTernan Kelly O'Neill, CEM Michael Oros, CPO, FAAOP Paul Prusakowski, CPO Scott Ranson Rick Riley John Roberts, CPO

The purpose of the O&P PAC is to advocate for legislative or political interests at the federal level that have an impact on the orthotic and prosthetic community. The O&P PAC achieves this goal by working closely with members of the U.S. House of Representatives and Senate and other officials running for office to educate

• • • • • • • • • • • • • • •

Cathy Rubel Scott Schneider Ed Sisson, CPO Chris Snell, BOCP Clint Snell, CPO Ted Snell, CP Wanda Stephans Sarah Stilley Terry Supan, CPO, FAAOP James Weber, MBA Ashlie White Chris Wilson Jon Wilson, CP Lilly Woodard Shane Wurdeman, CP, FAAOP, PhD, MSPO

them about the issues, and help elect those individuals who support the orthotic and prosthetic community. To participate in, support, and receive additional information about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online: bit.ly/pacauth.

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.

American Limb & Orthopedic Company of Valparaiso 201 E. Morthland Drive, Ste. 2 Valparaiso, IN 46383 219/531-7479 Patient-Care Facility American Orthopedics Inc. 1459 Marion-Waldo Road Marion, OH 43302 740/375-9100 Patient-Care Facility Kenney Orthopedics of Bloomington 474 S. Landmark Avenue Bloomington, IN 47403 812/727-3651 Affiliate

Minnesota Prosthetics and Orthotics 4040 Radio Drive, Ste. 100 Woodbury, MN 55129 651/275-2754 Affiliate National Prosthetic Center 1900 N. Meridian Street Indianapolis, IN 46202 317/296-7330 Affiliate SRT Holdings LLC 217 E. Southway Blvd., Ste. 100 Kokomo, IN 46902 765/865-3668 Affiliate SRT Prosthetics & Orthotics LLC 408 E. Washington Street Butler, IN 46721 419/633-3961 Affiliate O&P ALMANAC | NOVEMBER 2018

AOPA NEWS

CAREERS

Opportunities for O&P Professionals

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

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

Member $482 $634

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

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

Nonmember $678 $830

ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org. Member Nonmember $85 $150

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

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

Certified Prosthetist Orthotist (CPO)

Job location key:

Job Board

Mid-Atlantic

NOVEMBER 2018 | O&P ALMANAC

Central Virginia The Prosthetics and Orthotics Division in the University of Virginia’s School of Medicine seeks a certified prosthetist and orthotist (CPO) to consult, provide, and fabricate orthotic and prosthetic devices for adults and children with musculoskeletal impairments throughout Central Virginia. The successful candidate will be responsible for managing comprehensive orthotic and/or prosthetic patient care. This includes patient assessment, formulation of a treatment plan, implementation of the treatment plan, and follow-up care and practice management. Candidates for the position should have either a bachelor’s degree with completion of an NCOPE-affiliated certificate program and completion of NCOPE-affiliated residency program; or an associate degree with at least 10 years of direct P&O experience. Qualified candidates must be certified through the American Board for Certification in Orthotics, Prosthetics, and Pedorthics and have one year of post-certification experience. Some experience with foot/ankle and pediatrics is required. Also, candidates should be knowledgeable with durable medical equipment billing codes, insurance compliance, and current trends in the prosthetic and orthotic industry. Successful candidates for the position should also possess interpersonal skills to help build referral bases. A history of prior practice management is preferred, and supervisory and office management skills are a plus. Applicants should complete a staff application through the Jobs@UVa website, and provide a cover letter, résumé, and a list of three references. To apply for either position, visit https://jobs.virginia.edu, click on University Staff, and search for posting # 0622645 for the Certified Prosthetist Orthotist. For more information about the division, please visit https:// med.virginia.edu/orthopaedic-surgery/orthopaedic-divisions/ orthotics-and-prosthetics/. This position is restricted and contingent upon continued funding. University of Virginia Website: https://jobs.virginia.edu The University of Virginia is an equal opportunity and affirmative action employer. Women, minorities, veterans, and persons with disabilities are encouraged to apply.

CAREERS Mid-Atlantic

Northeast

CPO and/or CO

CO/CPO

Toledo, Ohio We are seeking a full-time position for an outgoing, bright, and energetic certified orthotist (CO) and/or a certified prosthetist/orthotist (CPO) practitioner for a wellestablished growing practice since 1991. We are located in the greater Toledo, Ohio, area. ABC certification is preferred. Candidate will see patients at our state-of-the-art facility, local hospitals, various physical therapy departments, and nursing homes. Candidate must be motivated, skilled, and hard working, and utilize a team environment. They also should desire a longterm career with a growing company. Competitive salary and benefits including: • 401(k) simple profit sharing • Health insurance plus • Vacation • Continuing education • Generous commission bonuses.

Long Island and Queens, New York Wanted: CO/CPO for busy Long Island and Queens practice. Excellent pay and comprehensive benefits package. Must be professional, knowledgeable, and caring. Upbeat practitioners need only apply. Apply by email to : Mark Goldberg Prosthetic & Orthotic Labs Email: careers@mgpolabs.com

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Résumés can be sent to:

Email: OPC419NReynolds @aol.com Address: 419 N. Reynolds Road, Toledo, OH 43615 Phone: 419/531-2222

Barry Smith Telephone: (O) 323-722-4880 • (C) 213-379-2397 e-mail: loyds@ix.netcom.com AD INDEX

Advertisers Index Company

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Allard

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ALPS

39 800/574-5426 www.easyliner.com

Amfit

800/356-3668

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Anatomical Concepts Inc.

800/837-3888

Cailor Fleming

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Cascade Dafo

800/848-7332

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Coyote Design

800/819-5980

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Custom Composite

866/273-2230

www.cc-mfg.com

Fabtech Systems LLC

800/FABTECH

www.fabtechsystems.com

Fillauer

37 800/251-6398 www.fillauer.com

Hersco

1 800/301-8275 www.hersco.com 9

Össur

19 800/233-6263 www.ossur.com

Ottobock Spinal Technology Inc. Surestep WillowWood

888/977-6693

www.npdevices.com

Naked Prosthetics

27, C4

800/328-4058

www.professionals.ottobockus.com

800/253-7868

www.spinaltech.com

23 877/462-0711 32-33 800/848-4930

www.surestep.net www.willowwoodco.com

O&P ALMANAC | NOVEMBER 2018

MARKETPLACE

Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac18 for advertising options.

ALPS ECO Liner Designed with the end user in mind, the ECO Liner is the newest seamless liner by ALPS. Featuring ALPS HD Gel, the firm nature of the gel provides active amputees with a great degree of control while still providing superior comfort. In addition, it utilizes a new distal construction with reduced stretch to control distal distraction. For more information, visit us at www.easyliner.com.

Anatomical Concepts Inc Anatomical Concepts Inc. is now accepting scanned images in conjunction with WillowWood® for our custom-made V-VAS™ OA Knee Orthosis. Especially tailored for our colleagues near and afar, you can now save on your time and casting materials—without having to ship us a cast impression. Expedite your turnaround time on getting the finished product back to you faster than before. We accept the following file formats: • .STL (preferred format) • .OBJ Please send scanned CAD file along with our fullycompleted V-VAS™ orthometry form, found on our website (V-VAS Knee Orthosis product page), to info@ anatomicalconceptsinc.com, ATTN: Bill DeToro, CPO. For more information, visit AnatomicalConceptsInc.com, or contact 800/837-3888 or 330/757-3569.

Coyote® Design Prosthetic Locks All of Coyote Design’s prosthetic locks are sand-, mud-, and water-resistant to give your patients the freedom to take on whatever life brings their way. For more information, contact Coyote Design at 208/4290026 or visit www.coyotedesign.com.

NOVEMBER 2018 | O&P ALMANAC

Make More Possible With the New 2018 ‘Crossover’ Knee The world’s first hybrid prosthetic knee that is user adaptable for walking, running, or sports. • Walking knee transforms into an activity knee • Mimics natural muscle function • Adjustable tendon durometers • Adjustable flexion range requiring no tools • Adjustable dampening and rebound • 275 lbs K2-K4+ activity • Use in any environment • Light and strong • Hybrid design. Call us about our evaluation program! Call 800/322-8324 or visit www.fabtechsystems.com.

Dynamic Walk AFO by Fillauer® The Dynamic Walk AFO is designed to allow people with dorsiflexor paresis or paralysis to confidently regain their stride. Whether their goal is to walk, hike, jog, or play, the Dynamic Walk’s flexible dorsi-assist joints allow them to move freely. Featuring a heat-moldable, trimmable calf band and foot plate, the Dynamic Walk ensures a comfortable fit every time. 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.

MARKETPLACE iLimb

Spinal Technology The i-limb product range combines functionality with style. Individually motorized digits, stall detection, and the unique software used to control the i-limb hands result in highly versatile prosthetic hands optimized to meet the needs of

your varied patient population. Visit ossur.com/touch or ask your Össur representative about i-limb® today.

WalkOn® Carbon Fiber AFO WalkOn ankle-foot orthoses (AFOs) are prefabricated from advanced prepreg carbon composite material designed to help users with dorsiflexion weakness walk more naturally. WalkOn AFOs are lightweight, low profile, and extremely tough. Their dynamic design can help patients achieve a more physiological and symmetrical gait, offering fluid rollover and excellent energy return. WalkOn offers a full range of AFO sizes and designs including the WalkOn Reaction Junior pediatric sizes. Fast and easy to fit, the WalkOn footplate is trimmable and can be shaped with scissors, often requiring only one office visit. Contact us at 800/328-4058 or professionals.ottobockus. com for details.

Flexibility Meets Stability With the Meridium Microprocessor Foot With real-time control and an unprecedented four-axis design, the Meridium® microprocessor foot has taken a giant step closer to approximating the human foot. Perfect for your low to mid K3 patients that are looking for a more natural gait pattern plus enhanced stability and safety. Ask your sales representative or visit professionals.ottobockus.com for more details.

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.

LimbLogic® M: Mechanical Vacuum Pump WillowWood now offers a simple elevated vacuum solution with LimbLogic M. This inline, mechanical vacuum pump has a low build height of 3.6 inches for flexibility in componentry selection and alignment. LimbLogic M offers: • Adjustable vacuum setting for optimal security and comfort • Shock absorption to reduce impact on limb • Adjustable stiffness to satisfy a range of weights and comfort preferences • Rotatable distal pyramid for easy alignment • Standard four-hole mount for simple and familiar set-up • Light and standard versions suiting weights from 100 to 330 pounds. For information, call 800/848-4930 or visit www.willowwoodco.com.

O&P ALMANAC | NOVEMBER 2018

CALENDAR

2018

Apply Anytime!

November 4–10

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

Apply anytime for COF, CMF, CDME; test when ready; receive results instantly. Current BOCO, BOCP, and 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. www.bocusa.org

November 5–10

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

November 7–9

NJAAOP. Harrah’s, Atlantic City, NJ. For more information, visit www.njaaop.com. Contact Brooke Artesi, CPO, LPO, with questions at Brooke@sunshinepando.com.

November 12–13

2018 Mastering Medicare: Essential Coding & Billing Techniques Seminars. Las Vegas. Register online at bit.ly/2018billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Coding & Billing Seminar

November 14

Evaluating Your Compliance Plan & WEBINAR Procedures: How To Audit Your Practice. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

November 28–30

New England Chapter AAOP. Please join us at Mohegan Sun in Connecticut for an outstanding ABC/ BOC continuing education program. Registration and more information at www.neaaop.org.

December 1

ABC: Practitioner Residency Completion Deadline for January 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.

December 6–8

Shirley Ryan AbilityLab: Elaine Owen. Pediatric Gait Analysis and Orthotic Management: An Optimal Segment Kinematics and Alignment Approach to Rehabilitation (OSKAR). Chicago. 25.5 ABC credits approved. For more information, contact Melissa Kolski, call 312/238-7731, or visit www.sralab.org/academy/PedsGait18. 62

NOVEMBER 2018 | O&P ALMANAC

December 9–14

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

December 12

New Codes, Medicare Changes, & Updates. Register online at bit.ly/2018webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. WEBINAR

2019 January 1

ABC: Practitioner Residency Completion Deadline for February 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.

January 4–6

AOPA 2019 Leadership Conference. The Scott, Scottsdale, AZ. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

January 9

Understanding the Knee Orthoses Policy. Register online at bit.ly/2019 webinars. For more information, email Ryan Gleeson at rgleeson@ AOPAnet.org. WEBINAR

January 11–12

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

CALENDAR January 25â&#x20AC;&#x201C;26

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

February 13

Patient Outcomes: Best Practices & How To Use Them. Register online at bit.ly/2019webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Free Online Training

Cascade Dafo Institute offers eight free ABC-approved online continuing education courses for pediatric practitioners. Earn up to 11.75 CE credits. Visit cascadedafo.com or call 800/848-7332.

WEBINAR

February 23â&#x20AC;&#x201C;24

PrimeFare Central Regional Scientific Symposium 2019. Renaissance Hotel, Tulsa, OK. Contact Cathie Pruitt at 901/359-3936, email primecarepruitt@gmail.com; or Jane Edwards at 888/388-5243, email jledwards88@att.net; or visit www.primecareop.com.

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

March 13

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

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

Words/Rate

Member

Nonmember

25 or less

$40

$50

26-50

$50 $60

51+

$2.25/word $5.00/word

Color Ad Special 1/4 page Ad

$482

$678

1/2 page Ad

$634

$830

Statement of Ownership, Management and Circulation (required by U.S.P.S. Form 3526) 1. Publication Title: O&P Almanac 2. Publication No.: 1061-4621 3. Filing Date: Revised 9/24/18 4. Issue Frequency: Monthly 5. No. of Issues Published Annually: 12 6. Annual Subscription Price: $59 domestic/$99 foreign 7. Complete Mailing Address of Known Office of Publication (Not Printer): American Orthotic & Prosthetic Association, 330 John Carlyle St., Suite 200, Alexandria, VA 22314 8. Complete Mailing Address of Headquarters or General Business Office of Publisher (Not Printer): Same as #7 9. Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor: Publisher: Thomas F. Fise, address same as #7. Editor: Josephine Rossi, Content Communicators LLC, PO Box 938, Purcellville, VA 20132. 10. Owner (Full Name and Complete Mailing Address): American Orthotic & Prosthetic Association, same as #7 11. Known Bondholders, Mortgagees, and Other Security Holders Owning 1 Percent or More of Total Amount of Bonds, Mortgages, or Other Securities: None. 12. The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes: Has Not Changed During the Preceding 12 Months. 13. Publication Name: O&P Almanac 14. Issue Date for Circulation Data Below: August 2018 Avg. No. Copies Each Issue During Preceding 12 Months 15. Extent and Nature of Circulation: a. Total number of Copies (Net Press Run) b. Paid and/or Requested Circulation (1) Paid or Requested Outside-County Mail Subscriptions (2) Paid In-County Subscriptions (3) Sales Through Dealers and Carriers, Street Vendors, Counter Sales, and other non-USPS Paid Distribution (4) Other Classes Mailed through the USPS c. Total Paid and/or Requested Circulation d. Free Distribution by Mail (1) Outside-County as Stated on Form 3541 (2) In-County as Stated on Form 3541 (3) Other Classes Mailed through the USPS (4) Free or Nominal Rate Distribution Outside the Mail e. Total Free or Nominal Rate Distribution f. Total Distribution g. Copies not Distributed h. Total i. Percent Paid and/or Requested Circulation

No. Copies of Single Issue Published Nearest to Filing Date

12,121

11,391

11,444 0 44

10,914 0 45

6 11,494

5 10,964

0 0 0 502 6 11,996 125 12,121 96%

0 0 0 202 5 11,166 200 11,366 98%

O&P ALMANAC | NOVEMBER 2018

ASK AOPA CALENDAR

Shoe Queries Answers to your questions regarding delivery and billing of diabetic shoes, 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.

When providing diabetic shoes, what information must be recorded or documented at the time of delivery?

According to policy, the supplier/provider must provide an objective assessment of the shoes at the time of delivery. This involves more than simply asking the patient if the shoes fit. You should consider documenting how the shoes accommodate the patient’s feet, or how the patient’s secondary foot condition is being alleviated by the shoes and inserts. You also may indicate if the shoes are rubbing or rising when the patient walks, and if he or she has enough toe space.

How do you bill for repairs to diabetic shoes?

You may bill for repairs using code A5507. However, remember that each unit of A5507 billed counts toward the total number of inserts/modifications a patient is eligible to receive each year. If a patient has already received his or her allotted amount of inserts/modifications, the repairs will be noncovered, and you must bill the patient.

Does Medicare cover replacement of an orthosis due to normal wear and tear?

No, Medicare does not cover the replacement of an item during its useful lifetime due to damage caused by everyday wear and tear. The only time Medicare will cover

NOVEMBER 2018 | O&P ALMANAC

the provision of a new item due to damage is if there is irreparable damage—and that damage can be linked to one specific incident or event. Are prescriptions or orders considered part of the medical record for the purpose of meeting medical necessity requirements?

No. According to policy and the durable medical equipment Medicare administrative contractor supplier manuals, an order is not considered part of the medical record. The order may contain information from the medical record to support medical necessity, such as the diagnosis code, but the order by itself does not justify medical necessity and must be corroborated by other information in the medical record.

Are coding verifications made by the pricing, coding analysis, and coding (PDAC) binding on Medicare providers?

Yes. Regardless of whether a request for PDAC verification is submitted voluntarily or as a mandatory submission as outlined in certain medical policies, once the PDAC has issued a coding verification, Medicare suppliers are required to bill Medicare using the Health-Care Common Procedure Coding System codes verified by the PDAC. Remember that not all O&P items require PDAC approval, and, typically, the PDAC coding recommendations only apply to Medicare claims, unless otherwise stated by the private payor.

www.bocusa.org

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100+ TOP-QUALITY ORTHOTIC, PROSTHETIC, AND PEDORTHIC EDUCATION COURSES.

EARN SCIENTIFIC, BUSINESS, AND PEDORTHIC CE CREDITS BY STUDYING THE COURSE MATERIAL AND PASSING THE QUIZ.

ACCESS YOUR PERSONAL ACCOUNT, VIEW VIDEOS, PRINT CERTIFICATES, OR REVIEW CE CREDIT HISTORY 24/7.

Learn & Earn TOP QUALITY

orthotic, prosthetic and pedorthic education and CE credits from the organization that knows O&P.

Itâ&#x20AC;&#x2122;s as easy as 1-2-3 1. Set up your free personal online account 2. Choose your education and study 3. Take the quiz and print your certificate Membership has its benefits:

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Better BUSINESS WITH AOPA

Learn more at www.AOPAnet.org/join

Start earning your credits today!

Visit www.aopanetonline.org/aopaversity.

YOUR GOAL

Successful patient outcomes OUR COMMITMENT To continue to raise the bar on safety and stability

with each iteration of the C-LegÂŽ so users like Katie

and thousands of others can return to their everyday work and home activities. To enhance features like Stumble Recovery, Intuitive Stance, and real-time

control that deliver superior performance and drive to better outcomes. Because when your patients succeed, we have all reached our goals.

ottobockus.com/forward-together

We all move forward, together.