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The Magazine for the Orthotics & Prosthetics Profession

F E B R UA RY 2017

Identifying 'Avoidable' Errors in Documentation

This Just In: Analysis of the Proposed Rule for Section 427 P.18


Clinical Practice Guidelines for O&P P.26




Pattern Recognition for Myoelectric Devices P.36










Make plans to participate in a

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


• Celebrate 100 years of the formalized O&P Profession in the United States. • Clinical Education so remarkable that it will be memorialized in an international scientific journal. • The best speakers from around the world. Hear from physicians, researchers and top-notch practitioners. • The largest exhibit hall in the Western Hemisphere will feature devices, products, services, tools and the latest technology from exhibitors around the world. • Earn 35+ continuing education credits. • Participate in hands-on learning and demonstrations during workshops



• Preparation for the changes that U.S. Healthcare reform is sure to bring and its influence on global health policy. • Networking with an elite and influential group of professionals. • Ideal Las Vegas location, chosen for its popularity, travel ease excitement.

Visit AOPAnet.org to learn more.


FE B R UARY 2017 | VOL. 66, NO. 2




20 | Patient Empowerment Prosthetists typically spend more time than other members of the health-care team with amputee patients—and are in a unique position to educate and encourage patients who are struggling with emotional and psychological issues related to limb loss. By taking steps to engage the larger care team, help patients assess their level of psychological distress, and offer resources about the limb loss community, O&P professionals can aid in a more complete rehabilitation process, and guide patients to appropriate self-management of their amputation. By Lia K. Dangelico

18 | This Just In

Clarifying Section 427 CMS has finally released a proposed rule regarding qualified providers to clarify Section 427 of the Benefit Improvement and Protection Act of 2000. AOPA members and O&P stakeholders have until March 13 to submit comments— but the rule may face scrutiny by the new administration and opposition from several business interests.


26 | Defining Best Practices Two recently published clinical practice guidelines offer recommendations for optimal patient care relating to prosthetic foot selection and acute postoperative care following transtibial amputation. These documents, which serve as “guides,” help start the conversation for evidence-based O&P practice and offer O&P clinicians the chance to shape the profession’s future under a value-based care model. By Christine Umbrell






34 | Then & Now The evolution of the AOPA Illustrated Guide

36 | Bridge to the Future



How pattern recognition will revolutionize myoelectric devices

DEPARTMENTS Views From AOPA Leadership......... 4

40 | The Global Professional

Insights from AOPA Board Member Jeffrey Lutz, CPO

Q&A with a practitioner from London

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

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

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


Research, updates, and industry news

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

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

Eliminate those errors that are under your control

AOPA News.............................................. 46

Transitions in the profession

Common Mistakes

AOPA meetings, announcements, member benefits, and more

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

Member Spotlight.................................42 n n

Welcome New Members ................. 48


Paceline Inc. R.J. Rosenberg Orthopedic Lab

Careers........................................................ 48 Professional opportunities

Marketplace............................................. 50

Ad Index...................................................... 53 Calendar......................................................54 Upcoming meetings and events

Ask AOPA...................................................56

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

Validation for the O&P Profession


EW AREAS OF HEALTH CARE are more visually impactful than O&P care. Even though our services represent less than 1 percent of the Medicare total spend, on a daily basis we see the huge difference our care makes for the patients we serve. Our vision of the benefits of O&P intervention has always been clear. However, there has been a lack of studies of the economic impact of our care. The original Dobson-DaVanzo study, supported by AOPA, was a groundbreaking effort to clearly demonstrate to all stakeholders the cost effectiveness of orthotic and prosthetic care. The study covered every new amputee in the Medicare system over the years 2007-2010, as well as approximately one third of all orthotic patients during that period. AOPA, working with DobsonDaVanzo, received special permission from CMS that allowed us to look at every health-care expenditure for these patients over a four-year period. The study determined that orthotic and prosthetic care is cost effective, and that treated patients collectively had fewer dollars of health-care costs than the counterpart group that did not receive any O&P treatment. The final study was completed in 2013, and the results were published in the peer-reviewed medical journal Military Medicine in February 2016. Currently underway is the follow-up effort, Dobson-DaVanzo 2. This work will build on the previous study. One year ago, AOPA set out to secure comparable Medicare data on prosthetic and orthotic patients for the 2011-2014 time period. This data set coincides with the major changes in policies implemented by CMS’s durable medical equipment Medicare administrative contractors (DME MACs) in August 2011, so comparing data for 2011-2014 with the comparable data for 2007-2010 should help highlight changes in pattern and quality of care that resulted from the DME MAC’s intervention. The data for Part D drug costs also are included for both data sets, and inclusion of drug data will give us a broader picture of total Medicare expenditures for both the treated and the untreated patients. The preliminary data runs and information from Dobson-DaVanzo 2 are scheduled to be available for coordination with the RAND study, which is a comprehensive analysis of the value of prosthetics to the U.S. health-care system that will be released in 2017. I personally am excited to see our profession validate with science and analyses what we as O&P professionals have always believed: Our care not only improves our patients’ quality of life, but also creates health-care savings.

Jeffrey Lutz, CPO, is a member of AOPA’s board of directors.



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

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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

Editorial Management Content Communicators LLC

Our Mission Statement The mission of the American Orthotic & Prosthetic Association is to work for favorable treatment of the O&P business in laws, regulation, and services; to help members improve their management and marketing skills; and to raise awareness and understanding of the industry and the association.

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



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

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

Don DeBolt, chief operating officer, 571/431-0814, ddebolt@AOPAnet.org MEMBERSHIP & MEETINGS Tina Carlson, CMP, senior director of membership operations and meetings, 571/431-0808, tcarlson@AOPAnet.org Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, koneill@AOPAnet.org Lauren Anderson, manager of communications, policy, and strategic initiatives, 571/431-0843, landerson@AOPAnet.org Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org

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

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

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

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

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

Catherine Marinoff, art director, 786/293-1577, catherine@marinoffdesign.com

AOPA Bookstore: 571/431-0865

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



Publisher Thomas F. Fise, JD

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Sheridan SUBSCRIBE O&P Almanac (ISSN: 1061-4621) is published monthly by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/431-0899, or email landerson@AOPAnet.org. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices. ADDRESS CHANGES POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. Copyright © 2017 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted. COVER PHOTO: Getty Images/JGalione

Advertise With Us! Reach out to AOPA’s membership and more than 13,000 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac17 for advertising options!


‘Alternative’ Health Care

Health-care facilities—including O&P companies—must adapt as newcomers enter the market


55 PERCENT Likely to send a digital photo of a rash or skin problem to a dermatologist for an opinion.

49 PERCENT Likely to have a wound or pressure sore treated at a clinic in a retail store or pharmacy.

39 PERCENT Likely to have a visit with a physician via smartphone app.

34 PERCENT Likely to get an MRI at a clinic in a retail store or pharmacy.


$ 69 Percent 66 Percent 56 Percent Consider cost of monthly premium an important factor.

Consider coverage of services and medications important.


64 Percent Open to trying nontraditional medical attention “if price is right.”

18 Percent Open to trying nontraditional medical attention “regardless of price.”

Consider doctors and hospitals in the network important.

“Traditional health companies will find it harder to compete on commodity services as lower-priced options emerge. Decide whether to chase commodity revenue or develop new revenue models anchored on core capabilities while investing in new ones.”

17 Percent

—“Health Care’s New Entrants,” PwC Health Research Institute.

Not open to trying nontraditional medical attention “regardless of price.”

HEALTH-CARE ADVICE FROM OUTSIDERS Consumers were asked whether they would take advantage of free advice for weight management or help with diet-related medical conditions from a nutritionist or dietitian from each of these entities.

Doctor Pharmacy Gym Employer Grocery Story Big Box Store

79% 59% 41% 38% 28% 17%

Percentage Who Answered “YES”

SOURCE: “Top Health Industry Issues of 2017,” PwC.



SOURCES: “Top Health Industry Issues of 2017,” “PwC Health Research Institute Consumer Survey, 2016,” “Health Care’s New Entrants,” Reports published by PwC Health Research Institute.

Encroachment may be a familiar concept to many O&P facilities, but the pace has picked up within the overall U.S. health-care market, with nontraditional entities offering health services. A survey by PwC’s Health Research Institute (HRI) finds that some consumers are willing to abandon traditional care venues for more affordable and convenient alternatives. As neighborhood drugstores, technology and telecommunications companies, and other industry disruptors enter the market, O&P businesses should seek to understand the new health economy and consider adapting business practices if necessary.

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AOPA Submits Comments on LowerLimb Prostheses Systematic Review In December, the Agency for Healthcare Research and Quality (AHRQ) solicited public comment on the key questions that would be used in its upcoming systematic review of clinical literature relative to lower-limb prostheses. AOPA, with significant input from its Medical Advisory Board and its steering committee, developed detailed comments and submitted those comments prior to the Dec. 20, 2016, deadline. AOPA’s comments addressed both the systematic review in general as well as responses to the eight key questions for which AHRQ requested comments. AOPA’s comments can be viewed on AOPAnet.org. AOPA also actively contributed to comments developed and submitted by the O&P Alliance, of which AOPA is a member. FAST FACT

ABOUT ONE IN 10 AMERICAN ADULTS HAS DIABETES, double or triple by 2050.



Facility/University Partnership Generates Outcomes Research Independence Prosthetics-Orthotics Inc. in Newark, Delaware, has worked closely with the University of Delaware’s department of physical therapy to establish a multidisciplinary amputee clinic with a goal of improving the documentation process. John Horne, CPO, CPed, president of Independence, partnered with Meg Sions, PhD, PT, DPT, assistant professor at the University of Delaware, and Tara Jo Manal, PT, DPT, OCS, director of the Delaware Physical Therapy Clinic, in developing prosthetic evaluations to document medical necessity for those struggling to get their prosthetic limb covered by insurance. Horne and Sions began working together clinically in September 2013, modifying the prosthetics evaluation based on emerging research in the field of prosthetics as well as visits to O&P national conferences. “Because there are very few multidisciplinary prosthetics research endeavors in outpatient sites [like the Delaware Physical Therapy Clinic], we decided to prospectively collect data during the amputee clinics to answer research questions related to patients with lowerlimb loss,” says Sions. “Questions like: How do you determine what the best prosthetic device is for a given person?” The data collection has gathered information on more than 140 patients with lower-limb amputations. To spur deeper analysis of the data they collected, Horne donated $300,000 from Independence ProstheticsOrthotics to create a postdoctoral research fund in the College of Health Sciences. Under the direction of Sions, the fund will provide support

for postdoctoral researchers who will work on outcomes-related research. Postdoctoral researchers will assist with analyzing and publishing the results from the patient evaluations. The analysis is intended to support advances related to postamputation clinical care and improve outcomes for individuals with limb loss. The researchers will seek to identify varying factors such as a poor prosthetic socket fit and comfort, lack of patient confidence with using devices, mental health issues, and other co-morbidities that may affect the best possible outcomes for an individual. If the research team can determine how these influences affect outcomes, they may propose interventions to improve the quality of function and life for the patient. “Understanding factors [that] limit patient progress is an important aspect of clinical research that needs more attention,” says Horne, who opened an Independence Prosthetics-Orthotics Inc. location on the university’s Science, Technology, and Advanced Research Campus. “If we are able to identify specific issues that hinder an individual’s ability to optimize [his or her] prosthetic to [his or her] full potential, then we will have made great strides in our industry.”

PHOTO: Getty Images/JohnnyGreig

according to the Centers for Disease Control and Prevention. If trends continue, that figure is expected to



VA Researchers To Study Upper-Limb Prosthetic Satisfaction PHOTO: Getty Images/Horsche

The Providence VA Medical Center is beginning a threeyear study to evaluate the needs of veterans with traumatic upper-limb amputations, with the ultimate goal of improving satisfaction. Led by Linda Resnik, PT, PhD, the research team will collaborate with investigators from U.S. Department of Veterans Affairs (VA) medical centers in Richmond, Virginia; Puget Sound, Washington; and Gainesville and Tampa, Florida, to complete the project. The researchers plan to include 1,100 veteran and active-duty service members with upper-limb amputations in the study. Participants will respond to survey questions about their amputations, their prosthesis use, the quality of their amputation-related health care, and how the amputations has affected their lives. The researchers will ask 125 participants to also complete physical performance tests. “We need data to better understand the needs of people with upper-limb amputations and to assess their limitations in functioning, their participation in life roles, and their satisfaction with prosthetic devices and the amputation

PHOTO: www.providence.va.gov

Providence VA Medical Center

rehabilitation care that they have received,” says Resnik. Data from the study will be used to improve the quality of amputation care in the VA and Department of Defense (DOD), and “to guide their evidence-based clinical practice guidelines for prescriptions, provision of rehabilitation services, and regulatory approval” by the U.S. Food and Drug Administration. The project is expected to be the largest and most comprehensive study of veterans and service members with upper-limb amputations, according to Resnik. She says she is hoping to fill a void in research relating to the state of science in upper-limb prosthetics, particularly the lack of studies that compare new technologies with older, commercially available devices. The study is being funded in part by the Department of Defense’s Orthotics and Prosthetics Outcomes Research Program, which has awarded a $2.5 million contract to the Ocean State Research Institute, the nonprofit arm of the Providence VA Medical Center, toward the study. Resnik says she expects to start acquiring data this spring. AOPA was instrumental in securing funding for this and other O&P research grants.


DME MACs Announce Format Change for LCDs The four durable medical equipment Medicare administrative contractors (DME MACs) have announced a change to the existing format for Local Coverage Determinations (LCDs). Specifically, the general documentation requirements that apply to all Medicare-covered services will be removed from individual LCDs and will be published as a single Policy Article that will apply to all Medicare-covered services. The DME MACs have stated in the past that revising and reissuing every LCD to reflect minor changes in general documentation language seemed redundant and overly time consuming. They will be revising the LCDs once the General Documentation Policy Article is written and published. While this format change does not create any new policies regarding Medicare coverage of O&P services, O&P providers will still be required to meet all of the general documentation requirements even though they will no longer be published as part of every LCD. AOPA will work with the DME MAC medical directors to ensure that the General Documentation Policy Article is consistent with what is currently published in individual LCDs and will work to ensure that providers are educated properly regarding general requirements for Medicare coverage.





CMS Announces Initial Implementation, Without Prosthetic Codes

David Shulkin Tapped as Secretary David Shulkin, MD, a physician who served in Barack Obama’s administration as the undersectary for the Department of Veterans Affairs (VA), has been named secretary of the VA by President Donald Trump. Shulkin, an internist who came to government with 30 years’ experience leading private hospitals, “will be able to lead the turnaround our Department of Veterans Affairs needs,” Trump said at a news conference. “His sole mandate will be to serve our veterans and restore the level of care we owe to our brave men and women in the military.”



CMS has announced the initial implementation of the Medicare prior authorization program that was authorized through the final rule published on Dec. 30, 2015. Taking a cautious approach, CMS has announced only two codes will be subject to prior authorization in the initial implementation, both of which describe power wheelchairs. CMS also has chosen to implement the prior authorization process in two phases for the power wheelchair codes. The first phase will be implemented on March 20, 2017, and will require prior authorization for the two codes in one state within each DME MAC jurisdiction. The second phase will be implemented on July 17, 2017, and will expand the prior authorization program for the two codes nationwide. While the initial implementation of the Medicare prior authorization program does not include any lower-limb prosthetic codes, the expectation remains that prior authorization for most lower-limb prostheses will be implemented at some point in the future.


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Stephanie Morgan Greene, Esq.

Stephanie Morgan Greene, Esq., has joined Ability Prosthetics & Orthotics Inc. as executive director, compliance. Greene began her career as a respiratory therapist 20 years ago, before attending law school. Her experience in medical billing, revenue management, and medical necessity coverage requirements bring industry expertise and leadership to Ability.

Ramen Landon, a board-eligible prosthetist and resident orthotist, has joined Ability Prosthetics & Orthotics Inc.’s York, Pennsylvania, patient-care team. He will complete his orthotic residency under Marlies Cabell, CPO. Ramen Landon Ramen earned his master's in prosthetics and orthotics and completed an 18-month prosthetic residency at the Rehabilitation Institute of Chicago (RIC), which included a six-month research rotation and upper-limb prosthetic project at the Center for Bionic Medicine within RIC.


Seth McLaughlin

Matt Swiggum


The Amputee Coalition has announced the addition of two new members to its board of directors: Seth McLaughlin and Matt Swiggum. The board's executive leadership has changed as well, with Dan Berschinski serving as board chair and Tom Coakley stepping into the role of treasurer. McLaughlin, who lives in Wyoming, Ohio, and owns the consulting firm Springfield Advisors, has a background encompassing executive and consulting roles focused on marketing, with strong skills in consumer branding. Swiggum is the president and chief executive officer of Ottobock North America and lives with his family in Austin, Texas.


The Board of Certification/ Accreditation (BOC) has elected www.bocusa.org its 2017 executive committee and has announced two additions to the board. The recently elected 2017 officers are the following: • Chair: L. Bradley “Brad” Watson, BOCO, BOCP, LPO, of Bowling Green, Kentucky, president of Clarksville Limb + Brace + Rehab • Vice chair: Rod Borkowski, CDME, president of Health Essentials • Secretary: Wayne R. Rosen, BOCP, BOCO, FAAOP, owner of W.R. Rosen Inc. • Treasurer: Shane Ryley, BOCP, BOCO, area clinic manager at Hanger Orthopedic Group in Torrance, California • Member-at-large: R. Jeffrey “Jeff” Hedges, CDME, president of R.J. Hedges & Associates • Immediate past chair: James L. Hewlett, BOCO, of Redding, California Von M. Homer, M.Sc., BOCPD, and John “Sion” Owen Jr., MA, BOCPD, CDME, are new additions to the BOC board. Homer is co-director of the Motion Analysis Center at the Barry University School of Podiatric Medicine, where he also serves as full-time clinical faculty assistant professor. Owen is owner of Foot Solutions stores in Columbia, South Carolina, and in Nashville, Tennessee.

Von M. Homer, M.Sc., BOCPD

John “Sion” Owen Jr., MA, BOCPD, CDME

Össur has completed full integration of Medi Prosthetics. Össur acquired Medi Prosthetics, a provider of mechanical lower-limb prosthetic components, from Medi of Bayreuth, Germany, last September, and the integration was complete as of Jan. 1, 2017. Ottobock and TaiLor Made Prosthetics have reached an agreement for Ottobock to be the exclusive distributor of the TaiLor Made prosthetic foot globally, starting in the United States. The TaiLor Made prosthetic foot is designed with toe and heel elements that move independently, along with a shock-absorbing mechanical spring pack. “Ottobock is excited to be the exclusive distributor of the TaiLor Made prosthetic foot,” says Brad Ruhl, president of US HealthCare for Ottobock.


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Common Mistakes Learn to avoid missteps in your billing practices

Editor’s Note—Readers of CREDITS Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 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.



HERE WAS A TIME when getting reimbursed for O&P services was a relatively simple process. You saw the patient, provided a service, submitted a claim, and got paid. Everybody was happy. Unfortunately, those days are gone. The process of getting reimbursed for the orthotic and prosthetic services you provide is getting more complex every day. The increased focus on physician documentation, growth in audits, and shift in philosophy to value-based care models have all had a significant impact on your ability to be reimbursed for the medically necessary services you provide. While there are many strategies you can implement to improve your ability to be reimbursed for the O&P services you provide, a simple strategy that can vastly increase your reimbursement success is to take steps to avoid simple mistakes in your billing process. These strategies are easy to identify, can be implemented quickly, and are completely within your control. This month’s Reimbursement Page highlights several areas where you can eliminate avoidable mistakes within your O&P practice.

Proof of Delivery Documentation







Eliminating claim denials as a result of missing or invalid proof of delivery would instantly reduce the claim denial rate by as much as 20 percent. The Medicare requirements for a compliant proof of delivery include the following: • Beneficiary’s name • Delivery address • Sufficiently detailed description of the item(s) being delivered • Quantity delivered • Date delivered • Beneficiary (or designee) signature There are several things you can do to make sure your proof of delivery documentation is compliant with Medicare requirements. First, ensure that the description of the items that are being delivered is detailed enough to allow the DME MAC staff to understand what was actually delivered to the patient. While inclusion of brand names and/ or serial numbers is no longer required, including this information can be useful in describing what was provided. Listing the Health-Care Common Procedure Coding System (HCPCS) codes and descriptors is acceptable again due to a recent change in policy, but if you choose to include the HCPCS descriptors on your proof of delivery documentation, you must list the entire HCPCS descriptor. Alternatively, you may use a detailed narrative description of the items delivered on your proof of delivery documentation. Second, verify that the delivery address on the proof of delivery form matches the actual location where the beneficiary took possession of the device. While the place

PHOTO: Getty Images/Pinkypills

The durable medical equipment Medicare administrative contractors (DME MACs) regularly report the results of their ongoing prepayment audits. Invalid or missing proof of delivery documentation is consistently one of the primary reasons for claim denials. Making sure that your proof of delivery documentation is compliant is one of the few things that is completely within your control.



of service on your claim will usually indicate the patient’s residence, the address on the proof of delivery form must reflect the actual delivery address—whether it is your office, a facility, or another location. Finally, the beneficiary or designee signature must be legible. While it is acceptable for a designee to sign the proof of delivery form if the beneficiary is unable to sign, the designee must be someone with no financial interest in payment of the claim, and his or her signature must be legible. If a designee signs the form, his or her relationship to the beneficiary should be documented on the proof of delivery form.

Detailed Written Orders

An invalid or missing detailed written order is another common cause of Medicare claim denials. Like proof of delivery, the detailed written order is a document over which you have complete control. Medicare policy is very specific regarding what is required in order for a detailed written order to be valid and compliant. The required elements of a detailed written order include the following: • Beneficiary’s name • Physician’s name • Date of the order • Detailed description of item(s) being ordered • Physician’s signature and date

PHOTO: Getty Images/PeopleImages

There are several steps you can take to make sure that your detailed written order meets Medicare requirements. First, make sure that if you deliver the items prior to obtaining the detailed written order, which is allowed under Medicare rules—assuming you have a valid dispensing order—the detailed written order must include a start date that is on or before the actual date of delivery. This “start date” is different than the physician signature date that is required on all detailed written orders. Second, check that every component that will be billed separately is included on the detailed written order. This requirement may be accomplished by including a list of HCPCS codes and

descriptors or through a narrative description of all components. Finally, make sure that the physician signature is either legible or matches a signature attestation from the physician or a signature log that you maintain.

Understanding Medicare LCDs and Policy Articles

Each of the four DME MACs publishes and maintains Local Coverage Determinations (LCDs) and Policy Articles for the majority of O&P services covered by Medicare. These documents together make up the medical policy that governs Medicare coverage of O&P devices. Both are equally important and integral in determining if a service is covered or not. Understanding both the LCD and the Policy Article is extremely important when determining what steps are necessary to ensure proper reimbursement for the services you are providing. As a general rule, the LCD addresses coverage related to medical necessity while the Policy Article addresses statutory coverage issues such as whether a service or item is a benefit under the Medicare program.

Recognizing Time Limits

Medicare claim denials that are attributed to failure to meet timely filing limits can be particularly devastating to your practice. Claims that are denied due to nontimely filing are not appealable and are essentially “dead” claims.

Current Medicare regulations state that claims that are not filed within 12 months of delivery are considered nontimely and are therefore nonpayable, regardless of the amount and type of documentation available to support the claim. While holding claim submission until all required documentation is available may be a successful strategy to reduce claim denials, you must be sure that all claims are filed within 12 months of the date of delivery of the items. Challenges to O&P reimbursement continue to multiply as Medicare and other insurers increase their scrutiny of O&P claims. Avoiding mistakes in the areas where you have significant control will go a long way in ensuring success in obtaining fair and reasonable reimbursement for O&P services. Joseph McTernan is director of reimbursement services at AOPA. Reach him at jmcternan@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:




This Just In

Clarifying Section 427 CMS has released a proposed rule regarding qualified providers, but its full implementation faces hurdles



turning point for O&P when CMS finally released a proposed regulation on Section 427 under the Benefit Improvement and Protection Act (BIPA) of 2000. AOPA greatly applauds CMS for finally releasing the proposed regulation. However, the proposal is far from perfect, and there are additional challenges to its implementation: • The start of the new Trump administration and the prospect that the administration could easily view the proposed regulations unfavorably as an effort to regulate business. • The fact that all signs indicate there is likelihood of several business interests in potential opposition to the rule.

AOPA Listening Survey

These factors make it critically important that AOPA, AOPA members, and the O&P community provide thoughtful and comprehensive comments by the March 13 deadline. The AOPA Board of Directors met on Monday, January 16, to discuss key aspects of AOPA’s position and took the following actions: (1) AOPA established a two- to threeweek “listening period,” which ran through Feb. 6, 2017, when AOPA members reviewed the



10 or so categories of potential concerns that likely will need to be addressed in AOPA’s comments. AOPA invited members to respond to a series of questions framed around aspects of the proposed regulation to be used as AOPA works, together with its partners in the O&P Alliance and elsewhere, to advance both the comments and the objectives of the proposed rule and of Section 427 of BIPA 2000. (2) AOPA has created a committee of four board members comprised of three patient-care professionals and one orthotic manufacturer to guide interim decision making on this issue informed by member comments. AOPA’s outside legal counsel, Alston & Bird, has prepared a comprehensive summary of the BIPA proposed rule, which may be viewed at bit.ly/proposalsummary. AOPA also will prepare a mechanism to facilitate members in submitting their own comments to CMS on the proposed regulation by the March 13, 2017 deadline. A recent article appearing in Bloomberg’s Bureau of National Affairs about the proposed BIPA 427 regulations cited specific actions by AOPA and its members that seemed to stimulate CMS into action:

This Just In

Medicare Reconsideration Appeals Contractor Announces Expansion of Formal Telephone Discussion Demonstration C2C Innovative Solutions, the Medicare appeals contractor that processes all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) appeals at the second level, also known as “reconsideration,” has announced implementation dates for its expansion of the formal telephone discussion demonstration. This program, currently limited to DMEPOS claims in Jurisdictions C and D, will be expanded to include claims for orthoses as of February 17 and claims for prostheses as of March 17. Claims for therapeutic shoes were added as of January 17. The formal telephone discussion demonstration is an opportunity for providers to interact directly with the medical review staff at C2C in an attempt to resolve issues that caused the claim to be denied by the durable medical equipment Medicare administrative contractor and subsequently denied at the redetermination level of the appeal process. To date, the demonstration has proven to be very successful, with a denial overturn rate approaching 86 percent. The recent announcement of the expansion of the program to both orthotic and prosthetic “A CMS spokesman told Bloomberg BNA that the proposal began appearing on the CMS regulatory agenda around the time of a 2013 letter to the Department of Health and Human Services from 35 House members suggesting that implementing the law could reduce fraud.” Those who attended AOPA’s 2013 Policy Forum and urged legislators to sign this letter can now see how their advocacy delivered results. (Mark your calendars for the 2017 AOPA Policy Forum, May 24-25—you can make a difference!) A beneficiary advocate, however, expressed concern that implementation of strict requirements on practitioners and suppliers could harm beneficiary access to needed items. “For example, qualified suppliers who submit claims for equipment that were not furnished by an entity that meets these requirements risks revocation of their Medicare enrollment and

services provides a welcome opportunity to potentially avoid the significant delay and backlog that currently exists at the administrative law judge (ALJ) level of the appeals process. Unfortunately, there is no way to “sign up” for this program. Your claim must be selected for review by representatives of C2C solutions. In addition, because this program was established as a demonstration project, there must be a study group (Jurisdictions C and D) and a control group (Jurisdictions A and B). As a result, it is unlikely that the demonstration project will be expanded beyond Jurisdictions C and D. In addition to the announcement of the expanded program, C2C has indicated that it has been authorized by CMS to overlook some common reasons for claim denial if the whole of the records support the medical need for the claim. An example of this authority is the ability to overturn denials based on a missing signature on a medical record. Cases where medical necessity is lacking will continue to be denied at reconsideration.

eligibility to submit claims for any [durable medical equipment, prosthetics, orthotics, and supplies] items or services,” Ashkon Roozbehani, an attorney for the Center for Medicare Advocacy, told Bloomberg BNA. “A reduction in the number of qualified suppliers available to a beneficiary in their locality may result in loss of access to otherwise unattainable medically necessary items and services.” A very important tactical issue included in the AOPA Listening Survey was that there may be as many as six groups that might potentially oppose the proposed BIPA regulation. So, among other topics on which AOPA sought feedback from members were the tactical choices between the very difficult odds of pulling through the proposed regulation applicable to all those persons essentially as written versus an improved prospect if we are open to some give-and-take to solidify support. As an example, tactical choices must be made on how to respond to the poignant criticism that this is an

antibusiness regulation by at least some of the potential opponents. Another challenge: Do we learn anything from the long history of negotiated rulemaking attempted years ago that produced conflict, no consensus, and no final BIPA regulations for these past 17 years? Does the O&P community remain absolutely resolute on the terms exactly as written, even if doing so greatly diminishes the prospect of getting any BIPA 427 qualified provider rule through the process to have the force of law? As noted above, AOPA has created a committee of board members composed of three patient-care professionals and one orthotic manufacturer to guide interim decision making on this issue and all content aspects of its position after reviewing AOPA member input and feedback. This important issue deserves everyone’s serious attention. Visit bit.ly/proposedregs to read the proposed rule, analysis by AOPA’s legal counsel, and the 2013 letter to HHS. O&P ALMANAC | FEBRUARY 2017



Patient Empowerment Going beyond ‘fitting the device’ to help patients improve their psychological health and boost their confidence By LIA K. DANGELICO




NEED TO KNOW: • Individuals with limb loss often experience some form of mental and emotional distress, such as depression, anxiety, body image dissatisfaction, or posttraumatic stress disorder. These issues can hinder patients’ progress in their rehabilitation. • Some successful prosthetists choose to take a more active role in ensuring comprehensive care for prosthetic patients, by engaging with the larger care team, educating and encouraging patients, and connecting patients with resources in the limb loss community.

• The Amputee Coalition and Johns Hopkins Medicine have created a program called “Improving Well-Being.” Using this program, patients complete a self-administered and selfscored assessment to rate their level of psychological distress, and clinicians review results to discuss options and resources.

• Helping amputees with their emotional well-being can lead to more confident, better connected patients who are willing to work hard at their rehabilitation—which also may lead to improved patient retention.

• Some O&P facilities help facilitate introductions between new amputees and mentors, who can relate to the experience of living with limb loss and provide information and encouragement.



PHOTO: Getty Images/JGalione

amputees—takes careful consideration of patients’ physical conditions and functional needs. O&P professionals have their hands full with evaluating patients, determining the best prosthetic solution, and ensuring a proper fit. But the most successful prosthetists understand that with O&P patients, there’s often more going on than meets the eye. Following amputation, most patients experience some form of mental and emotional distress, such as depression, anxiety, decreased quality of life, body image dissatisfaction, identity changes, or post-traumatic stress disorder (PTSD). Of those, one third experience significant depression and 15 percent experience a clinical level of depression, according to Stephen Wegener, MA, PhD, director of rehabilitation psychology and neuropsychology and professor of physical medicine and rehabilitation at Johns Hopkins University School of Medicine. And even for those who aren’t experiencing clinical-level issues, “they are still struggling with psychological challenges, body image challenges, and the challenges that come with having to negotiate and

navigate the health-care system and health-care team, which are no less significant,” he says. Many patients also struggle with persistent pain, such as peripheral neuropathy, phantom limb pain and sensations, and residual limb pain. A study published in the Journal of Clinical & Diagnostic Research by researchers at the Maharaja Agrasen Medical College in Haryana, India, found that pain was closely linked to negative outcomes, including poor adjustment with life, anxiety disorders, decrease in quality of life, poor adjustment to prosthetic use, and activity restriction. Patients with chronic or phantom pain also tended to have higher anxiety and depression scores. Similarly, research conducted by the Amputee Coalition suggests that “depression and psychological well-being are linked to prosthetic satisfaction, prosthetic use, the amount of steps taken with a prosthesis, and how many hours they wear it,” says George Gondo, MA, director of research and grants for the Amputee Coalition. “You can fit someone with a great device, but the psychosocial issues factor into how well someone adapts to their limb loss and how far they can progress.” O&P ALMANAC | FEBRUARY 2017



And while nearly all amputees struggle to “emotionally adapt” to limb loss, Wegener says less than 10 percent of patients actually receive the mental health care they need. This presents a huge opportunity for prosthetists, who may be just the right person at a crucial point in their patients’ care, especially those patients who are immediately post-hospital discharge and at the first prosthetic fitting. By taking steps to engage with the larger care team, educate and empower patients, and connect patients with resources in the limb loss community, prosthetists can help patients on the path to an able body, a sound mind, and a highquality life—and see their practice improve as a result.

A Crucial Role

Prosthetists likely spend more time than any other member of the healthcare team in assisting amputee patients with their limb loss care. Therefore, the O&P mindset must evolve into that of a more traditional, health-care


going to help people become aware of other needs and resources that could benefit them.” Wegener offers the following example: “As a psychologist, if I have someone coming into my office and I can see that their residual limb is moving up and down inside their prosthesis, I don't need to be a prosthetist to say, ‘How is that working for you?’ and, ‘Do you think you might need to contact somebody to get some help with that?’ That's not outside the scope of my practice.” The same mentality should apply to prosthetists as they address the mental and emotional needs of their amputee patients. That being said, it may be easier to comment on an obvious sore than to inquire about a patient’s mental state or mood. A survey conducted by the Amputee Coalition revealed that, for many prosthetists, their biggest reservations for entering into these discussions is that they were uncomfortable and didn’t know what to do or say. For some, it comes naturally. For others, it's quite awkward. Mark Hopkins, PT, CPO, MBA, knows firsthand how difficult yet important these conversations can be. “Prosthetists may not have always been the go-to person for discussing emotional well-being… but we have a very strong relationship with these patients, and if you're able to listen, sometimes they will just open up—raise an issue or concern—and you can help point them in the right direction,” says Hopkins, who is chief executive officer and president of Dankmeyer Inc.

PHOTOS: Top-Getty Images/JSmith; Bottom-Getty Images/Monkeybusinessimages


provider role. “This is an important, ongoing relationship that provides an opportunity to access patients and help them think about how they are doing after limb loss,” says Wegener. With that influence, prosthetists have to help push patients to take a more active role in their rehabilitation and care—or self-management. For many patients, this is a new idea. “Historically, they are expecting to go to a health-care professional and say, ‘OK, you're going to fix this problem,’” he says. “In the case of limb loss, that's unlikely to be the case.” Patients need to understand that limb loss is a permanent part of who they are. And they can’t do it alone. Patients need a tight-knit care team, where each member— physician, prosthetist, physical therapist, and family—knows his or her role and works together to help the patient manage a problem or condition. Most importantly, “we, on the health-care team, all need to be aware of the broader needs of the person sitting in front of us,” says Wegener. “The idea is not that prosthetists need to be mental health providers; it’s that they are concerned about the total well-being of their patients… so they are

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A Pivotal Time



Taking patient support one step further, Dankmeyer recently launched a Patient Navigator program, which pairs patients in need with a staff member who helps pilot patients through the health-care system and overcome hurdles in financial aid, transportation, education, and other challenging areas. Outside of the clinic, the company is actively engaged in its local limb loss community, including outreach events; support groups and peer mentor programs; its Amputee Walking School; continuing education for physical therapists; and more.

PHOTOS: Top-Getty Images/Dean Mitchell; Bottom-Getty Images/Geber86

In its efforts to better prepare clinicians and alleviate the stress of these interactions, Dankmeyer utilizes the Improving Well-Being program, which was created by the Amputee Coalition and Johns Hopkins Medicine and is being redeveloped for the web (amputeewellbeing.org); once the online version is made public, all practitioners will be able to access it. As part of the program, patients complete a self-administered and selfscored assessment, where they rate how they're doing after limb loss, their level of psychological distress, and their satisfaction with life. They also are asked to create three realistic goals for themselves. Results come in the form of a “Distress Score” and “Life Satisfaction Score,” and these numbers provide an easy segue for the clinician to discuss what’s going on and how they can help. “We’re much more comfortable after seeing [how the patient scored], and letting the patient talk about [what they’re experiencing],” says Hopkins. Afterwards, the team connects patients with national resources, such as the Amputee Coalition’s First Step guide and Limb Loss Resource Center, as well as local resources, including mental health clinics, local support groups, peer mentor programs, and adapted sports programs.

If all of this sounds like a lot of work, it is. Patients who are struggling with mental and emotional distress need a lot of support to be successful. The period immediately following limb loss is an especially complicated time. “There's that stigma in society surrounding mental health, but there's also a sense of being a failure and not wanting to burden other people with their problems,” says Gondo. While it is great to see people with limb loss—such as service members and Paralympians—becoming more visible in popular culture, “unfortunately, a lot of those individuals you see tend to be younger and more athletic, and it kind of creates a perception in someone who loses a limb that if they're not being super active like that then they're a failure,” he says. In these early stages, few things can be as helpful as a listening ear, especially from another amputee who can actually relate to the experience of living with limb loss. The Amputee Coalition’s Certified Peer Visitor program meets that need by matching patients with trained volunteers, many of whom are amputees themselves or family members of amputees, who provide information and encouragement before or after undergoing limb loss or limb difference. This can help to motivate patients by “allowing them


to see that someone else—not a Marine or an elite athlete, just an average person like them—has made it through this process,” says Gondo. “Patients see others made it through OK, and that gives them hope.” Another way to combat feelings of helplessness or hopelessness is to teach patients practical problemsolving skills to work through the issues and results they’ve experienced. It’s also helpful to generate feedback. "Some patients don't even know they're doing poorly,” says Wegener. “They have adjusted to this level of function so they just think, 'This is how life is now.'” Promoting Amputee Life Skills (PALS), another project of the Amputee Coalition/Johns Hopkins Medicine partnership, addresses that very problem. The PALS program started as in-person groups and is now being expanded into an online platform (palsamputeelifeskills.org) to provide broader accessibility. It comprises eight interactive video lessons, where patients learn how to develop self-management skills, how to work with their health-care team, how to recognize and manage mood and pain, and how to connect with others for support. For Wegener, who helped pioneer the program, it also helps to train patients in their role on the process. “A physician or prosthetist goes to school and learns how to do his or her job,” he says. “If we are going to ask patients and their families to ‘work’ as active members of this process, we have to teach them how to do their ‘jobs.’”

A New Normal

PHOTO: Getty Images/Freemixer

When members of the health-care team help patients maneuver the shaky first steps of limb loss, assist them in developing practical goals and measuring their progress, and connect them with resources and community support, amputee patients are bound to have more success—and that is good news for everyone involved. For prosthetists, these efforts often translate to a better client relationship and improved patient satisfaction. “Oftentimes, if a patient

isn’t progressing as he or she should, it’s because he or she doesn’t have a plan” to follow, says Hopkins. “So if we open up lines of communication early on in the process and help patients develop [a realistic plan] up front, they can use that information much more effectively.” Plus, efficiency matters. Patients would much rather come in for fewer, more impactful visits, and clinicians would prefer to be freed up to see other cases and work on projects. In addition, helping patients with their emotional well-being can lead to improved patient retention. A recent survey by the Amputee Coalition found that the ability of a patient’s prosthetist to provide comprehensive care, including mental and emotional health support, was a big factor in that patient’s decision to either stay with his or her prosthetist or switch to a different one. As the age-old business adage goes: It costs five times as much to attract a new customer as it does to keep an existing one. Supported patients benefit in many ways, too—from experiencing the

empowerment of being active participants in their care, to the relief that comes from learning to use exercise, stretching, and other tools to calm body and mind and manage their own pain. According to Wegener, these patients experience less depression, more positive moods, and higher confidence in their ability to manage their limb loss issues and challenges. They also may develop a tight-knit network of peers and friends who understand what they’re going through and can help to normalize the limb loss experience. “Feeling normal—you can’t put a price on that,” says Gondo. Some patients come to that realization slowly over time; for others, it’s like a switch that flips, where suddenly, “they get the message that they are not alone,” says Hopkins. “It’s really eye-opening for someone to come along and say, ‘Hey, I’ve been here before; I was here; I was you.’” Lia K. Dangelico is a contributing writer to O&P Almanac. Reach her at liadangelico@gmail.com. O&P ALMANAC | FEBRUARY 2017




BEST PRACTICES Two recently published CPGs help set the standard for value-based care in O&P

NEED TO KNOW: • Clinical practice guidelines (CPGs) are designed to reduce health-care variations, improve diagnostic accuracy, promote effective therapy, and discourage ineffective—or potentially harmful—interventions. • As health-care professionals move toward evidence-based practice and value-based care, CPGs also set a baseline of reference that prosthetists and orthotists can look to when planning treatment protocols and seeking reimbursement. 26


• Two years ago, several O&P professionals from Hanger Clinic decided to contribute to the O&P research foundation and spearhead a CPG development process. They modeled their process and guiding principles after the established American College of Physicians’ CPG program structure. • The group developed two CPGs, which were recently presented at a meeting of the American Congress of Rehabilitation Medicine and published in the Archives of Physical Medicine and Rehabilitation. This gives enhanced visibility to the recommendations, and means that more clinicians may benefit from the CPGs developed.

• CPGs are “guides” only, however, and will not be appropriate for all patients in all situations. They are not intended to replace clinical judgment of the prosthetist or other members of the surgical and rehabilitation teams. • Researchers at Hanger will continue to study the published topics and other best practices. They will monitor changes and improvements in patient care with the implementation of the CPGs.



PHOTO: Getty Images/asiseeit

a department of clinical and scientific affairs. James H. Campbell, PhD, health-care environment, most CO, FAAOP, and AOPA immediate medical professionals are shifting from past president was appointed chief fee-for-service care to a value-based— clinical officer, to lead the effort. It is or fee-for-value—model. As healththis group that spearheaded the CPG care professionals across the spectrum development process. move toward evidence-based Following the Model “We believe we have practice and value-based care, Once the researchers decided to create a responsibility to raise a few O&P clinicians and CPGs, they modeled their process and awareness by dissemresearchers are doing their guiding principles after the established part to advance the orthotic American College of Physicians’ CPG inating and sharing and prosthetic evidence-based program structure, says Campbell. research and clinical research pool by writing clinical For the CPG on “Acute experience within and James H. Campbell, practice guidelines (CPGs). Postoperative Care,” Campbell worked across the broader rehaPhD, CO, FAAOP CPGs are becoming a key with Phillip Stevens, MEd, CPO, bilitation community,” metric of quality health care. FAAOP, and John Rheinstein, says Campbell, As O&P continues to seek recognition CP, FAAOP, to develop a who is one of three authors as an important discipline within the guideline to present the most of the “Acute Postoperative health-care arena, CPGs can help current evidence and provide Care” CPG. “Presentation of substantiate the effort. CPGs have been our work at the ACRM and clinical recommendations for defined by the Institute of Medicine as perioperative care associated subsequent publication in the “statements that include recommenwith transtibial amputation. Archives of Physical Medicine Shane Wurdeman, “In developing this specific and Rehabilitation” is an dations intended to optimize patient MSPO, PhD, CP, FAAOP guideline, we based our important step in ensuring care that are informed by a systematic recommendations on peer-reviewed, the O&P profession is involved in review of evidence and an assesspublished analyses, using MEDLINE determining best practices, he says. ment of the benefits and harms of data through April 4, 2016, yielding 24 Campbell notes that this activity is alternative care options.” Simply put, abstracts,” says Campbell. especially important given the O&P CPGs translate best evidence into best profession’s inevitable move toward a practice. They are generally designed fee-for-value model. “It is important to promote quality by reducing healthto develop, publish, and disseminate care variations, improving diagnostic a series of CPGs that relate to specific accuracy, advancing effective therapy, areas of O&P management,” says and discouraging ineffective—or Campbell. potentially harmful—interventions. Developing CPGs also sets Late last year, several Hanger a baseline of reference that Clinic colleagues jumped into the prosthetists and orthotists CPG waters when they developed and presented guidelines on two O&P can look to when topics at a meeting of the American planning treatment Congress of Rehabilitation Medicine protocols and seeking (ACRM). These O&P CPGs also were reimbursement, says published in the Archives of Physical Shane Wurdeman, Medicine and Rehabilitation. The MSPO, PhD, CP, documents focused on two important FAAOP, who contribareas within the prosthetic profesuted to the “Prosthetic Foot Selection” CPG. sion: “Acute Postoperative Care of the “In the absence of clinResidual Limb Following Transtibial Amputation” and “Prosthetic Foot ical practice guidelines, Selection for Individuals With Lowerclinicians are vulnerable, Limb Amputation.” not having any official documents to reference,” he says. “By providing a Starting the CPG Process reference point for clinicians, Two years ago, several O&P profesthey can practice without having sionals from Hanger Clinic decided to external parties question their contribute to the O&P research foundation, and in 2015, Hanger established clinical judgment.” O&P ALMANAC | FEBRUARY 2017


For the “Prosthetic Foot Selection” CPG, Wurdeman says the process similarly began by searching the recently published literature reviews. He and his team studied several reviews and state-of-thescience conferences from the American Academy of Orthotists and Prothetists, which provided “a great starting point,” says Wurdeman. The team conducted additional literature reviews to fill in holes. The information in the literature was then examined for its implication on clinical practice, according to Wurdeman. Once the research phase of their project was finished, the clinicians developed “Conclusions”—a list of recommendations to follow when treating patients fitting the CPG description. (See the sidebars for a list of the recommendations included in each CPG.) The completed CPGs were then submitted and accepted for presentation at ACRM and publication in the Archives.


POSTOPERATIVE CARE Recommendations from “Acute Postoperative Care of the Residual Limb Following Transtibial Amputation: A Clinical Practice Guideline,” by Phillip Stevens, MEd, CPO, FAAOP; John Rheinstein, CP, FAAOP; and James Campbell, PhD, CO, FAAOP: 1. Rigid removable dressings should be used to reduce both the healing time of the residual limb and time to prosthetic fitting following transtibial amputation. 2. Rigid removable dressings should be used as the preferred means of reducing postoperative edema. 3. Given the comparable wound infection rates observed with the two treatment options, rigid removable dressings are preferred over soft dressing due to their additional attendant benefits.

Increased Exposure

Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to replace clinical judgment in the provision of patient care.

The guideline is intended to improve care and outcomes by providing clinicians with the findings and recommendations of published research. “This guideline is based upon the best available evidence related to this episode of care, and our research was limited to meta-analyses, systematic reviews, and evidence-based guidelines specifically focused on postoperative management of the residual limb following transtibial amputation,” Campbell says. The available literature studied for the patient education aspect of the postoperative CPG consisted of a 28


PHOTO: Getty Images/annebaek

SOURCE: “Oral Systematic/Meta-Analytic Review Presentations,” Oral Presentation 330: Acute Postoperative Care of the Residual Limb Following Transtibial Amputation: A Clinical Practice Guideline, Archives of Physical Medicine, 2016;97:e21-2.

recent systematic review, qualitative responses from recent semistructured interviews, and a multistakeholder needs assessment. “These sources allow synthesis of the type of education desired and valued by patients during the perioperative period,” says Campbell. The literature relating to peer mentoring is generally older and largely descriptive in nature; however, “the recommendation is that during the perioperative period, patients undergoing lower-limb amputation should be given access to a peer mentor who has received appropriate training.”

Publication of the guidelines in the Archives, and presentation of them at the ACRM in late 2016, gives enhanced visibility to the recommendations, and means that more clinicians may benefit from the CPGs developed by Campbell, Wurdeman, and their teams. “The Archives of Physical Medicine and Rehabilitation has the strongest impact factor among any rehabilitation journal,” says Wurdeman. “As a result, it gives the guidelines increased exposure and increased credibility, knowing that they were more heavily scrutinized prior to being accepted for publication.” “The guidelines are primarily meant to assist clinicians who want to integrate findings from published sources to guide and influence their clinical practice,” says Campbell. Going forward, Wurdeman hopes the CPGs will be used by all prosthetists. “It would be good for all clinicians to be aware and follow, when possible, as the information should help clinicians provide the best care possible for their patients,” he says.


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PROSTHETIC FOOT SELECTION Recommendations from “Prosthetic Foot Selection for Individuals With Lower-Limb Amputation: A Clinical Practice Guideline,” by Phillip Stevens, MEd, CPO, FAAOP; John Rheinstein, CP, FAAOP; and Shane Wurdeman, PhD, MSPO, CP, FAAOP: 1. For patients ambulating at a single speed that require greater stability during weight acceptance due to weak knee extensors or poor balance, a single-axis foot should be considered. PHOTO: AOPA

2. Patients at elevated risks for overuse injury (i.e., osteoarthritis) to the sound side lower limb and lower back should be managed with an energy-storage-and-return (ESAR) foot to reduce the magnitude of the cyclical vertical impact forces experienced during weight acceptance. 3. Neither patient age nor amputation etiology should be viewed as primary considerations in prosthetic foot type.

Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to replace clinical judgment in the provision of patient care. SOURCE: “Oral Systematic/Meta-Analytic Review Presentations,” Oral Presentation 602: Prosthetic Foot Selection for Individuals With Lower-Limb Amputation: A Clinical Practice Guideline, Archives of Physical Medicine, 2016;97:e21-2.

Speaking more specifically to the document he worked on, Campbell explains that embedded within the “Acute Postoperative Care” CPG are critical elements that relate to perioperative education and peer mentoring. Of course, it’s important to remember that CPGs are “guides” only—and will not be appropriate for all patients in all clinical situations. “The guide is not intended to replace clinical judgment of the prosthetist or other members of the surgical and rehabilitation team,” says Campbell. The literature referenced and associated with postoperative management of the 30


PHOTO: Getty Images/Thomas Northcut

4. Patients capable of variable speed and/or community ambulation are indicated for ESAR feet.

residual limb is “relatively robust with meta-analysis, systematic reviews, and numerous observational clinical trials. Given the strength of literature in the area, our recommendations are confined to those statements supported by the highest level of published evidence.” Wurdeman also emphasizes that CPGs “are not strict cookbooks” on how to make a prosthesis or orthosis. “Rather, they present evidence and recommendations. However, there is still reliance upon clinicians to use their clinical skills to tailor the device specific to the patient,” he says.

Wurdeman predicts that some clinicians may be surprised at some of the recommendations included in the Conclusions sections of the CPGs. “There is information that was extracted that is counter to many individuals’ preconceived notions about patients,” he says. “For example, with regard to prosthetic feet, age and etiology have seemingly become a characteristic that is being used in consideration for prosthetic foot type when the literature does not support this.”

Next Steps

Publishing a CPG on a specific O&P topic does not end the conversation about appropriate patient care—on the contrary, CPGs are intended to start the conversation. Campbell, Wurdeman, and the other CPG authors expect to continue their research in these areas. “The development and implementation of the guideline is only one step within the overall care of an amputee,” says Campbell. “The comprehensive outcome programs we are establishing are complementary to our guidelines and allow data to be collected and aggregated as we assess an entire episode of care.”

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CPGs From the VA The U.S. Department of Veterans Affairs (VA) has published several clinical practice guidelines (CPGs). The VA’s detailed documents seek to “improve care by reducing variation in practice and systemizing ‘best practices,’” according to the VA website. “Guidelines address patient cohorts, serve to reduce errors, and provide consistent quality of care and utilization of resources throughout and between the VA and Department of defense health-care system.” Two of the VA’s CPGs focus specifically on O&P-related topics, including “Lower-Limb Amputation” and “The Management of Upper-Limb Extremity Amputation Rehabilitation.” Visit www.healthquality.va.gov for details. Researchers at Hanger will continue to study the published topics as well as other best practices going forward. Wurdeman says he is working toward collecting outcomes of prosthetic patients. “After further awareness of the clinical practice guidelines, the next step will be to track changes and improvements in

patient care with the implementation of the guidelines,” he says. The development of CPGs and the implementation of comprehensive outcomes programs across Hanger Clinic is a process—“not a single event,” says Campbell. “We have several CPGs at an advanced stage that relate to key areas of orthotic

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and prosthetic management.” Down the road, the intention is to eventually develop CPGs for all arenas of care that orthotists and prosthetists are involved with directly, “to develop a compendium in a fashion that is analogous to our fellow physical therapists,” says Wurdeman. “They are continuously being developed.” While Campbell, Wurdeman, and the rest of the Hanger Clinic team are leading the way with O&P-themed CPGs, there is a need for involvement by all O&P professionals. As more prosthetists and orthotists recognize the value of the CPGs and contribute to the development of additional guidelines, the profession can only benefit. Those individuals who take part will be helping shape the profession’s destiny under the value-based care model. Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

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AOPA Illustrated Guide Reference manual standardizes O&P terminology

Then & Now is a monthly department for 2017. As part of AOPA’s Centennial Celebration, O&P Almanac will feature a different AOPA member benefit and discuss how that benefit has evolved over the years. This month, we focus on the AOPA Illustrated Guide.


VER THE PAST 100 years, the O&P profession has matured in many ways. The evolution from a regional mom-and-pop industry to a well-respected, nationally recognized profession has been facilitated in many ways by AOPA’s efforts. And the publication of the AOPA Illustrated Guide—originally published in 1986 as the Pictorial Reference Manual of Orthotics and Prosthetics—was a seminal moment in that progression.


“The Pictorial Reference Manual is one of the milestones of AOPA,” says H.E. Ted Thranhardt, CPO, an AOPA past president who took part in the development of the first edition of the manual. “When AOPA was founded, the entire field had its own nomenclature,” with very different names for the same devices in different areas of the country, he says. In creating the Pictorial Reference Manual, “we were trying to standardize terminology,” explains Jon Leimkuehler, CPO, FAAOP, another AOPA past president. In the mid 1980s, Leimkuehler served on the AOPA Business Procedures and Data Committee—the committee that guided the development of the manual. The project was intended to alleviate some of the confusion pertaining to the identification of specific devices, 34


“even among insurance companies,” Leimkuehler says. For example, before the Pictorial Reference was published, a device could be called a “short leg brace,” or it could be called by a name specific to the region where it was first used. But that device would officially become an “ankle-foot orthosis,” or AFO, in the manual. AOPA set out to create the Pictorial Reference Manual in an effort to educate orthotists, prosthetists, and third-party payors. But the decision was not without controversy: “There were some who were skeptical of things that were new and different, and who worried about divulging too much information about our field to the general public,” Leimkuehler says. Joseph M. Cestaro, CPO, who served as executive editor of the manual, and as AOPA’s president in 1984-1985, also recalls some concern among O&P professionals at the outset. “A lot of people were initially against the decision to publish the manual, because it took the mystery out of what we do,” he says. “But we decided that if we didn’t do it, someone else would— Medicare or the insurance companies. So we did it ourselves, so we would have some control,” says Cestaro. Though the book was originally intended for publication in 1985, the work took longer than expected, and


it did not publish until the following year. In the final product, names of devices were accompanied by illustrations. The majority of the work was completed after-hours by a group of committed members, including Cestaro, Leimkuehler, Thranhardt, members of the Business Procedures Committee, and other dedicated AOPA members. The volunteers donated their time and expertise to develop the text and create the illustrations, often working with the O&P schools to borrow illustrations from their textbooks. “This was before the Internet. We used a lot of FedEx to send copies back and forth, and we had different people reviewing the drawing and making corrections,” says Leimkuehler. “It required a lot of time and effort.” When the inaugural Pictorial Reference Manual was finally published in 1986, it featured 250 pages, plus appendices. AOPA sent out one copy to each member company, and offered additional copies for sale, says Cestaro. AOPA also sent copies to insurance companies and Medicare, to ensure standardization for reimbursement purposes as well, says Cestaro. The first version was well-received as a useful tool for O&P facilities— though many members offered suggestions to improve some of the original nomenclature and illustrations. “So we would have to come up with a different, or all-new, drawing for the next edition,” says Leimkuehler. “But overall the reception was very positive.” Since its initial publication, AOPA has continued to publish the manual each year. After the first year, L codes were added to the descriptions. The publication eventually became known as the AOPA Illustrated Guide. In 1991, the document served as the foundation for another seminal AOPA product, the AOPA Coding Pro—which originally served as the “electronic version of the Illustrated Guide,” according to Michael S. O’Donnell, CPO, who worked on the original Coding Pro.

ORIGINAL CONTRIBUTORS The following AOPA volunteers donated significant time and expertise to the publication of the first AOPA Illustrated Guide, originally published in 1986 as the Pictorial Reference Manual of Orthotics and Prosthetics:


The AOPA Illustrated Guide continues to be in great demand by the O&P community, widely known as “the most popular orthotic and prosthetic illustrated reference.” The publication is marketed as “an easy-to-use reference manual that provides an illustrated guide to the coding system in use for orthotics, prosthetics, and shoes, including the HCPCS code, the official Medicare descriptor, and an illustration for each.” The 2016 edition was 423 pages long. Despite significant advancements in technology since its original publication, the legacy of the Illustrated Guide continues, says Joseph McTernan, AOPA’s director of reimbursement services. “When asked why people still elect to use the print version of the Illustrated Guide, the most common response is, ‘I want to be able to take the book off the shelf and actually see what I am providing may look like,’” says McTernan. While the information contained in the publication is readily available through alternative resources, “the Illustrated Guide is still seen as the definitive resource for coding in O&P.”

Joseph M. Cestaro, CPO Executive Editor Tom Bart, CO Larry Bradshaw Carl Brenner, CPO John Eschen, CPO Gene Jones Jon Leimkuehler, CPO Joe Lydon, CO Brad Rosenberger, CPO H.E. Ted Thranhardt, CPO

EDITOR’S NOTE: The 2017 edition of the AOPA Illustrated Guide will be published in early March, and will be available via the AOPA Bookstore.




More Authentic Control Pattern recognition offers ‘brain power’ for myoelectric devices By CHRISTINE UMBRELL

Bridge to the Future: The Interviews is a monthly column for 2017. As part of AOPA’s Centennial Celebration, O&P Almanac will look to the next 100 years—by interviewing noted experts in the O&P field to learn their vision for the future of O&P. This month, we speak with Blair Lock, MScE, P.Eng., on the topic of pattern recognition.

Blair Lock, MScE, P.Eng.


OOKING TO THE FUTURE, it is likely that increasing numbers of upper-extremity amputees will be fit with myoelectric prostheses. Technologically advanced componentry enables users to perform tasks via electronic device in a manner similar to performing those tasks via biological body parts. More individuals with upper-limb deficiencies will likely choose to use prostheses as the devices become more intuitive to use. As more prostheses come to market, Blair Lock, MScE, P.Eng., predicts that myoelectric devices utilizing pattern recognition systems may overtake other options because they “hold the most promise to address many of the past challenges of myoelectric fittings that utilized one or two input electrodes.” Lock, who is co-founder and chief executive officer of Coapt LLC, says, “Myoelectric control has always represented an inherent level of control, which is more physiologically correct. Pattern recognition builds on the benefits of traditional myoelectric control and adds significant processing that defines exactly what the user intends.” In contrast to traditional myoelectric systems that require the patient to adapt to a preset control method, pattern recognition “adapts to the patient’s unique neuromuscular signature, thus allowing authentic volitional control of the prosthesis.”

The Rise of Pattern Recognition Technology



PHOTO: Coapt

Pattern recognition is a branch of machine learning that focuses on patterns and regularities in data. “Simply stated, pattern recognition is

an approach to recognizing specific patterns in data and then using this knowledge to classify new data into predefined categories,” says Lock. Lock, who has a background in electrical engineering, studied the real-time functional assessment of pattern recognition for upper-limb prosthesis control in graduate school. “My prior background in fiber optic network planning and advanced sonar technologies centered on signal processing. The jump to processing signals of the human body was a good fit,” he explains. From 2005 to 2014, Lock worked with a team at the Rehabilitation Institute of Chicago to evolve pattern recognition control for upper-limb prostheses in conjunction with the development of the targeted muscle reinnervation (TMR) procedure. As director of research operations, he oversaw clinical trials, developed algorithms, and created hardware for pattern recognition. In 2012, Lock became one of the founders of Coapt. Pattern recognition algorithms have to be “trained,” says Lock: “They are initially given sets of categorized example data so they can build their ability to recognize patterns and appropriately classify new data into predefined categories.” The term “pattern recognition” is widely used in many areas of signal processing and signal sciences—from financial data analytics and traffic pattern studies to voice and image recognition. “For those of us in O&P, we often think the term belongs only to us when, in fact, we are way behind the curve in using pattern recognition techniques to our benefit,” says Lock.

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When applied to control of powered prostheses, pattern recognition “takes multiple channels of myoelectric—or EMG—signals as input and outputs the corresponding desired prosthesis movement,” Lock explains. A user trains the system by performing a few repetitions of the preferred muscle contractions for each desired prosthesis movement. The system can then recognize these contraction patterns and use them to control the prosthesis in real time. “Today’s pattern recognition systems for upperlimb prostheses look at myoelectric input signals multiple times per second and therefore create a steady stream of prosthesis movement—and ‘no-movement’—commands.”

Application to O&P

The concept of using pattern recognition of muscle signals for device control dates back to the mid 1960s. It was initially tested for the remote control of tele-operated underwater vehicles and evolved to focus on controlling powered arm prostheses, says Lock. This research took place in parts of northern Europe, Canada, Russia, and the United States. Artist's rendering of the pattern recognition concept


New Possibilities

Pattern recognition control of upperlimb myoelectric devices may offer many significant benefits compared to traditional myoelectric control, according to Lock. The technology leverages the full spectrum of the biological information content of muscle signals, including the subtle interactions of various muscles that are naturally coordinated for different functions, he says. “In contrast, conventional systems ignore much of the signals’ content, only to make use of a single estimation of intensity from a very limited muscle area. Pattern recognition can therefore detect the natural intended movement of the user without relying on strong, independent muscle signals, and does not require any tricks to switch prosthesis modes,” Lock says. In addition, pattern recognition control can be “quickly adjusted to account for muscle fatigue or any changes in fit or function,” and makes myoelectric control feasible for users with weak muscle signals or significant signal myoelectric crosstalk,

individuals who tire quickly, and those who have scarring or sensitivity over optimal electrode placement sites, says Lock. “By offering an intuitive way to switch functions, pattern recognition also increases the user’s ability to control multiple prosthesis functions—such as multiple joints and multifunction hands—particularly when combined with the targeted reinnervation procedure. At its core, pattern recognition is providing the much-needed control improvement to the wearable devices that are already on the market.” While pattern recognition is not a “new” technology, it is new to the O&P market. Barriers to greater acceptance include development costs, evolving regulatory requirements, and lags in suitable reimbursement, according to Lock. “Knowledge is key: As clinicians learn about and adopt pattern recognition technology into their practice, the benefits to the user will be clearly demonstrated,” he says. “As pattern recognition systems are more widely used and understood, greater resources and effort will be put toward further development.” Some devices on the market today can be combined with pattern recognition to enhance functionality for users—for example, multifunction hands. “Most wearers of multifunction hands have remaining musculature from which the information for performing many different hand postures/grips can be recorded. Pattern recognition can be used to detect and use this information to provide intuitive control and improve functional performance,” says Lock. Pattern recognition also serves as a catalyst for the commercialization of devices that have not yet been made widely available due to poor control options, such as powered wrist flexors. Because pattern recognition is an improved way to utilize the myoelectric signals, “being able to acquire these signals more efficiently and with higher fidelity will improve prosthetic function and increase choice of prosthetic technology,” predicts Lock. Improved myoelectric signal recording

PHOTO: Coapt


Through much of the 1990s and 2000s, “research in this area focused on the core algorithms, and many competing approaches were published in academic journals,” says Lock. It is just in the past decade that the computing technology “became efficient enough to consider a wearable pattern recognition system.” The first commercial pattern recognition system for upper-limb prosthesis control was released in November of 2013. The past few years have seen “significant research on the use of pattern recognition for control of lower-limb prostheses, powered exoskeletal devices, powered wheelchairs, and more,” but there are no known commercial applications currently available for those, according to Lock.


will be made possible as socket and liner interfaces evolve and as advancements such as subcutaneous electrodes and osseointegration become available.

Looking Down the Road

PHOTO: Coapt

Over the next 10 to 20 years, the algorithms involved in pattern recognition are expected to improve, and may include more artificial intelligence to automatically adapt to user changes, says Lock. Also in the coming decades, “pattern recognition should expand beyond use with upper-limb amputees, to include lower-limb amputees and patients with other impairments not involving limb difference,” says Lock. “Pattern recognition will continue to broaden in its definition within the O&P field and may become inherently native to any assistive and/or diagnostic technology applied.” Lock also believes that as devices continue to increase their capabilities and the amount of input information needed from the user, pattern

recognition techniques will become necessary, and may become so commonplace that we may not define them independently from the devices. “Pattern recognition, in various forms and fashions, will become part of the ‘brain’ of our O&P technologies in the years to come. “I strongly believe that pattern recognition can provide O&P professionals with the ability to apply

Coapt system inside an upper-limb prosthesis

modern, beneficial technology to their patients while staying focused on the important core demands of fit, function, and functional training,” says Lock. The technology removes the burden on the prosthetist of creating the person-machine control interface for increasingly advanced devices and allows them to build prostheses with greater functional capabilities, he says. Discussing benefits to patients, Lock says that “pattern recognition changes their relationship with wearable technology by providing a more natural method of controlling their devices and reducing the burden involved with performing everyday tasks at home and at work.” In addition, the technology “widens the applicability of advanced prosthetic technology by opening the doors to those with difficult EMG presentations. Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.


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John Ross, BSc (Hons) London British prosthetist shares a typical day’s work at the Crystal Palace Rehabilitation Centre O&P ALMANAC: Describe a

typical workday for you.

As the O&P profession prepares for the Second O&P World Congress, to be held in conjunction with AOPA’s Centennial Celebration Sept. 6-9, in Las Vegas, the O&P Almanac in 2017 will feature a question-and-answer section with international O&P experts. Each month, we spotlight an O&P professional from a different part of the world to find out how each one practices the profession of orthotics and prosthetics, in anticipation of the global event coming in September.

John Ross, BSc (Hons) London


PHOTO: John Ross, BsC


JOHN ROSS, BSc (Hons): I am a clinical specialist at the Crystal Palace Rehabilitation Centre in London. Typically, our working day is from 8:30 a.m. until 4:30 p.m., with 45 minutes for lunch; however, as I live close, I normally arrive about 7:45. Arriving, I stick a coffee on and start rectifying any casts from the previous day—getting in early gives me time to check that everything is ready for clinic and for the reductions on any casts taken. Each prosthetist is expected to see four to six patients a day; we all have four patients booked into clinic at 9 a.m., 10 a.m., 11 Ross works on capturing the alignment and a.m., and 12 p.m. After lunch I contours of the ischium and ramus. usually have a 2 p.m. appointphysiotherapist’s training room and ment for complex cases, children, walking school is only eight minutes or vulnerable adults, leaving my last away in the opposite direction, so it’s appointment space for an emergency not uncommon to discuss ongoing socket fit or alignment/function issues patient issues or upcoming treatment that are putting a patient at risk. plans with them before the clinical Most of the afternoon is taken up by team meeting. the ever-increasing amount of paperwork required to ensure quality of care for the patient, ordering parts and O&P ALMANAC: Describe the locacompleting paperwork for payment, tion where you provide services. and making sure any casts taken that day are filled and reliefs on casts ROSS: I work in the community started in the morning are completed rehabilitation unit providing prosand handed to the workshop for thetics, orthotics, and wheelchairs, all fabrication. on one floor. There is a mixed multiI’m fortunate that the workshop is disciplinary team led by a part-time only 10 minutes from my office, and the rehabilitation consultant, supported


by prosthetists, orthotists, physiotherapists, occupational therapists, and rehabilitation engineers, with occasional support from a clinical scientist. O&P ALMANAC: How are the devices

you provide paid for?

ROSS: The Crystal Palace Rehabilitation

Centre is a state-run facility. We are contractors to supply the service, and once work has been completed, the government—through the National Health Service (NHS)—pays for the cost of the care. As a contracted service, costs are held low to win the contract, and the funding is guaranteed for three to seven years to look after patient care. There is, however, a provision to request additional funding for high-cost items such as microprocessor-controlled lower limbs and or advanced multifunction myoelectric arms. Osseointegration and military personnel also are funded additionally.

O&P ALMANAC: If the payor is other

PHOTO: Getty Images/FatCamera

than the patient, do nonpatient payors have an audit process? If there is an audit process, do you consider it to be fair? ROSS: All invoices are checked against our clinical notes. A rehabilitation engineer is tasked with auditing the orders on behalf of the service; disagreements are usually infrequent and easily sorted. The system encourages

the team to act together and work in unison to provide what can be afforded for the individual and provide the patient with the greatest chance to maximize his or her potential. Most common disagreements are on adaptors used to assemble the prosthesis—especially as different clinicians prefer different manufacturers and alignment systems, so agreeing with the rehabilitation engineer before swapping out a part is often advisable. Major components, such as feet and knees, are usually agreed by the group so there is rarely any problem with funding/payment. O&P ALMANAC: Describe your

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

ROSS: I’m a member of the International Society for Prosthetics and Orthotics (ISPO) and the British Association of Prosthetists and Orthotists. We are by law registered with the Health Care Professions Council, which oversees our education and fitness to work. My role is Band A, clinical prosthetist. We use a system from Band E to Band A, with Band A meaning you have a minimum of 10 years of clinical practice and have made a significant contribution in terms of research and clinical audits. I have published work on topics such as the use of the gait analysis laboratory and CAD/CAM,

but this is not always necessary. “Clinical specialist” is an additional recognition for someone who is a recognized professional in a certain field of rehabilitation medicine, and means that staff from our facilities can request our time to visit them and work through care plans for complex cases. With an ISPO Category 1 honor’s degree, there is a commitment to continuing professional development. Previously, continuing education was verified via points we collected, but this only showed participation in courses and did not necessarily mean that the attendee stayed for the full presentation or seminar. Now, 10 percent of the registered clinicians in each year are randomly chosen to write about their learning experience and how that learning experience has impacted and improved their clinical practice. Guidelines for writing the essay are provided, and dates and times of courses or presentations and seminars must be included. O&P ALMANAC: What’s the biggest

challenge you face as a practitioner, and how do you deal with it?

ROSS: My biggest challenge is time management, especially regarding completion of all paperwork. This has resulted in our profession dropping from typically 6.5 patients a day to five, resulting in the need for additional staff. Thus, in 10 years my facility has gone from five prosthetists to seven prosthetists to cover the increased administration responsibilities. O&P ALMANAC: Describe any

charitable work you or your organization does. ROSS: My employer allows the more experienced staff to help around the world, running seminars or courses to support other professionals. There is an agreed amount of time and money available to help with these sessions overseas. We complete work in Romania at a children’s clinic, and in Asia. Also, I have supported Uniting Frontiers in Central America for years. O&P ALMANAC | FEBRUARY 2017



Paceline Inc.


Leveraging Raw Materials North Carolina company offers fabrics, laminations, and other materials for O&P componentry





COMPANY: Paceline Inc. OWNER: Joe Davant LOCATION: Matthews, North Carolina HISTORY: 32 years

David Glontz (left) and Joe Davant on the production floor

employees, and vendors, all parties reach their goals faster and easier than any of us could on our own.” The company expanded further in May 2016 with the purchase of Acsys Orthopedics, a resin manufacturer. After that expansion, the company moved from three separate buildings into a new 50,000-square-foot facility in Matthews, North Carolina. The building houses the firm’s 80 employees and manufacturing, administrative, and research and development activities, as well as sales and customer service functions. Paceline serves several markets, including orthotics and prosthetics, orthopedics, labor and delivery, long-term care, podiatry, physical/occupational therapy, and lymphedema. Some of the products leveraged by O&P facilities include stockinette, carbon braid, PVA bags, resin, postoperative shrinkers, and more. The company also offers a variety of cut and sewn products, compression fabrics, and other specialty knitted items. Paceline products are purchased through distributors or directly by manufacturers.

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

PHOTOS: Paceline Inc.

goes back 32 years, when Allison Davant founded Rx Textiles in Monroe, North Carolina. The company began by manufacturing fabric to cover cervical collars, but soon expanded to make a variety of fabrics used in the orthotic and prosthetic industry. In 2006, Allison’s son, Joe Davant, assumed leadership of the company. Four years later, Rx Textiles acquired Minneapolis-based SPT Technology, which made polyvinyl acetate (PVA) bags and laminating resin, and distributed carbon and fiberglass braided products. “With that purchase, we became a one-stop shop for laminations,” says David Glontz, director of sales for Paceline. The acquisition and expansion also took Rx Textiles beyond textiles, so the company changed its name in March 2014 to reflect its expanding product line. Davant, an avid cyclist, chose the name Paceline, which is a cycling term that refers to a line of cyclists all pedaling in the same direction. “The cyclist at the front of the line does most of the work, while the other cyclists draft behind the cyclist at the front of the line,” explains Glontz. “When the cyclist in the front gets tired, he or she moves to the back of the line, allowing the next cyclist to move to the front. That process repeats itself, with each cyclist taking a turn at the front of the line. By working together, the entire group rides much faster than any of the cyclists could ride on their own.” Paceline Inc. follows a similar approach, says Glontz: “By working together with our clients,

The company uses a unique marketing strategy that often incorporates its sample program. For example, a recent marketing campaign focused on promoting individual facilities with their logo on a postoperative shrinker. Once practitioners received the mailer, they could request a sample of a Tensitube Blue postoperative shrinker with their company’s logo on it, ensuring their satisfaction with the product prior to making a large purchase. Once a company makes the decision to purchase, the sale is funneled through its distributor of choice. “Our sample program is really a fantastic way for customers to try our products and make sure they are satisfied prior to purchasing,” says Glontz. “It also allows us to stay in direct contact with our customers, receiving feedback on our products, and yet still utilize our network of distributors to facilitate the order.” Paceline has an active research and development (R&D) department. “We work with customers who need a unique solution specifically for them. It could be the development of a completely new product or to improve or replace an existing one,” says Glontz. “So our R&D is really a customizable service that we provide to our existing customer base, as well as new customers.” The company’s strategy is serving it well, Glontz says, and the company is always looking to grow by introducing new products, as well as by acquisition. “These are really the two areas where we see additional growth coming from,” says Glontz. “We want to continue to expand our product line for our O&P customers, as well as further expand our custom solutions division outside of the industry.”

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R.J. Rosenberg Orthopedic Lab

Successful Succession Planning Prosthetist purchases facility where he once worked as a resident





FACILITY: R.J. Rosenberg Orthopedic Lab OWNER: Ryan Spill, CP LOCATION: Cincinnati HISTORY: 37 years

Ryan Spill, CP

are made of thermoplastic, which reduces dust and fumes in the lab. A significant proportion of patients—as many as 30 percent—are upper-extremity amputees, according to Spill. “Rich sees more upper-extremity patients than most small clinics do, and I specialized in upperextremity prosthetics for several years, so we have a well-developed upper-extremity program,” he says. The facility relies on building face-to-face relationships with referral sources, and Spill offers educational lectures on prosthetics to local universities and other groups. One of Spill’s interests involves giving back to the less fortunate. He recently took part in his second volunteer trip to Port de Paix, Haiti, with the group STAND: The Haiti Project. The nonprofit organization provides orthopedic rehabilitation services to Haitians for two weeks, three times a year, through direct patient care and clinical training. Most participants are physical therapists, but other health-care professionals take part as well. Spill and another prosthetist

saw about 25 amputees and built several prosthetic devices during their visit. Spill also brought donated prosthetic limbs and tools for the one-week trip. One of Spill’s Cincinnati patients, who had grown up using lower-limb prostheses, donated all of her childhood prosthetic legs. “I ended up using her four smallest prosthetic feet on four young children,” says Spill. “Prosthetic limbs are basic in Haiti,” he says. “We try to use SACH [solid ankle cushion heel] feet and stay away from gel interfaces; we stick with simple, robust devices that people can maintain themselves until the next clinic. Upper-limb amputees use voluntary opening or passive hands.” Spill saw several children and adults in October that he had fit for prostheses on his first visit to Haiti. “It was gratifying,” he says. “The kids were so much bigger and ready for replacements, and the adults who were fit on the first trip are now up and walking. Some were coming in for minor adjustments and others for replacement sockets.” Spill says that the volunteer trips are one of his greatest accomplishments: “It’s a great way to stay grounded and realize how lucky we are in this country to have access to good care, even if we complain about insurance coverage. The clinic in Haiti relies exclusively on donations.” As owner of R.J. Rosenberg, Spill enjoys overseeing all aspects of the business and the ability to make clinical and business decisions as necessary. He expects to bring on a prosthetic resident at some point in the next few years. With luck, he’ll find someone as proficient and as devoted to prosthetics as he was, back in 2001. Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: R.J. Rosenberg Orthopedic Lab

Cincinnati nearly 40 years ago to look at an O&P facility for sale. Rosenberg and his wife liked the area so much that they moved there, and Rosenberg decided to establish his own practice in Cincinnati in 1980. In 2001, he hired Ryan Spill as his first prosthetic resident. Spill completed his residency and then moved to Philadelphia, where he practiced as a prosthetist until 2015. “Rich and I stayed in touch over the years, and he asked if I would consider moving back to Cincinnati to help him transition into retirement,” explains Spill. “So I moved back to Cincinnati and bought the practice at the end of 2015.” Rosenberg continues to see patients at the facility, along with Spill. Other employees include an office administrator/certified mastectomy fitter and a prosthetic technician, who have been with the organization for more than 30 years, as well as a parttime administrative assistant. Rosenberg and Spill provide prosthetic services and offer a variety of advanced technology to their patients, including microprocessor knees, hydraulic ankles, vacuum-assisted socket systems, myoelectric elbows, and advanced hands and feet. The 3,000-square-foot facility features a patient-care center and lab, where all prosthetic devices are fabricated. Rosenberg was an early adopter of computer-aided design, and the facility has used CAD/CAM since 1995. Although some frames are laminated, many

Ryan Spill, CP, works with a patient at his Cincinnati facility.


Products & Services For Orthotic, Prosthetic & Pedorthic Professionals





APRIL 10-11 | 2017

AOPA Coding Experts Are Coming to Denver, CO

14 CEs

Top 10 reasons to attend: 1.

Get your claims paid.


Increase your company’s bottom line.


Stay up-to-date on billing Medicare.


Code complex devices


Earn 14 CE credits.


Learn about audit updates.


Overturn denials.


Submit your specific questions ahead of time.


Advance your career.

Westin Denver Downtown, Denver, CO Join AOPA April 10-11 in Denver to advance your O&P practitioners’ and billing staff ’s coding knowledge. Join AOPA for this two-day event, where you will earn 14 CEs and get up¬-to¬-date on all the hot topics. AOPA experts provide the most up-to-date information to help O&P practitioners and office billing staff learn how to code complex devices, including repairs and adjustments, through interactive discussions with AOPA experts, your colleagues, and much more. Meant for both practitioners and office staff, this advanced two-day event will feature breakout sessions for these two groups, to ensure concentration on material appropriate to each group. Don’t miss the opportunity to experience two jam-packed days of valuable O&P coding and billing information. Learn more and see the rest of the year’s schedule at bit.ly/2017billing.

10. AOPA coding and billing experts have more than 70 years of combined experience.

Mark your calendar for the next seminar:

JULY 17-18 Pittsburgh, PA

The DoubleTree by Hilton Hotel and Suites Pittsburgh Downtown, One Bigelow Square, Pittsburgh, PA Find the best practices to help you manage your business.

Participate in the 2017 Coding & Billing Seminar! Register online at bit.ly/2017billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. .




Sign Up for the 2017 Webinars Mark your calendars for AOPA’s 2017 monthly webinars. One registration is all it takes to provide the most reliable business information and CE credits for your entire staff. If you’ve missed a webinar, AOPA will send you a recording of the webinar and quiz for CE credits—so you can still take advantage of the series discount and the valuable learning opportunities. Register for the complete 2017 series and get two free webinars! Members pay $990 and nonmembers pay $1,990, for the series. Register at bit.ly/2017webinars.

Upcoming Webinars • February 8: LSO/TLSO Policy • March 8: Marketing Your Business • April 12: Grassroots Advocacy • May 10: Modifiers: What Do They Mean and When To Use Them • June 14: Internal Audits: The Why and the How of Conducting Self-Audits • July 12: Know Your Resources: Where To Look To Find the Answers • August 9: What the Medicare Audit Data Tells Us and How To Avoid Common Errors • September 13: ABC Inspections and Accreditation • October 11: AFO/KAFO Policy • November 8: Gift Giving: Show Your Thanks and Remain Compliant • December 13: New Codes and Other Updates for 2018


What strategies are you using to market your O&P facility? During the March 8 “Marketing Your Business” webinar, experts will share business tips to help you revamp your marketing efforts and drive referral sources and patients to your facility. Get up-to-date information on the following topics: • Making your business stand out • Using your strengths to your advantage • How patient relationships may increase your referral opportunities • The value of both networking and marketing to your O&P practice • Knowing how to reach out to the right people • Building and maintaining relationships with referral sources • The importance of brand recognition in O&P AOPA members pay $99 (nonmembers pay $199), and any number of employees may participate on a given line. Attendees earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring at least 80 percent. Register at bit.ly/2017webinars. Contact Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0876 with questions. Register for the whole series and get three free webinars! The series costs $990 for members and $1,990 for nonmembers. All webinars that you missed will be sent as a recording. Register at bit.ly/2017billing.

PHOTO: GettyImages/andresr


Marketing Your Business



Grassroots Advocacy Your voice is needed to help elevate the profession and inform legislators about the value of O&P intervention. Be part of the solution by getting involved in grassroots advocacy efforts. Find out more during the April 12 webinar on “Grassroots Advocacy,” where you will learn: • How to effectively lobby for fair treatment of O&P on the local and national level • How to work with patients to help them become advocates for their own cause • How to effectively communicate with representatives in Washington, D.C., and in your office • How to act locally to change things nationally

Share Your Memories

Join AOPA's centennial celebration this year

AOPA would like to include personal member stories in its year-long 100-year anniversary celebration. Please visit bit.ly/celebrateaopa to share your photographs, memorabilia, and memories, which may be featured on AOPA’s commemorative website, on social media, and at the AOPA World Congress.

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

Purchase Your Copy of AOPA’s In-Demand Coding & Billing Manuals AOPA will be making a limited supply of the Mastering Medicare: Essential Coding and Billing Techniques Manual, used at AOPA’s popular Coding and Billing Seminars, available for purchase. Manuals can be purchased for $185 plus $7 shipping and handling. Get yours while supplies last! Purchase your copy at bit.ly/aopamanual.





HE OFFICERS AND DIRECTORS of the American Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an www.AOPAnet.org official member of AOPA if, within 30 days of publication, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership. At the end of each new facility listing is the name of the certified or state-licensed practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or state-licensed practitioner to be eligible for membership. At the end of each new supplier member listing is the supplier level associated with that company. Supplier levels are based on annual gross sales volume.

Coastal Prosthetics & Orthotics LLC 1924 Landstown Centre Way, Ste. 105 Virginia Beach, VA 23456 757/892-5300 Member Type: Affiliate Parent Company: Coastal Prosthetics & Orthotics LLC, Norfolk, VA Paul Harrington, CPO

Orthofit Inc. 220 Westinghouse Blvd., Ste. 405 Charlotte, NC 28273 980/585-3571 Member Type: Affiliate Parent Company: OrthoFit Inc., Virginia Beach, VA

ProCare Prosthetics & Orthotics 1445 Old McDonough Highway, Ste. A-1 Conyers, GA 30094 770/602-4315 Member Type: Affiliate Parent Company: ProCare Prosthetics & Orthotics, Buford, GA Prosthetic & Orthotic Group—Southern Colorado 729A Fortino Blvd. Pueblo, CO 81008 719/542-1313 Member Type: Affiliate Parent Company: Prosthetic & Orthotic Group Inc., Signal Hill, CA Glenn Matsushima, CPO, FAAOP

Upstate Prosthetics LLC 1624 Woodruff Road, Ste. 10 Greenville, SC 29607 864/288-4150 Member Type: Patient-Care Facility Jeffery Sanders Wright & Filippis Inc. 811 N. Macomb Monroe, MI 48162 734/523-6928 Member Type: Affiliate Parent Company: Wright & Filippis Inc., Rochester Hills, MI Anthony McDonald, CP



Opportunities for O&P Professionals Job location key: - Northeast - Mid-Atlantic - Southeast - North Central - Inter-Mountain - Pacific

Hire employees and promote services by placing your classified ad in the O&P Almanac. When placing a blind ad, the advertiser may request that responses be sent to an ad number, to be assigned by AOPA. Responses to O&P box numbers are forwarded free of charge. Include your company logo with your listing free of charge. Deadline: Advertisements and payments need to be received one month prior to publication date in order to be printed in the magazine. Ads can be posted and updated any time online on the O&P Job Board at jobs.AOPAnet.org. No orders or cancellations are taken by phone. Submit ads by email to landerson@AOPAnet. org or fax to 571/431-0899, along with VISA or MasterCard number, cardholder name, and expiration date. Mail typed advertisements and checks in U.S. currency (made out to AOPA) to P.O. Box 34711, Alexandria, VA 22334-0711. Note: AOPA reserves the right to edit Job listings for space and style considerations. For more opportunities, visit: http://jobs.aopanet.org. 48


North Central

Certified Orthotist Greeen Bay, Wisconsin Monroe BioTechnology is a privately owned facility. If you are passionate about using your clinical skills and talents to provide care for your patients’ orthotic needs, then we can offer you the environment to make that happen. Our administrative team takes care of scheduling, insurance authorizations, ordering, and billing, and can assist you in getting notes from the doctor to justify medical necessity. Our lab technicians work with you to fabricate items and develop the exact product you are looking for. This allows you to focus entirely on patient care and quality outcomes. The position is based out of Green Bay, with some travel to remote offices within a 30-mile radius. We are looking for a practitioner who has good communication skills with a desire to strive for service excellence within a supportive and fun-loving team. Visit our website at www.monroebiotech.com and send your resume to Stephanie Sheedy at stephanie@monroebiotech.com. Email: stephanie@monroebiotech.com Website: www.monroebiotech.com


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

ALPS Superior Performance Liner

Custom Fabrication Services

The Superior Performance Liner (SP) features a new black fabric that allows for additional comfort and stability for active patients. This liner is formulated with both ALPS GripGel and High-Density (HD) Gel, which contain properties that help facilitate donning as well as reduce pistoning and bunching behind the knee. The SP Liner provides superior comfort and diversity and is offered in 3-mm and 6-mm uniform thickness to accommodate most users. For more information, contact ALPS at 800/574-5426 or visit www.easyliner.com. ALPS is located at 2895 42nd Avenue N., St. Petersburg, FL 33714.

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

FootPrinter Impression Box Program Need a way to order custom foot orthotics without adding technology to your office? Keep it simple with impression foam for your custom foot orthotic orders. FootPrinter Program available for standard EVA, diabetic, carbon fiber, and polypropylene orthotics. No equipment or software necessary, just a quick and easy order form to get you on your way. A5513 PDAC-approved diabetic insert program includes return shipping to the lab and the finished inserts back to your door. Fabrication time from three to five business days. Contact our customer service team to learn more today. orders@amfit.com or 800/356-FOOT(3668), x250. 50


Give us the opportunity to lessen the demands of your in-house fabrication team so your clinicians can devote more of their time to their patients and/or marketing new referral sources. Our highly trained technicians at Anatomical Concepts can provide a wide variety of custom-made lower-extremity orthoses such as thermoplastic AFOs and KAFOs, as well as functional and accommodative foot orthotics. Any of the AFOs from our prefabricated PRAFO® family can be implemented to any custom-made KAFO system due to their unique modular designs, for exceptional stability and patient comfort. For more information, call 800/837-3888 or visit www.AnatomicalConceptsInc.com.

Switch to BOC Today Why make the transition to BOC? Award-winning customer service, nationally recognized credentials, and a www.bocusa.org user-friendly website are just a few of the benefits of choosing BOC. As your credentialing partner, we provide accreditation for your O&P facility at a discounted rate, guide you through the accreditation process, and support your future success! Plus, it’s easy and free! Make the switch to BOC accreditation for no up-front cost. Contact us today at 877/776-2200 or info@bocusa.org. We’re with you every step of the way. It’s our promise. Every patient. Every facility. Every day.TM

New Horizon® LT From College Park Made with aircraft-grade aluminum alloy, the Horizon LT is the lightest carbon fiber foot on the market. Like the original Horizon HD, the Horizon LT was meticulously crafted utilizing maximum stress predictions to increase strength and prevent failure. The rollover Enviroshell® design, combined with the specially engineered carbon composites, provides the perfect blend of comfort and ability. The Horizon LT brings an ultralow-profile, lightweight, and economical choice for moderate activity users. Order now at www.college-park.com/horizon-lt.

949/645-4401 ● 800/854-3479 ● www.kingsleymfg.com

MARKETPLACE SOFTIE™ and SOFTIE-TF™ Minimizing the effects of micro tears and/or injury to the incision area at bed rest holds a high priority. FLO-TECH® designed the SOFTIE™ and SOFTIE-TF™ to aid against distal end breakdown, easy access for wound care, and daily hygiene. We incorporated posterior struts to maximize extension control. Our SOFTIEs assist healing and increase the quality of rehabilitation for postsurgical amputees. The sockets are soft, nonconstricting, and easy to remove for examinations. Having an inventory of SOFTIE and SOFTIE-TF sockets allows you to fit any patient at a moment’s notice. They easily fit most sizes, including XL. For more information, call at 800/356-8324 or visit www.1800flo-tech.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 at 800/301-8275 or visit www.hersco.com.

Infinite TF and Infinite TT The Infinite TF and Infinite TT are the first custom-molded, modular, and dynamic prosthetic socket systems, offering adjustability at each component in response to volume and shape change of the residual limb. The Infinite Socket product line offers a holistic improvement in patient comfort and freedom through its unique, dynamic design. For more information, contact LIMInnovations.com by email at press@liminnovations.com or call 844/888-8546. 52


Pro-Flex® Is More Than a Foot. It's a Family. By now you've heard Pro-Flex generates exceptional mechanically powered toe-off, but did you know that ProFlex XC and Pro-Flex LP also feature a unique three-blade footblade design with a full effective toe lever and a more anatomical split toe? This innovative design contributes to a more fluid and natural progression from heel strike to toe off than a conventional energy storing and return foot.

Pro-Flex XC offers excellent vertical compression, all-terrain compliance, and toe-off energy for active users. Pro-Flex LP provides full-height dynamics in a low-profile foot for users with longer residual limbs. Learn more about the Pro-Flex family at www.ossur.com/proflex.

New Prosedo 3R31 K1 Knee Introducing the Prosedo 3R31 knee, a unique innovation to help your K1 patients with hydraulic flexion resistant sitting assist. The 3R31 includes: • a manual lock for stability while standing • a progressive flexion resistant sitting assist that helps provide stability while lowering into a seated position. The flexion resistance can be adjusted to the patient’s needs. At just 600 g, the lightweight knee can support patients up to 275 lbs / 125 kg. For more information, visit professionals.ottobockus.com or call 800/328-4058.

MARKETPLACE Introducing New Titanium Digits for All i-limb® Hands

WillowWood Custom Solutions WillowWood’s Custom Solutions team is an extension of your facility. We readily accept casts and CAD/CAM files to facilitate any clinician’s preferred workflow. Our custom fabrication capabilities include: • Positive model carvings • Lower-extremity diagnostic sockets • Single- and doublelamination sockets • Sockets with flexible liner and laminated frame • Lower-extremity foam cover shaping.

• New titanium material increases the maximum carry load at the proximal segment by 50 percent. • Titanium material improves the protection of the motor from impact forces. • Titanium digits add 1 oz of weight to the i-limb hand. • Available for i-limb™ quantum, revolution, ultra, and access hands—sizes S/M/L. Contact us to learn more! For more information, contact Touch Bionics Inc. at (855)MY iLimb or visit www.touchbionics.com.

We offer the most competitive pricing for customized prosthetic fabrication. Our pricing doesn’t include hidden fees, so it’s easy to see the total price at a glance. WillowWood Custom Solutions is your partner in providing patients with customized prosthetics. Visit willowwoodco.com or call 800/848-4930 for information.



Page Phone










800/837-3888 / 330/757-3569


Anatomical Concepts


Board of Certification/Accreditation




The Bremer Group




College Park Industries




ComfortFit Orthotic Labs Inc.




Custom Composite




Ferrier Coupler Inc.




Flo-Tech O&P Systems Inc.





49 800/301-8275


Kingsley Mfg. Co.












Spinal Technology Inc.







Touch Bionics WillowWood

29 800/848-4930

www.willowwoodco.com O&P ALMANAC | FEBRUARY 2017




March 13-18

February 8

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

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

March 17-18

March 1

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

ABC: Orthotic Clinical Patient Management (CPM) Exam. St. Petersburg College—Caruth Health Education Center, Pinellas Park, FL. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

April 10-11

2017 Mastering Medicare: Essential Coding & Billing Techniques Seminars. Denver. The Westin Denver Downtown, 1672 Lawrence Street, Denver, CO 80202. Register online at bit.ly/2017billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Coding & Billing Seminar

March 1-4

43rd Academy Annual Meeting & Scientific Symposium. Chicago, Hyatt Regency Chicago. Visit academyannualmeeting.org or contact Diane Ragusa at 202/380-3663, or dragusa@oandp.org.

April 12

March 8

Marketing Your Business. Register Webinar Conference online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

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

May 10

March 10-11

ABC: Prosthetic Clinical Patient Management (CPM) Exam. St. Petersburg College—Caruth Health Education Center, Pinellas Park, FL. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.


Apply Anytime!

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

Let us

your next event!


Free Online Training

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

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

Calendar Rates


Modifiers: What Do They Mean and When To Use Them. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Webinar Conference


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





25 or less




$50 $60


$2.25/word $5.00/word

Color Ad Special 1/4 page Ad



1/2 page Ad



CALENDAR May 24-25

AOPA Policy Forum. Washington, DC. Come make a difference! Educate Congress on issues affecting your patients. For more information, contact Devon Bernard at dbernard@AOPAnet.org or call 571/431-0876.

June 14

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

September 6-9

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

Webinar Conference

September 13

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

July 12

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

July 17-18

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

October 11

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

November 6-7

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

August 9

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

November 8

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

December 13

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

The Source for Orthotic & Prosthetic Coding

Manufacturers: AOPA is now offering Enhanced Listings on LCodeSearch.com. Don’t miss out on this great opportunity for buyers to see your product information! Contact Betty Leppin for more information at 571/431-0876.


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

Log on to LCodeSearch.com and start today. Need to renew your membership?

Contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org. www.AOPAnet.org




Bilateral Componentry Answers to your questions on custom shoes, functional level restrictions for bilateral amputees, and more

I have heard that functional level restrictions do not apply to bilateral amputees. Is it true that bilateral amputees can have any prosthetic componentry they want?


The Medicare lower-limb prosthetic policy states the following: “It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.” While this statement recognizes there may be individual circumstances where a bilateral amputee may have


a clinical need for componentry that exceeds his or her functional level assessment, it does not mean that a bilateral amputee has no limits on the type of prosthesis Medicare will pay for. Bilateral amputees must undergo a functional level assessment and, in most cases, will only qualify for prosthetic components within their functional level classification. If there is a specific clinical need for prosthetic components that exceed the patient’s functional level classification, the need must be well documented and supported by information in the patient’s medical record. I am providing custom shoes attached to a brace, but there is not a code for a custom shoe attached to a brace. How should I code the custom shoe?


The orthopedic shoe policy provides clear directions on this: Custom shoes attached to a brace must be coded as L3649 (orthopedic shoe, modification, addition, or transfer, not otherwise specified). Policy also states that, when using the L3649 in this instance, you must provide information as to what makes the shoe custom.


PHOTO: GettyImages/monkeybusinessimages

AOPA receives hundreds of queries from readers Q and members who have questions about some aspect of the O&P industry. Each month, we’ll share several of these questions and answers from AOPA’s expert staff with readers. If you would like to submit a question to AOPA for possible inclusion in the department, email Editor Josephine Rossi at jrossi@contentcommunicators.com.

Do rehabilitation hospitals follow the same rules as acute care hospitals and other types of hospitals?


Yes. Even though rehab hospitals are paid under a separate prospective payment system than acute hospitals, the rules regarding the rehab hospital’s responsibility to provide or pay for medically necessary care remain exactly the same as they are for acute care hospitals. From the O&P provider’s perspective, the same payment rules that apply to acute care hospitals also apply to rehab hospitals.



a repair?

Am I required to get a new prescription if I am doing



PHOTO: GettyImages/SolStock

No. A new order/prescription is not required when you are doing a repair or an adjustment, unless the repair requires you to replace a major component.



Need CEs? Learn and earn with the AOPAversity


Online Learning Center



Learn & Earn New videos added from the 2016 Assembly! • Osseointegration • Thranhardt Lectures • The Future of Pedorthics

• Human Resources: Performance Appraisal • Marketing: The Value of the Patient Story

It’s as easy as 1-2-3 1. Set up your free personal online account 2. Choose your education and study 3. Take the quiz and print your certificate

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American Orthotic & Prosthetic Association 330 John Carlyle Street, Suite 200 Alexandria, VA 22314

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Profile for AOPA

February 2017 O&P Almanac  

American Orthotic & Prosthetic Association (AOPA)

February 2017 O&P Almanac  

American Orthotic & Prosthetic Association (AOPA)