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The Magazine for the Orthotics & Prosthetics Profession

F E B R UARY 2021

Diabetic Shoes: Guidance on Who Can Act as the Certifying Physician P.14

Why Going Mobile Is Gaining Ground P.28

Studying the Outcomes of Insured O&P Patients





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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:

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

Prosthetic Association’s 2021 National Assembly, September 9-12, 2021, in Boston, MA.

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!

Submit your abstract by April 2, 2021 at bit.ly/AOPA21Paper.





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Mark your calendars for September 9-12, 2021, for an ideal combination of top-notch education and entertainment at the 2021 National Assembly in Boston, MA. Questions about the submission process or the National Assembly? Contact AOPA at 571/431-0876.











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FE B R UARY 2021 | VOL. 70, NO. 2





Views From AOPA Leadership......... 4 Investing in research and quality improvement

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

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

At-a-glance statistics and data

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

Research, updates, and industry news

People & Places........................................ 12

Transitions in the profession

18 | Pediatric Adjustments Creativity and flexibility—hallmarks of successful pediatric patient care—have become even more important during the ongoing COVID-19 pandemic. Find out how pediatric specialists are adapting their processes and procedures to treat young patients while ensuring that key collaborations with allied healthcare providers continue—and that patient interactions are safe and effective. By Christine Umbrell

Reimbursement Page.......................... 14

New Rules for Shoe Provision

Guidelines for nurse practitioners and physician assistants to act as the certifying physician Opportunity to earn up to two CE credits by taking the online quiz.

28 | The Mobile Model More O&P facilities are adding mobile services to their offerings as a key differentiator in their healthcare delivery model. Find out how such an approach can reduce costs and benefit patients—given the right patient population and geography—and explore the finer details of providing O&P care while on the road. By Michael Coleman

PRINCIPAL INVESTIGATOR Taavy Miller, PhD, CPO.............................................. 34 Meet a research scientist in Hanger Clinic’s Department of Clinical and Scientific Affairs. Taavy Miller, PhD, CPO, plays a critical role in the organization’s IMPACT studies, which assess outcomes among individuals with commercial health insurance, and engages in several other types of O&P research.



Member Spotlight................................. 38 n n

Kelsey Prosthetics & Orthotics VitalFit

AOPA News................................................42

AOPA announcements, member benefits, and more

Marketplace.............................................. 43 Careers......................................................... 47

Professional opportunities

Ad Index....................................................... 49 Calendar..................................................... 50

Upcoming meetings and events

State By State........................................... 52

Indiana, Kentucky, New York, Texas, and Washington






AOPA’s Investment in Research and Quality Improvement, Is an Investment in You


HETHER YOUR ROLE IN our profession is as a team member of a patient-

care facility or as an O&P manufacturer, each of us has a vital part to play in demonstrating the value and efficacy of quality orthotic and prosthetic care—not only for ourselves, but for the patients we serve. At AOPA, research is a central pillar of our mission, and we are committed to facilitating the expansion and development of research and quality improvement projects that support the advancement of clinical care and innovation in the field of orthotics and prosthetics. One way AOPA is working toward that end is through funding. Guided by our Medical Advisory Board and Research Committee, we are undertaking several key projects. We are funding the Center for Orthotic and Prosthetic Learning and Outcomes/ Evidence-Based Practice (COPL) Pilot Grant Program, which encourages researchers to further their careers in areas of study that contribute to the O&P community. Funding is issued in 10 areas of O&P research, including an open topic, at two funding levels for one-time grants, $15,000 and up to two proposals for $30,000 for one year. The program allows researchers to capture data required to design projects that are eligible for larger grant funding in the future. Since 2009, AOPA has funded $838,632 in COPL pilot grants. We also are investing in relationships with federal research partners at the Department of Defense and National Institutes for Health. As part of this initiative, AOPA shares insights into evidence gaps, areas of focus for profession-funded research, and information regarding how the findings are being incorporated into clinical practice. Through our relationships on Capitol Hill, we are advocating for the appropriation of federal dollars to ensure our federal partners and programs continue to be available as viable sources of funding for O&P researchers. In addition to funding O&P research, we are investing in the publication of research through a newly launched partnership with the Journal of Rehabilitation and Assistive Technologies Engineering (RATE). RATE is a peer-reviewed, open access, interdisciplinary journal, focusing on the engineering aspects and practical applications of rehabilitation and assistive technologies. It is indexed in both Web of Science and PubMed Central. AOPA members will receive a 50 percent submission fee discount, and the journal of proceedings for AOPA’s National Assembly will be published as part of a special collection. While these projects represent just a few of AOPA’s research initiatives for the first quarter of 2021, we will be rolling out more later this year. Stay tuned to AOPA Connection for the latest. Traci Dralle, CFm, is president of AOPA.



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

Board of Directors OFFICERS President Traci Dralle, CFm Fillauer Companies, Chattanooga, TN President-Elect Dave McGill Össur Americas, Foothill Ranch, CA Vice President Teri Kuffel, JD Arise Orthotics & Prosthetics, Spring Lake Park, MN Immediate Past President Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Treasurer Rick Riley O&P Boost, Bakersfield, CA Executive Director/Secretary (Nonvoting) Eve Lee, MBA, CAE AOPA, Alexandria, VA DIRECTORS Jeffrey M. Brandt, CPO Ability Prosthetics & Orthotics Inc., Exton, PA Mitchell Dobson, CPO, FAAOP Hanger, Austin, TX Elizabeth Ginzel, MHA, CPO Baker O&P, Fort Worth, TX Kimberly Hanson, CPRH Ottobock, Austin, TX John “Mo” Kenney, CPO, LPO, FAAOP Kenney Orthopedics, Lexington, KY Linda Wise WillowWood, Mount Sterling, OH James O. Young Jr., LP, CP, FAAOP Amputee Prosthetic Clinic, Tifton, GA Shane Wurdeman, MSPO, PhD, CP, FAAOP(D) Research Chair Hanger Clinic, Houston Medical Center, Houston, TX

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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


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, senior director, membership, education, and meetings, 571/431-0808, tcarlson@AOPAnet.org Akilah Williams, MBA, SHRM-CP, senior manager for finance, operations, and HR, 571/431-0819, awilliams@AOPAnet.org GOVERNMENT AFFAIRS Justin Beland, director of government affairs, 571/ 431-0814, jbeland@AOPAnet.org COMMUNICATIONS, MEMBERSHIP & MEETINGS Joy Burwell, director of communications and membership, 571/431-0817, jburwell@AOPAnet.org Betty Leppin, senior manager of member services, 571/431-0810, bleppin@AOPAnet.org 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 Kristen Bean, membership and meetings coordinator, 571/431-0876, kbean@AOPAnet.org AOPA Bookstore: 571/431-0876



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

STRATEGIC ALLIANCES Ashlie White, MA, director of strategic alliances, 571/431-0812, awhite@AOPAnet.org 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 10 times per year by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/4310876, fax 571/431-0899, or email info@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 © 2021 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. Visit bit.ly/AOPAMedia2021 for advertising options!

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Traumatic Amputation New study examines amputations caused by traumatic injury across the globe


57.7 Million People living with trauma-related amputation worldwide


East Asia South Asia Western Europe North Africa

5 6 7

Middle East North America Eastern Europe



Number of prosthetists needed globally to treat people with traumatic amputations


Falls Road injuries



Other transportation injuries


Mechanical forces



3.7 Million People living with trauma-related amputation in the United States

“We want to emphasize that our estimates only include amputations due to trauma and represent just a portion of the larger population. Therefore, the global need for prosthetic services is dramatically greater than previously estimated. We hope this study can be leveraged to support advocacy efforts in low- and middle-income countries to increase governmental funding and improve access for all who require prosthetic services.” —Cody McDonald, PhD, MPH, CPO

SOURCES: “Global Prevalence of Traumatic Nonfatal Limb Amputation,” Prosthetics and Orthotics International; Data provided by Cody L. McDonald, PhD, MPH, CPO

The need for prosthetic services to care for individuals with trauma-related amputation across the globe is significant, according to researchers at the University of Washington. The complete study findings were published December 2020 in Prosthetics and Orthotics International in an article titled “Global Prevalence of Traumatic Nonfatal Limb Amputation,” by University of Washington researchers Cody L. McDonald, PhD, MPH, CPO; Sarah WestcottMcCoy, PT, PhD, FAPTA; Marcia R. Weaver, PhD; Juanita Haagsma, PhD; and Deborah Karin, PT, PhD. Below are some highlights.


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California Team Studies Hand Gestures To Develop More Intuitive Prostheses An armband to control prosthetic hands based on electronic signals detected in the forearm is in development by engineers at the University of California, Berkeley (UC Berkeley). The system couples wearable biosensors with artificial intelligence (AI) and could eventually be used to control prostheses or to interact with other types of electronic devices, according to the research team. The system comprises a flexible armband that can read electrical signals at 64 different points on the forearm. Those signals are fed into an electrical chip that is programmed with an AI algorithm that associates the signal patterns in the forearm with specific hand gestures. The research team collaborated with Ana Arias, a professor of electrical engineering, in the design of the device. The researchers were able to “teach” the algorithm to recognize 21 individual hand gestures, including a

thumbs-up, a fist, a flat hand, and holding up individual fingers. “When you want your hand muscles to contract, your brain sends electrical signals through neurons in your neck and shoulders to muscle fibers in your arms and hands,” said Ali Moin, PhD, an embedded AI researcher who recently finished his PhD at UC Berkeley’s Department of Electrical Engineering and Computer Sciences. “Essentially, what the electrodes in the cuff are sensing is this electrical field. It’s not that precise, in the sense that we can’t pinpoint which exact fibers were triggered, but with the high density of electrodes, it can still learn to recognize certain patterns. “Prosthetics are one important

application of this technology, but besides that, it also offers a very intuitive way of communicating with computers,” Moin added. “Reading hand gestures is one way of improving human-computer interaction. And, while there are other ways of doing that—by, for instance, using cameras and computer vision—this is a good solution that also maintains an individual’s privacy.” Details of the study were published in the December issue of Nature Electronics.

Neurofeedback Helps Amputees Perceive Prostheses as Lighter Lower-limb amputees who perceive the weight of their prosthesis as heavy may be less satisfied with their devices, so researchers at ETH Zurich have demonstrated that connecting a prosthesis to the nervous system helps wearers perceive their devices as lighter. In a new study, led by Stanisa Raspopovic, PhD, in the Department of Health Sciences and Technology, researchers implanted electrodes in prosthesis wearers’ thighs. Information from tactile sensors under the sole of the prosthetic foot and angle sensors in the prosthetic knee joint were converted into pulses of current and passed to the nerves in the users’ residual limbs. 10


“To trick an above-knee amputee’s brain into the belief that the prosthetic leg was similar to his own leg, we artificially restored the lost sensory feedback,” explained Raspopovic. In a study published last year, he and his team showed that wearers of such neurofeedback prostheses can move more safely and with less effort. The researchers concluded that neurofeedback reduced the perceived weight of the prosthesis by approximately 23 percent. Raspopovic noted that the technology “can take the experience of patients with an artificial device closer to that with a natural limb.” The study was published in a recent issue of Current Biology.



Executive Order Reopens Federal Insurance Marketplaces


Healthcare Costs Associated With Diabetes Climb Globally Diabetes caused at least

$760 billion in health expenditures in 2019

—10 percent of total healthcare spending on adults worldwide. Consumers may once again sign up for the Affordable Care Act federal insurance marketplaces traditionally available only in the fall. President Joe Biden signed an executive order in January to allow consumers to sign up for plans between February 15 and May 15, 2021, through HealthCare.gov, the online insurance exchange geared toward individuals who cannot access affordable health benefits through their employment. More than 8.2 million people signed

up for coverage in 2020 during the open enrollment period in November and December. Approximately 1.8 million of those who signed up last year were new enrollees, and 6.4 million renewed their coverage on the exchanges. Biden also is directing federal agencies to reconsider rules and policies that limit Americans’ access to healthcare, including policies that undermine protections for people with pre-existing conditions.

—International Diabetes Federation’s Diabetes Atlas, Ninth Edition, 2019


‘Excess’ Diabetes Deaths Could Be COVID-19 Related

THE LIGHTER SIDE “Estimates of excess deaths can provide information about the burden of mortality potentially related to the COVID-19 pandemic,” according to the CDC, which found that some deaths due to COVID-19 may have been assigned to other causes of death—for example, if COVID-19 was not diagnosed or mentioned on the death certificate. In some states, deaths attributed to diabetes were at least 20 percent above the expected amount—deemed “excess deaths”—for the majority of 2020. Nationally, deaths attributed to diabetes were up 15 percent.




David Boone, MPH, PhD, chief executive officer of Orthocare Innovations, has been recognized with a Tibbetts Award from the Small Business Administration for demonstrating significant economic and social David Boone, impact from research and development MPH, PhD funding. Boone is one of only 14 individuals recognized for the award this year, which honors awardees for exceptional successes they achieved through SBA’s Small Business Innovation Research (SBIR) and Small Business Technology Transfer (STTR) programs. Boone was recognized because he “revolutionized prosthetics [and] blazed the trail for activity monitoring, and Orthocare Innovation’s StepWatchTM has become a gold standard for activity monitoring,” according to the Tibbetts Award website. “He is a leader in the SBIR/STTR arena through his commitment to mentoring scientists and engineers.” Jeff Eschenburg, CP, has been named Fillauer Clinic’s lead prosthetist. Eschenburg relocated to Chattanooga after 10 years in Las Vegas, most recently working as lead prosthetist at POP Prosthetics. This follows 15 years of experience Jeff Eschenburg, CP in Michigan where he began his career with Wright & Filippis, later owned his own business, and eventually partnered with Michigan Vascular Mobility Center. “I’m excited to be part of Fillauer, where I am confident in the company’s holistic approach to clinical care, from the clinic to education, to operations and even product development and manufacturing,” said Eschenburg, who lost his leg above the knee in a farm mishap at the age of 12. “It’s a good fit, and I’m thankful for the opportunity.” Matthew Waidelich has been appointed vice president of business development at Becker Orthopedic. Waidelich joins Becker with 45 years of experience in the O&P and orthopedic industries, with prior Matthew Waidelich senior roles at Ottobock Healthcare, Bio Cybernetics International, Össur North America, Royce Medical, and United States Manufacturing Company. “We are excited to have Matt join our family business and build upon our legacy as a leader in the global orthotic market,” said Becker President Rudolf B. Becker. “We are delighted to welcome Matt to our team.”




The Hanger Foundation has announced the creation of the Hanger Foundation Diversity Scholarship as part of its commitment to diversity and inclusion in the O&P profession. To help address nationwide systemic racism, interrupt bias, and ultimately create a more inclusive profession, Hanger Inc. committed to take tangible actions, including attracting more diverse candidates to O&P graduate programs. “Research has shown that clinicians of color are underrepresented within the O&P industry,” stated Hanger Foundation Executive Director Gloria Gonzales Dholakia, PhD. “It is our vision to help equip students from more diverse backgrounds with the tools they need to pursue a career in O&P. The Hanger Foundation is committed to this cause, and we look forward to building on the new program for years to come.” The scholarships will supplement the cost of the two-year MSPO program and will offer a two-year mentorship with the option of pursuing a residency with Hanger Clinic. Beginning this fall, the Hanger Foundation will issue the scholarships directly to a number of universities to help recruit underrepresented students of color into the O&P profession. “By aligning with the Hanger Foundation on this important initiative, Hanger is committing to help build a more inclusive profession to better serve our patients,” said Hanger President and Chief Executive Officer Vinit Asar. Orthotic and Prosthetic Group of America (OPGA), a division of VGM & Associates, has unveiled a newly redesigned website at opga.com. The new site has been designed to provide a more user-friendly experience and includes a membersonly portal. “At OPGA, we strive to provide savings and solutions to our members to help their businesses thrive,” said Todd Eagen, president of OPGA. “With the new website, we’re making it even easier for members to find the valuable information they need so that they can spend more time on what truly matters—their patients.” Thuasne has acquired U.S.-based company Knit-Rite and its Therafirm division. The Thuasne Group’s previous U.S. acquisitions include Townsend Design in 2011 and Quinn Medical in 2016. The transaction closed Dec. 30, 2020. The Knit-Rite acquisition is based on strong and structuring common points between the two companies, according to Thuasne: • Thuasne and Knit-Rite themselves design the devices they develop and put on the market. • The two companies have had an integrated industrial strategy, allowing them to master all stages of manufacturing and to align all the expertise in their specialty.


• Their capacity for innovation has resulted in a large number of patents filed each year. • Thuasne and Knit-Rite are both specialized in medical compression in the treatment of venous disease and of lymphedema. With this acquisition, Thuasne opens up to a new market: devices for orthopedic prostheses (postamputation prosthetic socks and prosthetic textile interfaces). Elizabeth Ducottet, Thuasne Group chairman and chief executive officer, stated, “This acquisition confirms the ambition for the Thuasne Group to have a global presence in both the phlebology and lymphology treatment categories, with compliance in each geographic specification. Thuasne’s expertise in French and German standards … complimented by Knit-Rite’s knowledge in the U.S. standards, gives us the capacity to provide solutions for patients globally.” “With this acquisition, we are optimizing our resources,

our visibility and our managerial organization in the United States,” said Delphine Hanton, Thuasne Group chief financial officer. “We salute the work accomplished by Mark Smith and the Knit-Rite management team over the last 15 years. which will engage the Thuasne Group in developing projects with the same spirit of excellence. As a family-owned French mid-sized company, we will rely on the local management teams and on their expertise to reinvest and develop the bases that were integrated by this acquisition.” Mark Smith, CP, Knit-Rite majority selling shareholder, stated, “I am so proud that Knit-Rite and Therafirm have served patients, practitioners, and our profession with excellence for over 98 years, three generations, and in 50 countries. It has been a tremendous blessing to be part of my whole life. In this light, I am extremely pleased we have the opportunity to pass the torch to Thuasne as a sixth-generation patient-driven company, which likewise serves both the O&P and compression markets.”


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New Rules for Shoe Provision Updated guidelines empower nurse practitioners and physician assistants to act as the certifying physician, in limited circumstances

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







ual who was eligible to act as the certifying physician for the provision of diabetic shoes was a medical doctor (MD) or a doctor of osteopathic medicine (DO). This limitation was the result of wording in the Social Security Act (SSA) requiring that an MD or DO certify that a beneficiary receiving therapeutic shoes and inserts is under a comprehensive plan of care for diabetes; the SSA did not mention any other type of practitioner or provider. In November 2020, CMS took two steps to update and address this limitation and allow for the delegation of this duty to nurse practitioners (NPs) and physician assistants (PAs). One step was immediate and intends to be permanent, and the other took effect January 1 on a demonstration basis. This month’s Reimbursement Page reviews the role of the certifying physician and the certifying statement in dispensing diabetic shoes and inserts, and examines when and how NPs and PAs may act as the certifying physician.

Certifying Physician and Certifying Statement

The certifying physician is the person responsible for diagnosing and treating the patient’s diabetic condition through a comprehensive plan of care. The certifying physician must document that the patient has diabetes mellitus, and the documented diagnosis should match one of the more than 200 ICD-10 14


diagnoses listed in the Policy Article portion of the Medicare medical policy. The certifying physician also is responsible for evaluating, documenting, and/or confirming and documenting that the patient has one or more of six approved secondary foot conditions: • Previous amputation of the other foot, or part of either foot • History of previous foot ulceration of either foot • History of preulcerative calluses of either foot • Peripheral neuropathy with evidence of callus formation of either foot • Foot deformity of either foot • Poor circulation in either foot. This individual must certify that an order for diabetic shoes and inserts is necessary because without the presence of a secondary condition that affects the foot, there is no need for diabetic footwear. The certifying physician may complete the secondary foot evaluation and documentation themselves, or someone else may conduct the evaluation and primary documentation. For example, the podiatrist ordering the shoes could be responsible for the diagnosis of the secondary foot condition. If another physician or practitioner completes the documentation of the secondary foot condition, they must forward a copy of the documentation to the certifying physician. The certifying physician then must review, initial, and date the findings indicating agreement.

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Next, the certifying physician must document that they are treating the patient under a comprehensive plan of care for diabetes. There is no one type of treatment plan in order for the patient to be eligible to receive diabetic shoes; the key is that the certifying physician documents that they have discussed the patient’s current condition and the patient’s current treatment plan. The timing regarding the documentation is critical: It must be completed during an in-person visit with the patient, and this in-person visit must occur within the six months prior to the initial delivery of the shoes and inserts. If more than six months have passed since the patient last had an in-person visit with the certifying physician, you may not deliver the shoes until the patient has another in-person visit with the certifying physician.

Finally, the certifying physician is responsible for signing the certifying statement, which confirms that the patient is being treated for their diabetes and also has a secondary condition that warrants the need for therapeutic shoes or certifies that coverage criteria have been met. Note, however, that the statement by itself does not meet the requirement for documentation in the medical records. There is no official certifying statement form, just a recommended form, and you may create your own, but it must contain all of the key elements found on the recommended form. The key elements of the certifying statement include the patient’s name; the certifying physician’s name and 16


signature; and a statement indicating that the patient has diabetes mellitus, has at least one approved secondary foot condition, is under a comprehensive plan of care for their diabetes, and requires diabetic shoes. The certifying statement is valid for 12 months, only after it is signed—but once signed, the initial delivery of the shoes and inserts must take place within three months. If the delivery takes longer than three months, then a new certifying statement must be completed and signed.

‘Incident to’ Services for NPs and PAs

The first update from CMS regarding the provision of diabetic shoes is geared toward NPs and PAs who are working or practicing under the direct supervision of an MD or DO, and whose duties would be “incident to” the MD’s or DO’s services—in other words, part of existing care being provided by the MD or DO, and the MD or DO is the individual billing for the services. In a nutshell, “incident to” means the PA or NP is working in the same practice as the MD or DO and working under the supervision of that MD or DO (the MD or DO must review and sign off on the PA’s or NP’s notes). The MD or DO is the individual or entity submitting the claim under their

national provider identifier (NPI)—not the NPI number of the PA or NP. In order for the NP or PA to act as a certifying physician under the “incident to” scenario, three distinct criteria must be met: • The supervising MD or DO must have documented in the medical record that the patient is diabetic and is being treated under a comprehensive plan of care. So, the NP or PA may not make the first evaluation and create the treatment plan for the patient. The MD or DO must make the first evaluation, then the NP or PA may carry out the plan of care and subsequent documentation. • The NP or PA must certify that the provision of diabetic shoes is part of the comprehensive treatment plan being provided to the patient. So, the NP or PA must follow up with the recommendations of the MD or DO and indicate that shoes and inserts are required. • The supervising MD or DO must review and verify all of the NP or PA notes in the medical record related to the provision of diabetic shoes and inserts. The MD or DO must sign off on all of the notes entered by the NP or PA and date their signature, indicating they are


in agreement with the findings and actions of the NP or PA. This would include the signing of the certifying statement, so the overseeing MD or DO must review and verify the certifying statement as well. All criteria must be met; if not, the NP or PA may not act as the certifying physician. Note that the NP and PA—especially the NP—must not be working independently of the MD or DO; they must be working under the supervision of a physician and not billing for the services with their own NPI. All of this information was included in the most recent revision of the diabetic shoe policy and has been in effect since Nov. 5, 2020.

NPs Enrolled in the Primary Care First Model

CMS, through its Innovation Center, is tasked with testing and experimenting with new payment and service delivery models to find ways to potentially reduce expenditures and improve the quality of care for beneficiaries. The Primary Care First (PCF) model is one of the models being tested. The PCF is based on “prioritizing the doctor-patient relationship; enhancing care for patients with complex chronic needs and highneed, seriously ill patients; reducing administrative burden; and focusing financial rewards on improved health outcomes.” Under this model, CMS is allowing NPs to certify that an order for diabetic shoes is required, or act as the certifying physician. However, there are some restrictions. First, this PCF model for NPs is only in place for a set period of time. Payment under this model began Jan. 1, 2021, and will end Dec. 31, 2025. Second, in order for an NP to be eligible to act as a certifying physician under the PCF model, the NP must elect to participate and enroll with Medicare. Approximately 916 participants are currently in the program; view the list of active participants at https:// innovation.cms.gov/innovation-models/ primary-care-first-model-options.

Areas Participating in the PCF Model Nurse practitioners may serve as the certifying physician under the Primary Care First model—if certain conditions are met—in the following areas: • Alaska

• Montana

• Arkansas

• Nebraska

• California

• New Hampshire

• Colorado

• New Jersey

• Delaware

• New York (only in the Greater Buffalo region and the North Hudson-Capital region)

• Florida • Hawaii, Kansas (only in Greater Kanas City region)

• North Dakota

• Kentucky (only in Northern region)

• Ohio

• Louisiana

• Oregon

• Maine

• Pennsylvania (only in Greater Philadelphia region)

• Massachusetts

• Oklahoma

• Michigan

• Rhode Island

• Missouri (only in Greater Kansas City region)

• Virginia

Finally, the model is not available in all states, and in some cases not even within all regions of a state. The PCF model is only available in the 26 states and regions listed above. If the above criteria have been met, then the PCF model allows the NP, practicing independently of a physician, to serve as the certifying physician—meaning they are eligible to: complete the face-to-face diabetic exam, verify other physician or practitioner documentation for the secondary foot condition, and sign the certifying statement.

Understanding the Options

These two new developments mean that NPs participating in the PCF model, even if they are working independently of a physician, or NPs working “incident to” a physician’s services, are eligible to serve as the certifying

• Tennessee

physician. PAs are only eligible to act as a certifying physician if they are providing “incident to” services. These two situations may not cover all NPs and PAs providing care and ordering/referring diabetic shoes and inserts; however, the new guidelines are a good step forward. 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





s d m u j t a





n me t s NEED TO KNOW • Orthotists and prosthetists who specialize in pediatrics have learned to be creative and flexible in their approach to patient care, which has been particularly important given the ongoing COVID-19 pandemic. • Telemedicine for pediatric patients can be challenging, so clinicians should carefully consider which circumstances and patient etiologies work best in the virtual environment. • O&P clinicians are finding new ways to collaborate with other members of the healthcare team—for example, joint appointments with therapists—to ensure optimal patient outcomes. • Practitioners who focus on pediatric care should engage in continuing education and stay informed regarding the latest devices for children.



caring for the youngest O&P patients, according to pediatric specialists. “Things are not always going to go the way we expect,” explains Jillian Okimoto, CPO, a clinician who specializes in treating pediatric patients with congenital limb differences and traumatic limb loss at Hanger Clinic in Phoenix. “Aligning a prosthesis might involve a game of tag. Fitting that new prosthesis could take an extra appointment if that kiddo just woke up from a nap and doesn’t want to participate that day,” she says. Being able to roll with the punches has been particularly important over the past year, as patients and parents have sought care during the ongoing pandemic. “The biggest difference in pediatric patient care for 2021 is the emphasis on flexibility”—not only among clinicians, but among their patients and families as well, explains Shannon O’Shea, CPO, an area clinic manager for Hanger Clinic in Kansas City, Missouri. With new safety protocols requiring extra sanitation between appointments and fewer individuals in the facility at a time, everyone involved in O&P patient care for children has had to adjust. From connecting with patients while wearing masks to adapting telehealth to children and finding new ways to collaborate with allied health professionals, O&P clinicians are embracing innovative strategies to ensure they deliver optimal care and appropriate devices to their youngest patients. O&P ALMANAC | FEBRUARY 2021



A pediatric patient room at Alliance O&P

How Are Clinicians Ensuring Safe and Effective Care?

to speak a little louder and clearer, as the masks can unfortunately muffle a conversation.” O’Shea says she frequently discusses “germs” with her older pediatric patients, and they seem to understand the new protocols. “I’m continually shocked about how good our kiddos are with wearing their own masks,” she says. The clinicians at her facility strive to keep the patient rooms upbeat and friendly. “While we’ve removed all toys from our offices for safety purposes, we encourage families to bring their own so the patients can continue to be preoccupied.” Of course, some patients and families remain reluctant to attend in-person appointments. “It’s important to acknowledge fears about risks” associated with in-person healthcare, says Amira Mouad, CPO, a pediatric specialist in the Asheville, North Carolina, office of Ability Prosthetics and Orthotics. Some of the pediatric orthotic patients have delicate immune systems, “so we offer options,” such as telehealth appointments, patients waiting in their cars until their appointment begins, and collaborating with physical therapists (PTs) for joint appointments.



PHOTO: Courtesy of Alliance O&P

Texas. Pediatric patients “pick up nonverbal cues” In addition to increased sanitation, when being seen by When Is Telehealth cleaning, and CDC-informed check-in healthcare practitioners, an Option? procedures at her facility, Okimoto “so it can be scary for O&P clinicians have Amira Mouad, CPO is treating some young patients on them” to see adults wearing become much more adept the outdoor patio of her Phoenix masks, with most of their at telehealth recently— clinic. “Some parents felt more face covered, he says. To break but telemedicine appointments with comfortable if an appointthe tension, Sheppard tries to play children can be a “unique” experience, ment was held outside and games with patients first, which says Mouad. Some children don’t not in an enclosed space makes the experience a little have the attention span. In addition, like a patient room,” less austere. some aspects of virtual appointments she says. “I stay Masks also have changed can be particularly challenging, such flexible so that both patient interactions for as interpreting nonverbal feedback, parents and children O’Shea. “When treating conducting virtual range-of-motion Jillian Okimoto, CPO infants, we previously relied are at ease, and we can testing, and overseeing gait analysis focus on clinical care for so heavily on smiles and cues through the screen, says Mouad. These a productive appointment.” with our mouths, which aren’t visible tasks can be difficult with a laptop, One of the biggest challenges in behind masks, so we’ve lost a small and just a bit easier when the parent treating pediatric patients over the past sense of connection in that way,” she is using a smartphone, she says. year has been the mask requirement, explains. “I’ve found myself winking so Given these obstacles, she believes says Alan Sheppard, CPO, LPO, owner much more, really attempting to smile telehealth is most effective for consulof Alliance O&P located in North with my whole body, and attempting tative purposes.

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How Can Clinicians Facilitate Collaboration?



PHOTO: Hanger Clinic

Working closely with other members of the healthcare team is an important aspect of pediatric patient care. Shannon O’Shea, CPO, Okimoto participates in a multidisworks with a cranial patient. ciplinary team with an orthopedic surgeon, PT, occupational thermultiple times prior apist, and child-life specialist. and who are accusWith this approach, “parents are Jim Haas, CO, owner of Orthotic & tomed to a normal able to ask questions, and the Shannon O’Shea, CPO team is able to assess the child all Prosthetic Labs Inc. in Massachusetts, in-person visit. has occasionally leveraged telehealth “What is missing in together and collaborate to help to get to know new patients. “We had these situations is the create the best possible outcome.” She a family referred to us from Boston combined quantifiable data,” she says, notes that the presence of a PT at these Children’s Hospital for an ankle-foot “but we can always pick that up in the appointments is crucial. “Whereas in orthosis,” he recalls. The family was next visit when we are in person.” the adult population, some patients reluctant to have an in-person visit, “so Telehealth is less common among may attend therapy to learn to walk we had a Zoom meeting, and reassured pediatric prosthetic patients, however. with their prosthesis and not return the family” that they could trust “Often times, the pediatric again, in the pediatric population, we the physician’s orders as well as prosthetic follow-up appointmay refer them back more frequently. the O&P care team. “After the ments require growth In some cases, it is for advanced gait Zoom meeting, they finally modifications that cannot be training or for specific biomechanical agreed to come into the completed without tools skills needed for sports,” says Okimoto. office,” he says. or machinery that are “The thing to remember with the O’Shea notes that in office,” says Okimoto. pediatric population is that there may virtual appointments have Most of her experience be additional comorbidities that need Jim Haas, CO been a successful option with telehealth appointto be monitored, and as they get older, with some of her postoperments have involved their needs and wants will change.” ative craniosynostosis patients. patients who live far away and want On the orthotics side, “you defi“I’ve been allowing virtual appointto know if it is necessary to drive to nitely want to get to know the ments when applicable, and when the the clinic for adjustments, “or if they therapists working with kids,” says families have to travel long distances,” can do minor fixes, like add socks, at Sheppard. “You do your patients a she says. “We set up a Zoom meeting home,” Okimoto says. In most cases, disservice if you don’t.” Prepandemic, and are able to assess the fit of their these appointments are completed Sheppard notes that he frequently cranial remolding orthosis and work during a joint physical therapy turned to therapists to help collect with the parents to help them make appointment—where she is collaborange-of-motion or manual muscle small adjustments.” O’Shea empharating with a PT who can help look data regarding a patient if the child sizes that this protocol is reserved for prosthetic length discrepancies or was having an “off” day when he for patients who visited the facility other recent changes. visited the O&P facility.


Many of the PTs in Mouad’s area have been working online, as their offices have been closed, so a large percentage of her orthotic patients are engaging in “virtual” physical therapy now. To facilitate more in-person

appointments, she has invited the PTs to come in to see patients in her O&P facility; that way, her patients get more hands-on therapy, and there is close orthotist/therapist collaboration. Sheppard notes that therapists

Patient-Provider Bonds Play Special Role in Pediatric Care

PHOTOS: Courtesy of Ability P&O

Pediatric clinicians often develop close bonds with their patients— some of whom present with unique disabilities. “Many of the children in my practice are born with atypical residual limb shapes or skeletal deformities,” says Jillian Okimoto, CPO, a clinician with Hanger Clinic in Phoenix. “This challenges me to continually create new solutions for them as they grow.” And because these patients’ goals Amira Mouad, CPO, evolve as they grow and mature, clinicians “need to keep learning assists a scoliosis patient with her brace. and adjusting their prosthesis to keep up with them and prevent limiting their abilities,” she says. Children with limb loss “have high demands from their prosthesis, and they don’t see limits unless someone else sets a limit for them. I am careful to never do that.” Mouad works On the orthotics side, clinicians with pediatric experwith a cranial tise are especially important because the treatment of remolding patient. many young patients may be time-specific. For example, scoliosis and cranial remolding are etiologies that are usually seen during childhood because treatment is most effective during growth cycles, says Amira Mouad, CPO, a pediatric specialist in the Asheville, North Carolina, office of Ability Prosthetics and Orthotics. Clinicians must work closely not only with their pediatric patients, but also with their parents to ensure proper device wear, says Mouad. “You have to consider that compliance or noncompliance issues don’t sit solely with the patient—there’s more reliance on the caregivers—so you have to manage from a team approach.” Orthotists and prosthetists also should be prepared for more informed parent involvement. Okimoto points out that family members have become more educated about healthcare in general, and are more likely to research topics related to their children’s diagnoses and potential treatments. “They are asking more component-specific questions,” she says. “They have their children’s best interest in mind, and they are more involved in directing their care.”



in his area also have been working remotely—guiding parents in their children’s rehabilitation through a screen. “In some situations, parents have become therapists,” he says, which means the only hands-on care is taking place at the O&P facility—and orthotists have to work more closely with parents. “We used to get a head’s up from therapists when devices needed to be adjusted,” but parents have become the communicators. “Parents have had to step up” and work more closely with their children on their rehab Alan Sheppard, and exercises, CPO, LPO and they must pay close attention to orthotic fit and any problems their children are experiencing with their braces, says Sheppard. Sheppard fosters collaboration by inviting his patients’ therapists to “virtually” take part in his in-person appointments. Appointments that he previously would have shared collaboratively with PTs have transitioned to appointments where the PTs “Zoom in” to participate. “With pediatrics, it’s always been a team approach. “That hasn’t changed. Because we had close relationships before, we’ve been able to pivot to a different way of doing things.”

How Can Clinicians Promote Timely Intervention?

Because many of the referrals for pediatric orthotic patients come from special education teachers and therapists affiliated with schools, Mouad has noted upticks in new patients when the schools are in-person, then lulls when the schools move to virtual due to COVID-19 restrictions. The school staff notice when patients’ braces are fitting incorrectly, or when they stop wearing them, and encourage children to see their orthotists, says Mouad, so the loss of in-person education can lead to lags in orthotic patient visits.



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In Massachusetts, many children are not attending school in-person, so “they’re not getting the services they need, and some may be falling through the cracks,” says Haas. His facility is relying on more referrals from pediatricians, rather than from school staff. He is concerned that some pediatricians may not realize they should be referring patients to O&P. Ability P&O has been flexible in accommodating missed or postponed appointments. “With schools opening back up, then closing again due to possible COVID exposures,”

many patients are advised to quarantine at the last minute, according to Mouad. In those cases, in addition to rescheduling appointments, “we can offer consultative care via telehealth, and can identify the issue and get the ball rolling on insurance” before the patients can be seen, she says. On the prosthetics side, Okimoto has been encouraging her patients to come in for regular appointments—which is critical for children who are growing quickly. “I am a big proponent of routine follow-ups and stress the benefits to the families of receiving safe care in-person, if they are comfortable, so we can adjust for growth, maintenance, and necessary alignment changes,” she says.



How Can Facilities Best Serve Young Patients?

As we continue to navigate a challenging healthcare climate amid the ongoing pandemic, pediatric specialists can ramp up efforts to work collaboratively to treat patients, and to show empathy in patient-care interactions. Although the year 2020 was a rough one, “we can look at the lessons learned as a silver lining,” says Mouad. “We need each other—we need to talk to each other, and know that everyone involved in a team is working to meet the goals to the best of our abilities.” Haas recommends that O&P facilities strive to be patient-focused. “If you put the patients first, then you won’t get stuck into patterns of doing things,” he says. O’Shea reminds clinicians to “show grace” in their day-to-day practice. “We have to keep in mind that families are juggling a tremendous amount— especially our patients with special needs. Many of these kids may not be able to go to in-person school or have social outlets, so it’s important to have fun in the appointments,” she says. “Make it engaging to come in and see you, and spend that extra second to help make their day extra special. Small gestures go so far.” Christine Umbrell is a contributing writer to O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

PHOTO: Hanger Clinic

Jillian Okimoto, CPO, assists Alora in acclimating to her prosthesis (left) and works with Fernanda, a young bilateral patient.

“I’ve found that ensuring a next appointment is set when the families leave ensures good follow-up care. I also realize the importance of flexibility and compromise during the pandemic, and that parents are making choices that best suit their families’ safety.” For those families who continue to express concern about in-person appointments, clinicians at Orthotic & Prosthetic Labs Inc. have been making more home visits, according to Haas. “We go out of our way” to make sure patients continue to be seen, even when they are concerned about coming into the O&P facility.

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The Mobile Model More facilities are bringing prosthetic and orthotic services to their patients—simplifying the O&P care experience for consumers while realizing some cost benefits By MICHAEL COLEMAN



Some O&P facilities are embracing mobile O&P care as business owners aim to reduce expensive office overhead, eliminate no-shows, and provide more flexible and personalized service for their clients.

During the ongoing COVID-19 pandemic, some providers are finding that mobile care is helping to keep their businesses afloat because some patients are hesitant to travel to healthcare facilities.

Companies considering adding mobile capabilities should keep in mind that planning, preparation, travel logistics, and staffing are some of the most significant challenges associated with this business model.

O&P clinics that are strategic in their mobile initiatives may form closer relationships with patients and gain a better understanding of their needs for mobility in their home environment.




opened Alltech O&P Services in Burleson, Texas, near Fort Worth in 1999, she took the traditional route— opening one brick-and-mortar clinic, followed by several more. Business was good, but over the ensuing decade Rector realized that many of her elderly and less ambulatory patients struggled to arrange transportation to and from her clinics. Public transit in many parts of the sprawling Dallas-Fort Worth metroplex is sporadic, and Rector noticed patients were sometimes dropped off outside her clinics before they opened—then waited a long time for rides after their appointments were over.

“They would be in our office for seven or eight hours waiting on the transit system to pick them back up,” Rector says. “We felt responsible for making sure that they had food to eat to regulate their blood sugar and that they had a comfortable place to wait. We ended up spending so much time taking care of non-prosthetic-related expenses and challenges; we ultimately decided that, for these particular patients, it would make much more sense for us just to go to their house.” Today, 90 percent of Alltech’s business is mobile, with clinicians providing comprehensive care via three customized Kia Soul vehicles that serve as O&P clinics on wheels. “It’s allowed us to close all but one of our locations,” Rector explains. “It was less expensive for us to implement mobile vehicles that were fully decked out with most types of equipment. The only thing that we can’t really do in the back of the car is fabricate something. We have vices, any tool needed for any kind of prosthetic alignment or prosthetic adjustment ... adding padding to a socket, changing trim lines, replacing valves. Anything that we needed in the field, we were able to outfit our vehicles with. We truly have a mobile practice.”

Opportunities and Challenges

PHOTOS: (Upper right) Agile Orthopedics, (Lower right) Mid State Artificial Limb

The trend toward mobile care in the O&P profession is steadily gaining momentum as business owners aim to cut down on expensive office overhead, eliminate no-shows, and provide more flexible and personalized service to their clients. In the midst of the highly contagious COVID-19 pandemic, O&P providers also are finding that mobile care is helping to keep their businesses afloat as some patients are understandably wary about spending time in waiting rooms with strangers. “People are a little bit leery about coming in right now,” says Ben Davis, an administrator at Mid State Artificial Limb in Jackson, Mississippi, which has one brickand-mortar facility but provides 80 percent of its services from the back of Ford vans. Most of Mid State’s

Agile Orthopedics in Denver offers a mobile-only approach to O&P care. mobile patients have disease-related amputations, with some trauma patients in the mix. “It seems to be a better way to serve our clients,” Davis says of the mobile care approach. “It just makes it easier for the patient, and that’s what we’re trying to do as much as we can—just take the burden off of them.” While mobile O&P care can offer advantages to both the business and the patient, it’s important to think through the decision to add these capabilities to a facility. Davis and other O&P professionals say that planning, preparation, and travel logistics

are some of the most significant challenges of the mobile business model. “You need to make sure you have everything the patient may need in that vehicle when you make that visit” because repeated trips add to your costs, Davis says. “We do whatever we need to do to make sure we take care of them in one visit, if possible.” Alltech clinicians have learned to be efficient to ensure each mobile appointment is revenue-producing, says Rector. “Windshield [driving] time doesn’t yield revenue, and constant adjustments, repairs, and changes don’t yield revenue.”

Mid State Artificial Limb provides 80 percent of its services via the mobile O&P model. O&P ALMANAC | FEBRUARY 2021


prosthesis while you’re at someone’s home, and be able to hand it back to them, so they’re never without it.” EastPoint clinicians also have the option of returning to the clinic for fabrication needs or major adjustments. At Alltech, staff has figured out how to equip vans to make adjustments on a smaller scale. “Any mechanical things that we needed for adjustments, alignments, … socket repairs—anything that we needed in the field—we were able to outfit our vehicles with,” Rector explains. For example, instead of having a huge sanding stone, “we were able to find a smaller substitute of that with just a Dremel tool.”

Inside EastPoint Prosthetics & Orthotics’ fully equipped van She notes that the functionality of the patient often dictates whether they receive care from mobile clinicians or if they need to come into the office. “Most of our in-office patients are at higher functional levels because we’re usually trying to dial in things a little tighter and better on those patients,” she explains. Logistics differ when caring for patients in their homes compared to treating those who reside in assistedliving facilities or other institutional environments, according to Rector. For example, the institutional settings sometimes require practitioners to park far away in a big garage or parking lot, as opposed to a patient’s driveway. “That visit might take longer because we’re having to make repeated trips back and forth out to the vehicle,” she notes. “That’s been a little challenging, especially during COVID, with all of the protocols that have to be followed.”

Paul Sugg, CPO, CPed, FAAOP, owner of EastPoint Prosthetics & Orthotics Inc., opened his first practice in Kingston, North Carolina, 14 years ago. Today, he maintains two brick-and-mortar clinics in North Carolina, supplemented by 14 vans on the road providing mobile O&P care. EastPoint also operates a clinic in central Ohio, with three mobile vans working the region. Sugg says his 30


decision to go mobile six years ago has transformed his business and eliminated the administrative and capital expenses of opening additional physical clinics. But he says the job of a “mobile certified clinician” isn’t for everyone. EastPoint practitioners are forging a new job description within the profession. They do all the driving, scheduling, and provisioning of O&P services, making sure they have the appropriate equipment for the job. “Staffing has been a little bit of a challenge,” Sugg explains. “When someone who has been doing patient care inside of a [nonmobile] facility comes into our practice, sometimes it’s very difficult for them because they’ve never gone outside, set up their own schedule, and driven their own business,” he says. “It’s not 8 to 5 in an office anymore.” Appointments may start early and end late, with long drives in between to see patients in various locations. Sugg adds that being a truly mobile clinician requires more than just carrying a clinic bag—it requires a fully equipped vehicle. “You’re in a van with a Trautman [carver], with the guns, with air compressors, with all the tools that you need to be able to work on a

Eric Neufeld, CPO, FAAOP, chief executive officer of Agile Orthopedics in Denver, started his business as an entirely mobile operation four years ago. He now has six sprinter vans serving the Denver and rural Colorado plans to expand operations from Denver to Fort Collins and Northern Colorado over the summer. In January, Neufeld also announced expansions to Colorado Springs and the High Country. While some mobile O&P operations tend to screen clients based on their needs to determine whether they are able to cost effectively provide the service they need, Agile Orthopedics accepts almost all patients. “Providing mobile care is not exactly new, but the way that we’ve done it by being only mobile, and … designing the whole model around it—and seeing everyone regardless of their circumstances—is a bit different,” Neufeld says. For Neufeld, the decision to go entirely mobile with his practice was philosophical. “I just believe in providing service on the patient’s terms,” he explains. “There are a number of factors why it improves their overall situation and the overall model of care delivery. At a very high level, it’s the right thing to do ... they’ve been through a lot. The benefit to the patient is convenience and safety.

PHOTOS: Inside EastPoint Prosthetics & Orthotics

Staffing and Equipment Considerations

Mobile-Only Approach


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There’s some physical safety [improvement for the patient], but also considering COVID, there’s the safety of not having to go to crowded waiting rooms and clinics and hospitals. It also eliminates the risks in traveling with a disability, navigating public transportation and buildings, ramps, stairs—those kinds of things. “The benefit for our clinic is a deeper connection to our patients and fulfilling the mission of providing truly patient-centric care,” Neufeld says.

Key Differentiator

Eric Neufeld, CPO, FAAOP, works with a prosthetic patient at his home. [patients] that weren’t even familiar with the service to begin with.” “Patients are thrilled that we’re mobile,” Sugg adds. “I’m hearing more comments about that [in the COVID era]. Our business went up because surrounding businesses didn’t have the mobile services that we offer, and since

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they didn’t, they weren’t prepared. And so, business from other companies has … migrated our way.” Rector says that safety of the patients and clinicians is paramount as the pandemic rages. “A challenge we ran into was how to protect ourselves enough that we were

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PHOTO: Eric Neufeld, CPO, FAAOP

Neufeld and Sugg both note that while they launched their mobile businesses well before the onset of COVID-19, the pandemic has only reinforced their confidence in the business model. “It was a really good idea to go mobile, and COVID and the pandemic really highlighted why it’s a good idea,” says Neufeld. “It also became a really good option for

creating safety for our clinicians, but also safety for the patients, because we do see more than one patient a day,” Rector explains. “We’re moving from spot to spot, making sure we’re doing shoe covers, gloves, masks, gowns ... and making sure our patients at home understand the procedures that we’re following.” Neufeld says the protocols can be time-consuming. “Being very disciplined about sanitizing equipment between all patients is an absolute must, even though it takes a little extra time,” he says. “And we really take some time to make sure that patients themselves don’t have COVID and haven’t been exposed to protect our own staff. We take these safety concerns between patients and our staff really seriously.” It’s not always easy. Sugg recounts episodes in which clinicians have arrived at a home to provide care only to find it full of extended family members

not wearing masks. In a situation like that, “you try to be as upfront and honest with the patient as you can,” he says. “You say ‘Mom, could you step out on the porch and speak with us a moment?’” Most of these scenarios are prevented by precall planning and questionnaires to determine whether the patient or family members have recently been sick.

Costs and Benefits

When it comes to getting paid for O&P devices, or reimbursed from insurance companies or Medicare/ Medicaid, there is little difference for mobile operations when compared to operating out of a traditional clinic, according to several mobile business owners. However, unlike with some home healthcare situations where medical care is involved, insurance companies don’t allow O&P clinics to recoup travel expenses, such as fuel for vehicles and mileage. “There’s

really no way to recoup those costs,” Rector says. “We just have to be really strategic in how we plan our days not to cover ground unnecessarily.” But O&P clinics that are strategic in their mobile initiatives reap rewards in the form of closer relationships with patients, who appreciate the home visits. “We’re able to draw closer to their caregivers or families who are truly responsible for most of their care and really give us good feedback about how the patient is doing with their prosthesis,” says Rector. “We’re able to look at their living environments ... and learn a lot of things about people that you don’t always get in just doing a case history, no matter how thorough you are. Unless the patient is going to give you that information, you only get what they tell you.” Michael Coleman is a contributing writer to O&P Almanac.




Making an Impact Clinician studies O&P outcomes data and what it means for patients, practitioners

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.





Taavy Miller, PhD, CPO, brings strong scientific skills in health economics and clinical expertise to her role as a research scientist in the Department of Clinical and Scientific Affairs at Hanger Clinic. “I leverage my knowledge and experience in using real-world data to capture when, where, and why patients with functional impairment and chronic diseases utilize health services along their journey to better understand the health outcomes and value of health services,” says Miller, who is well-versed in quantitative and qualitative data analysis. “In addition, I have experience in patient-reported outcomes assessing health utility and qualitative research.” Given her background, it comes as no surprise that Miller plays a critical role in the IMPACT studies, a collection of research reports published by Hanger in collaboration with researchers, clinicians, and academic institutions. These studies assess outcomes among individuals with commercial health insurance, and have demonstrated the economic benefit that timely and appropriate prosthetic services have on patient outcomes, according to Miller. In the most recently published study—the IMPACT 2—Miller

worked closely with Hanger Clinic’s Shane R. Wurdeman, PhD, CP, FAAOP(D), as well as researchers from the University of North Carolina at Charlotte’s Department of Public Health. They analyzed data on 510 patients with lower-limb amputations to evaluate how receipt of a prosthesis affects overall healthcare utilization. Emergency department (ED) use, a common proxy for healthcare utilization, was assessed in the context of the timing of receipt of a lower-limb prosthesis following amputation, as well as not receiving a prosthesis. Miller and her cohorts found that, across all age groups, individuals who received an early prosthesis—within three months following amputation— were 48 percent less likely to use the ED compared to those who did not receive a prosthesis. They also found that the percentage of ED use as a measure of overall healthcare utilization appears to have an upward trend as the time from surgery to prosthesis receipt increases. The findings were published in PM&R: The Journal of Injury, Function, and Rehabilitation. Miller led the study from conceptualization through executing the data analysis and writing the manuscript.


“The IMPACT 2 study is about assessing the influence that receiving a prosthesis may have on the potential health service resource utilization. While a lower-limb amputation may include high costs, long-term use of services, and even a burden to a healthcare system, provision of a prosthesis may mitigate the burden from an economic perspective,” explains Miller. “As other studies have shown, certain services or interventions can reduce resource utilization, thereby demonstrating the value of the service.” For example, for someone with a lower-limb amputation, “a prosthesis empowers an individual to be more functionally independent, prevents injurious falls, and can improve cardiovascular health.”

Drawn to Research

Miller first decided to explore the field of O&P research soon after earning her master’s degree from Georgia Institute of Technology. She is passionate about equitable access to O&P services, “given the connection between practice, policy,

OPAlmanac_Feb2021.indd 2

Patient outcomes and real-world data have become my focus as a way to assess the value of O&P services and devices.


and research evidence—yet it is difficult to demonstrate effectiveness and value of a device or service when empirical evidence is lacking,” she explains. As a new clinician-in-training, Miller found that trying to justify care plans or recommendations—and not being able to find the research needed to explain why or how a device would

be beneficial for patients—could be frustrating. “While O&P services are essential to millions of people’s health and function globally, we have a dearth of published evidence supporting what may seem logical to orthotists and prosthetists,” she says. Measuring and assessing patient outcomes is one of the best ways to communicate to other key stakeholders in the decision-making process, Miller adds. Last October, Miller earned a doctorate in health services research from the University of North Carolina at Charlotte. Her dissertation, titled, “The Value of Prosthetic Rehabilitation for Current and Potential LowerLimb Prosthetic Users,” leveraged information from a commercial claims database and patient functional outcomes data. Assessing the effectiveness, efficiency, and equity of O&P devices on an individual and population level is important to establish the economic value of O&P services, according to Miller.

1/14/2021 12:06:22 PM O&P ALMANAC | FEBRUARY 2021



Miller also has worked on several other projects that utilize clinical outcomes data, including assessing injurious falls and mobility. Another recent study in the MAAT series (Hanger’s Mobility Analysis of AmpuTees research studies) was an assessment of mobility across the lifetime. “The MAAT 7 study establishes reference values for mobility based on etiology for lower-limb prosthesis users.” In yet another key study, Miller and the Hanger research team published in early 2020 an analysis of a customized

upper-extremity short-form survey using the Patient-Reported Outcomes Measurement Information System (PROMIS) measurement tool. “This study was important and impactful to demonstrate the reliability of the customized upper-extremity PROMIS short survey,” she says. “It is critical to measure and capture our patients’ voices and experiences in order to facilitate shared decision making and communication.”

Long-Term Benefits

Miller, who is kept busy by a 1-year-old daughter when she’s not working, believes research into health economics

Studying the Economic Value of Early Prosthetic Intervention Taavy Miller, PhD, CPO, was the lead author of Hanger Clinic’s first IMPACT study in early 2020: “The Impact Study: Impact of Time to Receipt of Prosthesis on Total Healthcare Costs 12 Months Postamputation,” by Miller; Rajib Paul, PhD; Melinda Forthofer, PhD; and Shane R. Wurdeman, PhD, CP, FAAOP(D). In this study, published in the American Journal of Physical Medicine and Rehabilitation, the authors concluded that the clinical benefits of prosthetic rehabilitation can serve to potentially reduce other nonprosthetic costs, and that early delivery of a prosthesis is associated with reduced overall direct healthcare costs, as shown in the table below. Cost Result of Time to Prosthesis







Did not receive prosthesis

Received prosthesis between 0-3 months

Received prosthesis between 4-6 months

Received prosthesis between 7-9 months

Received prosthesis between 10-12 months







and outcomes will benefit patients in terms of individual care. These types of studies “will reduce barriers to critical technology, inform policy and clinical practice guidelines (CPGs), and ultimately improve health outcomes as individuals receive appropriate and timely O&P rehabilitation services,” says Miller. As the Hanger research team continues to work on assessing the value of O&P services, “we will be able to grow awareness of the benefits of orthotics and prosthetics and the expertise of O&P healthcare providers.” She also notes that some of the lessons learned from research during the COVID-19 crisis parallel the O&P research drive: “As we are currently seeing the power and benefit of epidemiology-based or populationlevel studies in the efforts on COVID, it is similar to how we apply the same methods to the O&P populations,” she says. “Generating evidence based on real-world data and patient outcomes will inform our field and shape CPGs.” Many payors reference CPGs, she says, and are interested in assessing how providing O&P services can increase their efficiency while improving patient outcomes. Looking to the future, Miller and her colleagues will continue to analyze patient outcomes among individuals with amputations—and expand those studies to include patients that use ankle-foot orthoses, spinal devices, and more. “Another goal will be to capture health utility data as a measure of patient outcomes and to demonstrate effectiveness of O&P services.” The most pressing issue, going forward, is to ensure that patients have equitable access to devices, according to Miller. “As the demands increase for value-based outcomes and real-world evidence, it is imperative we continue to evaluate the impact of prosthetic and orthotic services. Determining and demonstrating value will help patients improve access to appropriate, high-quality, and beneficial O&P devices in a timely manner.”


Kelsey Prosthetics & Orthotics


Building a Practice in the Badger State Wisconsin facility features in-house fabrication and hands-on patient care





Kelsey Prosthetics & Orthotics staff at an annual charity golf outing for the CJ Lomas Foundation

FACILITY: Kelsey Prosthetics & Orthotics OWNERS: Brian Kelsey, CPO, and Sherri Kelsey LOCATION: Greenfield and Wauwatosa, Wisconsin HISTORY: Nine years

Brian Kelsey, CPO, with his first osseointegration patient

gives me as good results as hand casting. I feel hands-on casting gives me much better control over the fabrication process.” The practice is so busy that finding time for traditional marketing efforts is difficult, Kelsey says. “I have always professed that providing exceptional patient care and exceptional customer service to patients as well as to the whole rehab team is the best marketing we have,” he says. “Our interactions with doctors, therapists, and patients have truly been the way we’ve grown the business. And since 2012, our growth has been very encouraging.” Kelsey does find time for community and professional activities, including involvement in the Midwest Chapter of the American Academy of Orthotists and Prosthetists and becoming a board member of a new nonprofit, Dignity for Amputees International, that provides upper-extremity prostheses to amputees in Africa. Like other facilities, Kelsey P&O was hit hard by the pandemic, particularly in the early months. Amputee clinics in three

hospitals shut down for three months. “We had patients just sitting and waiting, and physicians not allowed to schedule appointments,” says Kelsey. “My employees were worried both about contracting the virus and passing it on to our patients, many of whom are elderly, diabetic, or in poor health to begin with.” Kelsey furloughed his employees for about six weeks. During that time, he saw patients in Greenfield, while a single office manager handled billing and scheduling from the Wauwatosa office. By mid-May, most of his employees felt more comfortable coming back to work. Kelsey had secured a loan from the Payroll Protection Program, so even though patient numbers were not back to normal, everyone came back to work. “Amputee clinics resumed in August, and by fall, we were very busy again,” Kelsey says. Staff wear personal protective equipment, offices are thoroughly cleaned and sanitized, and patients are often asked to wait in their cars instead of crowding the waiting room. Once the pandemic has passed, Kelsey may consider further expansion, although that has never been his primary goal. “We’ve always grown organically. As referrals increased, we responded with more practitioners and another office,” he says. “But I’m proud of the personal quality of patient care we provide, and I don’t want to sacrifice that in the name of growth.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: Kelsey Prosthetics & Orthotics

Kelsey Prosthetics & Orthotics nine years ago after he and his business partner in Kenosha, Wisconsin, decided to go their own ways. Their facility, founded in 2002, had two offices, so each partner assumed ownership of one. Kelsey took over the office in Greenfield, Wisconsin, about 15 minutes from downtown Milwaukee. Kelsey and his wife, Sherri, were the facility’s only two employees in 2012, with Kelsey handling clinical and technical work and his wife carrying out the administrative functions. “We’ve been growing fast ever since,” says Kelsey. Today, the company has three clinicians, two technicians, and four administrative employees. In 2018, Kelsey P&O acquired another office, in Wauwatosa, Wisconsin, from a retiring prosthetist. That same year, the facility became a residency site for the National Commission on Orthotics and Prosthetics Education, and Jason Oldejans, CPO, became the facility’s first resident. He joined the practice after completing his residency. Each of the company’s locations houses a fabrication lab, and staff members build everything in-house, with the exception of a few orthotic devices. While Kelsey uses computer-aided design (CAD) occasionally, he prefers hand casting. “I’ve been in this field since 1995, and I have seen so many different CAD systems come along,” he says. “I’ve used many of them, but I have yet to find a CAD system that

Staff members celebrating a Christmas party during the COVID-19 pandemic


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Skin Care Solutions California company offers products for individuals with amputation, diabetes, and other conditions





A sampling of VitalFit products geared toward individuals with limb loss and diabetes

Paul Dean, MD, MPH, FAAD

COMPANY: VitalFit OWNER: Paul Dean, MD, MPH, FAAD LOCATION: La Mesa, California HISTORY: Two years

Those who wear orthotic devices enjoy similar benefits, he says. VitalFit markets to patients and O&P facilities in the United States, and works with a partner in Australia. The company has a robust website that features regular blog entries and educational webinars and videos for amputees. Physical therapist Cosi Belloso, MSPT, and Paralympic athlete Greg Mannino, CP, offer several presentations on YouTube, Facebook, and the website on topics pertinent to the amputee community, including phantom pain, skin care, selection of prosthetic feet and ankles, and wearing schedules. The company’s online presence, including Instagram postings, has expanded since the pandemic began. “Once we were unable to meet people in person at trade shows and other physical events, we ramped up our webinars and videos,” says Christine Erbacher, who manages the company’s national sales. “The pandemic actually helped us to make information more accessible to a larger audience.”

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

PHOTOS: VitalFit

advanced degree in public health, and becoming a fellow of the American Academy of Dermatology, Paul Dean, MD, MPH, FAAD, became an entrepreneur. In 2007, he launched Skin Resource.MD, a company that offers a line of skin care products designed to reverse, prevent, and control the signs of aging. Dean’s entry into the O&P arena was serendipitous. “My general manager came to me one day, saying his father was disabled from diabetes and had terrible issues with his prosthesis,” recalls Dean. “He wondered what skin care product [he] should use. I soon realized we would need a whole system of products to address his needs and those of other amputees—to cleanse, reduce friction, moisturize, and prevent infections and inflammation on the residual limb.” Dean founded VitalFit in 2019 to provide exactly that. Working with a chemist, he developed a system comprising four products: a daily cleanser, moisturizers for day and night, and Liquid-to-Powder Plus, which is designed to reduce odor and sweat and help protect against shear and friction. Both the cleanser and the day moisturizer are antibacterial, antifungal, and antiinflammatory; the night moisturizer contains antioxidants and helps relieve dry, chapped, or cracked skin, according to Dean. The same system is beneficial for the amputee’s sound side as well, and for patients with diabetes, to prevent damage, particularly on the feet, where a lesion can lead to serious disability, says Dean.

VitalFit is involved in the amputee community, both locally and nationally. It is a sponsor of the Amputee Coalition and the Challenged Athletes Foundation, which is based in nearby San Diego, and the company frequently participates in amputee clinics. Dean would like individuals with amputation to have a range of ways to access the VitalFit system. The company’s affiliate program for clinics offers incentives to make VitalFit products available in O&P facilities. Giving patients access to the skin care system in the clinic is especially important for the elderly, who may not be comfortable buying online. Dean also is pursuing partnerships with manufacturers of other O&P products, such as liner companies. “It’s important to be forward thinking and consider all options, including engaging with other manufacturers,” he says. And he is exploring the development of additional products, such as a moisturizing wipe, and other configurations of the four-element system. “The major cause of device abandonment is skin irritation,” says Dean. “It doesn’t matter how amazing the device is; if the patient is experiencing skin problems, the patient won’t wear it. Feedback from both patients and practitioners has been very positive. Healthy skin is the foundation for positive outcomes, and that’s the end goal.”



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during these one-hour webinars, held the second Wednesday of each month at 1 p.m. ET. One registration is all it takes to provide the most reliable business information and CE credits for your staff at a single office location. Visit www.AOPAnet.org/ education/monthly-webinars for details and registration information.


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Inpatient Billing: Working With Your Care Partners



the upcoming live tutorial to learn about one of the best resources available for O&P practices, the AOPA Co-OP. A Wikipedia for all things O&P, the Co-OP is a one-stop resource for information about reimbursement, coding, and policy. This searchable database provides up-to-date information on developments in Medicare policy, statespecific legislation, private-payor updates, and more. Members can access detailed information on everything from modifiers to product-specific L codes and associated policies. Register for the next Co-OP Live Tutorial hosted by AOPA Director of Strategic Initiatives Ashlie White, who FEBRUARY 2021 | O&P ALMANAC

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Smart Orthotic Treatment (SOT) Resting Hand Orthosis

Many complications can cause reduced mobility in the hand, which can result in contractures if left untreated. Starting hand therapy at an early stage, before spasticity is established, may help to maintain or increase mobility of the hand. Smooth and lightweight, the SOT Resting Orthosis has an aluminum core that allows adjustment to the desired resting position. A good biomechanical position may reduce the risk of flexor shortening in the wrist and fingers. The soft, elastic cover eliminates pressure points from bulky straps. Sizes: XXS - XL For more information, contact customer service at 888/678-6548 or email info@allardusa.com. Support for Better Life

The ALPS Smart Seal Cushion Liner and VIP Are the Perfect Duo Our Smart Seal features raised bands that grip the socket wall to form a secure interface. The low modulus bands stretch against the socket wall, while the smooth inner wall conforms easily to the residual limb. Available in locking and cushion suspension. The locking version of this innovative liner features a new distal construction to control distal distraction. This is a single piece construction, with new seamless knitted construction, and is available only in High Density Gel. Our Smart Seal Cushion Liner is a perfect match with our VIP. The Vacuum Integrated Pump (VIP) is essential for even weight distribution, and is able to be easily used in conjunction with the Smart Seal Cushion Liner. The VIP stabilizes the residual limb, overcoming all issues connected with the limb changing volume during the day. Easy to install, and does not require batteries or other power sources. Call us or visit www.easyliner.com for more information.



Apis custom programs offer practitioners best options and services for patient compliance. All products are covered under risk-free guaranteed-fit promise. We stand firmly behind our words. Call us at 1-888/937-2747.

Becker GEO™ (Gait Evaluation Orthosis) The Becker GEO™ is a prefabricated, carbon composite evaluation orthosis used to assess the benefit of an ankle-foot orthosis on ankle and knee stability. Please contact our customer service department today for more information. Visit BeckerOrthopedic.com.

Boston Brace 3D® The Boston Brace 3D® is our next innovation in the nonoperative treatment of idiopathic scoliosis. Our clinical experts, working with pediatric orthopedic surgeons, have combined their knowledge of the three-dimensional scoliosis curvature with the latest in shape capture and CAD/CAM technologies to develop a brace that provides higher in-brace correction without reducing adherence. Outstanding Outcomes The combination of in-brace curve reduction and adherence to wear schedules has shown in multiple studies to reduce the curve progression, and in some cases, actually improve the curve. To get these results for your patients, contact Jamie Benelli at 508/638-1175 or visit BostonOandP.com.



MARKETPLACE 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.

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.



Point Partial The Point Partial is a mechanical, passive articulating prosthetic finger designed to be lightweight and strong, using a patented, novel ratcheting mechanism to lock into seven unique positions of flexion. The Point Partial was designed to meet the needs of individuals with partial finger amputation. Point Designs’ prosthetic fingers are designed for patients with finger loss who require a durable device and the ability for one-handed operation and various levels of flexion. The prosthesis is made of titanium and stainless steel, comes in three standard lengths (45, 50, and 55 mm), and has a 150 lb (68 kg) load capacity. For more information, contact Point Designs at 720/600-4753 or visit www.pointdesignsllc.com.

RUSH ROGUE® The PDAC approved RUSH ROGUE® provides the most realistic and dynamic foot and ankle motion available. The Vertical Loading Pylon (VLP) provides vertical shock relief while offering +/- 8 degrees of torsion, allowing the user to push the foot and themselves to the limits. The RUSH ROGUE is made of our advanced fiberglass composite, which is three times more flexible than conventional prosthetic feet. The roll-through characteristics of the foot provide exceptional energy return with no “dead spot.” The RUSH ROGUE is also available in the EVAQ8 elevated vacuum and H2O models. #goROGUE

MARKETPLACE Amparo Confidence TT Socket From Ottobock

Are you ready for a revolution in interim socket technology? The Amparo socket is formed over a liner directly onto the user’s residual limb, which means a new socket can be made in one go. Benefits include: • One-visit fittings • Easy alignment with offset distal adapter • No plaster casting required • Remoldable material for fast socket (re)shaping and adjustments • Mobile oven and toolset for anywhere, anytime socket adjustments • Valve or pin suspension options. For more information, contact your sales representative or visit professionals.ottobockus.com.

WalkOn® Carbon Fiber AFOs WalkOn AFOs are prefabricated from advanced prepreg carbon composite material designed to help users with dorsiflexion weakness walk more naturally. WalkOn AFOs are lightweight, low-profile, and extremely tough. Their dynamic design can help patients achieve a more physiological and symmetrical gait, offering fluid rollover and excellent energy return. The WalkOn family of AFOs offer a full range of AFO designs and sizes, including the WalkOn Reaction junior. Fast and easy to fit, the WalkOn Trimable footplate can be shaped with scissors, often requiring only one office visit.

Ottobock Children’s Myoelectric Solutions

Built for exploration, the Electric Hand 2000 is available in four sizes to fit children with upper-limb differences as they grow from infancy through adolescence. Paired with the MyolinoWrist 2000, equipped with a ball joint and adjustable friction, children are able to easily position the hand to support a wide range of activities. Visit professionals.ottobockus.com or speak with your sales rep for more information.

Runner Junior by Ottobock The Runner Junior by Ottobock is characterized by a durable and lightweight carbon spring that provides powerful drive and stable turning. With adaptable dynamics and spring stiffness, every junior athlete can tailor settings to their individual needs. Contact your Ottobock representative to learn more or visit our website at professionals.ottobockus.com.

Contact us at 800/328-4058 or professionals.ottobockus.com for details. O&P ALMANAC | FEBRUARY 2021


MARKETPLACE The Xtern Foot Drop AFO by Turbomed Orthotics Think outside the shoe! This one-of-akind orthosis (AFO) is a game changer for foot drop patients: The Xtern is totally affixed outside the shoe to maximize comfort, and prevent skin breakdown and rubbing injuries. Its flexibility promotes maximal ankle range of motion and calf muscle strength. The Xtern allows running, walking, and even mountain hiking as long and as far as you want without any restrictions, and moves from sandals to boots flawlessly. Turbomed’s innovative products are designed in Quebec, Canada, sold in over 26 countries, and distributed by Cascade in the United States. Visit turbomedusa.com to get your life back!

Spinal Technology Inc.

Spinal Technology Inc. is a leading central fabricator of custom spinal and scoliosis orthoses. Our ABC-certified staff orthotists collaborate with our highly skilled, experienced technicians to provide the highest quality products and fastest delivery time, including weekends and holidays, as well as unparalleled customer support in the industry. Spinal Technology is the exclusive manufacturer of the Providence Nocturnal ScoliosisÂŽ System, a nocturnal bracing system designed to prevent the progression of scoliosis, and the patented FlexFoamTM spinal orthosis. For information, contact 800/253-7868 or visit www.spinaltech.com.

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Opportunities for O&P Professionals

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Pacific Associate Professor or Professor (Prosthetics and Orthotics Program Director)— Rehabilitation Medicine Seattle, Washington The University of Washington’s Department of Rehabilitation Medicine invites applications for program director and associate chair, Division of Prosthetics and Orthotics, Department of Rehabilitation Medicine. This position is a full-time (12-month) tenured faculty position at the associate professor or professor rank, dependent on experience and qualifications. The ideal start date for the position is July 1, 2021. The successful applicant will engage in teaching, academic scholarship, and administration in prosthetics and orthotics. The University of Washington, the Department of Rehabilitation Medicine, and the Division of Prosthetics and Orthotics are strongly committed to equity, diversity, and inclusion as diversity in our students, staff, and faculty fosters excellence. As P&O program director, the successful applicant should actively cultivate a culture of inclusion and diversity among the community of faculty, staff, and students. The University of Washington Prosthetics & Orthotics Program is accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) upon the recommendation of the National Commission on Orthotic and Prosthetic Education (NCOPE). As a UW faculty member, there are many opportunities to teach in areas of expertise, mentor master’s and PhD students, mentor postgraduate fellows, engage in research, and develop new degree programs. The program director and associate chair is responsible for the overall management and administration of the Division of Prosthetics and Orthotics. These responsibilities include strategic planning, curriculum development, program review and accreditation, faculty development, personnel supervision, budget management, and quality improvement. In addition to administrative leadership responsibilities, this person will be expected to maintain active scholarship and participate in


service to the university and prosthetics and orthotics profession. This person should also be supportive of the interprofessional educational efforts in the department. This position will use strong communication skills to effectively foster collaborations and drive innovation and excellence in the profession. This position will perform duties including curriculum design and evaluation, strategic planning, and managing human and fiscal resources to facilitate ongoing program development. The program director must: 1. Possess a PhD in prosthetics and orthotics or related field (or foreign equivalent degree) 2. Be credentialed in the profession of orthotics and prosthetics through a certification program accredited by the National Commission for Certifying Agencies (NCCA) 3. Have a minimum of five years of teaching, clinical, and administrative experience in prosthetics and orthotics. Candidates must also hold or be eligible for a professional prosthetist and/or orthotist license in the state of Washington. Applications will be accepted until the position is filled. We will start reviewing applications immediately and on an ongoing basis until the position is filled. Interested candidates should submit curriculum vitae, a responsive cover letter that includes statements of teaching, leadership, and research, and four professional references. In addition, all candidates must provide a written description of their personal commitment to diversity, equity, and inclusion and strategic vision for fostering diversity in P&O. Apply at https://apply.interfolio.com/79851. For questions about the position, contact Dr. Friedly, Search Committee Chair, by email: ahrrehab@uw.edu. Website: https://apply.interfolio.com/79851 Email: ahrrehab@uw.edu



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

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Career Opportunities... California

CO-Modesto CPO-Salinas Oregon CPO –Portland

Established in 1987, Pacific Medical Prosthetics and Orthotics has become a tenured company in the industry for superior patient care, products and services. The positions we offer are created for candidates that are looking to create opportunity, self-driven, motivated, and enjoy serving and helping others.

To apply, submit resume to: careers@pacmedical.com

A competitive salary, benefits and profit sharing are offered based on position/experience.

Our Culture & Commitment “We will serve and help others grow personally, professionally, and strive to put others needs first and foremost as demonstrated by our positive attitude, teamwork and professionalism.” AD INDEX

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March 29

ISPO 18th World Congress Deadline for Free Papers. For more information, contact the ISPO World Congress team at info@ispo-congress.com or call +49/341-678-8237.

April 1

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

April 1

2021 February 5 WEBINAR

Co-OP Tutorial. Noon ET. For more information, visit www.AOPAnet.org.

ABC: Practitioner Residency Completion 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/individual-certification.


February 10

Know Your Audit: Understanding the Difference. 1 PM ET. For more information, visit www.AOPAnet.org. WEBINAR

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/individual-certification.

April 12–17

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 300 locations nationwide. Contact 703/836-7114, email certification@ABCop.org, or visit ABCop.org/individual-certification.

April 14

Pedorthic Clinician Corner: Understanding and Treating Charcot Foot. 1 PM ET. For more information, visit www.AOPAnet.org. 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/individual-certification.


Co-OP Tutorial. Noon ET. For more information, visit www.AOPAnet.org.

April 20–22, April 27–29

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

May 4–7

47th Academy Annual Meeting & Scientific Symposium. Virtual. For more information, visit www.oandp.org/ page/annual_meeting.

March 8-9

AOPA Virtual Coding and Billing Seminar. Noon-4PM ET. Earn 8 CE credits. For more information, visit www.AOPAnet.org/education/coding-billing-seminar. SEMINAR

March 10

Inpatient Billing: Working With Your Care Partners. 1 PM ET. For more information, visit www.AOPAnet.org. WEBINAR


Co-OP Tutorial. Noon ET. For more information, visit www.AOPAnet.org.



May 12–14

AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.

New York State Chapter of American Academy of Orthotists and Prosthetists (NYSAAOP) Meeting. Rivers Casino & Resort, Schenectady, NY. For more information, visit nysaaop.org/meeting.



November 10

Co-OP Tutorial. Noon ET. For more information, visit www.AOPAnet.org.

AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.



December 8

Co-OP Tutorial. Noon ET. For more information, visit www.AOPAnet.org.

AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.



AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.



Co-OP Tutorial. Noon ET. For more information, visit www.AOPAnet.org.

January 9–11

U.S. ISPO Pacific Rim Conference. Waikoloa, Hawaii (Big Island). For more information, visit www.usispo.org.


AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.

January 30–February 3

Hanger Live. Dallas, TX.

August 11 WEBINAR

AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.


March 2–5

AAOP. Atlanta, GA. For more information, visit www.oandp.org/events/event_list.asp?DGPCrSrt=&DGPCrPg=2.

AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.

May 12–14

NYSAAOP. Schenectady, NY.

September 9–12

May 20–21

AOPA National Assembly. Boston. For more information, visit www.AOPAnet.org.

October 13 WEBINAR

AOPA Monthly Webinar. 1 PM ET. For more information, visit www.AOPAnet.org.

Orthotic & Prosthetic Innovate Technologies Conference. Minneapolis, MN. For more information, go to http://cecpo.com/documents/OrthoAndProstheticTech_2022_1up.pdf.

November 1–4

ISPO 18th World Congress. Now virtual. For more information, contact the ISPO World Congress team at info@ispo-congress.com or call +49/341-678-8237.

Calendar Rates

September 29–October 1

AOPA National Assembly. San Antonio, TX. For more information, visit www.AOPAnet.org.

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Teaming Up O&P professionals push advocacy efforts in Indiana, Kentucky, New York, Texas, and Washington


Each month, State by State features news from O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This section includes information about medical policy updates, fee schedule adjustments, state association announcements, and more.

Become an AOPA State Rep

AOPA is currently recruiting members interested in participating in the AOPA State Reps network for the following states: Alaska, Connecticut, Colorado, Florida, Idaho, Kansas, Maine, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oklahoma, Oregon, Rhode Island, South Dakota, Utah, Vermont, West Virginia, and Wyoming. Please email awhite@ aopanet.org if you are interested in becoming an AOPA State Rep.


Indiana O&P companies have announced the formation of the Indiana Association of Orthotics and Prosthetics (IAOP). IAOP’s goals are to advocate for orthotics and prosthetics and promote the O&P industry in the state for the betterment of citizens of Indiana. 52


O&P advocates continue to work with Kentucky Medicaid to reevaluate the pricing model for cranial remolding orthoses. Currently, S1040 is manually priced. The “cost-plus” methodology used by Medicaid in the state does not adequately account for the time required from an orthotist to provide the appropriate and necessary care associated with orthotic intervention.

New York

A bill has been introduced in the New York State Assembly that, if passed, would require health insurance policies and contracts to provide coverage for the diagnosis and treatment of lymphedema; and would require such coverage to include benefits for equipment, supplies, devices, complex decongestive therapy, and outpatient self-management training and education for the treatment of lymphedema. Compression garments and “orthotic shoes and devices” are among the items this bill would require to be covered for patients diagnosed with lymphedema. Also in New York, O&P advocates continue to push for a Medicaid fee schedule increase. In addition to ongoing fundraising efforts, the New York State Chapter of AAOP has launched an advocacy campaign with a sign-on letter that speaks to the importance of access to O&P devices for vulnerable patient populations in the state. For more

information on how to write to New York State Assembly members, visit the New York section on the AOPA Co-OP.


On November 23, the Texas Commission of Licensing and Regulation passed an emergency rule related to the COVID-19 pandemic. Under this rule, all Texas Department of Licensing and Regulation licensees with a renewable license that expired between Aug. 1 and Nov. 30, 2020, are considered to hold an emergency license valid for up to 120 days after their license expiration date.


A final rule was published on December 16 by the Office of the Insurance Commissioner regarding Washington state essential health benefits. Language in the final rule includes specific references to prosthetics and orthotics as rehabilitative and habilitative services that must be covered by insurance carriers. These reports are accurate at press time, but constantly evolve. For up-to-date information about what is happening in your state, visit the Co-OP at www.AOPAnet.org/resources/co-op. Submit Your State News To submit an update for publication in the State by State department of O&P Almanac, email awhite@AOPAnet.org.

AOPA Member Benefit

AOPA’s Co-OP is

THE Compendium of O&P A confluence of coding, billing, and policy information, the AOPA Co-OP provides a cooperative space for collaboration among O&P colleagues. This easily accessible, online resource enables your organization to be successful in today’s everchanging healthcare environment.

Tutorial Webinars Co-OP Live on Friday at Noon ET March 5

May 14

April 2

June 4

July 2

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


After creating your Co-OP account, Download to your mobile device at aopanet.atlassian.net.

FOLLOW US @AmericanOandP



Learn more and sign up at www.AOPAnet.org/co-op.


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Every child deserves mobility

Provide wonder and adventure.

Children explore the world with curiosity and excitement – and that requires a lot of function, flexibility and mobility. Give your youngest patients the ability to move and play with products designed to meet the unique needs of their growing bodies.


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February 2021 O&P Almanac