December 2019 O&P Almanac

The Magazine for the Orthotics & Prosthetics Profession

D E C E M B E R 2019

Progress on the Medicare O&P Patient-Centered Care Act P.12

New Codes for the New Year P.18

Alternative Strategies for Pain Management P.34

Leveraging Reinforcement Learning and Pattern Recognition for O&P

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contents

DECE M B E R 2019 | VOL. 68, NO. 12

COVER STORY

FEATURES

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DECEMBER 2019 | O&P ALMANAC

24 | Team Building O&P facilities are forging closer connections with physical therapists, embracing a multidisciplinary approach to patient rehabilitation.

While some facilities send prosthetists to patient PT appointments, others provide educational sessions to help PTs learn to work with patients with limb loss, and still others position their facilities next to PT offices. These collaborative efforts are resulting in increased patient compliance and goal achievement, a larger pool of outcome measures data, and demonstrable value for payors.

By Christine Umbrell

22 | This Just In

Payment Policy Changes for 2020 Changes are in store regarding the gap-filling process used for pricing and the HCPCS codes subject to prior authorization. Find out how your facility will need to adjust its business practices to comply with CMS-1713-F, the final payment rule for durable medical equipment, prosthetics, orthotics, and supplies, in the coming year.

34 | Pain and Relief Residual limb pain and phantom limb pain pose real problems for individuals with limb loss—but opioids are not a long-term solution. Learn the role prosthetists play in reducing discomfort and identifying patients in physical and emotional distress, and find out which alternative solutions are growing in popularity—including nonopioid medications, yoga, medical marijuana, meditation, and acupuncture.

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contents

PRINCIPAL INVESTIGATOR

DEPARTMENTS

He (Helen) Huang, PhD............................ 40 Meet a North Carolina researcher who has devoted much of her career to studying reinforcement learning and pattern recognition to advance prosthetic tuning and control.

Views From AOPA Leadership......... 6 AOPA President Jeffrey Lutz, CPO, on differentiation for O&P

AOPA Contacts.......................................... 8 How to reach staff

Numbers...................................................... 10 At-a-glance statistics and data

Happenings................................................12

Research, updates, and industry news

People & Places........................................16 Transitions in the profession

P.12

COLUMNS Reimbursement Page.......................... 18

2020 Preview

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AOPA News...............................................47

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

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AOPA meetings, announcements, member benefits, and more

Boston Orthotics & Prosthetics

O&P PAC Update .................................. 48 Welcome New Members.................. 48

Mid State Artificial Limb

Careers........................................................ 49

Professional opportunities

Marketplace............................................. 50 Ad Index......................................................52 Calendar...................................................... 53 Upcoming meetings and events

Ask AOPA...................................................56 Reasonable useful lifetime for O&P devices

P.44 4

DECEMBER 2019 | O&P ALMANAC

P.46

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VIEWS FROM AOPA LEADERSHIP

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

The Road to Differentiation

T

O DIFFERENTIATE MEANS TO recognize or ascertain what makes someone or something different. But what does it mean for O&P? Differentiation from durable medical equipment (DME) means that O&P clinicians are universally considered an integral part of the healthcare team, that we get reimbursed for our care, and that there will be an adequate workforce to ensure patients can get the O&P care they need—when and where they need it.

AOPA has made significant progress in the direction of differentiating from DME, but we still have a long road ahead. So, how do we get there?

AOPA has worked to become a voice in Washington, pushing for federal policies that protect O&P businesses and preserve patient access to quality care—most recently with the Medicare O&P Patient-Centered Care Act. We need to double down on our legislative and regulatory efforts to focus on protecting the future of the profession, in large part by empowering the clinician.

To do this, we need to explore more collaboration with other allied healthcare professionals as well as build relationships with payors that are based on mutual trust rather than suspicion. We need to tell our story and the story of our patients, and show policymakers what life would look like without quality O&P care.

We know the importance of data. AOPA has invested in growing the evidence base, by funding research that reinforces the clinical efficacy and cost effectiveness of the orthotic and prosthetic care we, as clinicians, provide. The road ahead involves a focus on better promotion of these efforts, especially on how the current evidence-based work is driving the future of O&P as well as how it highlights the challenges we face. The road includes the development of additional measures for quality improvement that ensure we are providing the best possible care to patients. To elevate our value within healthcare, we need to support the Limb Loss and Preservation Registry. And again, we need to collaborate with other agencies that are funding and conducting research.

An investment in the workforce also has to be made. Diversity can improve the quality and be the catalyst for a better return on investment in staff. As a profession, we need to commit to diversity and inclusion at all levels so that all voices within O&P are represented. We all know the workforce is aging. A sustained focus on feeding the pipeline needs to be undertaken. To do this, we need to develop a strategy informed by the perspectives of students and residents, educators, and business owners.

All of these are critical to differentiation from DME, to the survival of the profession, to being able to provide care to those who need it. The time is now. We must differentiate. We can no longer be perceived or referred to as “vendors.”

Serving as AOPA’s president is an honor and a responsibility. With your support and engagement, I will spend my term guiding AOPA in leading the profession in the implementation of all of these efforts in hopes of moving us further down the road of differentiation from DME. I believe this is where true transformation of the O&P profession will happen, and I hope you will travel this road with me.

Jeffrey Lutz, CPO, is president of AOPA.

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DECEMBER 2019 | O&P ALMANAC

Board of Directors OFFICERS President Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA President-Elect Traci Dralle, CFm Fillauer Companies, Chattanooga, TN Vice President Dave McGill, JD Össur Americas, Foothill Ranch, CA Immediate Past President Jim Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO Treasurer Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics Inc., Exton, PA DIRECTORS J. Douglas Call, CP Virginia Prosthetics Inc., Roanoke, VA Mitchell Dobson, CPO, FAAOP Hanger, Austin, TX Elizabeth Ginzel, MHA, CPO Fort Worth, TX Kimberly Hanson, CPRH Ottobock, Austin, TX Teri Kuffel, JD Arise Orthotics & Prosthetics Inc., Spring Lake Park, MN Rick Riley Townsend Design Inc., Bakersfield, CA Linda Wise WillowWood, Mount Sterling, OH NONVOTING MEMBERS Shane Wurdeman, MSPO, PhD, CP, FAAOP(D) Research Chair Hanger Clinic, Houston Medical Center, Houston, TX Eve Lee, MBA, CAE Executive Director/Secretary American Orthotic and Prosthetic Association, Alexandria, VA

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AOPA CONTACTS

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

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

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

Our Core Objectives AOPA has three core objectives—Protect, Promote, and Provide.

These core objectives establish the foundation of the strategic business plan. AOPA encourages members to participate with our efforts to ensure these objectives are met.

EXECUTIVE OFFICES

REIMBURSEMENT SERVICES

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

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

Tina Carlson, CMP, chief operating officer, 571/431-0808, tcarlson@AOPAnet.org GOVERNMENT AFFAIRS Justin Beland, director of government affairs, 571/ 431-0814, jbeland@AOPAnet.org COMMUNICATIONS, MEMBERSHIP & MEETINGS

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

STRATEGIC ALLIANCES

Joy Burwell, director of communications and marketing, 571/431-0817, jburwell@AOPAnet.org

Ashlie White, MA, director of strategic alliances, 571/431-0812, awhite@AOPAnet.org

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

O&P ALMANAC

Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, kelly.oneill@AOPAnet.org Ryan Gleeson, CMP, assistant manager of meetings, 571/431-0836, rgleeson@AOPAnet.org Yelena Mazur, communications specialist, 571/431-0835, ymazur@AOPAnet.org Kristen Bean, membership and meetings coordinator, 571/431-0876, kbean@AOPAnet.org AOPA Bookstore: 571/431-0876

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

DECEMBER 2019 | O&P ALMANAC

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

Design & Production Marinoff Design LLC Printing Sheridan SUBSCRIBE O&P Almanac (ISSN: 1061-4621) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/431-0899, or email 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.

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

Copyright © 2019 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials.

All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.

Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com Catherine Marinoff, art director, 786/252-1667, catherine@marinoffdesign.com Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

Advertise With Us! Reach out to AOPA’s membership and more than 11,400 subscribers.

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

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NUMBERS

A Decade of Advocacy Remembering some of the seminal moments during the 2010-2019 time period

The past 10 years have been busy for O&P professionals, who have had to maneuver documentation and policy changes while providing optimal patient care and running successful O&P practices. Here’s a look back at some of the big wins and important O&P research from the last decade.

DOCUMENTATION CHALLENGES & VICTORIES

August 2011 CMS publishes the infamous “Dear Physician” letter indicating that O&P notes are not part of the medical record for lower-limb prostheses

LCD FOR LOWER-LIMB PROSTHETIC COVERAGE

After much lobbying from AOPA and O&P stakeholders, Section 50402 of the Medicare O&P Improvement Act is signed into law as part of the Bipartisan Budget Act of 2018, recognizing O&P clinical notes as part of the medical record

PUBLICATIONS DEMONSTRATING VALUE OF O&P

July 2015

July 2013

DME MACs publish a draft Local Coverage Determination (LCD) and Policy Article for lower-limb prosthetic coverage that would restrict amputees’ access to prosthetic coverage

“Retrospective Cohort Study of the Economic Value of O&P Services Among Medicare Beneficiaries,” Dobson-DaVanzo, commissioned

by AOPA and Amputee Coalition

August 2015 AOPA and O&P stakeholders submit letters expressing concerns; O&P organizes patient rally outside of HHS Headquarters; AOPA and O&P Alliance leaders meet with senior HHS officials

November 2015 Both the White House and CMS announce the draft LCD and will not be finalized, but a workgroup will be convened

June 2018 The Interagency Workgroup recommends, and CMS confirms, that the draft LCD and Policy Article is retired and should be removed from the DME MAC websites

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February 2018

DECEMBER 2019 | O&P ALMANAC

Retrospective Cohort Study of the Economic Value of Orthotic and Prosthetic Services Among Medicare Beneficiaries Final Report

Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com

© 2013 Dobson DaVanzo & Associates, LLC. All Rights Reserved.

February 2016 “Economic Value of O&P Services Among Medicare Beneficiaries (Part 1): A Claims-Based Retrospective Cohort Study, 2007-2010,” Dobson-DaVanzo, commissioned by AOPA

September 2017 “Economic Value of Advanced Transfemoral Prosthetics,” RAND Corp., sponsored by AOPA

September 2018 “Economic Value of O&P Services Among Medicare Beneficiaries (Part 2): A ClaimsBased Retrospective Cohort Study, 2011-2014,” Dobson-DaVanzo, commissioned by AOPA

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Happenings

O&P ADVOCACY

Legislators Introduce Medicare O&P Patient-Centered Care Act After months of advocacy and legwork on the part of AOPA and O&P stakeholders, the Medicare O&P Patient-Centered Care Act was officially introduced in the U.S. House of Representatives on November 22. This bipartisan legislation, HR 5262, would improve access to, and quality of, orthotic and prosthetic care received by Medicare beneficiaries while simultaneously combating fraud and abuse.

The bill would accomplish the following important objectives: • Restore congressional intent by revising the overly expansive regulatory interpretation of the meaning of “off-the-shelf” (OTS) orthoses to clarify that competitive bidding may only apply to orthoses that require minimal self-adjustment by patients themselves, not the patient’s caregiver or a supplier.

Congress created a definition of OTS orthotics as orthotic devices “requiring minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding assembling, or

Medicare O&P Patient-Centered Care Act H HR 5262 H customizing to fit to the individual.”

However, CMS has changed and expanded the definition beyond Congress’s intent. CMS defines minimal self-adjustment as an adjustment the “beneficiary, caretaker for the beneficiary, or supplier can perform”—which is clearly not “self-adjusted.”

• Distinguish the clinical, serviceoriented nature in which O&P is provided from the commodity-based nature of the durable medical equipment (DME) benefit. O&P care includes a patient-care component that is decidedly more in-depth and personal than simply supplying

DME. Most O&P devices are custom fabricated or custom fit and require the expertise of an orthotist or prosthetist who has earned a master’s of science degree and completed residency training before becoming a certified practitioner.

• Reduce the likelihood of waste, fraud, and abuse in the Medicare program by prohibiting the practice of “drop shipping”—shipping an orthosis or prosthesis to a beneficiary without first receiving direct patient care from a trained, certified, or licensed healthcare practitioner—of orthotic braces that are not truly “off-the-shelf.”

AOPA took action as soon as the legislation was introduced, reaching out to members and O&P stakeholders asking that they write their representatives to urge them to support HR 5262. AOPA provided a sample letter featuring the key provisions and explaining how the bill would benefit orthotic and prosthetic patients.

For the latest information on the Medicare O&P Patient-Centered Care Act and details on the legislation, visit the AOPA website at www.aopanet. org. Contact Justin Beland, AOPA director of government affairs, with any questions at jbeland@aopanet.org.

FACILITY CYBERSECURITY

Healthcare-Related Data Breaches On the Rise Data breaches will cost healthcare companies $4 billion in 2019, according to a new study conducted by Black Book Research. Ninety-three percent of surveyed provider organizations had experienced a data breach in the past three years, with 57 percent experiencing more than five data breaches during that time period.

“Not only has the number of attacks increased; more than 300 million records have 12

DECEMBER 2019 | O&P ALMANAC

been stolen since 2015, affecting about one in every 10 healthcare consumers,” according to the report authors.

Healthcare companies are at risk from a growing number of cyberattacks by both criminal and nation-state backed hackers, according to Black Book. Ninety-six percent of IT professionals agreed with the statement that data attackers are outpacing medical enterprises.

Report authors warn that the provider sector remains exceedingly susceptible to ongoing breaches.

HAPPENINGS

RESEARCH ROUNDUP

Advanced Prosthetic Hand System Delivers Stimulation Pulses

PHOTO: Courtesy of R. Jung, Florida International University

A team in the Adaptive Neural Systems Laboratory at Florida International University (FIU) has developed a neural-enabled prosthetic hand (NEPH) system and will be expanding testing of the system, thanks in part to a $6 million award from the U.S. Department of Defense.

The researchers, led by Ranu Jung, PhD, professor and chair of biomedical engineering, designed the system to restore a sense of touch to users and enable grasping and opening via stimulation of sensory nerve fibers in the residual limb. Sensors in the prosthesis communicate information that commands an implanted neurostimulator, resulting in the delivery of stimulation pulses to the sensory nerve fibers.

The first subject to test the new system has been using it successfully for more than 18 months, according to the researchers. In the next phase of testing, additional participants will undergo surgery to have components of the NEPH system

implanted and will participate in a series of tests over a two-year time span.

Upgrades will allow the use of different prosthetic hands and will allow the device to be used by individuals with bilateral upper-limb amputation.

“We developed the NEPH system to improve the quality of life of people with upper-limb amputation, many of whom served in the military,” said Jung, emphasizing that the system is still an investigational device, limited by federal law to investigational use. “We hope this technology, that is designed to provide senses of touch and grasp force, will allow them to perform daily tasks and, perhaps one day, even activities related to military duty.”

The first recipient of the ANS neural-enabled prosthetic hand system has been using it successfully for more than 18 months.

Upper Limb Loss Population Found To Be at Greater Risk of Falls Individuals with upper limb loss or absence have been found to experience a higher prevalence of falls, and the use of prostheses among this population increases fall likelihood by six times, according to a recent study. The investigators, led by Matthew Major, PhD, and Steven A. Gard, PhD, published their findings in October in Physical Medicine & Rehabilitation.

The researchers, who are affiliated with the Jesse Brown VA Medical Center and Northwestern University Prosthetics-Orthotics Center, noted that natural arm dynamics in able-bodied individuals are important and help reduce the metabolic energy required to walk steadily and recover from perturbations. Their investigation sought to identify the level and covariates of fall risk among individuals with upper-limb amputations.

The study was designed to leverage static posturography

to examine postural control of standing balance among individuals with unilateral upper limb loss wearing no prosthesis and wearing a prosthesis that was similar in mass, inertia, and length to their sound limb. The investigators measured centerof-pressure anterior-posterior range, medial-lateral range, sway area, and weight-bearing symmetry. The researchers also studied able-bodied controls for comparison purposes.

The study subjects were found to display greater standing postural sway than the control subjects. The investigators found that upper-limb prosthesis use, while improving weightbearing symmetry, also increases postural sway, particularly in the medial-lateral direction. “The relatively greater postural control demands might help explain the increase[d] fall prevalence in this patient group,” they concluded. The full article is titled “Effects of Upper Limb Loss or Absence and Prosthesis Use on Postural Control of Standing Balance.”

O&P ALMANAC | DECEMBER 2019

13

HAPPENINGS

FAST FACT

Last year, 3,049 comprehensive orthotic and prosthetic facilities, 180 pedorthic facilities, and 21 central fabrication facilities were accredited by and in good standing with the American Board for Certification in Orthotics, Prosthetics, and Pedorthics.

SOURCE: “ABC 2018 Annual Report,” ABC, 2019.

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DECEMBER 2019 | O&P ALMANAC

MILITARY MEDICINE

Report Details Best Practices in Caring for Military Members Who Lose Limbs A new report from the RAND Corp. identifies a set of services that are integral to optimal amputation rehabilitation among service members with one or more deployment-related amputations. Since 2001, the U.S. Department of Defense (DoD) has rehabilitated more than 2,100 service members and veterans who lost a limb during the conflicts during Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.

The number of amputations peaked in 2011 and has decreased in recent years as deployments in areas of conflict have involved fewer service members.

Report authors interviewed 100 patients, family members, healthcare providers, and subject matter experts to learn about the behaviors observed in physician and rehabilitation specialists involved in amputation care, including prosthetists and orthotists. They developed a list of competencies that are needed by providers in nine areas of rehabilitation, including O&P. They also defined the “amputee coalition phases of care,” which include the pre- and postoperative phases, preprosthetic phase, preparatory prosthetic training phase, definitive prosthetic training phase,

Amputations During Conflicts in Iraq and Afghanistan, 2001-2016 Single-Limb Amputations

1,134

Two-Limb Amputations Three-Limb Amputations

463 56

Four-Limb Amputations 6 SOURCE: “Core Competencies for Amputation Rehabilitation,” RAND Corp.

To ensure ongoing best practices and to capture the skills, abilities, and related information developed during the years of high numbers of military amputations, the DoD Extremity Trauma and Amputation Center of Excellence asked RAND Arroyo Center to conduct an investigation. The recently published report, “Core Competencies for Amputee Rehabilitation,” features the results of the study. The report summarizes key findings on optimal care, which are designed to aid the military medical community in keeping their skills sharp and to ensure the military healthcare community is prepared should another conflict occur that drives an increase in amputations.

reintegration phase, and maintenance.

In addition, they defined “competency frameworks” for each provider type.

Best practices for DoD providers of amputation services, according to the report, should include a multidisciplinary approach to care, co-location of services in the same building, avoiding resource and reimbursement constraints in order to provide optimal rehabilitation services, availability of in-house prosthetists, technological offerings to facilitate rehabilitation (including virtual reality-type rehabilitation systems), and support groups for patients and family members. The report also includes a section on best practices in civilian amputee care.

HAPPENINGS

O&P LEADERSHIP

AOPA Board of Directors Sets Direction for New Decade

We ARE AOPA

ADVOCACY | RESEARCH | EDUCATION

December is a busy month at AOPA, as new and returning board members embrace their positions for the new term. This 2020 AOPA Officers year, the beginning of a new decade marks a renewed focus on advocacy, research, and education. The 2019-2020 AOPA Board of Directors, whose members were elected during the 2019 AOPA National Assembly in San Diego, will be led by President Jeffrey Lutz, CPO. “Serving as AOPA’s president is an honor and a responsibility I do not take lightly,” said Lutz. “I thank you for your support and I look forward to working with each and every one of you to achieve our perfect vision.”

Jeffrey Lutz, CPO, Traci Dralle, CFm, Lutz takes the reins from Jim Weber, MBA, who served as President President-Elect president for the 2017-2018 and 2018-2019 terms. Weber will continue serving the association as immediate past president.

During the 2019 Annual Business Meeting in September, Weber told Assembly attendees, “We have spent the past two years renewing AOPA’s focus on our mission and purpose in the interest of better serving you—our members and our patients. We have mentioned many times the focus on who we ARE—advocacy, research, and education. In addition to these three pillars of our guiding principles, Dave McGill, JD, Jim Weber, MBA, Jeffrey M. Brandt, there is a guiding principle focused on members: demonstrating Vice President Immediate Past CPO, Treasurer AOPA’s value to encourage membership and engagement.”

President As Lutz begins his term as president, he will be supported by Traci Dralle, CFm, president-elect; 2020 AOPA Board Members Dave McGill, JD, vice president; Jeffrey M. Brandt, CPO, treasurer; Eve Lee, MBA, CAE, secretary; and eight additional board members.

Two board members who made significant contributions to AOPA and the O&P community are ending their board service at this time: Michael Oros, CPO, FAAOP, and David Boone, MPH, PhD. Oros spent two years as immediate J. Douglas Call, Mitchell Dobson, Elizabeth Ginzel, Kimberly Teri Kuffel, JD CP CPO, FAAOP MHA, CPO Hanson, CPRH past president following his tenure as president in 2016-2017. Weber told Assembly attendees, Nonvoting Members “I have personally depended on Michael’s experience, advice, and most of all friendship. I know my fellow AOPA board members and the AOPA staff sincerely appreciate Michael’s many contributions over the past nine years.”

Boone served for two years as AOPA’s clinical Rick Riley Linda Wise director as well as chair of AOPA’s Research Pillar.

Shane Wurdeman, MSPO, Eve Lee, MBA, “It is hard to quantify the value of research, but in PhD, CP, FAAOP(D) CAE, Secretary addition to taking AOPA’s research portfolio to new heights, [Boone] has helped us message the David Boone, Michael Oros, value research brings to O&P and healthcare as a Special MPH, PhD CPO, FAAOP whole,” said Weber.

Thanks to To the right is the full list of current AOPA Retiring board members, who took office Dec. 1, 2019, and Members will serve through Nov. 30, 2020.

O&P ALMANAC | DECEMBER 2019

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PEOPLE & PLACES PROFESSIONALS

BUSINESSES

ANNOUNCEMENTS AND TRANSITIONS

ANNOUNCEMENTS AND TRANSITIONS

Maynard Carkhuff has been elected president of the California Orthotic & Prosthetic Association (COPA), effective Jan. 1, 2020.

Carkhuff, chairman of Freedom Innovations, also was honored with a 2019 AOPA Maynard Carkhuff Legislative Advocacy Award in September.

“It’s an honor to represent Freedom Innovations while stepping into this new leadership role alongside my industry colleagues at COPA,” said Carkhuff. “COPA does essential work promoting the art and science of orthotics and prosthetics to create and communicate innovative solutions for positive patient experiences—which dovetails perfectly with our own mission at Freedom. I look forward to the opportunity to contribute, particularly in the areas of growing membership, ensuring patient access to appropriate care, and strategic planning.”

Martin Bionics has been selected by R&D Magazine as a recipient of its 2019 R&D 100 Award in recognition of its Socket-less Socket™ interface technology. “We are excited to be named among the nation’s leaders in research and development as an R&D 100 award winner,” said Jay Martin, CP, FAAOP, the company’s founder.

Rick Riley, a member of Townsend’s executive team for nearly 25 years, including 16 years as chief executive officer, will leave the organization at the end of 2019. “Rick announced his plans to me and the owners several months Rick Riley ago, and we have been organizing the reassignment of his responsibilities,” said Thierry Arduin, president of Thuasne USA, who has co-managed the company with Riley since 2014. Arduin will serve as the company’s president and chief executive officer upon Riley’s departure.

Riley also is a member of AOPA's Board of Directors.

“Without the influence and efforts of Rick Riley, The Thuasne Group would not own Townsend, and would not have achieved the strategic acquisition of Orthotic Composites,” said Elizabeth Ducottet, president and chief executive officer of The Thuasne Group. “Rick has provided valuable leadership to our USA subsidiary, especially through his strong relationships with O&P industry executives, business owners, and clinicians.”

Regina Weger has been promoted to president of Hanger Inc.’s SPS subsidiary. Weger has been with SPS for more than 20 years, most recently serving in the role of vice president and general manager, and prior to that time, vice president of SPS sales Regina Weger and marketing. Weger started her career in the customer service function at SPS and has taken on additional roles and responsibilities throughout the years. In this new role, Weger will report directly to Hanger President and Chief Executive Officer Vinit Asar.

Weger is a 2015 recipient of the J.E. Hanger Award for Leadership and a recently appointed board member of the National Association for the Advancement of Orthotics and Prosthetics.

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DECEMBER 2019 | O&P ALMANAC

Forty-four O&P providers were recently honored by OPGA with a 2019 Freedom Award in recognition of their exceptional care of military personnel. “We’re excited to recognize these O&P providers for the exceptional care they provide to the men and women who have sacrificed for our freedoms,” said Todd Eagen, president of OPGA. “These dedicated professionals blend patient care with precision design to ensure our military heroes can have increased mobility and independence.” Recipients of the 2019 Freedom Award received a framed award to showcase in their patient-care facility.

The 2019 Freedom Award recipients include the following: Abilities Unlimited Inc., Colorado Springs, CO Adaptec Prosthetics LLC, Littleton, CO Allegheny Orthotics & Prosthetics, Altoona, PA Body in Motion Bracing & Prosthetics, Toms River, NJ Carolina Prosthetics and Orthotics, Greenwood, SC Central Brace and Limb Co., Indianapolis, IN Clark & Associates Prosthetics and Orthotics, Cedar Rapids and Waterloo, IA Decker Integrated Orthotics and Prosthetics, Overland Park, KS Durrett’s Orthotics and Prosthetics LLC, Edgewood, KY Fidelity Orthopedic, Dayton, OH Fikes Orthopedic Specialties, Prescott, AZ Georgia Prosthetics, Atlanta, GA Hope Artificial Limb and Brace, Montebello, CA Leimkuehler Inc., Cleveland, OH LeTourneau Lifelike Orthotics and Prosthetics, Inc., Beaumont, TX Limb Lab, La Crosse, WI, and Mankato, Minneapolis, and Rochester, MN Limbcare Prosthetics and Orthotics of Georgia Inc., Albany, Americus, La Grange, Tifton, and Valdosta, GA NovaCare, Fond du Lac, WI, and Oshkosh, WI O&P1, Waterloo, IA Orthocare America, Inc., Aurora, OH OrthoPro Services, LLC, Dublin, GA Orthotic & Prosthetic Designs, Columbus, IN Premier Prosthetics & Orthotics, St. Louis, MO

PEOPLE & PLACES

Presque Isle Medical Technologies, Erie, PA Prosthetic Orthotic Solutions International (POSI), Marlton, NJ Rehability, Spring Hill, FL Snell’s Orthotics and Prosthetics, Shreveport, LA Syracuse Prosthetic Center, Syracuse, NY Tegerstrand Orthotics & Prosthetics, Chico, Mt. Shasta, and Redding, CA Teter Orthotics and Prosthetics, Inc., Traverse City, MI Total Care Orthotics & Prosthetics LLC, Tulsa, OK University of Pittsburgh, Pittsburgh, PA Valley Institute of Prosthetics & Orthotics, Bakersfield, CA Össur and the Alfred Mann Foundation (AMF), an independent nonprofit medical device incubator, have signed an agreement that allows Össur to further develop and license AMF’s implanted myoelectric sensor (IMES®) system as both organizations continue exploring the potential of mind-controlled prosthetic technologies. The sensors are implanted in muscles that directly control the desired movement of a bionic prosthetic limb. The implants sense a small electrical charge in the muscle tissue and send information wirelessly to the prosthetic limb when the user intends to make specific movements. As a result, the bionic limb responds with the

IntRoduCIng nEW REStECH

desired movement in virtually the same way that a sound arm, hand or leg would respond, according to Össur.

AMF’s mission is to develop and commercialize innovative solutions for significant unmet medical conditions, including limb loss, diabetes, neuromuscular disorders, and chronic pain.

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2/27/19 4:31 PM O&P ALMANAC | DECEMBER 2019

17

REIMBURSEMENT PAGE

By DEVON BERNARD

2020 Preview Learn the new codes and find out how the DMEPOS fee schedule will change

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

After reading this column, simply scan the QR code or use the link on page 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.

CE

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BUSINESS CE

CREDITS P.20

18

DECEMBER 2019 | O&P ALMANAC

I

T’S DECEMBER, AND TIME to think

about policy changes that will take effect in the new year—whether there will be new or updated codes, what the fee schedule increase or decrease will be, and how the deductibles will change. This month’s Reimbursement Page examines recently released Healthcare Common Procedure Coding System (HCPCS) code set changes and the anticipated fee schedule release—as well as a few other monetary updates for 2020.

New and Updated Codes

$

L8033 L200 6 $

CMS released its annual update to the HCPCS code set on November 8.

The update, as in recent years, did not contain any earth-shattering surprises.

However, there were some changes: The official descriptor for code L8032 was corrected, CMS introduced two new codes, and no codes were deleted.

These changes are effective for claims submitted on or after Jan. 1, 2020.

Regarding L8032, the current code descriptor is, “Nipple prosthesis, reusable, any type, each.” For 2020, the new code descriptor simply added the word “prefabricated” and will read, “Nipple prosthesis, prefabricated, reusable, any type, each.” This minor change was made to distinguish the L8032 from one of the two newly created codes for 2020, the L8033.

The new L8033 code will be used to describe a custom nipple prosthesis.

Its official code descriptor is, “Nipple prosthesis, custom fabricated, reusable, any material, any type, each.” Currently, there is no indication to as to how or when this code may be covered; we will have to wait until the External Breast Prostheses Policy is updated. If the

$ L8032

current policy’s coverage rules for a custom breast prosthesis (L8035) are followed, the L8033 may be considered not reasonable and necessary.

The next new code and final change for 2020 is the L2006, which will be used to describe a microprocessor-controlled knee-ankle-foot orthosis (KAFO). The official code descriptor for the L2006 is, “Knee-ankle-foot device, any material, single or double upright, swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated.”

The L2006 was most likely created in response to the official HCPCS code application filed by Ottobock for the C-Brace. At this time, there is no published guidance or coverage rules for the L2006, and there is no information in the current AFO/KAFO Policy or guidance from the preliminary reviews of the CMS HCPCS Panel. These resources may eventually provide insight into possible payment and coverage rules.

At the time this article was written, the Medicare allowables for the two new codes had not yet been released.

Fee Schedule Changes

The 2020 durable medical equipment, prosthetics, orthotics, and prosthetics (DMEPOS) fee schedule had not been officially released when this article was written, but it was anticipated that the 2020 fee schedule would be slightly higher than the 2019 fee schedule, with a possible overall increase in the ballpark of 0.9 percent. The DMEPOS fee schedule is calculated using two figures, and at the moment only one is known and verified.

REIMBURSEMENT PAGE

All increases or decreases in the DMEPOS fee schedule are tied to the increases and decreases in the Consumer Pricing Index for All Urban Consumers (CPI-U), for the period between June 2018 and June 2019. The CPI-U is the average change over time in the prices paid for certain goods and services, such as food and transportation, and is calculated by the U.S. Bureau of Labor and Statistics (BLS).

Since the CPI-U calculation period ended in June, we know with certainty that the CPI-U adjustment will be 1.6 percent; however, the second component of the equation, the annual legislatively mandated reduction to the DMEPOS fee schedule or the productivity adjustment, has not been released and is still unknown.

The productivity adjustment also is calculated by BLS but is based on a 10-year rolling average of changes in annual economy-wide private nonfarm business, or a multifactor productivity.

The L2006 is a new code introduced for 2020. It will be used to describe a microprocessor-controlled knee-ankle-foot orthosis.

Historically, the productivity adjustment has been in the range of 0.5 to 1.0 percent, which would indicate a fee increase between 0.6 percent and 1.1 percent. While the 2018 productivity adjustment for DMEPOS has not been published, the productivity adjustment for such things as ambulance services has been published and is set at 0.7 percent.

Traditionally, the DMEPOS productivity adjustment has been similar to these other services, since it is based on similar calculations—so it is anticipated that the

Ferrier Coupler Options!

productivity adjustment for DMEPOS suppliers will be 0.7 percent as well.

When you take the 1.6 percent CPI-U increase and subtract the anticipated productivity adjustment 0.7 percent, you will see an overall increase in the 2020 fee schedule of 0.9 percent. In addition to this possible increase, don’t forget that sequestration will still be in effect for all 2020 claims. Sequestration is the mandatory 2 percent deduction, applied after the Medicare allowable amount, based on the fee schedules.

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

Model A5

Model F5

Model P5

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

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

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

Model FA5

Model FF5

Model FP5

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

Female portion of coupler accepts a pyramid.

Model T5

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

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

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

The unit is waterproof and has a traction base pad.

O&P ALMANAC | DECEMBER 2019

19

REIMBURSEMENT PAGE

Closing Out 2019: Gift-Giving Restrictions

$

’Tis the season for showing gratitude and spreading holiday cheer to patients and referral sources by offering presents. Gift-giving is acceptable—but be aware of some restrictions and caveats.

When providing gifts to patients, remember that gifts of cash or cash equivalents of any kind are strictly prohibited. The use of nonmonetary gifts is acceptable as long as they are of nominal value—meaning the value of the gifts should not exceed $15 per gift, with a $75 aggregate per calendar year. So, you may offer your patients a maximum of five gifts valued at $15 each in any calendar year. And remember that there may not be terms associated with the gift. For example, you cannot require that the patient come in for an evaluation in order to receive a gift, or that the patient can only receive the gift if they choose to receive a particular service or item.

When shopping for and providing gifts to referral sources, remember that—as with gifts to beneficiaries—gifts of cash or cash equivalents are strictly prohibited. Nonmonetary gifts are allowed under limited circumstances. First, the value of the gift may not be tied to the volume of referrals received.

For example, you cannot provide a gift of higher value to your regular referral sources than you do to practices that only refer patients periodically. While you are not required to offer the same gift to all of your referral sources, you cannot base your decision on the number of referrals you receive. Second, the gifts may not be directly solicited by referral sources. In addition, there is a limit to the amount of money that may be spent on gifts for referral sources. For 2019, the aggregate limit is $416, so any gift or gifts provided to a referral source in 2019 may not exceed $416.

Remember that just because Medicare has not released coverage rules or fees for the newly created and updated codes, it is not an indication of coverage or noncoverage. In these instances, Medicare coverage and payment decisions for these items will be based on the discretion of the durable medical equipment Medicare administrative contractors until official guidelines have been established.

Additional Medicare Monetary Updates

CMS recently announced some additional monetary figures for 2020 that should be updated in your systems, including Part A and Part B deductibles, premiums, and co-insurance amounts— also known as the amounts your patients must pay before Medicare pays a claim, and the amounts your patients must pay in order to receive certain benefits.

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DECEMBER 2019 | O&P ALMANAC

The monthly Medicare Part B premium, or the amount paid in order to obtain Part B services and coverage, will begin at $144.60 This is slightly higher than the 2019 amount of approximately $135. The premium is on a sliding scale and will increase based on the patient’s income, topping out at $491.60.

The Medicare Part B deductible for 2020 has increased by $13 and will be set at $198; this means that the patient must pay $198 out of pocket before Medicare will begin to pay a claim. As always, the Medicare Part B co-insurance remains at 20 percent.

The deductible for 2020 Medicare Part A, or hospital/skilled nursing facility (SNF) insurance, is set at $1,408, and the daily co-insurance amount for days 61-90 is $352. For the lifetime reserve days, the 2020 co-insurance rate is set at $704. Lastly, for days 20-100 of a Part A SNF stay, the co-insurance

amounts for 2020 will be set at $176.

The amounts in controversy (AIC) for the 2020 calendar year also have been released. The AIC is the monetary threshold that must be met to file an appeal with an administrative law judge (ALJ), the third level of appeal, and with the federal district court, the fifth level of appeal. The 2020 AIC for the ALJ is $170, a $10 increase over the 2019 amount. The AIC for the federal district court is $1,670, an increase of $40. The new AICs will be effective for all appeal requests filed on or after Jan. 1, 2020. As a reminder, if you are unable to meet the AIC with a single appeal, you may combine multiple appeals to meet the threshold.

In addition, if you are scheduled to revalidate any of your facility locations or open any new facility locations next year, you should be aware of the 2020 DMEPOS supplier application fee. The fee is $595, and it will be required with any new enrollment application submitted on or after Jan. 1, 2020, and on or before Dec. 31, 2020. This application fee does not apply to any changes or updates you may make to a current application.

Staying In-the-Know

As we kick off a new year, knowing all of the codes and their appropriate descriptors and understanding the updated fee schedule is a critical aspect of running a successful O&P business. Be sure to look for policy updates and additional information in future issues of O&P Almanac.

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

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

Earn CE credits accepted by certifying boards:

www.bocusa.org

Allard USA would like to CONGRATULATE

CAROL HIEMSTRA-PAEZ

as she announces her RETIREMENT. Carol has spent over 50 years selling, marketing and developing products for the O&P industry, working for various companies such as Stryker, Zimmer, Camp Healthcare, Hanger and Allard USA. Carol Hiemstra-Paez “Is the reason Allard USA exists today” says Dennis Williams, Allard USA CEO. Carol started working for Allard in 1997 with the mission to introduce two industry significant products into North and South America. The two newly patented, innovative products;

1. The world’s first carbon composite AFO, named ToeOFF® 2. S.W.A.S.H®, the world’s first variable abduction hip orthosis.

It wasn’t an easy road in the early days for the ToeOFF® AFO, she recalls many practitioners’ inital response, “There is no way a prefabricated AFO can offer the stability and support of my custom fabricated plastic AFO”.

S.W.A.S.H®, was also initially met with some resistance, physicians saying “I fix adductor tone with surgery”.

Thanks to Carol’s dedication and passion for these life-changing products, she was instrumental in developing creative marketing and education strategies to change those mindsets and to set up the American distribution center in Rockaway, New Jersey.

In addition, over the past 22 years, she has been a key liaison working closely with the Swedish R&D development team and marketing department to develop products and marketing strategies to meet the needs of its customers and patients creating “Support for Better Life”.

Carol tells us, “she plans to use her golden years to spend more time with her family, help her husband with the gardens surrounding their Florida home, and make use of her pottery studio”.

This Just In

Payment Policy Changes for 2020 More HCPCS codes will be subject to prior authorization when CMS-1713-F takes effect

C

MS HAS RELEASED ITS annual

final rule regarding changes for the upcoming year to the Medicare payment rules for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). CMS-1713-F, the final rule for 2020, follows the issuance of a proposed rule in late July and a comment period during which interested members of the public could provide written comments on the proposed rule, which ended September 27.

AOPA reviewed the proposed rule and submitted comments on several proposed changes to Medicare DMEPOS payment policy for 2020.

AOPA’s concerns focused on potential changes to the gap-filling methodology that Medicare is statutorily required to use to establish Medicare fee schedules for new Healthcare Common Procedure Coding System (HCPCS) codes, the proposed combination and expansion of the CMS “master list” of HCPCS codes subject to prior authorization, face-to-face visit requirements, written orders prior to delivery (WOPD), and the authority of CMS to reduce Medicare fee schedules for products that have had price reductions through market competition within five years of the creation of a new HCPCS code.

While CMS acknowledged all of

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DECEMBER 2019 | O&P ALMANAC

the comments it received, the only section of the proposed rule that it elected not to finalize was a provision that would use technology assessments, which would compare new DMEPOS technology to existing DMEPOS technology in order to help CMS establish Medicare fee schedules for new HCPCS codes. CMS decided to consider this provision of the proposed rule in the future. All other original provisions related to DMEPOS were finalized in the final rule—despite significant concerns from the public that were expressed during the comment period.

Significant changes to DMEPOS payment policy for 2020 that were created by the final rule include the following: 1. Changes to the CMS gap-filling process that will allow CMS to use retail prices found online and in catalogs to establish baseline pricing that will then be deflated back to 1986 prices and reinflated to current day prices. AOPA expressed concern that using pricing sources that did not account for clinical care in the delivery of O&P service would create an artificially low baseline that would be further reduced through the statutory gap-filling process.

This Just In

2. Expansion of the CMS “master list” of HCPCS codes subject to prior authorization, face-toface visit requirements, and/or written orders prior to delivery.

Currently, 82 O&P HCPCS codes are potentially subject to Medicare prior authorization. The final rule reduced the financial threshold for inclusion on the master list from an average reimbursement of $1,000 to an average reimbursement of $500. This reduction in the reimbursement threshold expands the list of eligible O&P codes to 226 codes. In addition, the final rule also exposes the 226 O&P codes to potential inclusion in Medicare requirements for face-to-face visits with prescribing practitioners and WOPD, two requirements that were previously not applicable to O&P services.

3. Expansion of CMS authority to reduce Medicare fee schedules when CMS determines

that market competition has driven the price of new technologies down within five years of creation of an HCPCS code.

AOPA’s comment on this provision was that CMS already has the authority, through the inherent reasonableness process, to reduce Medicare fee schedules that are deemed to be excessively high or low. CMS disagreed with AOPA’s comment on this provision and elected to finalize the expansion of its own authority in this regard.

AOPA is disappointed in CMS’s lack of response to the comments it received regarding the proposed rule.

In most instances, CMS simply stated that it disagreed with the submitted comments, with minimal explanation as to why, and indicated that it would finalize the proposed provision as written.

AOPA understands the importance of establishing and maintaining a

positive relationship with CMS and its value in achieving AOPA’s mission of improving patient access to quality orthotic and prosthetic care through advocacy, research, and education.

AOPA continues to strive toward creating effective, two-way communication with CMS, its contractors, and its leadership. Past successes include efforts to prevent the creation of an unreasonable, non-patient-focused Local Coverage Determination for lower-limb prostheses, AOPA representation on councils for the Durable Medical Equipment Medicare Advisory Contractor, and successful challenges to inappropriate Recovery Audit Contractor audit activity.

AOPA will continue to press CMS for increased transparency and greater stakeholder input in its policymaking process and will continue efforts to be the voice of the O&P profession on policy issues.

View the complete final rule at bit.ly/CMS-1713-F.

Next-level Pattern Recognition

leading the way to enhanced function

see

in action:

O&P ALMANAC | DECEMBER 2019

23

COVER STORY

Team BUILDING

O&P facilities forge closer relationships with physical therapists to facilitate patients’ rehabilitation

By CHRISTINE UMBRELL

24

DECEMBER 2019 | O&P ALMANAC

COVER STORY

NEED TO KNOW • Many O&P facilities • Taking part in physical and tear” on their • It’s important that are working closely therapy assists patients sound side, resulting in patients understand with physical therapists in reaching milestones, contralateral limb issues they may see any (PTs), taking a and measuring and compensatory healthcare provider multidisciplinary outcomes at both damage to their hips, of their choosing, and approach to care that O&P and PT facilities knees, and backs. that facilities have the benefits patients as helps to quantify appropriate business they navigate their patients’ advances— • Several O&P facilities agreements in place rehabilitation journeys. building evidence to have positioned and comply with all demonstrate the value their offices next regulations regarding • Some O&P clinicians of O&P intervention. to PT facilities, the provision of services. offer education to forging stronger PTs on the nuances of • Many clinicians relationships and working with limb loss see benefits in encouraging patients patients, while others recommending PT not to make consecutive accompany patients on only for patients with appointments to reduce one or more PT visits recent limb loss, but the time they spend to answer questions also for older patients travelling to see their regarding amputation with decades-old healthcare providers. level, prosthetic fit, or amputations. Some componentry selection. senior patients have experienced “wear

R

EFERRING O&P PATIENTS TO

physical therapists (PTs) and communicating with PT facilities about patient goals and progress during rehabilitation has been common practice at some O&P facilities for years.

But today, many more O&P companies are seeking closer connections with PTs—particularly given the migration toward value-based healthcare and multidisciplinary medicine.

While some O&P practices encourage clinicians to communicate closely with PTs, others send prosthetists to attend PT appointments with patients. Some O&P clinics seek out PT facilities that “specialize” in amputation care, and still others take the extra step of providing in-services to educate therapists on the nuances of working with individuals with limb loss or limb difference. And a few O&P companies even co-locate their facilities to be near PT offices.

“The integrated approach of O&P and physical therapy working

together is being more commonly stressed,” explains Shamel Allen, CP, MPT, a center manager for NovaCare Prosthetics and Orthotics in St. Louis.

Allen, who practiced physical therapy for 10 years before migrating to prosthetics, believes that positive patient outcomes demonstrate the value of a collaborative approach to care.

When O&P clinicians work closely with physical therapists, “patients are more likely to meet the goals that therapists and prosthetists set for them a little sooner,” Allen says.

“They’re more confident in their ability to use the prosthesis successfully. They have more of a positive outlook, knowing that they have a ‘team’ of people working on their behalf, supporting them in their rehab and overall recovery. Patients are more compliant and responsible in meeting the expectation of the ‘team,’ and have greater confidence knowing that we’re all working together for a common goal.”

O&P ALMANAC | DECEMBER 2019

25

COVER STORY

Integrating Care Early On

Measuring Outcomes— Allen also encourWith the Help of PT Particularly for new amputees, ages O&P clinicians to Taking part in physical and Allen recommends that they educate PTs regarding occupational therapy assists see a physical therapist as the unique therapeutic patients in reaching milestones, soon as they are fit with their interventions required and measuring outcomes helps to prosthesis—then she “follows by patients with limb demonstrate patients’ advances. the care” by attending one of loss and difference. “I do Shamel Allen, “Outcome measures are very the patient’s first PT appointsome adjunct teaching CP, MPT important for patients—particularly ments, followed by return trips and lecturing at local to explain to insurance companies on an as-needed basis. “I start PT and PTA schools, where your patient is starting [in his all my evaluations with new amputees and I always stress the importance of or her initial abilities using a first talking about how important it is to prosthetists and PTs working closely prosthesis] and then in documenting follow up with therapy,” she explains. together,” she says.

“Patients need to know the importance of physical therapy and rehabilitation in order to be able to use their devices successfully and to understand that the therapy is an integral part of the overall process.”

Allen says she recommends several PT facilities if patients ask for Shamel Allen, CP, MPT, a center manager for NovaCare Prosthetics suggestions—facilities that employ and Orthotics in St. Louis, practiced physical therapy for 10 years experienced professionals who have before becoming a certified prosthetist. She offers the following list worked successfully with limb loss of questions that prosthetic patients should be able to answer before patients in the past. Some, but not all, selecting a physical therapy facility: of these facilities are owned by Select Medical, the same parent company X Does the PT facility have experience in that owns NovaCare—this arrangeworking with patients with limb loss? ment can facilitate communication.

X Does the facility have parallel bars?

But it’s important, she adds, that patients understand they can choose X Does the facility have a therapist on staff any therapy facility. She only offers who specializes in working with amputee recommendations when asked, but she patients? Has this individual worked with always arms patients with questions patients who have a similar type or level of to ask the potential PT clinic to make amputation (below-knee experience for a sure that facility will meet their needs below-knee patient, etc.)? (see sidebar).

When a new patient is fit with X Does the PT facility provide his or her first prosthetic device and transportation?

Shamel Allen, heads to the initial therapy appointCP, MPT, ment, Allen likes to reach out to the X How many days per week will presented a therapist and offer to answer any they attend therapy? course on "The questions regarding amputation Rehabilitation X

How long are typical therapy sessions? level, prosthetic fit, or componentry of the Lowerselection. She then attends one of Limb Amputee" the early PT appointments to make during the any alignment or fitting adjustments.

Missouri “As a patient starts using a prosthesis Physical Therapy more frequently, their residual limb 2019 Spring changes,” she says—so it’s important Conference. to keep the lines of communication open throughout the rehabilitation process. If the therapist is less familiar with patients who have limb loss, Allen attends additional PT appointments as well.

Helping Prosthetic Patients Seek Out Successful Therapy

DECEMBER 2019 | O&P ALMANAC

PHOTOS: Shamel Allen, CP, MPT

26

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AllStar

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COVER STORY

28

DECEMBER 2019 | O&P ALMANAC

PHOTO: Getty Images

progress,” says Allen. “PTs be advantageous to O&P have a lot of training and facilities. Lowrie, a secondeducation in conducting year student in the MSOP outcome measures and program at California State in completing thorough University—Dominguez documentation,” she Hills, has a bachelor’s says. “When you can degree in kinesiology give an objective and worked as a PT aide Kathryn Lowrie measurement—an actual supervisor at ProSports number demonstrating Physical Therapy in Costa improvement—that seems Mesa for several years to make more of a difference” to the before pursuing her MSOP. She realpayor sources. ized during her O&P coursework that While Allen’s facility collects most partnerships between the two types of of its own outcome measures—by facilities could be mutually beneficial. documenting progress via the Timed“PT clinics have the ability to not Up-and-Go (TUG) test, AMP-Pro only strengthen patients, but they can and AMP-No Pro, PLUS-M, and also work side-by-side” and collect other measures—being able to share outcome measures that may be useful information with a PT facility offers to O&P facilities in strengthening their a greater data pool to draw from to data and ultimately gaining reimbursedemonstrate efficacy and the value of ment for high-quality componentry, O&P intervention, Allen says. explains Lowrie. “PTs are paid In California, Kathryn Lowrie, a to [perform and gather] outcome forward-thinking young O&P profesmeasures,” whereas O&P professionals sional, recently sparked a collaboration are paid in a different manner, via between local O&P and PT facilithe Healthcare Common Procedure ties when she recognized that the Coding System (HCPCS). “Because experience of physical therapists in outcome measures are ingrained in collecting outcome measures could PT, physical therapists can conduct

outcome measures while helping patients get stronger and improve their mobility,” she says.

Lowrie was recently introduced to Rick Myers, CP, owner of Southern California Prosthetics, who mentioned an interest in working more closely with a PT facility staffed by appropriately trained therapists. Lowrie reached out to ProSports—a PT practice with an active and athletic patient base—and suggested she conduct in-services to provide guidance to the company’s therapists on some of the unique aspects of working with patients who have lost a limb. She has conducted several sessions so far, explaining to participants about the process of amputation, residual limb volume issues, dermatological problems, gait training, and even what would be helpful to O&P facilities in terms of outcome measures. She also prepared a binder full of backup information.

The arrangement is still in its early stages, and Lowrie and Myers are looking into how the PT facility can share outcome measurement data with the O&P facility in a manner that is compliant with the Health Insurance Portability and Accountability Act (HIPAA)—probably via HIPAAcompliant software. They already have referred some patients to ProSports and accompanied those patients on their first visit, and plan to keep the lines of communication open between the two facilities.

Lowrie believes more O&P facilities should forge partnerships with PT facilities that can benefit both companies—and their patients.

“Research shows that when a person with a transfemoral or transtibial amputation undergoes proprioceptive neuromuscular facilitation (PNF) gait training—a type of therapy that PTs specialize in—there is a significant difference in regard to gait parameters,” says Lowrie, explaining that improvements in step length and weight acceptance are often seen in patients who have participated in PNF training when compared to traditional gait training.

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And while the PT facilities that work with individuals with limb loss may get a boost in business by working with a new patient population, the O&P facilities benefit from closer communications with another stakeholder and a multidisciplinary approach to patient care—while gathering additional outcome measures to support a value-based care model.

Providing More Comprehensive Patient Care

Although physical therapy for new amputees is of particular importance, individuals who have lived with amputation for years also benefit from coordinated O&P/PT care. At Rhode Island Limb Co., headquartered in Cranston, there has been an increased effort over the past several years to collaborate and take a multidisciplinary approach in partnering with both PTs and physiatrists.

The facility works with many older amputees, including Korean War and Vietnam era veterans who have worn

prostheses for decades. “Today, the technology is much more sophisticated” and designed to promote a more natural gait, but some older patients have worn less advanced devices over the years, explains Jonathan Teoli, MSPO, CPO, clinical director at the facility. Some of these patients have experienced “wear and tear” on their sound side, resulting in contralateral limb issues and compensatory damage to their hips, knees, and backs. “We want to be mindful of these issues and treat the whole patient,” so the clinicians at Teoli’s facility collaborate with PTs at several designated outpatient treatment centers. Rhode Island Limb Co. also is licensed and credentialed to provide PT services at its headquarters, and does so on occasion—adhering to the separate billing and scheduling procedures required.

“We try to provide the clinic environment,” Teoli explains. While there are some “administrative challenges” when providing care in this manner, the facility works with insurance

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DECEMBER 2019 | O&P ALMANAC

Co-Locating With a PT Facility

Like Rhode Island Limb Co., Medical Center Orthotics & Prosthetics (MCOP), headquartered in Silver Spring, Maryland, has recognized the benefits that come from providing O&P and PT services at a convenient location. Over the past several years, MCOP has come to co-locate some of its offices with PT in subletting arrangements. “Patient retention is our goal,” explains Ian Fothergill, BOCP, so the company has “invested in the success of the patients” by partnering with a physical therapy company.

“We can’t go it alone” in ensuring the long-term success of amputees, so MCOP now works closely with the PT group at Adventist Rehabilitation Hospital in Rockville, according to Fothergill. Some locations of MCOP have sublet space to Adventist physical therapy offices, and vice versa. “We’ve put together ‘care packages’ with outpatient rehabilitation services in a crossover approach,” Fothergill explains.

The two companies remain completely separate for legal purposes, with separate billing and scheduling—although patients are encouraged to set consecutive appointments. In fact, the current arrangement with co-located O&P/ PT facilities was driven, in part, “by a realization that it’s difficult for patients with amputations to get through the rehabilitation process— especially given the very laborious process with so many appointments,”

PHOTO: Ian Fothergill, BOCP/Medical Center Orthotics & Prosthetics

Ian Fothergill, BOCP, works with a patient at Medical Center Orthotics & Prosthetics (MCOP), a facility that sublets office space at some locations to physical therapy practices.

companies to ensure services are billed separately and appropriately.

O&P companies that work closely with PTs are more successful in meeting their joint patients’ needs, says Teoli. “PTs see patients much more frequently, and if we’re nearby, we can help out” with O&P device issues that might arise during therapy appointments, Teoli says. Plus, when prosthetists and PTs “blend their knowledge,” patients see the benefits, he says. “The patients seem to do better, faster,” when working with healthcare practitioners from both disciplines.

COVER STORY

PHOTO: Ian Fothergill, BOCP/Medical Center Orthotics & Prosthetics

Aaron Foreman, MSPT, CPO, owner of Blue Sky Orthotics and Prosthetics, is a licensed physical therapist as well as an ABC-certified clinician.

Although he does not currently offer PT services at Blue Sky, he did offer both O&P and PT at his last facility, Orthotic and Prosthetic Technologies.

“It’s a good model,” he says. “PT is a critical component to both prosthetic and orthotic rehab, so O&P and PT can really mesh well together.”

Foreman was able to provide a continuity of care at Orthotic and Prosthetic Technologies. With new amputee patients, “I would see the patient in the hospital postamputation, then once discharged would start PT to get them ready for their prosthesis,” he says. “When the patient’s residual limb was healed, prosthetic casting and fitting would start.” Foreman would then continue with physical therapy gait training/strengthening with the patient. “It was the best of both O&P clinicians at MCOP have put together "care worlds,” resulting in more streampackages" with outpatient rehabilitation services lined care for many patients. “In this in a crossover approach to patient care. day and age, more services are being brought under one roof to offer convein agreement with Lowrie. nience and optimal care says Fothergill. Administrators at With the partnership, MCOP for the patients.”

MCOP “ask patients when their next has become “a much more Foreman cautions that PT session is, and we try to align our evidence-based practice.” the two businesses must appointments with theirs” to save Fothergill cautions O&P be kept separate, with patients time and reduce the overall facilities that are considering the PT part of the businumber of appointments. “The new partnering with PT facilities ness becoming properly system ensures patients get the care in a similar manner to be licensed and accredited they need,” says Fothergill. “In our Aaron Foreman, patient and be prepared for for the provision of PT. O&P clinics, PTs and OTs can run MSPT, CPO “a long haul.” At MCOP, “it’s For PT, billing is charged their spaces right beside ours. It’s a patient-focused model.” taken a core team almost 15 by the time and services Regarding the legalities, MCOP years” to implement the partnership provided, while O&P services are has appropriate business associate in its current form. “These systems billed using HCPCS codes. “You have agreements in place, and it makes always look good on paper, but you to stay very organized, and have sepasure to inform patients that they may need to get key stakeholders from both rate scheduling,” Foreman says. choose other options in selecting professions together” and work collabAnd with such an arrangement, their O&P or PT provider. “Neither oratively for the good of the patients, it’s also important to evaluate the location is exclusive to joint patients,” he says. landscape and ensure you won’t be he says. “Outcome and data sharing competing with your referral sources, should happen regardless of locaJoint Services Foreman adds. But if competition with tion,” whether the facility is located Some facilities have staff members local therapists is not a factor, then it’s who have been trained in both PT a model that should be considered. next door or across town, says and O&P—and they can leverage Fothergill. PTs can release notes to their training to help patients in both Christine Umbrell is a contributing O&P clinicians, as long as all HIPAA disciplines. But doing so requires writer and editorial/production associate regulations are abided. Plus, “we can separation of facilities, billing, for O&P Almanac. Reach her at take advantage of the PTs’ training in and scheduling. cumbrell@contentcommunicators.com. outcome measures,” Fothergill says, O&P ALMANAC | DECEMBER 2019

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By MEGHAN HOLOHAN

Pain and Relief

As the opioid epidemic rages on, experts turn to alternative strategies to help O&P patients manage their discomfort

NEED TO KNOW Many individuals who experience residual or phantom limb pain turn to prescription opioids to manage their pain, but these medications come with serious risks. Each year, there are 47,600 opioid-related deaths in the United States.

A retrospective study on usage of prescription opioids among transfemoral amputees found that individuals who are using prescription opioids prior to amputation are much more likely to report frequent use of opioids postamputation.

Increased public attention to the opioid epidemic has resulted in less availability of these drugs.

Since 2014, there’s been a 13 percent decrease in the number of patients who are receiving opioids from orthopedic surgeons.

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DECEMBER 2019 | O&P ALMANAC

Prosthetists can play a significant role in pain management solutions by being aware of patients’ medication usage, providing information on support groups, and ensuring proper alignment and socket fit to increase comfort during prosthesis wear.

Alternative strategies for pain management include ibuprofen and acetaminophen, neuro-modulators, yoga, meditation, massage, heat therapy, acupuncture, electrical nerve stimulation, and medical marijuana.

Healthcare professionals and patients should consider a shift in thinking; rather than eradicating pain, perhaps it can be managed to a tolerable level.

R

YAN MILLER, A VETERAN who lost his leg after an explosion in Iraq, recently told CNBC that the year after his accident felt like constant surgeries and opioid prescriptions.

But it was much more than bodily pain he experienced. He felt emotionally distressed, too. “It wasn’t just a pain, a physical thing,” Miller said, explaining that the experience took over his life.

“It just sucks. You feel like a prisoner.”

This sentiment is echoed by many individuals with limb loss throughout the country. Some amputees experience residual limb pain—pain that originates in the remaining part of the limb, caused by amputation or by medical conditions that preceded the surgery. Some also experience phantom limb pain—ongoing painful sensations that seem to originate from the absent limb.

Many of the individuals suffering from residual and phantom limb pain turn to prescription opioids—such

as hydrocodone, oxycodone, and morphine—to manage their pain. But that solution can be problematic. While these medications can reduce pain during short-term use, they come with serious risks, including addiction and death from overdose when taken for longer periods of time or at high doses, according to the Centers for Disease Control and Prevention (CDC). Physical dependence—meaning the opioid user begins having withdrawal symptoms when a medication is stopped—can develop within just a few days.

Overprescription of opioids, in combination with illegal use of opioids, has resulted in an epidemic in the United States, leading to a need for alternative solutions to pain management.

Opioid Overuse

Each hour in the United States, approximately five people die from opioid overdose. That’s 130 opioidrelated deaths per day, and 47,600 per year, according to CDC. Since the 1990s, rates of opioid addiction have skyrocketed: In 2017, there were six times more opioid deaths than in 1999.

Since 2014, there’s been a 13 percent decrease in the number of patients who are receiving opioids from orthopedic surgeons, according to athenaResearch.

These numbers are especially problematic for the limb loss population, many of whom have been prescribed opioids for pain management. “It’s estimated that about 15 percent of the adult population leaves the hospital with an opioid prescription, and about 42 percent are still taking opioids at the three-month

follow-up,” Kenton Kaufman, PhD, PE, told attendees at the 2019 AOPA National Assembly during a session on “Opioid Use in Adults With AboveKnee Amputations.” Approximately 20 to 40 percent of the patients receive opioids for chronic noncancer pain, which includes musculoskeletal pain, according to Kaufman, who is program director/principal investigator for the national Limb Loss and Preservation Registry and serves as director of the Motion Analysis Laboratory at the Mayo Clinic.

Kaufman recognizes that up to 80 percent of amputees may experience phantom limb pain two years postsurgery, and he acknowledges that opioids are effective for controlling severe postamputation pain. He also notes that pain may be exacerbated by the depression and despair often associated with an amputation. But in using opioids to relieve the pain, he said, “it’s very easy to become addicted.”

Kaufman recently helped lead a retrospective study into the usage of prescription opioids in people with transfemoral amputation, and the factors associated with long-term use. He and his team studied the records of 70 patients and concluded that patients who had already begun receiving opioid prescriptions prior to amputation had a much harder time getting off opioids prescribed postamputation, compared to “naïve” patients who were prescribed opioids for the first time postamputation.

What’s more, prior users “reported more post-op pain, more chronic pain, more stump complications, and more depression,” Kaufman said.

In fact, 60 percent of non-naïve patients recorded frequent use of opioids postamputation, but only 10 percent of naïve patients reported frequent use. “So, if they’re using opioids before the amputation, they’re most likely to use opioids after amputation,” Kaufman concluded at the Assembly.

Fortunately, the increased attention on the opioid epidemic over the past few years is making a difference in the number of prescriptions being

prescribed. Doctors are “starting to monitor the amount that they give out, and the rate at which they give it out, so they give out a much smaller dosage” and require patients to call in for renewals, said Kaufman.

Since 2014, there’s been a 13 percent decrease in the number of patients who are receiving opioids from orthopedic surgeons, according to athenaResearch. This trend is helpful in preventing opioid-related deaths— and has led to a renewed focus on alternative pain management strategies.

Prosthetists can play a part in pain management solutions— not only by detecting if a patient appears too dependent on opioids and speaking with the patient’s doctors, but also by ensuring proper alignment and socket fit of a patient’s prosthesis.

Treating Pain Without Opioids

While opioids are effective in treating pain, they are not advised as a long-term solution. The CDC now recommends that acute pain be made more tolerable by short courses of opioid medication, and recommends only three to seven days of use, even after a major surgery or injury.

Experts believe a holistic approach is needed. “This is a clearly an interdisciplinary problem that requires close coordination with the medical providers,” Kaufman says.

O&P ALMANAC | DECEMBER 2019

35

Amputee Coalition Offers Tips for Managing Pain The Amputee Coalition includes pain management information in the National Limb Loss Resource Center section of its website, amputee-coalition.org.

Residual Limb Pain To help patients manage their residual limb pain, the website suggests the following: ■ Begin exercises as soon as your surgeon allows it, including standing, walking, and muscle stretching.

■ Desensitize your residual limb, following the instructions of your physical or occupational therapist; this includes both massaging and wrapping your residual limb.

■ Work with your prosthetist to maintain proper prosthetic alignment and to choose prosthetic components that are appropriate to your needs.

■ Keep a pain journal. Keep track of your symptoms and sharing them with your healthcare team.

■ Practice relaxation.

Phantom Limb Pain The Amputee Coalition notes that while physicians may recommend some medications to alleviate phantom limb pain, individuals experiencing this type of pain may also wish to try the following nonmedication treatments: ■ Acupuncture ■ Massage of the residual limb ■ Use of a shrinker ■ Repositioning the residual limb by propping on a pillow or cushion ■ Mirror box therapy ■ Biofeedback ■ TENS (transcutaneous electrical nerve stimulation) ■ Virtual reality therapy ■ Imagery ■ Music.

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DECEMBER 2019 | O&P ALMANAC

Prosthetists can play a part in pain management solutions—not only by detecting if a patient appears too dependent on opioids and speaking with the patient’s doctors, but also by ensuring proper alignment and socket fit of a patient’s prosthesis. “It’s incredibly important,” says Mary Ann Miknevich, MD, a physical medicine and rehabilitation doctor at the University of Pittsburgh Medical Center. When patients who have been doing well with a prosthesis report discomfort in their limb or phantom pain, Miknevich consults with a prosthetist.

“One of the first things we do is try to make sure we get prosthetists in there to look at their socket,” she explains. Prosthetists “can help in making sure that the prosthesis is the correct device” and that shifts in residual limb volume are not causing discomfort. For example, she notes, “sometimes we’ll see people in a pin-locking liner who have tremendous pain, so just getting them out of that liner … and into a different socket design can sometimes help.”

Kaufman agrees. “Socket comfort is very important, and if the socket isn’t fitting properly,” the prosthesis will not function appropriately, resulting in discomfort.

When Miknevich lectures O&P students, she talks about how becoming an amputee might change patients’ bodies in ways that contribute to pain, and she encourages prosthetists to be mindful of these changes.

“Some of the other things we cover in that lecture, for example, are issues related to people who have significant volume changes in their limbs, people with ischemia, so that in the process they are more aware of conditions that can impact or can cause pain,” she says.

Miknevich notes that medical schools are now incorporating formal lectures focusing on the opioid epidemic, in compliance with a recent national mandate to increase the awareness of physicians of the dangers of opioids. Medical students also get direct experience in dealing with issues related to narcotic medications on their clinical rotations.

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Prosthetists, for their part, have an opportunity to assist their patients by ensuring they have the emotional support they may require. Many patients find that going to a support group for limb loss, trauma, or phantom pain can make it easier for them to grapple with some of the physical discomfort they experience.

“If you’re under a lot of stress, it’s a little harder to cope with other things that happen,” and emotional issues can exacerbate physical ones, Miknevich says. “You know they’re having pain that’s bothering them, [and that] it’s building up, and then you start adding an inability to do things they want to do.”

Miknevich asks all of her patients if they have adequate support from family and friends as an intake question during every visit. Just adding that one question to her practice has helped her learn that many of her patients lack adequate aid. In such instances, she directs patients to online or in-person support groups. Miknevich says that other providers, including prosthetists, can add a similar question to their intake procedures to try to understand where their patients are, and can assist patients in dealing with their pain by directing them to supportive groups.

“It’s just a segue into opening that discussion,” she says.

opioids. Opioids are attractive because they’re effective at eliminating most pain. But perhaps clinicians need to think of how to ensure pain is manageable—not eradicated. “So rather than saying the goal [is] no pain, the goal is more like: What type and level of pain would be tolerable?” he explains. Then healthcare professionals can try to manage pain to that “tolerable” level.

Some believe that medical marijuana can reduce pain and prevent dependence on opioids. The Veterans Cannabis Project, for example, advocates marijuana usage to help the 15 percent of soldiers who regularly rely on opioids.

Alternative Approaches

Miknevich, for her part, says she has had some patients who have experienced subjective benefits from medical marijuana, but she believes more research is needed. She also recalls seeing one study that noted that amputees who used medical marijuana experienced worse outcomes. “I actually found one article that commented about rebound pain, and the [subject] actually had more pain with medical marijuana,” she says.

Some individuals are finding relief via alternative, non-drug treatments.

The U.S. Veterans Administration has been implementing new treatment offerings, such as yoga, meditation, and acupuncture. The Cleveland VA only provides opioids for 4 percent of its patients because it has found alternative treatments to be effective.

With physicians prescribing fewer opioids, other solutions for pain management are available—but each patient is different and no one-size-fits-all solution exists. CDC recommends several nonopioid options, including pain relievers like ibuprofen, naproxen, and acetaminophen; acupuncture or massage; and application of heat or ice.

When Miknevich lectures O&P students at the University of Pittsburgh, she discusses pharmaceuticals other than opioids that might help, including neuro-modulators, such as gabapentin, a drug used for seizures and to treat shingles pain.

Kaufman says that a shift in how experts think of pain management can also help reduce dependence on 38

DECEMBER 2019 | O&P ALMANAC

Opioids are attractive because they’re effective at eliminating most pain.

But perhaps clinicians need to think of how to ensure pain is manageable—not eradicated.

Angie Cuzzola, an occupational therapist in Edison, New Jersey, has seen firsthand how yoga can improve a patient’s quality of life while reducing pain. She recently spoke at a meeting of the New Jersey Chapter of the American Academy of Orthotists and Prosthetists about alternative approaches to pain management, discussing the yoga classes she hosts for an amputee support group. After only two classes, she noticed a difference in the patients. “We were getting good feedback from the group saying that they felt really great. They felt confident, strong, and balanced,” she says.

Cuzzola recalls one patient who had a bilateral lower-limb amputation who struggled with pain. He had been dependent on opioids but felt like they were no longer working for him.

Finally, he sought out alternative treatments, including medical marijuana, and he took one yoga class. He was stunned by how much better he felt after yoga. Cuzzola wasn’t surprised; research suggests that people experience a better quality of life from yoga.

“Yoga kind of touches a whole other aspect of pain,” she explains.

That’s why she thinks yoga has the potential to work well at treating phantom limb pain. It helps patients address the mind and body. “Yoga can definitely benefit people experiencing phantom limb pain because now you’re working with the brain/body connection, instead of just working on that physical ability,” Cuzzola says.

Some of Miknevich’s patients have reported a reduction in pain after undergoing compression techniques or using electrical nerve stimulation. And both Miknevich and Cuzzola have seen mirror therapy reduce phantom limb pain in patients.

For both phantom limb pain and residual limb pain, the experts agree that considering a variety of treatments is necessary when it comes to managing pain without opioids. Says Miknevich, “There is no one magic thing that works.”

Meghan Holohan is a contributing writer to O&P Almanac.

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PRINCIPAL INVESTIGATOR

Revolutionizing Prosthesis Tuning He (Helen) Huang, PhD, leads studies on reinforcement learning and pattern recognition

O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and healthcare 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.

DECEMBER 2019 | O&P ALMANAC

E (HELEN) HUANG, PhD, says one

of her greatest professional accomplishments is leading the team that demonstrated that a tuning algorithm based on reinforcement learning could reduce the time needed to fit a robotic knee from hours to about 10 minutes.

“My motivation was derived from my observation in clinics on how a powered prosthesis is customized/tuned. It is done manually and heuristically by a prosthetist, which is time- and laborintensive,” she explains. Instead, Huang proposed leveraging machine intelligence “to alleviate the human clinician’s effort, as well as increase the accuracy and efficiency of the prosthesis tuning.”

Huang, a professor at the Joint Department of Biomedical Engineering at University of North Carolina/North Carolina State University (UNC-NCSU) and director of the UNC-NCSU Closed-Loop Advance Engineering for Rehabilitation (CLEAR) Center, believes the new method will expedite—rather than eliminate—human tuning. The method works by equipping a transfemoral amputee with a powered prosthetic knee with randomly set control parameters that are safe for the amputee to ambulate. Sensors within the prosthesis collect data on the device as well as the patient’s gait. Huang and her team

developed an intelligent algorithm that adapts the parameters on the device and compares the patient’s gait to the profile of a normal walking gait in real time. Using reinforcement learning, the computational algorithm identifies the set of parameters that allows the user to walk “normally.” During trials, the algorithm successfully targeted kinematics in approximately 300 gait cycles, or 10 minutes, according to Huang.

“A human expert can only adjust one parameter at a time,” says Huang.

“The machine can learn and adjust multiple parameters at once and speed up the process.” The method and subsequent research may contribute to a stability control algorithm for prosthetics tuning procedures, as well as to clinical tuning of functional electrical stimulation technologies, exosuits, and more, according to Huang.

“Our current research shows that reinforcement learning is a promising method to achieve our goal,” says Huang. “Additional research efforts are needed to both understand how individuals with above-knee amputations interact with the robotic devices in walking and refine the reinforcement learning algorithm to be more time-efficient in order to translate the system into clinical use.”

PHOTO: He (Helen) Huang, PhD

40

H

PRINCIPAL INVESTIGATOR

During trials, an intelligent algorithm developed by He (Helen) Huang, PhD, and her team was tested and successfully targeted kinematics for users with powered prosthetic knees in approximately 300 gait cycles.

Gravitating to O&P

PHOTO: He (Helen) Huang, PhD

Huang first became interested in rehabilitation and neural engineering research as a college student. She earned a bachelor’s degree in electrical engineering in China before moving to the United States for graduate work. She earned master’s and doctoral degrees in biomedical engineering at Arizona State University, then moved to Chicago to complete her postdoctoral studies at the Rehabilitation Institute of Chicago/ Northwestern University. There, she worked in the Neural Engineering Center for Artificial Limbs (NECAL), where she helped to develop neural-machine interfaces to enable amputee users to operate their upper- and lower-limb prostheses based on their intent.

Huang worked on many research projects in the O&P field during her predoctoral and postdoctoral training— for example, she studied the mechanism of epidural spinal cord stimulation for improved walking function among incomplete spinal cord-injured patients.

She also developed the control of a wearable robotic arm and a virtual reality system for stroke rehabilitation, in addition to novel technologies in prosthetics to improve the motor function in upper-limb and lower-limb amputees.

In 2008, Huang took a position as assistant, then associate, professor in the Department of Electrical, Computer, and Biomedical Engineering at the

University of Rhode Island, before moving to North Carolina in 2013 and embracing her current roles as a professor and director of the CLEAR Center.

Continuing Contributions

In addition to her work on tuning robotic knees, Huang has been involved in numerous research initiatives at CLEAR. She recently developed a new hip exoskeleton that can assist gait and balance at the same time for individuals with hip weakness. The hip exoskeleton will be tested on patient populations—such as stroke survivors— in the future as an assistive device.

Another significant contribution to the O&P research well was the development two years ago of technology to decode neuromuscular signals to aid in controlling prosthetic hands and wrists.

Huang and her team designed computer models that closely mimic the natural behaviors of the forearm, wrist, and hand. They designed a user-generic, musculoskeletal model, then enlisted six able-bodied volunteers and individuals with transradial amputations to participate in a study. The researchers placed electromyography sensors on the participants’ forearms and tracked which neuromuscular signals were sent when the individuals performed actions using their wrists and arms.

Using this data, the researchers created a generic model that translates those

neuromuscular signals into commands that control a powered prosthesis.

While pattern recognition control requires patients to “train” their prostheses, the new technology is designed to be more intuitive, according to Huang.

“When someone loses a hand, their brain is networked as if the hand is still there,” she says. “So, if someone wants to pick up a glass of water, the brain still sends those signals to the forearm. We use sensors to pick up those signals and then convey that data to a computer, where it is fed into a virtual musculoskeletal model. The model takes the place of the muscles, joints, and bones, calculating the movements that would take place if the hand and wrist were still whole. It then conveys that data to the prosthetic wrist and hand, which perform the relevant movements in a coordinated way and in real time— more closely resembling fluid, natural motion.” In preliminary testing, both able-bodied and amputee volunteers used the model-controlled interface to perform hand and wrist motions.

Proving Value

Much of Huang’s research may play an important role in outcomes data for payors while enhancing life for O&P consumers. “For the lower-limb prosthesis tuning project, I envision the technology will significantly reduce the duration for a prosthesis tuning procedure.

O&P ALMANAC | DECEMBER 2019

41

PRINCIPAL INVESTIGATOR

Huang and her team at the Closed-Loop Advance Engineering for Rehabilitation Center at the University of North Carolina/North Carolina State University

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DECEMBER 2019 | O&P ALMANAC

Looking forward, Huang believes that O&P research that focuses on the “personalization” of robotic prostheses and exoskeletons will be extremely valuable to the O&P profession.

Such research will determine how to personalize prosthesis/exoskeleton design and control for optimal motor functions as well as how to provide personalized clinical training for each

individual user who can make the best use of these modern assistive devices.

In the future, Huang’s “wish list” of study topics includes investigating how sensory feedback of the prosthesis hand or foot improves the motor functions of individuals with limb loss. In addition, she hopes to work with O&P industrial partners “to translate my technology to benefit individuals with limb loss.”

Notable Works He (Helen) Huang, PhD, is the author or co-author of more than 115 peer-reviewed articles. Some of her most impactful published contributions include the following: • Wen, Y., Si, J., Brandt, A., XGao, X., Huang, H. “Online Reinforcement Learning Control for the Personalization of a Robotic Knee Prosthesis.”

IEEE Transactions on Cybernetics 2019 (Accepted).

• Pan, L., Crouch, D., Huang, H. “Myoelectric Control Based on a Generic Musculoskeletal Model: Towards A Multi-User Neural-Machine Interface.” IEEE Transactions on Neural System and Rehabilitation 2018; 26(7), 1435–1442.

• Huang, H., Zhang, F., Hargrove, L, Dou, Z., Rogers, D., Englehart, K. “Continuous Locomotion Mode Identification for Prosthetic Legs Based on Neuromuscular-Mechanical Fusion,” IEEE Trans Biomed Eng. 2011; 58(1), 2867-2875.

• Huang, H., Kuiken, T.A., R. D. Lipschutz, R.D. “A Strategy for Identifying Locomotion Modes Using Surface Electromyography.” IEEE Trans Biomed Eng. 2009; 56, 65-73.

PHOTO: He (Helen) Huang, PhD

That will be translated to the reduction of cost for fitting advanced powered prostheses,” she explains. In addition, because machine tuning will tune the prosthesis in order to optimize certain gait performance metrics— such as joint motion, gait symmetry and stability—the technology, if designed well, “ensures the improved gait and balance in individuals with lower-limb amputations.”

For her studies that relate to neural control of prostheses, Huang believes the outcomes may improve amputees’ motor function by enabling them to operate a prosthesis based on their intent and adapt to various tasks. “The technology also may reduce phantom pain and generate prosthesis embodiment in individuals with limb loss,” she says.

And when studying the biomechanics of amputees, Huang and her team intend to contribute important knowledge on how prosthesis mechanics influence the amputee user’s movement function. “The outcome may inform better design and control of advanced prostheses.”

Huang’s research initiatives are complemented by her time spent teaching and mentoring graduate and undergraduate students in biomedical engineering. She also organizes outreach activities to K-12 students to promote science, technology, engineering, and math (STEM) education.

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MEMBER SPOTLIGHT

Boston Orthotics & Prosthetics

Support Staff Boston patient-care and manufacturing company empowers employees to meet patients’ needs

B

OSTON ORTHOTICS & PROSTHETICS, formerly

known as Boston Brace, is closing in on its 50th anniversary. The company was founded in 1970

by M.E. “Bill” Miller, who worked with John Hall, chief of clinical orthopedics at Boston Children’s Hospital, to design and patent a new thermoplastic scoliosis bracing system. Since then, “the Boston Scoliosis Brace has become the gold standard of nonoperative scoliosis care,” says Tom Morrissey, president of Boston O&P.

Caption

James "Rusty" Miller, CPO, and Lauren Houle, PT, DPT, CPO, work with a patient.

COMPANY: Boston Orthotics & Prosthetics A staff member examines an X-ray and electronic scan during manufacturing of a 3D brace.

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DECEMBER 2019 | O&P ALMANAC

HISTORY: 49 years

Miller (front) and David Fine, CPO, adjust braces.

clinics in concert with medical staff at the top-rated children’s hospitals in the country,” explains Morrissey. These include Boston Children’s Hospital, Children’s Hospital of Philadelphia, and Children’s Specialized Hospital of New Jersey.

Boston O&P emphasizes education for providers to ensure the efficacy of its products.

Morrissey notes, “The material and the design of the brace are important, but even more so is the way the practitioner fits the device.” The company holds regular training classes at its manufacturing facility in Avon, Massachusetts, including a two-day course in the Boston Brace 3D and single-day courses in cranial remolding helmets and dynamic movement orthoses. Each course includes training at various skill levels in the evaluation, scanning and measuring, and fitting process used at Boston O&P. Boston O&P employees own a third of the company through an employee stock option plan (ESOP). “We want our employees to come to work every day with the mentality that they own the business—because they do,” says Morrissey.

The company embraces the “lean” business model, which focuses on creating “perfect value” for the customer. “Each team in the company has the autonomy to make sure that the patient experience is the best it can be,” explains Morrissey.

“Through the ESOP and lean culture, our employees are empowered to do everything they need to do for that patient to want to come back to us again. As a result, our employee turnover is very low, and our patient satisfaction results are very high.”

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

PHOTOS: Boston Orthotics & Prosthetics

The company’s patient-care and manufacturing divisions were known as National Orthotics and Prosthetics Company clinics and Boston Brace International, respectively. In 2017, the two united under one name: Boston Orthotics & Prosthetics. In addition to its own 26 O&P patient-care facilities, Boston O&P partners with independently owned clinics nationwide that are certified in the use of its products.

In 2017, the company introduced the Boston Brace 3D. It is custom fabricated from an X-ray and a scan of the patient that creates a three-dimensional model, which is then modified in Rodin4D CAD software. The Boston Brace 3D was trialed and

LOCATION: Avon, Massachusetts

tested for six years by Boston’s certified orthotists prior to its release. As a result, says Jim Wynne, CPO, FAAOP, vice president, director of training and education, “we can precisely quantify the corrective force vectors that are built into the device to de-rotate and shift the spine toward midline to reduce the curve while maintaining sagittal balance.” Internal pads are used to enhance the vectors as the spine straightens and to allow for adjustments as the patient grows or the curve changes, according to Wynne.

“The corrective forces are balanced by open or void areas that allow for easier breathing.”

In addition to a variety of scoliosis bracing designs, Boston O&P manufactures custom spinal orthoses, corrective plagiocephaly helmets, and custom lower-limb devices. The Dynamic Movement orthosis is distributed

by Boston O&P as well. The products marketed and supported by the company “are tested for efficacy through the Boston O&P

By DEBORAH CONN

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MEMBER SPOTLIGHT

Mid State Artificial Limb

By DEBORAH CONN

Mobile Care Mississippi facility sees rural patients in their homes to ensure optimal outcomes

T

ROY LUSTER, BOCP, says

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DECEMBER 2019 | O&P ALMANAC

The team at Mid State Artificial Limb sees patients at its Jackson, Missisippi, location and provides mobile services to rural patients.

FACILITY: Mid State Artificial Limb OWNER: Troy Luster, BOCP LOCATION: Jackson, Mississippi HISTORY: 31 years

physical therapy room, and a lab, where prosthetists fabricate 99.9 percent of devices, says Luster.

Nearly two-thirds of Mid State’s patients are older, with disease-related amputations, and about a quarter lost a limb from trauma. The facility also sees some pediatric patients, who require refitting every three or four months as they grow.

Mid State serves areas in Mississippi and Louisiana and sees nearly all its patients in their homes. “Our typical patient is about 100 miles away,” Luster says. “Once we do a measurement, we can basically service them where they live. Typically, we need to see them three or four times, and older people, especially, find it hard to make that trip. We thought it best to meet them on their own terrain.”

The facility has two vans equipped for mobile service, says Davis. “Each one has pretty much all a prosthetist needs, including electrical hookups for drills and a heat gun, a saw, and all the necessary supplies for casting and fitting.”

Fitting patients with devices in their homes enables practitioners to assess their “natural habitats” while easing the rehabilitation process, Luster explains. “We see how they navigate stairs in their homes and how they maneuver in their yard. Patients appreciate that, and we get a lot of business through word-of-mouth.”

Mid State employees are highly involved in the local communities.

The facility sponsors area softball teams and participates in charitable activities through the church Davis and Luster attend. Luster welcomes high school students who want to learn more about the prosthetics profession, and he has mentored young people through the 100 Black Men organization.

The company outsources some marketing activities, although both Davis and Luster make it a point to visit physicians, physical therapists, and other referrers.

Luster expects to hand the facility’s day-to-day operations over to Davis before long, and he anticipates Davis will eventually expand the business to its former complement of practitioners.

Luster has no plans to retire, though. “I like what I’m doing,” he says. “It’s been a terrific journey.

There are no words to state what this endeavor has allowed me to enjoy. I appreciate the people I’ve met in this field—I look at the smiles on our patients’ faces when we’ve satisfied them, and there is no greater reward.”

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

PHOTO: Mid State Artificial Limb

he became the first AfricanAmerican in the United States to own a prosthetics facility when he opened Mid State Artificial Limb in 1988. Since then, he has employed dozens of African-American prosthetists over the years. “I guess I’m kind of like the godfather,” he jokes.

Luster initially entered the prosthetics profession as a business owner. Seven years ago, at the urging of one of his prosthetists, Robbin Alexander Wright, CP, he became BOC-certified, allowing him to treat patients as well as manage his practice.

(Wright was just returning a favor: Luster had mentored her as a young woman, encouraging her to become certified, and then hired her as a prosthetist.)

At one point, Mid State Artificial Limb had 25 employees, but at age 73, Luster has cut back a bit. Today, Mid State has three certified prosthetists and a fitter, and since 2014 the office has been run by Ben Davis, CDME, a certified durable medical equipment specialist.

Luster and Davis became friends through their church. “I didn’t have to teach him much,” says Luster. “He was a professional and already had experience running a business. I don’t know what I’d do without him now.”

Mid State has been in the same location in Jackson since 1989, and while the practice has become smaller, Luster says there is room to expand again in the future. The facility occupies about 3,100 square feet, including two fitting rooms, a

AOPA NEWS

Don’t Sleep on the Latest AOPA Member Resource: AOPA Co-OP Are you utilizing your AOPA membership to its fullest? Be sure to visit the AOPA Co-OP at www.aopanet.org/resources/ co-op/.

A Wikipedia for all things O&P, the Co-OP is a one-stop resource for information about reimbursement, coding, and policy. It is a searchable database that provides up-to-date information on developments in Medicare policy, state-specific legislation, private payor updates, and more. Members can access detailed information on everything

Co-OP

from modifiers to product-specific L codes and associated policies.

Additionally, members can share information and insights on developments impacting the entire O&P profession.

This is your opportunity to learn about O&P's most comprehensive resource for coding, billing, and reimbursement.

Ashlie White, AOPA’s director of strategic initiatives, will demonstrate how to use the Co-OP and answer all of your questions. Contact Betty Leppin, bleppin@aopanet.org, for details.

SAVE THE DATE

New Year, New Webinars Set Your Calendar for Upcoming AOPAversity Webinars AOPAversity is off and running for 2020! Plan now to take part in the first three webinars of the new year: • January 8—Modifiers: Enhance Your Claims Two Letters at a Time • February 12—O&P Coding & Billing Myths: The Truth Is Out There • March 11—New Technical Credits— Clinician’s Corner: Orthotics During the one-hour monthly webinars, AOPA experts provide the most up-to-date information on a specific topic. Webinars are held the second Wednesday of each month at 1 p.m. EST. One registration is all it takes to provide the most reliable business information and CE credits for your entire staff. If you’ve missed a webinar, AOPA will send you a recording of the webinar and quiz for CE credits, so you can still take advantage of the series discount and the valuable learning opportunities.

Earn 1.5 Business CEs each by returning the provided quiz within 30 days and scoring at least 80 percent. All webinars begin at 1 p.m. EST. Visit www.AOPAnet.org to learn more.

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O&P ALMANAC | DECEMBER 2019

47

O&P PAC UPDATE

T

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 recently received donations from the following AOPA members*:

• Lindsey Kline • Ted Muilenburg, CP, FAAOP

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 House and Senate and other officials running for office to educate them about the issues, and help elect those individuals who support the orthotic and prosthetic community.

To participate in, support, and receive additional information about the O&P PAC, federal law mandates that

eligible individuals must first sign an authorization form, which may be completed online: bit.ly/aopapac. *This list was created on Oct. 31, 2019, and includes only donations and contributions made or received between Oct. 7, 2019, and Oct. 31, 2019. Any donations or contributions made or received on or after Oct. 31, 2019, will be published in a future issue of O&P Almanac.

NEW MEMBERS

Welcome New AOPA Members

T

HE OFFICERS AND DIRECTORS of the American

Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an 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 statelicensed 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.

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DECEMBER 2019 | O&P ALMANAC

Brighton Center for Specialty Care 7500 Challis Road Brighton, MI 48116 734/263-4000 Affiliate Clinical Prosthetics & Orthotics LLC 7 Wells Street, Ste. 207 Saratoga Springs, NY 12866 518/580-0267 Affiliate

Oakland Orthopedic Appliances Inc. 1117 S. Van Dyke Road, Ste. 100 Bad Axe, MI 48413 989/623-0931 Affiliate

CAREERS

Opportunities for O&P Professionals

Inter-Mountain Prothetist/Orthotist

Job location key: - 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

Nonmember $678 $830

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

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

Houston/Beaumont, Texas Freedom Prosthetics and Orthotics is not the largest prosthetic company in Texas, but we are at the top and strive everyday to be the best. You will enjoy coming to work, great benefits, hours, and salary commensurate with experience. Company car available in some positions.

Reply to: Fax: 281/580-8229 Email: legfixr@aol.com

North Central Certified Orthotist/Prosthetist

Marquette, Michigan Certified orthotist/prosthetist needed to join our team at a busy, full-time orthotics and prosthetics practice.

Responsibilities are to supervise and participate in the design, fabrication, and fitting of orthotic devices for patients with congenital/acquired deformities of the body and disabling conditions of the limbs and spines. Eligibility for, or completion of, the certification examination by the American Board for Certification in Orthotics and Prosthetics is necessary.

If you are looking for a long-term career with a company of dedicated professionals, come join our team in beautiful Marquette, Michigan. Job type: Full-time.

Respond by email only to: Email: rfettig@teterop.com Visit our website at: www.teterop.com

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

WANTED! A few good businesses for sale.

Lloyds Capital Inc. has sold over 150 practices in the last 26 years.

If you want to sell your business or just need to know its worth, please contact me in confidence.

Barry Smith Telephone: (O) 323/722-4880 • (C) 213/379-2397 Email: loyds@ix.netcom.com

Pedorthist, Orthotic Tech, Shoe Cobbler/Tech

Sacramento, California Independent Sacramento orthotic and pedorthic facility now hiring experienced talent for the following positions: • ABC pedorthist WE ARE HIRING • ABC orthotic tech COME JOIN OUR TEAM • Shoe cobbler/tech Must be a team player with a great attitude and have the ability to communicate effectively. Must be responsible and able to work independently. We hope to hear from you!

Send résumés to: Email: Mike@streamlineorthopedic.com O&P ALMANAC | DECEMBER 2019

49

MARKETPLACE

Feature your product or service in Marketplace.

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

Visit bit.ly/almanac20 for advertising options.

ALPS Silicone Pro Liner The ALPS Silicone Pro is a medical grade silicone liner that is one-fifth the friction of regular silicone liners.

Protected by ALPS knitted fabric, the fabric allows for extended durability and helps to reduce pistoning. It is available in Locking or Cushion Suspension and will comfortably suspend patients in their prosthesis and allow for freedom of movement.

For more information, call us or visit www.easyliner.com.

The Original Preflexed Suspension Sleeve ESP created the Flexi family of suspension sleeves as a comfortable, durable, and cost-effective alternative to traditional suspension sleeves. Preflexed at 43 degrees for maximum comfort and natural unrestricted movement.

For more information, call ESP LLC at 888/932-7377 or visit www.wearesp.com.

Bounders for Kids Store & Return Energy— Mimicking Normal Muscle Function New “Sutti Bounders” modular pediatric dynamic elastomers are a patent-pending elastomer technology that offer two progressive solutions.

Sutti Bounders store and return energy— mimicking normal muscle function to produce both eccentric and concentric contractions and, if needed, a ground-reaction force. Smart and simple modular design, standardized sizes, and three levels of performance to choose from add up to an easy to use expandable dynamic system to treat your pediatric and young adult patient base.

For more information, visit www.fabtechsystems.com/bounders or call 800/322-8234.

50

DECEMBER 2019 | O&P ALMANAC

AllPro Foot From Fillauer The AllPro foot from Fillauer crosses all boundaries, combining high flexibility and dynamic performance into a foot that allows the user to work and play like a pro. Whether walking on a flat surface or traversing steep hills, the AllPro performs to meet multiaxial needs. If exercise or sports are on your activity list, this “do-it-all” foot easily transitions from the gym to the tennis and basketball courts, as well as the soccer, football, and lacrosse fields. Play like a pro!

For more information, contact Fillauer at 800/251-6398 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.

Naked Prosthetics Naked Prosthetics designs and manufactures high-quality prosthetic devices specifically for finger loss. Our mission is to assist people with digit amputation(s) and positively impact their lives with fully articulating, custom finger prostheses.

Our product aims to restore the ability to perform most tasks, supporting job retention and an active lifestyle. Our customers have lost fingers to power tools, equipment malfunctions, injury in the line of military service, random accidents, and infections; in some cases, multiple digits have been lost. NP provides a viable functional prosthesis, as opposed to a passive cosmetic solution. Our design mimics finger motion and utilizes the remainder of an amputee’s digit to power the device.

For more information, visit www.npdevices.com.

MARKETPLACE Ottobock’s Omo Neurexaplus Shoulder Orthosis Redefine recovery with Ottobock’s Omo Neurexaplus.

The shoulder orthosis facilitates active rehabilitation by correctly positioning the arm and promoting movement for patients with shoulder subluxation. The Omo Neurexaplus inhibits pathological movement patterns, improves body posture and gait, and can be applied by patients themselves with one hand.

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

Ottobock’s Uneo Unique Liner The new polyurethane formula of the Uneo Unique custom liner provides improved tear and puncture resistance, while cushioning even highly sensitive or scarred residual limbs.

The Uneo Unique allows for comfortable impact absorption and good pressure distribution within the socket. Additionally, it is available in both antibacterial and fresh scent options, so that patients are less affected by sweat and dirt.

Because the liner is easily fit using the Custom4U app, it is completely customized to each patient and is fabricated in less than a week.

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

i-Limb® Wrist The first-ever wrist rotator to perform simultaneous rotation upon grip selection.

While entering a grip with the i-Limb Quantum hand, the wrist will rotate to the optimal position for the grip selection. With the ability to choose from three methods of control, i-Limb hand users can accomplish a wide-variety of daily activities.

Learn more on ossur.com/touch or call your Össur representative to schedule a demo.

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Discover the exciting PROTEOR USA product line today! A whole new look. A whole new vibe. A whole new world. #HumanFirst. Visit us at proteorUSA.com.

The Xtern Foot Drop AFO From TurboMed Orthotics This unique ankle-foot orthosis (AFO) was designed for patients suffering from foot drop. It is worn 100 percent outside of the shoe.

The Xtern is HCPCS code L1951 validated.

Turbomed innovative products are now available through distributor partnerships in more than 26 countries.

Its unique design and material composition give another meaning to walking and running. There is no limitation with the Xtern for the customers—not even a weight limit! For orthotists and professionals, a trial kit called AT (assessment tool) is available to quickly and easily assess patient compatibility with the Xtern in less than five minutes. Available in USA from Cascade Supply, SPS, Lakes Medical Innovations, Kevin Orthopedic, and Physio Tech.

For more information, visit www.turbomedorthotics.com.

O&P ALMANAC | DECEMBER 2019

51

MARKETPLACE AOPA Compliance Guide CD This Compliance Handbook helps patient-care facilities follow the fraud and abuse prevention guidelines recommended by the Office of the Inspector General (OIG). This product will assist you in developing a compliance plan for your facility, including guidelines for developing a standard of conduct, billing policies and procedures, and much more. With the help of the AOPA Compliance Handbook CD, you will be able to create an effective Audit/ Quality Assurance Program to monitor compliance and conduct introductory training sessions for employees. Order at www.AOPAnet.org or call AOPA at 571/431-0876.

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

COMPLETE CONTROL

SUBSCRIBE

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

AD INDEX

Advertisers Index Company

Website

Allard USA

21

866/678-6548

www.allardusa.com

ALPS South LLC

11

800/574-5426

www.easyliner.com

Amfit

43 800/356-3668

www.amfit.com

Cailor Fleming

7

800/796-8495

www.cailorfleming.com

Coapt

23

844/262-7800

www.coaptengineering.com

ESP LLC

5

888-WEAR-ESP

www.wearesp.com

Fabtech Systems LLC

800-FABTECH

www.fabtechsystems.com

Ferrier Coupler Inc.

19

810/688-4292

www.ferrier.coupler.com

Fillauer Companies Inc.

27

800/251-6398

www.fillauer.com

1 800/301-8275

www.hersco.com

Hersco

17, 29

Naked Prosthetics

37

Össur

3 800/233-6263

Ottobock PROTEOR USA TurboMed Orthotics 52

Page Phone

DECEMBER 2019 | O&P ALMANAC

32, 33, C4

888/977-6693 800/328-4058

C2 855/450-7300 9

888/778-8726

www.npdevices.com www.ossur.com www.professionals.ottobockus.com www.proteorusa.com www.turbomedorthotics.com

CALENDAR

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

Cascade Dafo Institute

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January 8 WEBINAR

visit www.AOPAnet.org.

Modifiers: Enhance Your Claims Two Letters at a Time. For more information,

January 10–11

ABC: Orthotic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/8367114, email certification@ABCop.org, or visit ABCop.org/certification.

January 17–23

US ISPO Pac Rim Meeting. Sheraton Maui Resort & Spa, Lahaina, Maui, HI. Visit www.usispo.org.

January 24–25

ABC: Prosthetic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa, FL. Contact 703/8367114, email certification@ABCop.org, or visit ABCop.org/certification.

2019 December 9–14

ABC: Written and 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 350 locations nationwide. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.

December 11

New Codes for 2020, Other Updates, and Yearly Roundup. Register online at bit.ly/2019webinars. For more information, visit www.AOPAnet.org.

WEBINAR

December 12–14

Pediatric Gait Analysis and Orthotic Management: An Optimal Segment Kinematics and Alignment Approach to Rehabilitation (OSKAR). Chicago.

25.5 ABC credits. For more information, contact Melissa Kolski at 312/238-7731 or visit www.sralab.org/academy/PedsGait19.

February 1

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

February 10–11

Coding & Billing Seminar. Las Vegas. For more information, visit www.AOPAnet.org.

SEMINAR

February 10–15

ABC: Written and 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 350 locations nationwide. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/certification.

February 12 WEBINAR

2020 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 ABCop.org/certification.

visit www.AOPAnet.org.

O&P Coding & Billing Myths: The Truth Out There. For more information,

February 14–15

PrimeFare Central Regional Scientific Symposium. Renaissance Hotel and Convention Center, Tulsa, OK. For more information, visit www.primecareop.com, call 888/388-5243, or email primecarepruitt@gmail.com.

O&P ALMANAC | DECEMBER 2019

53

CALENDAR

May 5–6

March 1

ABC: Application Deadline for Spring CPM Exams.

All practitioner candidates have an additional 30 days after the application deadline to complete their residency.

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

AOPA Policy Forum. Washington, DC. For more information, visit www.AOPAnet.org.

May 13 WEBINAR

March 1

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

visit www.AOPAnet.org.

May 13–15 NYSAAOP Meeting. Schenectady, NY. Visit www.nysaaop.org/meeting.

June 10

March 10 WEBINAR

visit www.AOPAnet.org.

New Technical Credits—Clinician’s Corner: Orthotics. For more information,

New Technical Credits—Clinician’s Corner: Prosthetics. For more information, visit www.AOPAnet.org.

WEBINAR

July 8

March 19–21

Georgia Society of O&P. Alpharetta, GA. Visit www.georgiasop.com.

WEBINAR

visit www.AOPAnet.org.

April 8 WEBINAR

Social Media Mayday: Increase Your Footprint. For more information,

A Policy Review: LSO/TLSO. For more information, visit www.AOPAnet.org.

April 23–25

International African–American Prosthetic Orthotic Coalition Annual Meeting. The Shriners Hospital for Children-Houston.

Houston. For more information, contact Amandi Rhett at 404/754-4337, email arhett1@gmail.com, or visit www.iaapoc.org.

The ABCs of Appeals: Know the Players and Get the Tips. For more information,

July 31–August 1

PrimeFare East Regional Scientific Symposium.

Renaissance Hotel and Convention Center, Downtown Nashville. For more information, visit www.primecareop. com, call 888/388-5243, or email primecarepruitt@gmail.com.

August 12 WEBINAR

www.AOPAnet.org.

Contracting 101: Understanding the Basics. For more information, visit

April 27–28 SEMINAR

Coding & Billing Seminar. Charlotte, NC. For more information, visit www.AOPAnet.org.

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

Questions? Email ymazur@AOPAnet.org.

CREDITS

54

September 9–12

AOPA National Assembly. Mandalay Bay, Las Vegas.

For more information, visit www.AOPAnet.org.

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.

DECEMBER 2019 | O&P ALMANAC

Words/Rate

Member

Nonmember

25 or less

$40

$50

26-50

$50 $60

51+

$2.25/word $5.00/word

Color Ad Special 1/4 page Ad

$482

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1/2 page Ad

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$830

THE PREMIER MEETING FOR ORTHOTIC, PROSTHE TIC, AND PEDO RTHIC PRO FESSI O NAL S.

Call for Papers Contribute to high-value clinical and scientific offerings and share your expertise with over 2,000 orthotic, prosthetic, and pedorthic professionals.

We are looking for:

Submit your proposal for the American Orthotic and

• Business Education Program The top papers will be considered for the prestigious Sam E. Hamontree, CP (E) Business Education Award.

Prosthetic Association’s 2020 National Assembly, September 9-12, 2020, in Las Vegas, NV.

Abstracts will be considered for both podium and poster presentations and must be submitted electronically; e-mail or fax submissions will not be accepted. Each submission will be graded by the review committee via a blind review process, based on the following criteria.

• Clinical Free Papers The top scoring papers will compete for the prestigious Thranhardt Award.

• Technician Program • Symposia

• Relevance, level of interest in categories • Quality of scientific content • Quality of clinical content • Quality of technical content

What are you waiting for? Advance your career. Gain recognition. See your name in the Vegas lights.

Submit your abstract by March 20, 2020 at bit.ly/AOPA20Paper.

We ARE AOPA

ADVOCACY | RESEARCH | EDUCATION

FOLLOW US @AmericanOandP

Questions about the submission process or the National Assembly?

Contact AOPA at 571/431-0876.

www.AOPAnet.org

ASK AOPA CALENDAR

How Long Should They Last?

RULs for orthoses and prostheses

AOPA receives hundreds of queries from readers and members who have questions about some aspect of the O&P profession. 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.

Q

Q/

What is the reasonable useful lifetime (RUL) for an orthosis?

According to Medicare guidance, the RUL is decided through program instructions—medical policies, coding announcements, etc.—or other regulations. In the absence of program instructions, the RUL cannot be less than five years.

Simply put, the RUL for orthoses is five years unless otherwise stated.

This means that the RUL for anklefoot orthoses, knee-ankle-foot orthoses, lumbosacral orthoses, thoracolumbosacral orthoses, and all upper-extremity orthoses is set at five years.

The RUL for knee orthoses (KOs) is less than five years because there are program instructions within the KO Policy Article. The RUL for KOs is based on the brace coding. All custom KOs have a RUL of three years, as do braces described by the following codes: L1836, L1843, L1845, L1851, and L1852. KOs described by codes L1831, L1832, L1833, and L1850 have a RUL of two years. All other KOs have a RUL of one year.

A/

Q/

What is the RUL for a prosthesis?

As with an orthosis, the RUL for a prosthesis is determined by program instructions, or it defaults to

A/

56

DECEMBER 2019 | O&P ALMANAC

five years. The Benefits Improvement and Protection Act (BIPA) of 2000 determined that prosthetic items may be replaced at any time, regardless of useful lifetime restrictions. This means that prosthetic items are not tied to RULs and may be replaced at any time, as long as the replacements are medically necessary. However, BIPA 2000 states that any replacement that is less than three years old should have solid justification for the replacement, including a physician’s determination.

In addition, there is a set RUL of two years for silicone breast prostheses and a RUL of six months for fabric/foam/ fiber-filled breast prostheses. These RULs are established in the External Breast Prosthesis medical policy.

Q/

Is it possible to replace an item during an established RUL?

Yes. Medicare will traditionally cover a replacement item, even if the RUL has not been met, under certain circumstances—for example, if the original item is lost or stolen, if there has been irreparable damage to the device, or if there has been a change in the patient’s condition.

Remember that “irreparable damage” does not include damage caused by everyday wear and tear; it means that the damage can be pin-pointed to one specific event or cause.

A/

Update Your Coding and Billing Procedures for 2020 Attend the Mastering Medicare: Essential Coding and Billing Techniques Seminar in Las Vegas, February 10-11.

But don’t take our word for it. Attendees from the last seminar said:

I’ve learned more in the past few days than I’ve learned in the past year.

All practitioners should attend this conference so they can learn to document the correct way and ensure compliance.

For more than 20 years, our faculty have helped thousands of attendees get claims paid, survive audits, collect interest from Medicare, file successful appeals and code miscellaneous items.

The speakers are very knowledgeable and helpful. This is my second time at a seminar and I’m still learning so much.

Register before January 9 to take advantage of the early bird rate.

Attendees are responsible for making their own hotel reservations.

Book at bit.ly/CB2020HOTEL by January 10 for the $105 plus $18 resort fee/night rate.

Each Seminar is updated based on the latest developments, feedback from previous attendees, and needs of the profession. It is two days full of valuable instruction on topics O&P providers face daily, like prior authorization, competitive bidding, Medicare documentation requirements, and new codes. Additionally, 14 CE credits can be earned.

Register online at bit.ly/AOPA2020CB. For more information, email info@AOPAnet.org.

February 10–11, 2020

.

www.AOPAnet.org

AgiliumÂŽ Vantage Less Pain. More Life.

Dynamic Y force strap system Unloads the knee joint with a single pull to minimize rotation and reduce pain

11/19 Š2019 Ottobock HealthCare, LP, All rights reserved.

Meet the Agilium Vantage, a low-profile wraparound knee brace designed to provide lasting pain relief for patients with mild unicompartmental osteoarthritis.

Easy to don and doff Four adjustable, numbered closure straps for quick and easy application

Reduce inventory Trimmable sleeves to fit a broader range of patients with three sizes

professionals.ottobockus.com