Page 1

The Magazine for the Orthotics & Prosthetics Profession

M AR C H 2018


Guidance on New Code K0903






Practical Tips for Collecting Outcome Measures Data P.30

Meet an O&P Researcher Advancing in Gait Biomechanics P.37

Billing for Patients in Skilled Nursing Facilities






This Just In: O&P Notes Provision Becomes Law P.20






Vancouver is easy to explore during your time at the downtown Vancouver Convention Centre as there are many nearby top attractions. • • • • • •

Capilano Suspension Bridge Vancouver Aquarium Forbidden Vancouver Stanley Park Horse-Drawn Tours Harbour Cruises & Events Flyover Canada

• Vancouver Lookout • Dr. Sun Yat-Sen Classical Chinese Garden • Vancouver Art Gallery • Science World • Grouse Mountain

Experience Beyond Vancouver’s unbeatable location makes it the perfect gateway to the rest of British Columbia and beyond, providing you with outstanding opportunities for pre- and post-conference travel. • Whistler • Okanagan Valley • Jasper • Victoria • Banff • Cruise to Alaska


Experience all the AOPA National Assembly has to offer while visiting Vancouver.


MARCH 2018 | VOL. 67, NO. 3



20 | This Just In

A Well-Documented Victory



The first year of the Trump administration has been marked by a loosening of some regulations and the potential migration of some decision-making capabilities from the federal to state governments. While the recent legislation recognizing O&P clinicians’ notes is a decisive “win” for the O&P community, other proposed and actual changes to U.S. health-care laws may have troubling repercussions for O&P patients and clinicians. By Christine Umbrell

30 |

Measure for Measure

More O&P patient-care facilities are implementing formal policies and processes to capture outcomes data from their patients. In addition to aiding in designing optimal treatment plans, this type of data can be aggregated and shared with payors to support the efficacy of O&P intervention and can serve as the basis for retrospective chart review research. By Christine Umbrell PHOTO: Ability Prosthetics & Orthotics

O&P stakeholders are celebrating the recognition of O&P clinicians’ notes as part of the official medical record, which was signed into law in February as part of the continuing resolution to fund the U.S. government. This is a step in the right direction, but questions remain about implementation and timing, and many O&P leaders continue to advocate for additional provisions featured in the proposed Medicare O&P Improvement Act.

22 | U.S. Health-Care Score Card


PRINCIPAL INVESTIGATOR Steven A. Gard, PhD.......................... 37 Meet the executive director of Northwestern University Prosthetics-Orthotics Center, and find out how his early interests in medicine and engineering led to a career in O&P and a wide range of research interests.

DEPARTMENTS Views From AOPA Leadership......... 4 Preview of the 2018 AOPA National Assembly from board member Rick Riley

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

Investigating Inserts

When to use diabetic insert codes A5512, A5513, and K0903 CE Opportunity to earn up to two CE credits by taking the online quiz.


Member Spotlight................................ 40 n


Munger Prosthetics and Orthotics Inc.


Anatomical Concepts Inc.

People & Places........................................14 Transitions in the profession

AOPA News.............................................. 44 P.16

AOPA meetings, announcements, member benefits, and more

PAC Update.............................................. 46 Welcome New Members ..................47 Careers.........................................................47 Ad Index......................................................47 Marketplace............................................. 48 Calendar..................................................... 50 Upcoming meetings and events


Ask AOPA...................................................52 P.42

Reimbursement during skilled nursing facility stays




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

Passport to Vancouver—and Our Industry’s Future


T’S A PICTURESQUE INTERNATIONAL CITY, featuring an amazing glass-

shrouded convention center perched on the waterfront, with astounding views that set the perfect stage for the emerging technology and value-based patient care that will define the future of O&P services. Vancouver—the destination for AOPA’s 2018 National Assembly, themed “Passport to Innovation”—will be a venue like no other for this year’s foray into clinical, technical, and business education. This exquisite world-class meeting spot will provide the most memorable experience you have ever had at AOPA’s annual gathering of providers and suppliers. There will always be other O&P meetings in Vegas. Chicago is guaranteed. Orlando is a sure thing, too. But could this be the first and last time AOPA offers an educational experience in Vancouver? Vancouver was selected as this year’s host city several years ago, following a very successful National Assembly in Seattle. Keeping the beautiful Pacific Northwest in the regional rotation allows attendees to travel to new destinations— and Vancouver is one of the greatest cities on the North American continent. The National Assembly, September 26-29, is the most visible, noteworthy event on AOPA's annual calendar. The event also provides significant funding for other activities, such as winning the battle to get orthotists’/prosthetists’ notes recognized as part of the official medical record. Whether you are a seasoned practitioner or relatively new to this industry, don’t pass up this incredible opportunity to merge learning with a life experience. Too often, clinicians and suppliers fly in and fly out of these events, barely getting beyond the hotel, classrooms, and Exhibit Hall. Take a day or two, or a week, on the front end or back end, and do something more memorable than earning CEUs. Here are a few recommendations to make your trip to this year’s Assembly one for the record books: • Fly to Seattle and take the train to Vancouver. The views are spectacular, and the passport control officers inspect your documents while you are traveling. • Spend the weekend before or after the meeting exploring Vancouver and surrounding areas. • Pack your outfit for the ’70s-themed PAC fundraiser. This “see and be seen” event will feature the industry’s power brokers disco dancing to raise money for lobbying activities. Dozens of volunteers are actively working to make sure “Passport to Innovation” is a worthy investment. It is the committee chairs and the committee members, working closely with AOPA staff, who make it possible for attendees to show up with every detail carefully considered. Mark your calendar now, and start planning your visit to Vancouver. Rick Riley is a member of AOPA’s Board of Directors and is co-chairing the 2018 AOPA National Assembly with Teri Kuffel, JD.



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


Introducing the new Iceross Seal-In X-Classic, Seal-In X-Volume and Seal-In X-Grip movable seals, for use with Seal-In X and Seal-In X TF liners. Featuring an improved textile donning aid and Easy Glide low-friction coating, these seals make donning a socket easy by eliminating the need for alcohol or lubricant spray. Seal-In X is Unity™ vacuum system compatible and provides a personalized fit and secure suspension to help improve skin and limb health, control volume and reduce pistoning and rotation.


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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

Publisher Thomas F. Fise, JD Editorial Management Content Communicators LLC

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

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Sheridan

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,

Joe McTernan, director of coding and reimbursement services, education, and programming, 571/431-0811,

Tina Carlson, CMP, chief operating officer, 571/431-0808, Don DeBolt, chief financial officer, 571/431-0814, MEMBERSHIP & MEETINGS Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, Lauren Anderson, manager of communications, policy, and strategic initiatives, 571/431-0843, Betty Leppin, manager of member services and operations, 571/431-0810, Yelena Mazur, membership and meetings coordinator, 571/431-0876, Ryan Gleeson, assistant manager of meetings, 571/431-0876, AOPA Bookstore: 571/431-0865

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, SPECIAL PROJECTS Ashlie White, MA, manager of projects, 571/431-0812, Reimbursement/Coding: 571/431-0833,

O&P ALMANAC Thomas F. Fise, JD, publisher, 571/431-0802, Josephine Rossi, editor, 703/662-5828, Catherine Marinoff, art director, 786/252-1667, Bob Heiman, director of sales, 856/673-4000, Christine Umbrell, editorial/production associate and contributing writer, 703/6625828,



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

Advertise With Us! Reach out to AOPA’s membership and more than 11,800 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email Visit for advertising options!



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What’s Your Worth? Compensation data for experienced O&P professionals

AOPA’s 2017 Compensation and Benefits Report* captured data on how O&P facilities compensate employees, and analyzed the data based on job title and years of experience. The numbers below are specific to O&P professionals with “11 or more” years of experience, some of whom have been certified by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) or the Board of Certification/Accreditation (BOC). Total compensation includes base salary, bonus, and commission.







ABC-certified orthotists

ABC-certified prosthetists

ABC-certified prosthetist/orthotists




BOC-certified orthotists

BOC-certified prosthetists

BOC-certified prosthetist/orthotists0



$42,500 Fitters

Practitioner assistant/extenders


ABC-certified technicians


Non-ABC-certified technicians


89 Percent

Percentage of companies offering retirement plans.

87 Percent

Percentage of companies offering retirement plans that do so via defined distribution plans.

Types of Defined Contribution Plans Simplified Employee Pension (SEP) Employee Stock Ownerships Plan (ESOP)

12% 3% 25%

Profit-Sharing Plan


401(K) Salary Deferral SIMPLE 401(K) 403(B) Other

15% 9% 8%

EDITOR’S NOTE: For more detailed analyses of compensation findings, including median salary and bonus information as well as comparisons by company size, community size, and more, visit the AOPA Bookstore at to purchase AOPA’s 2017 Compensation and Benefits Report.

* The information in AOPA’s 2017 Compensation and Benefits Report is based on 2016 data, which captured the financial facts from 88 companies representing 350 full-time facilities and 77 part-time facilities. 8



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Researchers Test Strategies To Improve Poststroke Rehabilitation progressively increase the weight of the arm across therapy sessions as reaching function improves. The study involved using a robotic device to control shoulder effort and precisely measure reaching movement with accurate identification of the location of brain activity in real time through the application of 160 electrodes on each participant’s head. “We plan to study the use of the nonaffected side of the brain and associated indirect motor pathways during early recovery from stroke,” explained Julius Dewald, PhD, principal investigator on the project. “We will do this by progressively increasing the weight of the affected limb while measuring reaching performance at set times during the recovery process. … The neural mechanism underlying the flexion synergy phenomenon is believed to be mediated by indirect motor pathways via the brainstem from the nonaffected side of the brain. We are also investigating whether targeted drugs can manipulate these ‘backup’ motor systems poststroke, which could ultimately open a door to new therapies to aid physical rehabilitation,” said Dewald.

Redesigned O&P News Features Research Studies Late last year, AOPA acquired the assets of O&P News (formerly known as O&P Business News) from Healio. Beginning with the January 2018 issue, AOPA has redesigned the magazine with a focus on educating and informing health professionals who serve the greater limb-loss community and those using orthotic devices. A “Research & Presentations” section in the revamped O&P News features recent O&P-related studies and reports. The following topics have been covered in this section of the magazine: JANUARY 2018 Comparing the Transfemoral HiFi System to a Traditional Ischial Containment Socket By Tyler D. Klenow, MSOP, CPO, LPO A Flexible AFO: Contradiction to Traditional Thought? By Suzanne Guiffre, PT, EdD; Joseph Whiteside, CO, LO; and Cathy Bieber Parrott, PT



FEBRUARY 2018 Finding the Right Balance By David Moser, PhD, BEng, BSc, and Mike McGrath, PhD Improving Patient/Practitioner Communications By Andrea Sherwood, MPO, CPO MARCH 2018 Choosing the Optimal PD-AFO for Your Patient By David Knapp, CPO Liner With Embedded Electrodes for Myoelectric-Controlled Prostheses By Matthew Wernke, PhD; Cody Doddroe; Alexander Albury, CPO; Michael Haynes, MS; and Luke Beery To view digital edition of the 2018 issues of AOPA News, visit AOPA’s website at

IMAGE: Courtesy of American Heart Association

A team at Northwestern University is developing stroke rehabilitation interventions that promote the use of the affected side of stroke patients to improve movement control. Nearly 80 percent of stroke survivors experience hemiparesis, or one-sided weakness, and suffer from the loss of fine motor control in the arm and hand on the opposite side from where damage occurred in the brain. Northwestern researchers noted that when a stroke survivor attempts to move the affected arm, activity in the brain switches from the affected side to the nonaffected side, which normally controls movement of the opposite arm. While this allows the brain to tap into backup motor systems that bypass regions damaged by stroke, this process also involuntarily activates the elbow flexor muscles—a common motor impairment known as “flexion synergy.” In a study published in a recent issue of The Journal of Physiology, the Northwestern team detailed its use of a robotic device to encourage the brain to use the affected side to improve movement control and reduce the effects of flexion synergy. The team is investigating rehabilitation devices that begin by unweighting the affected arm and then


‘E-Skin’ Promotes Sense of Feel in Prosthetic Limbs

PHOTO: Jianliang Xiao/University of Colorado—Boulder

Scientists at the University A section of the electronic skin of Colorado—Boulder have developed by scientists at the developed electronic skin, or University of Colorado—Boulder “e-skin,” a thin, semitransparent material designed to measure temperature, pressure, humidity and air flow. The e-skin mimics functionalities and mechanical properties of natural skin and can be used in conjunction with prosthetic devices, according to the research team, which was led by Jianliang Xiao, assistant professor of of otherwise passive systems,” including mechanical engineering. prosthetic applications, said Xiao. The “dynamic covalent thermosetIf the skin is wrapped around a prosbased e-skin” is connected through thetic hand, for example, the e-skin robust covalent bonds and has tactile, could enable the prosthesis to sense temperature, flow, and humidity for pressure when holding a glass cup, sensing capabilities, according to the according to Xiao. The material also researchers. The skin has been designed has applications for future robots. to “reheal” when damaged and can A full study on e-skin , titled be “recycled” at room temperature, “Rehealable, Fully Recyclable, and after which it regains mechanical and Malleable Electronic Skin Enabled electrical properties comparable to By Dynamic Covalent Thermoset the original e-skin. Nanocomposite,” was published E-skin “has quite broad applicain February in Science Advances. tions, in a sense, to enable sensation

Access AOPA Member-Funded Research on Shared Decision Making A recent issue of Prosthetics and Orthotics International features research conducted by Michael Dillon, PhD, of LaTrobe University, and funded

by AOPA. The study explores the topic of shared decision making, a consultative process designed to encourage patient participation in decision making by providing accurate information about treatment options and supporting deliberation with the clinicians about treatment options. Access the abstract of the article, titled “Development of Shared Decision-Making Resources To Help Inform Difficult Health-Care Decisions: An Example Focused on Dysvascular Partial Foot and Transtibial Amputations,” at


Facilities Seek Partial Payments Via Low-Volume Appeals Initiative The low-volume appeals initiative (LVA), a new program in place from CMS and the Office of Medicare Hearing and Appeals, has been designed with the intention of reducing the number of pending appeals. The LVA program is geared toward patient-care facilities that have fewer than 500 appeals pending at administrative law judge level or higher, with each appeal having a billed amount of no more than $9,000. Participants in the program may file an expression of interest for a limited settlement agreement. If approved, the agreement will result in a timely one-time partial payment of 62 percent of the net Medicare-approved amount of the appeals in question. Those suppliers whose National Provider Identifier (NPI) numbers end in an even number (0, 2, 4, 6, 8) must file an expression of interest by March 9, 2018, to participate in the program. Those suppliers with an NPI ending in an odd number (1, 3, 5, 7, and 9) may take part in the LVA program between March 12 and April 11, 2018. Visit expressionofinterest to file an expression of interest. FAST FACT

Forty-seven percent of Internet users

search online for information about doctors or other health professionals.


Source: Pew Research.





Schedule Day Trips and Tours in Vancouver Join AOPA September 26-29 for the 2018 National Assembly in Vancouver, British Columbia, Canada, and get to know the iconic area by planning day trips and tours of the region. AOPA has partnered with Landsea Tours & Adventures to offer AOPA Assembly attendees and their traveling companions special rates on sightseeing tours of Vancouver and the surrounding

areas. Landsea is offering seven different tours, including a four-hour tour of Vancouver’s city highlights, and longer trips to Capilano Suspension Bridge Park, Whistler, Victoria, the Sea to Sky Gondola, and more. The special rates are available between September 22 and October 1. Private tours also are available. Browse the tour options at


O&P Professionals Convene in Vegas for Hanger Education Fair



and physical therapists. Topics included clinical management strategies, advancements in surgical techniques and prosthetic componentry, and more, with an emphasis on the important role of clinical outcomes. The company’s national business meeting took place on February 2, with a special panel introduced by James Campbell, PhD, Hanger Clinic chief clinical officer, that spoke to the value of clinical outcomes. The event also featured more than 115 exhibits. Several vendors and partners were recognized for their contributions at the Hanger Partner Awards during the meeting, including ST&G Corporation as a “Rising Star,” Orthomerica for “Collaboration,” Coapt LLC for “Innovation,” and WillowWood for “Operational Performance.”

PHOTOS: Hanger Inc.

More than 1,100 Hanger employees, including more than 900 clinicians and therapists, traveled to the Rio Hotel in Las Vegas from January 29 to February 2 to take part in Hanger Inc.’s 2018 Education Fair & National Business Meeting. With a theme of “Breaking Barriers,” the event kicked off when five Hanger Clinic patients shared their personal stories, explaining how the values espoused by the Hanger community enabled them to achieve their goals—from a patient-focused team running a 5K alongside a woman with limb loss, to an innovative clinician designing a custom prosthesis for a world-class kayaker. Participants attended several clinical keynote sessions led by medical experts, including orthopedic surgeons


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Data Breaches Pose Continuing Threat to Health-Care Companies Nearly one quarter of all of the reported U.S. data breaches in 2017 were experienced by medical/healthcare companies, according to the “2017 Annual Data Breach Year-End Review.” In total, 347 breaches took place at health-care companies, according to the report, which was published by the Identity Theft Resource Center and CyberScout. More U.S. companies experienced data breaches in 2017 than in any previous year, with 1,579 breaches filed last year among all U.S. companies,

according to the report. This represents a 45 percent jump over last year’s record of 1,091 breaches. The top three causes of data breaches included hackers who specifically target companies, “phishing” incidents, and ransomware/malware. As of January 31, 31 medical and health-care data breaches have been reported for 2018, accounting for 27 percent of breaches across all sectors, according to the Identify Theft Resource Center’s January data breach report.


The Amputee Coalition is accepting applications through April 6, 2018, for the Christina Skoski, MD, Scholarship and for the Scott Decker, MD, Memorial Scholarship. Both scholarships offer $1,000 in tuition assistance to students attending a college or university in the 2018/2019 school year. Visit the Amputee Coalition website for details, Coapt LLC, which offers intuitive control systems for prosthetic arms, has been recognized with the 2018 Hanger Partner Award for Innovation. Coapt earned this honor for demonstrating innovation in the development of its COMPLETE CONTROL advanced prosthesis control system. The fifth annual Hanger Partner Award for Innovation recognizes a supply chain partner that demonstrates expansive thinking in product innovation and technology, resulting in positive clinical outcomes. The award was chosen by members of Hanger’s clinical and operational teams and presented at the annual Hanger Education Fair and National Business Meeting. 14





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Investigating Inserts Coding and documentation guidance for codes A5512, A5513, and the new K0903

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



ODE K0903, A NEW temporary code to describe custom-fabricated, total contact inserts that are manufactured through a direct-milling process, will become active next month for claims with a date of service on or after April 1. This brings the total number of billable/coverable diabetic inserts to three: A5512, A5513, and K0903. While the K0903 is very new and there are still some things that we don’t know regarding the associated fee, now is an appropriate time to review coding and documentation information regarding inserts, based on the diabetic shoe policy as well as coding announcements from the durable medical equipment Medicare administrative contractors (DME MACs) and the pricing, data analysis, and coding (PDAC) contractor.

Diabetic Insert Coding







• Has a base layer that has a minimum of 1/4-inch material of Shore A 35 durometer, or 3/16-inch material of Shore A 40 durometer (or higher) • Has the specified thickness of the base layer extending from the heel through the distal metatarsals (may be absent at the toes) • Retains its shape during use for the life of the insert. In addition, any insert being billed as A5512 must be reviewed by the PDAC and placed on the product classification list. If a prefabricated insert is not listed on the product classification list, it must be coded as A9270, noncovered. Codes A5513 and K0903 describe custom-fabricated inserts and are very similar in that they share the same following characteristics: • Is a multiple-density insert • Is made from basic materials • Has total contact with beneficiary’s foot, including the arch, and conforms to the plantar surface • Has a base layer that has a minimum 3/16-inch material of Shore A 35 durometer (the central portion of the heel may not be less than 1/16 inch thick) • Has the specified thickness of the base layer extending from the heel through the distal metatarsals (may be absent at the toes) • Has a heat-moldable top layer, and may be of a lower durometer • Retains its shape during use for the life of the insert.

PHOTO: Getty Images

In early February 2018, the DME MACs and PDAC issued a correct coding bulletin that updates the diabetic shoe policy and addresses the proper coding of the three diabetic shoe inserts: A5512, A5513, and K0903. Code A5512 describes a multidensity prefabricated insert that is directly heat-molded to the patient’s foot to meet the plantar surface of the foot, and also has the following characteristics: • Is direct formed by molding to the beneficiary’s foot with an external heat source of 230 degrees Fahrenheit or higher • Has total contact with beneficiary's foot, including the arch


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The difference between codes A5513 and K0903 is the fabrication method used. The A5513 is molded to a specific beneficiary using a physical model, and the K0903 is directly milled from a beneficiary-specific rectified digital/virtual model. This means that if the fabrication process involves a direct scan of the patient’s foot or an indirect scan of the foot via a mold made by the patient’s foot (e.g., crush boxes), or even a scan of a model directly made from a mold, and then the scanned digital/virtual model is rectified using computer-aided manufacturing equipment to directly carve or mill a unique custom-fitted insert for the particular patient, then it is considered a K0903—a directmilled insert. K0903 does not describe therapeutic shoe inserts created using manufacturing techniques such as 3-D printing or similar processes. The correct coding bulletin also indicates that the PDAC coding redetermination review project, which was initially announced in August of 2017 and scheduled to be completed by June 1, 2018, has been extended to a new completion date of Aug. 1, 2018, to allow manufacturers and central fabricators additional time to submit applications for their respective products. All diabetic inserts billed to Medicare using A5513 or K0903 must be listed on the PDAC

product classification list no later than Aug. 1, 2018. Direct-milled inserts described by K0903 must be billed using K0903 for dates of service on or after April 1, 2018, the effective date of the code, regardless of how they are currently listed on the PDAC product classification list. Inserts that are not included on the PDAC list by Aug. 1, 2018, must be coded as A9270 and will be considered noncovered by Medicare. Even though it was not directly expressed, it is believed that the same rules for PDAC coding verification of A5513 would apply to the K0903. Inserts that are custom fabricated by a manufacturer/central fabrication facility and then sent to someone other than the beneficiary must be listed by the PDAC, if they are to be billed. However, if the inserts are custom fabricated from raw materials that are dispensed directly to the beneficiary by the supplier that fabricated the insert, the inserts do not have to be listed on the PDAC list. The supplier, however, must provide a list of the materials that were used and a description of the customfabrication process upon request.

Diabetic Inserts and Toe Fillers The Policy Article for diabetic shoes is fairly vague on the use of toe fillers; it simply states: “Inserts for missing toes or partial foot amputation should be

coded L5000 or L5999, whichever is applicable.” However, the DME MACs have issued more in-depth guidance regarding the proper coding of toe fillers and diabetic shoe inserts. In short, the guidance informs providers and suppliers that a patient cannot receive both custom diabetic shoe insert(s) (A5513) and a partial foot toe filler (L5000) on the same foot. The patient would receive one or the other, and the proper coding depends on the need of the patient. If the patient has diabetes and is missing toes or the forefoot, and doesn’t require any extra rigidity or toe-off support for an improved gait, then the insert must be coded as A5513. The custom fabrication nature of the code would include the additional material needed to create a toe filler. The L5000 describes a shoe insert with a rigid longitudinal arch support with additional soft material added where contact is made with the residual limb/toes, and is designed to provide standing balance and toe-off support for improved gait. So, if the patient has diabetes and is missing the hallux or a forefoot that would require additional rigidity and support for an effective gait, then the L5000 must be used instead of the A5513. At the present time, this guidance announcement has not been updated to reflect the release of the new custom-fabricated code K0903, but it would be safe to assume that the same rules would apply. If you are providing a direct-milled insert to a patient who has diabetes and is missing toes or the forefoot, and who doesn’t require any extra rigidity or toe-off support for an improved gait, then the insert must be coded as K0903.

Documentation in the Certifying Physician’s Record

In addition to documenting and certifying that the patient requires a pair of shoes and that the patient has one of the approved diagnoses of diabetes mellitus, the certifying physician must document two key aspects of the patient’s condition and treatment plan, which are components of the certifying statement. 18



First, the certifying physician must document that the patient has one or more of the six approved secondary foot conditions: previous amputation of the other foot, or part of either foot; history of previous foot ulceration of either foot; history of pre-ulcerative calluses of either foot; peripheral neuropathy with evidence of callus formation of either foot; foot deformity of either foot; or poor circulation in either foot. The certifying physician may complete this documentation directly, or someone else could handle it. For example, the podiatrist ordering the shoes could be responsible for the diagnosis of the secondary foot condition, or it could be the responsibility of a nurse practitioner or a physician assistant. If one of these other approved individuals completes the documentation of the secondary foot condition, he or she must forward a copy of the documentation to the certifying physician. The certifying physician then must review, initial, and date the findings indicating his or her agreement. Remember that the date the certifying physician initials the documentation must be prior to the date he or she signs the certifying statement, and it must be within six months prior to the initial delivery of the shoes and inserts. Second, the certifying physician, and only the certifying physician (the medical doctor or doctor of osteopathic medicine), must document that he or she is currently treating the patient under a comprehensive plan of care for diabetes. There is no one approved or recognized treatment plan; all that is required is that the physician has documented that he or she has discussed the patient’s current condition and the patient’s current treatment plan, as well as the way the patient is to manage his or her diabetes. This documentation must be completed during an in-person visit with the patient, which must take place within six months prior to the initial delivery of the shoes and inserts. While it is not mandatory, during this in-person visit the physician may choose to sign or complete a certifying statement; however, if the physician doesn’t sign the statement during the in-person visit, he or she must

sign it within three months before delivery of the shoes and inserts. Even though the physician has signed the certifying statement, the above information still needs to be documented in the record. Policy is clear that the certifying statement, by itself, is not enough to establish medical necessity; the information must also be documented in the certifying physician’s record. Also, once signed, the certifying statement is valid for 12 months after it is signed; but once signed, the initial delivery of the shoes and inserts must take place within three months. If the delivery takes longer than three months, then you would need to have a new certifying statement completed, and check to make sure the approved documentation is still timely.

Documentation in the Supplier’s Record

There are two key pieces of information that must be included in the supplier’s record. First, the supplier must conduct and document an in-person evaluation of the patient, prior to the patient selecting shoes and inserts. Thus, you must document that, prior to the patient selecting his or her shoes, you took and recorded all linear measurements of the patient’s foot—this requires more than simply stating that the patient is a size X. You will want to document the abnormalities that need to be accommodated by the shoes, especially if you are providing custom shoes/inserts, because

if you are providing custom shoes or inserts, the nature and severity of the deformity must be well documented. Second, you must conduct and document an in-person evaluation at the time of delivery of the patient wearing the shoes, and document that the shoes fit properly. This evaluation must be as objective as possible and cannot be solely based on subjective statements made by the patient, such as, “They are not too tight.” This in-person requirement means that you may not mail shoes to a patient, and you may not leave shoes with a patient in a facility unless the patient tries them on in your presence. Understanding the coding and documentation rules for codes A5512, A5513, and K0903 will help you provide the most appropriate diabetic inserts for your patients—and ensure that you are reimbursed for your efforts. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit Earn CE credits accepted by certifying boards:



This Just In

A Well-Documented Victory New law recognizes O&P notes as part of the official medical record



O&P professionals are celebrating an important legislative win regarding their documentation. On February 8, the provision from the Medicare O&P Improvement Act recognizing the orthotist’s and prosthetist’s notes as part of the medical record was signed into law as part of the continuing resolution to fund the U.S. government. The following O&P provision has officially been signed into law: SEC. 50402. ORTHOTIST’S AND PROSTHETIST’S CLINICAL NOTES AS PART OF THE PATIENT’S MEDICAL RECORD. 13 Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph: “(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS. – For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”



Since the August 2011 release of the “Dear Physician” letter changing the physician documentation requirements for lower-limb prosthetics, one of AOPA’s highest priorities has been advocating for the prosthetist’s/ orthotist’s notes to be part of the patient’s medical record. Recognizing the clinician’s notes was one of the provisions of S. 1191/H.R. 2599: Medicare Orthotics and Prosthetics Improvement Act of 2017, introduced in the House by Rep. Glenn Thompson (R-Pennsylvania) and in the Senate by Sen. Chuck Grassley (R-Iowa).

Sen. Chuck Grassley (R-Iowa)

Rep. Glenn Thompson (R-Pennsylvania)

This provision included in the continuing resolution does not encompass all aspects of the Medicare O&P Improvement Act—just the O&P notes provision. AOPA will continue

to advocate for the full Medicare O&P Improvement bill, which also includes provisions to require Medicare to reimburse only qualified O&P providers; distinguish O&P from durable medical equipment; and limit the “off-the-shelf orthotics” eligible for competitive bidding. As with any law, the notes provision is subject to interpretation, and exactly how it will be implemented is uncertain as of press time. AOPA is working diligently and has sent written communication to CMS officials to discuss the new law and how it may be implemented in the future. It is important to remember that the law specifically addresses that O&P notes are part of the medical record “to support documentation for physicians and other eligible professionals.” While there is much work to be done, the law is a crucial step in the goal of full recognition of O&P practitioners as medical professionals. O&P stakeholders and leaders spent several years advocating for the recognition of the orthotist’s/prosthetist’s notes. There are many individuals whose dedication and hard work should be recognized as instrumental in these efforts, including the following:

This Just In

• Legislative co-sponsors: Reps. Glenn Thompson (R-Pennsylvania), Mike Thompson (D-California), Mike Bishop (R-Michigan), Peter King (R-New York), Dutch Ruppersberger (D-Maryland), and Michael Kelly (R-Pennsylvania), as well as Sens. Chuck Grassley (R-Iowa), Mark Warner (D-Virginia), Bill Cassidy (R-Louisiana), Ben Cardin (D-Maryland), and Tammy Duckworth (D-Illinois). Sens. Orrin Hatch (R-Utah) and Ron Wyden (D-Oregon) of the Senate Finance Committee, and Reps. Kevin Brady (R-Texas) and Richard Neal (D-Massachusetts) of the House Ways & Means Committee, as well as the staff of all the above legislators, deserve special recognition. • Former Sen. Bob Kerrey (D-Nebraska) as well as the Amputee Coalition and its leaders, especially Jack Richmond, Jeff Cain, MD, and Dan Ignaszewski. • AOPA lobbyists Stephanie

Kennan, Michael Park, and Mark Rayder, with very solid, vigilant, and long-standing support from Peter Thomas, JD, of the National Association for the Advancement of Orthotics and Prosthetics (NAAOP) and O&P Alliance, and former Rep. Scott Klug (R- Wisconsin) representing Hanger. • O&P Alliance partners: the American Academy of Orthotists and Prosthetics; the American Board for Certification in Orthotics, Prosthetics, and Pedorthics; the Board of Certification/ Accreditation; NAAOP; and all members of the ITEM Coalition. • Current and prior AOPA presidents, officers, and board members who have been steadfast in their support, including a multiyear financial investment in support of this important work. • All AOPA members who have attended the AOPA Policy Forum; attended fundraisers sponsored by, or made direct contributions to,

the O&P PAC; or wrote or visited their legislators to encourage their support, and others who, while not members of AOPA, have done one or more of the above activities. The inclusion of the O&P notes provision in the continuing resolution is reason to celebrate within the O&P community. But questions about implementation and timing remain, and there is much work to be done in influencing legislators to pass additional provisions from the Medicare O&P Improvement Act. EDITOR’S NOTE: To read additional commentary about the legislation recognizing the orthotist’s/prosthetist’s notes, as well as information about how other legislative and regulatory proposals may affect O&P in the coming year, see “U.S. Health-Care Score Card” on page 22.

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PHOTO: Getty Images/FluxFactory

The proposed and actual changes to laws and regulations from the past year have mixed effect on O&P


NEED TO KNOW • Health care and related coverage issues have been hot topics in the U.S. legislative arena over the past year. While several attempts to repeal and replace the Affordable Care Act (ACA) failed, the law has been impacted by fewer subsidies, a shorter enrollment period, repeal of the individual mandate, and other regulatory changes. • The recent legislation recognizing O&P clinicians’ notes is a victory for the O&P community, but it is unclear whether some of the other proposed and actual changes to U.S. health-care laws may have negative consequences for O&P patients and clinicians. • Several states have begun seeking ACA Section 1332 waivers, which allow states to pursue innovative strategies to provide residents access to high-quality, affordable health insurance while retaining the basic protections of the ACA.



the Trump administration and Republican-controlled Congress took office a little more than a year ago. For the O&P industry, there’s been good news on the legislative front as a result of the continuing resolution/spending bill passed last month. That legislation included a provision noting that “documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in 1848(k) (3)(B).” This is a clear “win” for the profession, as it recognizes orthotists and prosthetists in the documentation process supporting the reimbursement of O&P services. Aside from this important victory, there have been other developments related to the U.S. health-care delivery rules and regulations that are having an impact on the provision of O&P services. While several attempts at

Kentucky, for example, has received permission to impose work requirements for some Medicaid recipients, and at least 10 other states have made similar requests. • O&P professionals are watching to see whether states may get a say in what are considered “Essential Health Benefits” (EHBs). Any changes could impact the coverage of orthotics and prosthetics benefits, which are currently covered under the rehabilitative and habilitative services and devices category of the EHBs defined in the ACA. • Change is inevitable, so O&P facilities should focus on providing optimal patient care, examining their practices for efficiencies and cost-management opportunities, remaining vigilant regarding documentation, and advocating on behalf of O&P patients.

repeal-and-replace legislation aimed at the Affordable Care Act (ACA) have failed, there has been an overall weakening of many health-care-related regulations, which could have an effect on O&P patients and their clinicians. The O&P notes provision, combined with other legislative and regulatory activities over the past several months, have left the O&P community with a sense of cautious optimism about the future. It is clearly a “positive” that O&P clinicians’ documentation will be considered by government payors going forward. But many questions remain regarding regulatory changes that may push more decisions out to the states—including what constitutes an “Essential Health Benefit”—and some of these changes could result in fewer Americans covered by health insurance. As O&P business owners and clinicians look to the future, it will be important to focus on optimal patient care—which includes advocating on behalf of O&P patients. O&P ALMANAC | MARCH 2018



A Legislative Win

The decision to include O&P notes as part of patients’ health-care records represented the culmination of years of hard work and “advocacy in action” by O&P stakeholders, says Jim Weber, MBA, AOPA president, and owner of Prosthetic & Orthotic Care Inc. “For years, since the issuance of the Physician Documentation Letter in 2011, AOPA, all O&P Alliance members, the Amputee Coalition, and O&P professionals who took the time to get involved advocating for their patients have been calling for our notes to be recognized, and the result of that multiyear advocacy effort is this significant milestone for our industry and, most importantly, for the care of our patients,” says Weber.

Jim Weber, MBA

“The seminal moment for our profession is that our documentation is finally recognized as medical record,” adds John “Mo” Kenney, CPO, LPO, FAAOP, chair of the Amputee Coalition and founder of Kenney Orthopedics. “Now we can at least have a chance to be heard on what is appropriate for a Medicare recipient.” Leading up to this victory, a lot of energy and resources have been committed to achieve “the professional recognition by CMS that we already have from our referral sources and our patients,” says Michael Oros, CPO, LPO, FAAOP, immediate past president of AOPA and president of Scheck & Siress Inc. Now that the provision has been legalized, O&P clinicians hope to see the durable medical equipment Medicare administrative contractors (DME MACs) make changes to their policies, so their notes will be formally recognized along with the physicians’ notes for the purposes of determining the medical necessity of a particular prescribed device, Oros explains. “This is the next step that has to be taken” for the law to have its intended effect. 24


Leading up to this victory, a lot of energy and resources have been committed to achieve “the professional recognition by CMS that we already have from our referral sources and our patients.” —Michael Oros, CPO, LPO, FAAOP, immediate past president of AOPA and president of Scheck & Siress Inc. Rebecca Hast, senior vice president of strategic initiatives at Hanger Inc., recommends that O&P clinicians proceed with caution while celebrating this win. “While this is a very positive step for the industry, it will still be important that the physician’s—or other eligible professional’s—documentation and O&P clinical documentation are aligned with regard to medical necessity. Additionally, local coverage decision policies that require certain physician documentation are unlikely to change,” Hast says. “On the bright side, this does bring a renewed significance to the quality and completeness of O&P clinical notes and should encourage clinicians in our industry regarding the importance of documenting their work. It is important to note that this acknowledgement is related only to CMS programs. Commercial carriers and other payors may or may not choose to adopt this policy.” While the O&P community watches to see how all of this unfolds, many O&P clinicians will take the next steps to begin submitting their notes as part of patients’ official medical records.

Regulatory Rollback

Aside from the O&P notes victory, the past year has been notable for a great deal of activity aimed at making changes to the U.S. health-care system. One of the core themes has been “fewer regulations and a lessening of the [regulatory] burden across the board,” says Weber.

We have seen a “continuous attempt to dismantle the ACA by whatever means possible,” says Oros. While several efforts to repeal and replace the ACA have failed, the law has been weakened in several ways. In October, President Donald Trump signed an executive order directing the government agencies responsible for implementing the ACA to consider how to improve choice and competition, and how to lower costs, in the individual and small group insurance markets. The order aims to achieve at least some of the administration’s reform objectives through regulations or guidance that do not require congressional approval.

Michael Oros, CPO, FAAOP As a result, the Trump administration has done away with some of the subsidies, shortened the insurance enrollment period, invested fewer marketing dollars in advertising the open enrollment period, and allowed for some “skimpy” new health plans. To date, the impact of some of those measures has been limited, and, in fact, approximately 8.8 million people signed up for 2018 health insurance plans on the federal exchanges run by, which is only a 4 percent decline from signups for 2017. But Oros believes the current


THE EVOLUTION OF THE ACA: Q&A With Jason Altmire O&P Almanac recently spoke with Jason Altmire, who also was a speaker at the AOPA Leadership Conference in January. Altmire served as a U.S. Representative for Pennsylvania’s 4th congressional district from 2007 until 2013, then worked until 2017 as an executive with Florida Blue, Florida’s Blue Cross Blue Shield (BCBS) company, which became a subsidiary of the GuideWell Mutual Holding Company. During his time there, he worked to ensure a successful implementation of the Affordable Care Act (ACA). Here, Altmire shares his views on the ACA and offers his opinions on the future of health care in the United States.

O&P ALMANAC: In 2010, you voted against the ACA. Why is that? JASON ALTMIRE: With all votes, I considered three things: how I felt about the bill; what was the overall view of constituents in my district; and what would be the impact of the bill on my district. With the ACA, because health care had been my career, I brought a lot of experience to the debate. In the end, I didn’t believe the bill did enough to reduce costs. Also, constituents in my district were overwhelmingly against the bill. Lastly, because my district had a high number of Medicare recipients (and Medicare was cut in the bill) and a relatively low number of uninsured, the impact of the bill would be negative in my district. All of these factors led me to vote against the bill. O&P ALMANAC: Has your opinion changed since then, given your work with Blue Cross Blue Shield? Why or why not? ALTMIRE: I do not regret my vote because I know it was the right vote for the district I was elected to represent given the facts [above]. However, I am glad the law has, by and large, worked well. Now that it is the law and millions of Americans are benefiting from it, I want the law to succeed. Certainly, some improvements can be made, but I think the law has worked well in implementation. O&P ALMANAC: During your discussion at the Leadership Conference, you said that few policy makers truly understand the intricacies of health care. How much of a factor is that in the ongoing debate?

ALTMIRE: As is the case with any issue, few members of Congress have an actual working experience and depth of knowledge with the business of health care. It impacts the debate because members and their constituents know the personal impact of health care but are less familiar with the policy and business implications. That is where the interest groups and advocacy organizations come in—to help members better understand the implications of their actions. O&P ALMANAC: How do you envision repeal of the individual mandate (i.e., penalty) in the tax law to affect the marketplace generally and the O&P sector? Do you think Medicaid expansion will ease the expected rise in uninsured? ALTMIRE: Medicaid expansion certainly makes a positive difference in states where it has been implemented. In states like Florida, where I live now, Medicaid has not been expanded and hundreds of thousands lack coverage as a result. The repeal of the individual mandate [which was enacted this year via the Tax Cuts and Jobs Act] will raise costs for those with chronic health conditions if the more healthy Americans choose not to buy insurance. The O&P sector should definitely be interested in finding ways to expand the insurance risk pool and getting as many young and healthy people to buy insurance. O&P ALMANAC: After seeing the latest news about the addition of work requirements for certain Medicaid recipients in Kentucky, do you think we will see a lot more of this in other states? What is your opinion of that type of requirement?

ALTMIRE: I think lots of states will follow Kentucky’s lead and try to impose work requirements on Medicaid. I think it is reasonable to ask recipients of public welfare programs to support the system in some way and work if they are able, but we need to make sure to not impose an unreasonable burden on those who are documented to be physically or otherwise unable to work. O&P ALMANAC: Some reports are predicting Congress may address telehealth reimbursement sometime this year. How do you think such legislation would impact the health-care environment? ALTMIRE: I believe telehealth needs to be addressed, given the explosion of new technology facilitating remote medical treatment and consultation. Health-care providers must realize that new technology should create efficiencies that lower costs, meaning less reimbursement than a standard office visit will be expected from insurers. That’s the crux of the policy debate in Congress and the states. O&P ALMANAC: We know that Essential Health Benefits, particularly the “habilitative and rehabilitative” benefits, are important to O&P patients. What possible changes to EHBs do you envision could be on the table in the future? ALTMIRE: Essential Health Benefits have been under great scrutiny since implementation of the ACA. With Democrats likely to win more seats in 2018, EHBs are likely safe and unlikely to face repeal.




atmosphere is “not disability-friendly” right now, and there may be some further impacts in the not-so-distant future. “We’re standing on the edge of a rollback of the number of lives covered,” he says. Despite the inability of Congress to pass comprehensive repeal-andreplace legislation, one significant change was made to the ACA when the Tax Cuts and Jobs Act was enacted earlier this year. A provision in that legislation repeals the individual mandate in the Affordable Care Act, which requires individuals to have health insurance or face a penalty fee of 2.5 percent of income, or $695.

Rebecca Hast

Hast has some concerns regarding the repeal. “The purpose of the individual mandate was to help create risk pools that have enough ‘well’ population to offset the ‘sick,’ and help keep premium costs reasonable,” she says. “If the assumption holds true that the ‘well’ participants are less likely to sign up if there is no mandate, then it could adversely affect the risk pool. There is some disagreement over whether that will actually happen.” The



Congressional Budget Office estimates that the absence of the mandate will result in an increase of 13 million in the number of uninsured Americans by 2027. “The repeal of the individual mandate will result in fewer healthy individuals in the overall risk pool,” agrees Oros. If that happens, “then there’s some legitimacy for insurers to raise premiums. It provides an opportunity for insurance companies to raise their premiums— and it may be justified.”

More Control by States

Perhaps the most significant changes in the U.S. health-care climate are occurring not at the federal level, but at the state level. Hast expects to see incremental changes “as states make more decisions about what will be best for their specific population and needs,” she says. “The rise in the number of Section 1332 waiver applications and programs demonstrates the current interest.” Section 1332 of the ACA permits a state to apply for a State Innovation Waiver “to pursue innovative strategies for providing its residents with access to high-quality, affordable health insurance while retaining the basic protections of the ACA,” according to CMS. Hast predicts that if the requirements of those waivers lessen compared to the original ACA

framework, “I think you will see even more control shifting to the states.” In fact, this is already beginning to happen. In January, the Trump administration approved waiver requests from Kentucky and Indiana to terminate Medicaid coverage for able-bodied enrollees who do not meet new program work requirements. Ten other states have asked to do the same. As Medicaid Administrator Seema Verma explains it, “we must allow states, who know the unique needs of their citizens, to design programs that don’t merely provide a Medicaid card but provide care that allows people to rise out of poverty and no longer need public assistance.”

Seema Verma

Reaction to work requirements in state Medicaid programs are mixed. Kenney, whose facility has several locations in Kentucky, believes the work requirements are a positive step because they may allow some additional individuals to work. “A lot of [Medicaid recipients] want to go to work. And for those patients who are concerned about the change, there are exemptions out there,” he says. Encouraging individuals to work is in alignment with O&P goals, adds Kenney. “Our profession turns our patients into taxpayers,” he says, and O&P intervention is often leveraged to transition some patients “from full debilitation to full rehabilitation.” It’s believed that Kentucky may serve as a test case for imposing work requirements. “All other states are looking to see what happens in Kentucky when this is enacted in June,” Kenney says. The requirements may affect only a small percentage of the Kentucky Medicaid population, explains Kenney, “but it just may allow them to get back to work, and the ability to have dignity and a better quality of life.”


Oros agrees that such provisions may affect only a small percentage of Medicaid recipients because the majority of enrollees are children and individuals with disabilities that prevent them from working. “I’m not sure how much such a rule will impact the specific patient population we serve,” he says. With several other states seeking similar waivers, Hast believes “we will see more ‘conditions’ put in place to maintain coverage in Medicaid. Employment, job searching, or job training are examples of some things being considered by states,” she says. “I think we will also see some additional ‘check-in’ requirements, or even a very low premium payment, to create a sense of value and ownership by the covered person. There are mixed sentiments about this. Some believe that it could have a negative effect on enrollment.” O&P professionals seeking more information on state-level changes can get involved in regional advocacy via AOPA’s state reps’ organizations, which “have been gaining momentum,” says Weber. Getting involved in the AOPA state organizations keeps members informed of the new rules and changes specific to each state. “AOPA is a resource that is providing the ability for all of our members to stay in touch,” Weber adds.

An Alternative Health-Care Delivery Model



Re-Examining the EHBs PHOTO: USA International Trade Administration, via Wikimedia Commons

AMAZON, JP MORGAN CHASE, AND BERKSHIRE HATHAWAY are teaming up to enter the health-care arena. In a January 30 announcement, Berkshire Hathaway Chairman and Chief Executive Officer Warren Buffett said that health-care costs are “a hungry tapeworm on the American economy.” The three organizations plan to create a new company with the goal of providing highquality health care for their U.S. employees at a low cost. The company will be “free from profit-making incentives Warren Buffet and constraints” and will seek to cut costs and boost satisfaction with the health-care plan, according to a news release. It’s too soon to know how the companies’ re-examination of health-care delivery may have an effect on O&P or health care in general in the future, but it’s an area to watch in the coming months. “It’s not surprising that Amazon—a tech-driven company that thrives on disruption—plus Berkshire, which has some experience in health care,” are joining forces, says Michael Oros, CPO, LPO, FAAOP, immediate past president of AOPA and president of Scheck & Siress Inc. These three companies, which account for approximately 1 million employees across the country, “obviously see some fat or value in the current delivery care model,” he says. “They want to take some of the waste out of the system. It could serve as a wake-up call to commercial insurers. If successful, they will create a model for others to follow.” Oros notes it will be interesting to see what happens when the three companies try to manage health care across the nation in what is traditionally a more “regionally driven” provision of services. “These conglomerates are trying to take health care into their own hands because they’re not happy with how our government is handling it,” notes John “Mo” Kenney, CPO, LPO, FAAOP, chair of the Amputee Coalition and founder of Kenney Orthopedics. While questions remain about what this initiative will entail and whether it will be successful, Kenney notes that the idea of Amazon venturing into pharmaceutical distribution “is something to watch.”

O&P professionals also are watching to see whether states may get a say in what are considered “Essential Health Benefits,” or EHBs. Under ACA, O&P services are required to be covered under the rehabilitative and habilitative services and devices category of the EHBs defined in the act. If any changes are made to this requirement, there could be major repercussions for some O&P patients, says Hast. Last October, CMS issued a proposed rule that would give states more flexibility in EHBs, which would take effect in 2019. O&P stakeholders “fought for core benefits [and coverage of O&P in the EHBs] in the ACA” when it was initially enacted, says Weber. “If a new federal plan comes in that is


not governing the EHBs—what may happen?” One concern is that if a revision is made to allow the states to define EHBs, coverages may change, or different payors could offer different coverages with regard to O&P benefits, says Weber. “It seems likely that states will have more control over EHBs in the future,” says Hast. “If the decision to have states more involved in decision-making, and some of the requirements of ACA are removed on plan design, there could be situations where O&P benefits are not included. And rather than looking to a federal program to define what must be included, the O&P industry would find it necessary to start working with every state where changes were contemplated. It reminds me of a time before ACA when ‘parity’ was the discussion of the day.” If states are allowed to define EHBs, Oros believes the O&P community should pay close attention to how coverage of orthoses is handled. “Noncustom orthotic coverage could find itself at greatest risk,” he says.

John “Mo” Kenney, CPO, LPO, FAAOP

Kenney, who believes that some of the changes over the past year have provided some relief from regulatory burdens associated with health care and reimbursement, does have concerns “that they may allow some waivers for EHBs that may have some effect on amputees. … There’s an underlying concern regarding whether there will be coverage for amputees.” Kenney’s concerns are personal as well as professional, as he is an amputee. “You’re opening the door to allow states the ability not to take care of our amputees.”

Keeping Focus on the Patients

O&P business owners, clinicians, and patients are celebrating their “big win” with the provision in the spending bill recognizing the orthotist’s/

prosthetist’s notes—and rightly so. This recognition has been a long time coming and will enable the O&P experts—certified orthotists and prosthetists—to document optimal care for their patients and have the documentation recognized by payors. But in the wake of this victory, O&P professionals must remain vigilant and keep up with all of the changes—and proposed changes—in the form of federal and state laws and regulations affecting U.S. health-care delivery. “O&P professionals should be aware that all of this is going on, and be willing to accept that the existing delivery model is going to change,” says Oros. “You’ve got to be willing to adapt.” If there’s one thing we can be sure of in health care today, it’s that “change is inevitable,” agrees Hast. “We’ve spent many years in O&P where things didn’t change much from year to year. But those days are over and not coming back.” Hast suggests all O&P facilities examine their practices for efficiencies and cost-management opportunities; get smart and disciplined about clinical documentation, both for pre-authorization and appeals; spend time with payors to understand how they are translating “value”; and think about the “patient experience” and what can be done to improve it. “The bottom line is we’ve got to take care of our patients,” agrees Weber, “and stay involved in advocacy

and education daily. We cannot sit on our hands and expect someone else to take care of it.” The most effective way for O&P professionals to get involved, says Weber, “is to ask, ‘What are you doing for your patients?’ Think about it from their perspective. Is it OK for you not to be aware of what’s going in the larger health-care climate to make sure your patients are getting care?” And O&P professionals should always remember that they are the “experts”—the “best ones to educate those who are making the decisions affecting our patients’ coverage and care,” says Weber. “At AOPA, we have raised the level of awareness of what we do for our patients,” he says. “O&P is a small percentage of a relatively small part of health-care delivery.” Over the past five years, AOPA and O&P professionals have “raised visibility and understanding” of O&P, and it’s imperative that these efforts continue, Weber says. “The changes in regulation will never stop. It’s our responsibility to educate our legislators and regulators, to develop relationships with our patients, payors, and legislatures. … It’s a responsibility we all have.” Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at O&P ALMANAC | MARCH 2018



How and why collecting outcome measures data now can benefit your facility—and your patients—in the future

NEED TO KNOW Many O&P patient-care facilities are implementing formal policies and processes to capture outcome measures data from their patients, particularly for lower-limb amputees. At some facilities, clinicians or other staff members are responsible for conducting several recognized tests, such as the Amp Pro/NoPro, the timed up-and-go test, and more, during patient visits. This information can be input into HIPAA-compliant databases and leveraged to generate reports and provide comparison data. Having well-documented outcome measures data may prove useful when working with payors and in streamlining the documentation process. Some clinicians predict that insurance companies and Medicare will soon require outcome measures data as part of the movement toward fee-for-value care. Another benefit of enhanced data collection is the availability of data to support O&P research efforts. Outcome measures data can be leveraged for retrospective chart review research and other types of studies, as long as the data is de-identified appropriately. Some patient-care companies that have embraced an evidence-based practice approach have encountered obstacles, such as clinicians who are reluctant to alter their appointment routines. But most clinicians come to see the benefits of such an approach. Many manufacturers already recognize the value of outcomes measure data collection. Some companies are partnering with patient-care clinics in these efforts, and others are developing tools to facilitate the data collection process.





decision to implement comprehensive procedures for outcome measures data collection happens gradually, after reading about the benefits of such endeavors or hearing about data collection activities at nearby facilities. But for Scott Sabolich, CP, owner of Sabolich Prosthetics & Research, the decision to become an evidence-based practice was made almost overnight, and it took less than two months for the facility to implement processes to measure outcomes for all lower-limb prosthetic patients. This sudden jump into outcome measures collection was driven by a seminal event. “In 2014, we suffered a minor audit of microprocessor knees,” says Sabolich. Then “we shut down until we figured out” what needed to be done to prevent audits and promote reimbursement from payors, he says. “We partnered with great minds to seek a best-case scenario to show due diligence to Medicare and to show outcomes.”

Sabolich sought to make the business “more audit-proof and to try to prove that patients are at a particular activity level,” he explains. After working closely with Ottobock— primarily with Andreas Kannenberg, PhD, executive medical director, North America, at Ottobock, and Bob Gailey, DPT—“we decided to track, from first visit on, seven different outcomes tests for each patient,” says Sabolich. Scott Sabolich, CP

PHOTO: Ability Prosthetics & Orthotics

“Now, we start with a four-hour appointment to do the proper testing and gain preapproval from our internal compliance officer before we do casting, sometimes two weeks later.” While this process has “slowed the wheels of production” a bit, Sabolich states it’s been a necessary change, resulting in much more favorable reimbursement. As of Jan. 1, 2018, Sabolich had accumulated three full years of data. Analysis of that data points to “overwhelmingly positive” patient outcomes: Sabolich reports that lower-limb prosthetic intervention has resulted in 50 percent of patients showing noticeable improvement, 25 percent showing no change, and 25 percent falling to a lesser activity level, which may be attributed to aging or comorbidities. He has turned all of the data from his facility into a research study “showing we are reducing fall risks and increasing the speed of walking, as well as the comfort level of wearing the device,” and achieving those goals at a rate that is “better than average,” according to Sabolich. These study results were presented last month during the Annual Meeting of the American Academy of Orthotists and Prosthetists.

Ability P&O's Brian Kaluf, BSE, CP, administers the functional reach test with a patient.

Not Such a Stretch

While many O&P patient-care facilities have not yet implemented formal processes to capture data from outcome measures in a meaningful way, most are at least recognizing the value of such projects. “Two years ago, maybe 10 percent of facilities were taking some sort of outcome measures,” says Sabolich. “In 2018, maybe 50 or 60 percent are doing some sort of testing.” O&P facilities are starting to understand they have an important role to play in both managing healthcare costs and educating payors about the value of O&P intervention. “Mitigating the continued rise of health-care costs is now a public priority, and the field of O&P has a valuable opportunity to contribute to these efforts,” explains James Campbell, PhD, CO, FAAOP, Hanger Clinic’s chief clinical officer. “Measuring, reporting, and comparing outcomes is perhaps the most important step toward unlocking

rapid outcome improvement for patients and making good choices about reducing costs.” James Campbell, PhD, CO, FAAOP

Fortunately, collecting outcome measures data may not be as difficult as feared—especially since all facilities already collect data as part of their regular patient intake and reimbursement processes, says Brian Kaluf, BSE, CP, clinical outcome and research director at Ability Prosthetics & Orthotics. “We already have to collect, report, and store data. We’re already capturing a patient’s insurance information and demographics, height O&P ALMANAC | MARCH 2018


and weight, functional classification level, [and] coding information,” he says. And facilities that are accredited by the American Board for Certification in Orthotics, Prosthetics, & Pedorthics (ABC) are required to conduct patient satisfaction surveys. So, collecting outcome measures just takes those efforts one step further, according to Kaluf. “Collecting outcome measures has the reputation of being an additional burden” for a facility, says Kaluf. “But from my perspective, knowing more about a patient’s functional status is much more important and useful than the other data we collect.” Brian Kaluf, BSE, CP

A Well-Defined Process

In adopting an evidence-based patient-care model, ensuring a uniform methodology—by administering the same tests at specific intervals over the course of patient care—is important. 32


“If you just say that you are going to start collecting ‘data,’ knowing you will probably need it in the future—that’s not a good approach and will not likely lead to practitioners routinely collecting data in a meaningful way,” says Kaluf. Instead, a facility should start with a strategic vision of why data collection is necessary and design processes and procedures to fulfill that mission. “We look at what goal we are trying to achieve—balance confidence or pain reduction, for example—then utilize an outcome measure that assesses that domain,” Kaluf says. At Sabolich Prosthetics & Research, clinicians follow specific steps when treating all lower-limb patients. “Every single [patient] at both the Oklahoma City and Dallas locations gets tested by one person in the facility, then our data goes to Ottobock’s number crunchers,” says Sabolich. “Because we have 12 prosthetists, it’s more efficient and more exact to have one person do all the testing.” The staff member responsible for data collection is Jordynn Brittain, medical administrative assistant, who ensures all tests are administered in a standard way for optimal data capture and comparison. So far, Sabolich has collected data from more than 3,000 patients. Brittain administers seven separate tests to capture outcome measures: the Amputee Mobility Predictor (Amp Pro/NoPro); the two-minute walk test; the 10-minute walk test; the timed up-and-go (TUG) or fourstep square test (depending on the patient’s anticipated activity level);

and three more patient-reported outcome modules, or PROMS, which are the Prosthetic Limb Users Survey of Mobility (PLUS-M), ABC test, and the EQ-5D-5L, according to Brittain. Those tests are administered at the very beginning of the evaluation of the patient, again one month after delivery, and then every six months until the patient needs a new prosthesis; then the cycle repeats itself. Those same tests are administered across the board at Sabolich, as well as at two other patient-care companies that Ottobock has “clinical partnerships” with, according to Sabolich. This effort is being overseen by Ottobock’s Kannenberg, who is driving uniformity of testing. Jordynn Brittain

Sabolich uses OPIE software to input data and generate reports. “When I’m in the room with a patient, I can pull up his or her chart, open it up, and look at all the data,” he says. The patient data also is shared with his partners at Ottobock—but only in a HIPAA-compliant format, with no patient identifying information, according to Brittain.

PHOTO: Ability Prosthetics & Orthotics

What’s more, the recent announcement that the continuing resolution/ spending bill includes a provision noting that documentation created by an orthotist or prosthetist will be considered part of the individual’s medical record “makes the quality of documentation even more important for O&P practitioners,” explains Kaluf. “This legislation creates a new opportunity for practitioners to defend themselves in the event of an audit, but it comes with a great responsibility. Now more than ever, O&P practitioners’ notes will be scrutinized even closer to test if they satisfy all medical necessity requirements and support the clinical judgement. Outcome measures are a great way to improve the quality of documentation in the O&P practitioner’s clinical notes.”

Outcome measures testing at Ability Prosthetics & Orthotics

Manufacturers Facilitate

Outcome Measures Data Collection



collection of outcome measures data, many O&P manufacturers are doing their part to promote such efforts. Brian Frasure, CP, believes that data collection initiatives are “crucial to establishing best clinical practices and running an evidence-based practice.” Frasure, who is senior clinical specialist at Ottobock Healthcare North America, suggests that all clinicians should prioritize the use of scientifically validated outcome measures to ensure they are providing the best quality of care to every patient, as well as justifying the components they select to payors. “These devices, after all, will have a huge impact on the patient’s general health and quality of life,” he says. Frasure, who has worked with several Brian Frasure, CP O&P manufacturers over the years, has seen a “general understanding in the manufacturing space for the increased involvement of these companies in supporting peer-reviewed research on the products they provide, reimbursement assistance, and patient-reported outcomes.” Ottobock has helped facilitate data collection processes in several ways. For example, the company supports independent research studies on select manufactured products. It also has designed some of the company’s high-tech products to collect various walking data. “Most of the microprocessor-driven products from Ottobock have the capability to collect some sort of walking data, such as step counts, walking velocity, types of terrain, etc.,” Frasure explains. The data generated from Ottobock’s microprocessor devices is linked by product serial number to protect patients’ identities. Data is stored electronically in protected files. Frasure says the data may be used to drive future product development and improvement as well as research studies. The company also has provided data to payors, “mainly in the form of reimbursement assistance by using published peer-reviewed studies to show functional validation of certain products,” he explains. Orthocare Innovations LLC is another company that has focused its attention on the importance of gathering outcome measures data. The O&P research and development company designs and manufactures several products

that facilitate the capture of outcomes measures, including the StepWatch (Modus Health), which captures measurable data on ambulation; the Europa+ (in partnership with SPS), which is an integrated electronic limb component for advanced prosthetics measurement, analysis, and automatic outcomes reporting; and, as PRS, the team developed the Prosthesis Evaluation Questionnaire (PEQ), a self-report questionnaire designed to measure the specific domains of interest in amputee care. The tools developed by Orthocare are designed to help clinicians “better understand the function of the patient and to provide evidence they might need for reimbursement,” according to Sarah Chang, PhD, director of research. These instruments also are useful in determining which components are appropriate for patients of different K levels, says David Boone, MPH, PhD, a prosthetist and chief executive officer for Orthocare Innovations. Currently, approval of microprocessor-controlled components is not generally made for K2 ambulators. “But these amputees could probably benefit the most from safety provided by the technology,” says Boone. “So, outcomes in those patients could help us change this illogical restriction on K2 patients.” “Our primary motivation in creating David Boone, MPH, PhD these instruments was to make it really easy for clinicians to collect and collate good data,” says Boone. Not only is such information useful in tracking patient function and integrating with patients’ electronic records but also it offers a 360-degree view of a patient, he explains. And analysis of the data has applications in designing new components, as well as in supporting new opportunities in telerehabilitation, according to Boone. Looking to the future, Boone and Frasure agree a more integrated approach to data collection may be needed, as well as collaboration across the board in standardizing the patient-care approach. “This will require a commitment from practitioners, manufacturers, and researchers to work together in order to make this happen,” says Frasure. “We need more facilities collecting pertinent data via validated measurement tools in order to create the big picture that will drive research topics and the types of future products that should be developed to best serve the users we work for.”



Tyler Cook, CPO, MPO, administers the Amputee Mobility Predictor test at Ability P&O.



same age and classification categories, Kaluf explains. Ability’s HIPAA-compliant database solution simplifies the process of data collection and report generation, according to Kaluf. “Practitioners can generate reports with the click of a button, then see the graphical representation. It’s formatted in a way that is easy to understand for multiple stakeholders—including patients, referring physicians, and occupational and physical therapists.” These graphs may show patients’ historical scores and allow space for practitioners to summarize the interpretation of the outcome measure scores. Ability clinicians can access the data and generate reports to help solve patients’ problems in real-time. Hanger Clinic has been involved in data collection for several years, according to Campbell. “The Department of Clinical and Scientific Affairs was created in 2015 because we recognized that the push toward a value-based emphasis across health

Benefits Abound

Having well-documented outcome measures data is proving useful when working with payors, particularly when questions arise, according to Sabolich. “For potential denials, we can go back and prove a patient is at a specific activity level, and prove that the type of device the prescribing physician says the patient needs is accurate,” he says. Kaluf notes that focusing on outcome measures streamlines the documentation process. Providing quantifiable and statistical data “can be more valuable to payors than several paragraphs of text,” he says. He foresees the day when insurance companies and Medicare will require outcome measures as part of the movement toward fee-for-value care, and the information his facility is amassing now provides a starting point. Ability already has more than 1,700 data points within its outcome measure aggregation. “This helps

PHOTO: Ability Prosthetics & Orthotics

At Ability P&O, the data collection process is a little different. Stakeholders redesigned company procedures in 2012 to require that each clinician collect and track specific outcome measures during lower-limb patient appointments, according to Kaluf. “We revisited how our data was entered into our EMRs [electronic medical records], and how to extract the most useful information from outcome measure scores,” he explains. Ability initially utilized its EMR software but quickly outgrew the capabilities of that system. The company also designed its own database solution to use iPads for data collection and include a dashboard that generates graphical representations of data entered. Thus, clinicians can quickly and easily compare patient scores to currently published data, and view how a patient is progressing. It’s easy to see, based on a patient’s last appointment, whether the patient is the same, better, or worse, based on his or her outcome measure scores, and how that patient compares to others in the

care would require new systems to manage and analyze health-care data, including new efforts for standardization, measuring outcomes, and understanding quality measures in orthotic and prosthetic care provision,” he says. At Hanger, data collection at the clinic level involves both administrative and clinical staff, according to Campbell, with data analyses and aggregation carried out by members of the company’s clinical and scientific affairs team. “The overall purpose is to assemble and disseminate objective evidence regarding O&P care that can be used to demonstrate the true value of what O&P professionals do and how the care we provide positively impacts quality of life,” Campbell explains. “Longitudinal data collection allows us to assess both the immediate and long-term impact of orthotic and prosthetic care and also gives us the ability to continuously monitor our patients’ mobility, satisfaction, and quality of life. The data can be used to determine definitive study areas and also to facilitate predictive analytics.”

us prepare for when payors require outcome measures in future healthcare models.” To be ready for such a transition, Ability has leveraged some of the data it has collected to simulate some of the benchmarks that Medicare is currently using to incentivize and penalize hospitals, which helps Ability executives self-assess the facility’s preparedness for the future. “We have a good idea that if MIPS [CMS’s Meritbased Incentive Payment System] was instituted [for O&P facilities] tomorrow, we know areas we would be OK in—and areas where we would need to improve,” Kaluf says. Of course, providing evidence for payors is just one reason more O&P facilities are gathering outcome measures data. O&P companies also are using the information gathered to improve the patient experience. Since Sabolich’s facility has implemented its new processes, “we can now self-reflect and compare which of our two facilities is doing better? Which clinicians are having best results? How do we compare to the national average?” Sabolich explains. Kaluf notes that information generated from outcome measure data is beneficial to both patients and clinicians—especially since Ability’s dashboards feature colorful graphs. “Data collection improves the patient experience and quality of care we provide,” he says. Kaluf also notes that the reports generated from outcome measures data collection has helped the facility benchmark clinicians’ performance. The executive team has begun using this information to offer monthly feedback to clinicians. Another benefit of enhanced data collection is the availability of data to support O&P research efforts. Just as Sabolich has pulled from his company’s data to generate the groundbreaking research presented at the Academy meeting, Ability also is leveraging its data for O&P research studies. Once a patient-care facility has amassed a meaningful amount of data, “there’s a huge potential for retrospective chart review research,”

Outcome Measures:

What to Collect?

Currently, there is no one universal management tool that can be used in the O&P profession to adequately compile all of the information needed to drive decision making. Instead, clinicians should “put in the time to educate themselves on all the validated tools available to them, and choose the ones that best represent the patient demographic of their practice,” says Brian Frasure, CP, senior clinical specialist for Ottobock Healthcare North America. Generally speaking, however, he suggests this three-pronged approach may be a good way to start:

1 Establish a detailed patient

history for every patient, which should sync with the prescribing physician’s notes.


Adopt performancebased measures to assess K level and track functional abilities over time. “The Amputee Mobility Predictor [AmpPro/AmpNoPro], six-minute walk test, timed up-and-go, and Berg balance scale are great tools to employ, and most take less than 15 minutes to administer,” he says.

explains Kaluf. A retrospective chart review protocol can be reviewed and exempted by an Institutional Review Board (IRB). Such a protocol involves accessing patient data, removing personally identifiable information, then applying statistical analysis to test a hypothesis or draw comparisons. “If you are pulling from existing data, it’s relatively straightforward to design a protocol that de-identifies the data so an IRB can decide to exempt the study. Then you are ready to apply your study analysis, write a manuscript, and submit for peer-reviewed publication,” says Kaluf. “This uses real-world data, which in certain ways is preferred for research. It’s easier to get larger sample sizes, and you don’t need to fund research assistants,


Gather patient-reported outcomes, which are crucial to understanding how certain products and techniques impact patient functionality and quality of life. “There are many great tools in this area, such as OPUS, PLUS-M, TAPES, Socket Comfort Score, PEQ, etc.,” says Frasure. so it’s less costly. With our current data collection process, we now have the autonomy to pursue the research questions that are meaningful for our practitioners and patients.” Kaluf has developed partnerships with universities and signed limited data share agreements with those entities, resulting in increased capabilities for detailed statistical analysis of the data accumulated at Ability. “We’ve collaborated with Northwestern and Latrobe Universities, and the partnership has resulted in a published article on a statistical model for predicting K levels, based on the data we collected in Ability facilities,” he says. That study, “Predict the Medicare Functional Classification Level (K level) Using the Amputee Mobility O&P ALMANAC | MARCH 2018


Predictor in People with Unilateral Transfemoral and Transtibial Amputation: A Pilot Study,” was published last year in Prosthetics and Orthotics International. At Hanger Clinic, Campbell and Shane Wurdeman, PhD, CP, FAAOP, leveraged some of the data collected at their facilities in a study that was published last year in Prosthetics and Orthotics International titled, “Mobility Analysis of AmpuTees (MAAT I): Quality of Life and Satisfaction Are Strongly Related to Mobility for Patients With a LowerLimb Prosthesis.” They conducted a retrospective chart review of the PLUS-M and the Prosthesis Evaluation Questionnaire—Well-Being Subsection (PEQ-32 WB). Analyzing the data from more than 500 patients, mobility was found to be positively correlated to quality of life and general satisfaction, as well as their arithmetic mean, according to Campbell. Studies leveraging outcome measures data, such as the ones undertaken at Ability, Sabolich, and Hanger Clinic, bring with them greater visibility of the profession, and more respect from payors and

other health-care professionals, says Sabolich. “Outcomes are a way for us to get a seat at the decision makers’ table.”

Medicare to justify a denial on your next leg, he says.

Obstacles and Opportunities

While there may come a day when a more standard approach to collecting outcome measures is required across all O&P practices, no such standard currently exists. But collecting such data now, via validated outcome measures, will position practices for success when fee-for-value becomes a reality. For now, “I think it’s healthy for different practices to collect their own battery of outcome measures based on their patients and goals,” says Kaluf. In addition, outcome measures are a critical part of patient care, says Kaluf. “The motivations for collecting outcome measures at Ability are for our own purposes and mission—to provide optimal patient care,” he explains. “Even if, somewhere down the road, requirements change and a different outcome measure is required, we are getting a value-add through what we are doing right now.” While Kaluf concedes that the practice may need to adjust its data collection methods in the future, “it’s easier to change what we’re doing than to start from nothing.” For those facilities that have not yet started collecting this type of data, it’s OK to transition slowly, says Sabolich. “Start with the AMP Pro/NoPro, then keep adding tests gradually,” he suggests. “Once you see that you will better secure your future by implementing an outcome measures process, you will want to do it.” Campbell emphasizes that size of facility should not be a limiting factor— rather, all facilities should “recognize that achieving good patient health outcomes is the fundamental purpose of health care,” and he encourages clinicians to “focus on outcomes that are meaningful to your patients.” “You are what you measure,” adds Kaluf. “If you’re not measuring quality, you’re likely not providing quality.”



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

PHOTO: Sabolich Prosthetics & Research

While implementing processes to capture patient outcomes data is important, getting support from staff members is sometimes a challenge. Sabolich was able to fast-track the transition at his facilities because he is the company’s central decision-maker. “I’m the sole owner—my facility is like a small boat with a big rudder,” he explains. “So after our audit, we decided to make a dramatic change, to stop what we were doing, and to get all of our preapprovals before we even touch a patient,” he says. Sabolich says that some of his facility’s practitioners had a harder time than others with the new procedures. “Some clinicians hated it and didn’t want to do the outcomes testing,” he says. “But others recognized that this is the future of health care—and those are the clinicians who are still with me.” Kaluf also notes that some of Ability’s clinicians were slow to adopt the changes required of their patientcare interactions once the facility began requiring collection of outcome measures. But the fact that the new processes have become part of every visit—with the “goal of reinforcing the habit each time it’s performed”—led to a smoother transition. Patients at facilities where these types of transitions have occurred have been known to push back against the procedures—especially long-time patients who are wary of change. But once patients see that these processes aid in securing reimbursement, patient buy-in follows, says Sabolich. “If we can say that you are a functional Level 3, and you’ve Jordynn Brittain works with a patient been that way for three at Sabolich Prosthetics & Research. years, then it’s hard” for

A Necessary Evolution


A Perfect Blend of Medicine and Engineering Steven A. Gard, PhD, combines his fascination with medicine and his engineering skills in his research and career achievements

For 2018, O&P Almanac is introducing individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and health-care professionals who have carried out studies and gathered quantitative and/or qualitative data related to orthotics and prosthetics, and find out what it takes to become an O&P researcher.



research, the name Steven A. Gard, PhD, should come to mind. In addition to serving as the executive director of the Northwestern University Prosthetics-Orthotics Center (NUPOC) and as an associate professor in the Department of Physical Medicine & Rehabilitation at Northwestern’s Feinberg School of Medicine, Gard also has duties as a research health scientist at the Jesse Brown Veterans Affairs (VA) Medical Center (VAMC) and as director at the Jesse Brown VAMC Motion Analysis Research Laboratory. Gard has been interested in the human body and improving how it works for as long as he can remember. “I became interested in biomedical engineering when I was a senior in high school,” in 1982, recalls Gard. “There was considerable coverage of a new artificial heart device in the news at that time, and I liked the idea of combining engineering with medicine. When I was an undergraduate student in college, I wanted to develop artificial organs for the body. However, I had a professor tell me at the time that I would probably never see implantable artificial organs in use during my lifetime.” It was at that point that Gard shifted his focus to prostheses and orthoses. During his graduate education, Gard was mentored by Dudley Childress, PhD, a former director of NUPOC and the Northwestern University Prosthetics Research Laboratory, who

instilled in Gard an appreciation for research. Childress “is highly regarded for his work with myoelectric control in upper-limb prostheses, and he was just beginning to develop interest in lower-limb prostheses when I entered his laboratory, about 30 years ago,” says Gard. He also “had an intense passion for O&P research that fostered my interest in the field.” For Gard’s master’s project, he investigated the feasibility of using strain gauges for applications in upper-limb prostheses. “Strain gauges have many distinct advantages for use as a sensor, but they typically utilize too much power for long-term application in battery-powered prostheses,” he says. O&P ALMANAC | MARCH 2018



“Therefore, I developed low-powered circuitry that would enable strain gauges to be used in upper-limb prostheses for extended periods of time.” When it came time to develop a doctoral research project, Gard began investigating issues pertaining to foot clearance in transfemoral prosthesis users, again under the guidance of Childress. “Additionally, though, I was fortunate to collaborate on one aspect of my research project with Jack Uellendahl, CPO, who exposed me to the clinical side of P&O,” Gard recalls. “Jack identified a clinical question about four-bar linkage knees that I was able to tackle with my engineering skills. It was through that experience that I first recognized the value of clinical input and collaboration on addressing research problems.”

Roles and Responsibilities

Over the past three decades, Gard has published many O&P papers and spoken at countless conferences on O&P-related research topics. Through the years, he has been able to count on the support of his wife of 32 years, Kristin, and his two children, Nathaniel and Chelsea. As the current executive director at NUPOC, Gard has administrative responsibilities over both research and education, “though I tend to focus more on the research side,” he says. His research responsibilities include writing and submitting grant proposals to obtain funding to support research efforts, managing research studies and personnel involved in those projects, and disseminating research findings through presentations at professional conferences and publishing in scientific journals. He also teaches classes to engineering students at Northwestern University on O&P-related topics, and teaches O&P students on the topic of “research methods.” In addition, Gard advises graduate engineering students on their research projects for the master’s and PhD degrees. In his position as a research health scientist with the Jesse Brown VA Medical Center, Gard applies for and receives funding from the VA Rehabilitation Research and 38


Development Program. “The VA has a long history for supporting prosthetics- and orthotics-related research, particularly as it relates to the needs of veterans,” he says. When he’s not hard at work on one of his many research O&P projects, Gard enjoys spending time in one of his favorite activities, deer hunting. “I grew up in rural southern Missouri, so I developed a love of hunting and fishing at an early age,” he says.

Wide Array of O&P Interests

Throughout his career, Gard has studied many aspects of O&P, including prosthetic feet, knees, shock-absorbing components, sockets, liners, ankle-foot orthoses, knee-ankle-foot orthoses, and reciprocating gait orthoses. “I am very interested in how these different technologies affect gait biomechanics, so I typically use quantitative gait analyses to learn more about how the functions of gait are affected,” he says. One of his most significant studies involved investigating the effects of prosthetic ankle units on bilateral lower-limb amputees. “Up until that time, there were no published studies reporting quantitative gait data on that particular population, much less looking at the effects of different prosthetic interventions,” Gard recalls. “We recruited 19 bilateral transtibial and four bilateral transfemoral prosthesis users to participate, and ended up publishing several papers on normative gait data for this population, differences in gait characteristics when delineated by amputation etiology, and the effects of prosthetic ankle motion on gait biomechanics.” Gard also has focused some of his research on the topic of shock absorption during ambulation. “I began by investigating the effects of shock-absorbing pylons (SAPs) in transtibial amputees, a study that we published in 2003. Unfortunately, we really didn’t observe much effect during gait when subjects walked with and without the SAPs, but that finding was pretty consistent with those of others performing similar studies at the time,” he says. He found the lack of an observed response to be “intriguing, suggesting

that something else may be going on with subjects while walking with SAPs.” A few years ago, Gard and his team followed up on this topic and conducted a similar study with transtibial amputees, “but we reduced the stiffness of the SAP considerably, with the thought that we would induce considerable shock absorption,” he says. “However, the gait data still failed to indicate a biomechanical response. Therefore, we performed impact testing with research subjects by dropping them onto a force plate and measuring peak forces generated under their prosthesis. Surprisingly, there were no differences in the peak forces when the stiffness of the SAP was varied. Eventually, we figured out that the primary shock absorption was occurring in the soft tissues at the residual limb/prosthetic socket interface, a finding that we reported in one of the publications on the study.” At the moment, Gard is continuing to look at shock absorption in the gait of prosthesis users. “I have some new ideas for providing shock absorption through improved mechanism designs that I would like to pursue, but first I have to get the grant funding to conduct the study,” he says. Gard also is looking at how to best distribute prosthetic stiffness between the ankle and foot keel in transtibial amputees in order to optimize both standing and walking performance. Gard’s team recently received a grant from AOPA to investigate the effects of a hydraulic foot-ankle component on standing and walking in K-2-level


ambulators, which has not been previously investigated, he says. “At NUPOC, we tend to focus on clinically relevant problems that are commonly identified and observed by both practitioners and P&O users, so continued communication and collaboration with prosthetists and orthotists is essential,” he says.

Power of Partnerships

Much of the work Gard does is funded by grants through such agencies as the VA; the National Institute on Disability, Independent Living, and Rehabilitation Research; the National Institutes of Health; and the Department of Defense. “We also apply for smaller grants through AOPA and the Orthotic and Prosthetic Education and Research Foundation,” he says. In addition, some of his studies are supported by industry, notably O&P manufacturers. “We have good working relationships with many O&P manufacturers on previous and current research projects,” Gard says. When partnering with manufacturers, “I think we often share similar concerns about product efficacy and approach the research with a number of common questions.” Gard’s team sometimes partners with companies on research proposals “that can be mutually beneficial to everyone involved. “Even if we don’t formally partner

with manufacturers, we may end up utilizing their products for our investigations,” he says. “In those cases, we still work to establish good relationships with the companies and rely on their expertise to facilitate our research. I like to think that manufacturers rely on laboratories like ours to provide the O&P field with objective assessments of their products and help them refine and improve upon their current technologies.”

Looking Forward

As the O&P profession marches ahead with ever-advancing technologies, Gard continues to enjoy all aspects of his work, and says he particularly enjoys working with young people on their research projects. “I have mentored many master’s and PhD students in biomedical engineering, and recently I have had the privilege of advising a number of MPO students on their capstone projects,” he says. “It’s thrilling to interact with these individuals and share new discoveries with them.” Gard notes the importance of training future and current practitioners to be better consumers of research, even if they don’t intend to conduct research full time. “As researchers, we have a responsibility to translate new knowledge about research

findings to practitioners in a palatable form, through both presentations at conferences and publications in scientific journals that are geared specifically to the P&O professional.” Looking to the future, Gard believes the most pressing questions in the field relate to the interface between a prosthesis or orthosis and the user. “Solutions to these problems will involve the development and evaluation of new technologies, such as subischial transfemoral sockets; the improved manufacture of these custom interfaces, such as using 3-D printers; or the evaluation of completely new types of suspension systems, such as osseointegration. There is a lot of good research that needs to be conducted in these areas to substantially advance the field.” Gard also emphasizes the importance of O&P research in providing scientific evidence to support clinical decision making and to justify reimbursement by third-party payors. “Through our research studies, we aim to fill many of the gaps that currently exist in the scientific knowledge base,” he says. “I sincerely hope that this type of evidence can be used to optimize fitting procedures and justify the prescription of prosthetic and orthotic devices in order to provide individuals with the highest quality of life possible.”

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Munger Prosthetics and Orthotics Inc.


Patients First in the Last Frontier Alaska facility sees patients from remote locations





Munger Prosthetics and Orthotics’ main office in Anchorage, Alaska In part because he is an upper-limb amputee, Munger was FACILITY: an early adopter of CAD/CAM Munger Prosthetics technology. “Having only one and Orthotics Inc. arm, it really helped with efficiency,” he says. The company LOCATION: routinely uses CAD/CAM Anchorage, Fairbanks, scans for prostheses, although clinicians still rely on traditional and Wasilla, Alaska casting methods for orthoses. OWNERS: The Alaskan environment can Trevor Munger, CPO be tough on practitioners and patients alike, Munger observes. He personally uses a bodyHISTORY: powered prosthesis, for example, 14 years instead of a more expensive myoelectric device. “You have to factor in the weather,” Munger says. “You can have temperature swings from 90 above to 60 below—and a lot of high-end microprocessors don’t do well in really low temperatures.” Patients, too, have to deal with Alaska’s realities. Munger’s patients sometimes fly in from remote interior locations that might require two separate flights, nine hours of travel, and overnight accommodations. Munger travels throughout the state as well. “We’ve flown out to Patient Judith Abrahams do prosthetic fittings as far north enjoys the Alaskan lifestyle. as Barrow and as far south as

Deborah Conn is a contributing writer to O&P Almanac. Reach her at

PHOTOS: Munger Prosthetics and Orthotics Inc.

distances and extreme temperatures, offers unique challenges to an O&P clinician like Trevor Munger, CPO, president and owner of Munger Prosthetics and Orthotics. Munger serves a diverse Alaskan population, including patients with diabetes and victims of traumatic amputations. “We treat the full range of ages, including quite a bit of work with veterans and active-duty military,” Munger says. “We also have a large diabetic population—in prosthetics, that’s our largest demographic.” The main Anchorage office, with about 4,100 square feet and three exam rooms, employs two practitioners—Munger and Brian Johnson, CPO—and two administrative staffers. The company also has two satellite offices, one in Fairbanks and another in Wasilla. The company provides a full range of state-ofthe-art prostheses and orthoses. Munger, born in Alaska, is a transhumeral amputee who developed an early interest in O&P after being treated at the Shriner’s Hospital for Children in Portland, Oregon. He studied at the University of Washington, where he graduated from the Prosthetic and Orthotic Division of Rehabilitative Medicine in 1995. He completed his professional O&P education and certifications while working for two O&P companies in California before returning to Alaska, where he founded Munger P&O in 2004.

Juneau—and there are 1,100 miles between the two,” he says. Gathering complete medical documentation can be a challenge for patients who live in remote areas. Some of the clinics making referrals, Munger notes, may have a physician who visits only once a month. Like many O&P practices, Munger finds that compliance issues can be daunting—a task he shares with the office manager. The company’s implementation of electronic medical records, he says, has helped improve efficiency and care. Munger regularly attends continuing education courses. For marketing, he relies on word of mouth as well as direct communication with referral sources. Munger is eager for the company to grow—but in a cautious and carefully planned manner. He also is sensitive to the varied needs of his patients, both as a professional and as the parent of a son with special needs who uses specialized orthoses. “Our field is important to me because I can relate firsthand to what we bring to our patients,” he says. “I can empathize with them because our family goes through that every day.” In the end, he says, Munger P&O works to keep its products and services up to a level that will meet the demands of the Alaskan lifestyle.

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Anatomical Concepts Inc.


Orthotics Innovator Ohio manufacturer offers orthoses and a ‘launchpad’ to explore new ideas





Deborah Conn is a contributing writer to O&P Almanac. Reach her at

PHOTOS: Anatomical Concepts Inc.

had its origins in an unmet need. In 1990, William DeToro Sr., CO, LO, then co-owner of patient-care facility Youngstown Orthotic Prosthetic Laboratory Inc., had a challenging request for an early-stage ankle-foot orthosis (AFO) that would offload the patient’s heel, reduce heel ulcerations, and aid with related conditions like drop foot. DeToro investigated and found nothing suitable so he decided to design his own AFO. The resulting product, the PRAFO orthosis, is an adjustable modular AFO system that incorporates an adjustable aluminum single posterior upright that can be used to manage multiple lower-extremity conditions for ambulatory and nonambulatory patients. “Initially, my father did a lot of lecturing at national and state meetings, and things took off from there,” says William DeToro Jr., CPO, LPO, the company’s president. “Colleagues appreciated the PRAFO’s quality and versatility—a modular design that can fit a whole range of patient sizing. That means you don’t have to keep multiple sizes and can hold down inventory costs.” The PRAFO’s success led to the creation of Anatomical Concepts Inc. The company, based in the township of Poland, Ohio, outside Youngstown, provides a wide range of prefabricated and custom-fitted orthotic devices based on PRAFO technology. Its clients include O&P practitioners, hospitals, and physical therapy and rehab clinics around the world. Anatomical Concepts is primarily

a family owned and operated business, which includes Andrea DeToro Rupeka, DeToro Jr.’s sister, as vice president of production, and Lindsay DeToro, another sister, as marketing director. Anatomical Concepts does not use PVC plastics in its products, says DeToro Jr., out of concern for the negTop: Anatomical Concepts team members ative health effects of who assemble and produce products; bottom: William DeToro Sr., CO, LO outgassing when such materials are heated COMPANY: for shaping and adjustment. Anatomical Hospitals, moreover, must guard Concepts Inc. against latex and related allergies. DeToro Jr. got an early start in LOCATION: the industry. In high school, he Poland, Ohio spent time cleaning and serving as an apprentice orthotist at OWNERS: his father’s patient-care facility, William DeToro Sr., which eventually was sold to CO, LO; William the Hanger Corp. He studied at DeToro Jr., CPO, Youngstown State University LPO; Andrea DeToro and Northwestern University, earned his O&P certifications, Rupeka; Lindsay DeToro; and Elizabeth and worked as a practitioner with Hanger before joining his father (James) Mancini at Anatomical Concepts in 2004. The company’s facility comprises HISTORY: approximately 18,000 square feet 28 years and employs about 20 people, some full time, others part time or seasonal. DeToro Jr. and other company executives regularly attend major national meetings and remain active in organizations such as AOPA and the American Academy of Orthotists and Prosthetists. “We’ve also really ramped up our online presence to William DeToro Jr., CPO, LPO, president of educate colleagues and patients,” Anatomical Concepts DeToro Jr. says, although he Inc., fits an offloading/ realigning knee brace. continues to value the opportunity

to talk directly with patients. In recent years, the industry has become even more competitive, he notes, making it vital to hold the line on costs while paying close attention to quality. One of the company’s newest products is the ELLIOTT, a prefabricated adjustable lower-limb orthotic system designed to prevent or minimize impairments and maximize function in a variety of acute and nonacute rehabilitation settings, according to DeToro Jr. “The idea was to have an orthosis immediately available to rehab patients,” he says. A big asset of the ELLIOTT system is its versatility, with 11 different diagnostic gait tuning options that the clinician can employ to treat a patient. The company also offers inventors and clinicians an opportunity to create and fabricate their own designs— just as DeToro Sr. did nearly three decades earlier—through the company’s new Product Launchpad operation, created with a local patent attorney. Product Launchpad offers O&P clinicians or other medical professionals the opportunity to explore their ideas for innovative orthotic products, whether completely new or as a variation on an existing device. “It’s a way to welcome innovators,” says DeToro Jr. “If they come up with an idea and don’t have the time or resources to develop it, we can do market research and use our R&D department to see if the product is worthwhile. We’ve had a good handful of people with viable ideas who have at least come up with a prototype.” Anatomical Concepts—which itself has designed, patented, and marketed more than 20 orthotic devices—is confident it can continue to serve as model of innovation.

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Here’s where you’ll find the best “Coding 101” webinar you could ask for. Take part in the May 9 webinar to learn the background and basics regarding the all-important L-code system you use everyday. AOPA experts will address the following important topics: • History of the L-code system • How new codes are created • Basic tenets of code selection • “Base” codes vs. “Addition” codes.

Are you maximizing your cash flow and staying up-to-date with accounts receivable (AR)? Plan to participate in the April 11 webinar to access tips and suggestions from AOPA experts on these key topics: • General concepts of AR collection • Basic strategies for AR improvement • When to ask for outside help • How and when things can be written off (co-pays, deductibles, etc.).

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 Contact Ryan Gleeson at or 571/431-0876 with questions.

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O&P PAC Update

The O&P PAC Update provides information on the activities of the O&P PAC, including the names of individuals who have made recent donations to the O&P PAC and the names of candidates the O&P PAC has recently supported. The O&P PAC recently received donations from the following AOPA members*: • Ryan Arbogast • George Breece The purpose of the O&P PAC is to advocate for legislative or political interests at the federal level, which have an impact on the orthotic and prosthetic community. The O&P PAC achieves this goal by working closely with members of the House and Senate, and other officials running for office, to educate them about the issues, and

help elect those individuals who support the orthotic and prosthetic community. To participate in, support, and receive additional information about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online: forms/op-pac-authorization, or contact Devon Bernard at You also may complete and return the authorization card at the bottom of this page. *Due to publishing deadlines this list was created on Feb. 15, 2018, and includes only donations/contributions made/ received between Jan. 1, 2018, and Feb. 15, 2018. Any donations/ contributions made or received on or after Feb. 15, 2018, will be published in the next issue of the O&P Almanac.

O&P PAC Authorization I authorize the O&P PAC to share information with me, executive, administrative, and professional personnel associated with the company designated by me below. Name: __________________________________________________________________________ Company: _______________________________________________________________________ Address:_________________________________________________________________________ Telephone: ______________________________________________________________________ Email: __________________________________________________________________________ AOPA must obtain the signature of a corporate officer, or a person that can authorize for their company. Signing multiple dates eliminates the need to contact you for authorization approval in upcoming years and reinforces your commitment to the O&P PAC. 2018____________________________________________ 2019____________________________________________ 2020____________________________________________ As required by federal law, my company has not authorized a federal PAC solicitation by another trade association during any calendar year in which this “authorization” is granted to O&P PAC. Signing this card in no way obligates me or others to contribute; it just gives them the opportunity to do so.



Return completed form to: AOPA Attn: O&P PAC 330 John Carlyle Street, Ste. 200 Alexandria, VA 22314 Or fax to: 571/431-0899


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


- Inter-Mountain


- Pacific

Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an official member of AOPA if, within 30 days of publication, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership. At the end of each new facility listing is the name of the certified or state-licensed practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or state-licensed practitioner to be eligible for membership. At the end of each new supplier member listing is the supplier level associated with that company. Supplier levels are based on annual gross sales volume. Fior & Gentz GmbH Dorette-von-Stern-Strase 5 Lüneburg, D-21337 Germany Member Type: International +44313124445 Cornelia Schultheis

Singular Prosthetics and Orthotics 918 Bellows Road Hartsel, CO 80449 Member Type: PatientCare Facility 303/396-9557 Lara Knudson, CPO

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 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.


Certified Prosthetic/Orthotic Clinicians

Albuquerque and Santa Fe, New Mexico Advanced Prosthetics and Orthotics is currently seeking skilled, dedicated, and hard-working ABC-certified prosthetic/orthotic clinicians for our Albuquerque and Santa Fe offices. CPOs and COs must possess a strong clinical background as well as provide quality and compassionate care. We offer competitive salary; medical, dental, vision, and retirement options available. Email:






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Coyote Design Adhesives

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

LEAP Balance Brace

We now have two glues to choose from. • Coyote Quick Adhesive—30-second set time. • Coyote Smooth Adhesive—new 60-second set time option. Coyote’s glues are great for attaching componentry and multiple repairing uses. They ship nonhazardous and are safe with no odor. For more information, contact Coyote Design at 208/429-0026 or visit


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Hersco’s Lower-Extremity Ankle Protection (LEAP) brace is designed to aid stability and proprioception for patients at risk for trips and falls. The LEAP is a short, semirigid ankle-foot orthosis that is functionally balanced to support the foot and ankle complex. It is fully lined with a lightweight and cushioning Velcloth interface, and is easily secured and removed with two Velcro straps and a padded tongue. For more information, call 800/301-8275 or visit

Ottobock’s ProFlex™ Plus Sealing Sleeve Countdown to flexibility for you and your patients with Ottobock’s ProFlex™ Plus Sealing Sleeve • Three colors and sizes • Two lengths • Number one choice. ProFlex Sleeves—delivering proven performance for the last 10 years. This soft, yet tough, sealing sleeve is designed with a more flexible fabric and smoother proximal seam. It features 15 degrees of flexion for easier bending and less bunching behind the knee; a preformed knee cap for lower stress on the patella; and a conical shape proximal for improved thigh fit and tighter distal shape for enhanced sealing on socket. Check out for details.

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

Iceross Seal-In X Options Introducing the new Iceross Seal-In X-Classic, Seal-In X-Volume, and Seal-In X-Grip movable seals. For use with the Seal-In X and Seal-In X TF liners, these seals feature an improved textile donning aid and Easy Glide low-friction coating, making donning the socket easier without the use of alcohol or lubricant spray. Improve your patients’ skin and limb health, control volume, and reduce pistoning and rotation. Seal-In X provides personalized, optimal fit and secure suspension. Recommended for use with Unity sleeveless elevated vacuum for excellent volume control and suspension, with minimal added weight and no added build height. Ask your Össur rep about a demo today! For more information, contact Össur at 800/233-6263 or visit

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

2018 AOPA Coding Products Get your facility up to speed, fast, on all of the O&P Health-Care Common Procedure Coding System (HCPCS) code changes with an array of 2018 AOPA coding products. Ensure each member of your staff has a 2018 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors. • 2018 Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers • 2018 CodingPro CD-ROM (single-user version): $185 AOPA members, $425 nonmembers • 2018 CodingPro CD-ROM (network version): $435 AOPA members, $695 nonmembers • 2018 Illustrated Guide: $185 AOPA members, $425 nonmembers • 2018 Quick Coder: $30 AOPA members, $80 nonmembers. Order at or call AOPA at 571/431-0876.





April 11

Enhancing Cash Flow & Increasing Your Accounts Receivable. Register online at For more information, email Ryan Gleeson at WEBINAR

March 7-8

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

April 26-28

New York State Chapter Annual Meeting (NYSAAOP). Rivers Casino & Resort, Schenectady, NY. For more information, visit

March 12-17

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

March 14

Medicare Coding Guidelines: MUEs, PTPs, PDAC, and More. Register online at For more information, email Ryan Gleeson at WEBINAR

April 30 – May 1

2018 Mastering Medicare: Essential Coding & Billing Seminar Coding & Billing Techniques Seminars. San Antonio, TX. Register online at For more information, email Ryan Gleeson at

May 1

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

May 4-5

April 1

ABC: Practitioner Residency Completion Deadline for May Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email, or visit

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

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Phone numbers, email addresses, and websites are counted as single words. Refer to 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 along with VISA or MasterCard number, the name on the card, and expiration date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit calendar listings for space and style considerations.





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

May 9

Coding: Understanding the Basics. Register online at For more information, email Ryan Gleeson at WEBINAR

September 26-29

AOPA National Assembly. Vancouver Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0876 or, or visit

October 10

Year-End Review: What Should You Do To Wrap Up the Year & Get Ready for the New Year? Register online at For more information, email Ryan Gleeson at WEBINAR

October 18-20

May 18-19

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

June 13

Audits: Know the Types, Know the WEBINAR Players, and Know the Rules. Register online at For more information, email Ryan Gleeson at

July 11

Administrative Documentation: WEBINAR The Must Haves and the Sometimes Needed. Register online at For more information, email Ryan Gleeson at

July 13-14

PrimeFare East Regional Scientific Symposium. Hilton Downtown Nashville. Contact 888/388-5243 email, or visit 20th Anniversary of PrimeFare East!

July 23-24

2018 Mastering Medicare: Essential Coding & Billing Techniques Seminars. St. Louis, MO. Register online at For more information, email Ryan Gleeson at Coding & Billing Seminar

August 8

Outcomes & Patient Satisfaction Surveys. Register online at For more information, email Ryan Gleeson at WEBINAR

International African—American Prosthetic Orthotic Coalition Annual Meeting. Embassy Suites Downtown Medical Center, Oklahoma City, OK. For more information, contact Tony Thaxton Jr. at 404/875-0066, email, or visit

November 4-10

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

November 12-13

2018 Mastering Medicare: Essential Coding & Billing Techniques Seminars. Las Vegas. Register online at For more information, email Ryan Gleeson at Coding & Billing Seminar

November 14

Evaluating Your Compliance Plan & Procedures: How To Audit Your Practice. Register online at For more information, email Ryan Gleeson at WEBINAR

December 12

New Codes, Medicare Changes, & Updates. Register online at For more information, email Ryan Gleeson at WEBINAR

2019 September 25-28

September 12

Medicare As a Secondary Payor: WEBINAR Knowing the Rules. Register online at For more information, email Ryan Gleeson at

AOPA National Assembly. San Diego Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0876 or, or visit




Billing Skills Who’s responsible for payment when patients are in a skilled nursing facility?

AOPA receives hundreds of queries from readers and Q 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

Hospital? or


If an item is ordered in a hospital but delivered in a skilled nursing facility (SNF), who is responsible for payment?


The answer depends on the type of item being delivered. If the item in question is a customfabricated orthosis or prosthesis, then the hospital is responsible for payment. However, if the item in question is a prefabricated orthosis or prosthesis, then the SNF would be responsible for payment.


If I begin fabrication on an item and then, when I go to deliver it, the patient is in an SNF, can I still deliver it? If so, who is responsible for payment?


Yes, you may still deliver the item, but responsibility for payment depends on whether the item was custom fabricated or prefabricated. If the item was custom fabricated, you may bill Medicare, but your date of service will not be your delivery date; instead, you must use your start date.




If the item is prefabricated, then you must bill the SNF, and all other SNF billing rules would apply (e.g., the exclusion of certain prosthetic codes). Are orthoses and prostheses exempt from the Outpatient Prospective Payment System (OPPS) for emergency rooms?


Yes, orthoses and prostheses are exempt from the OPPS, and you may bill Medicare for services provided in an emergency room setting. However, be aware that if the patient is admitted to the hospital, then the patient and your claim would be subject to standard hospital billing rules; and you would need to seek payment from the hospital.


If the patient is in a home health episode, do I need to submit my claim with a special modifier to receive payment?


No. The only modifiers you must use are the standard modifiers: LT, RT, KX, GA, etc.


AOPA Coding Experts Are Coming to

San Antonio April 30-May 1


ESSENTIAL CODING & BILLING TECHNIQUES SEMINAR Join AOPA April 30-May 1, in San Antonio to advance 14 CEs 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-todate 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


FEB. 26-27 | 2018

Top 10 reasons to attend: 1. Get your claims paid. 2. Increase your company’s bottom line. 3. Stay up-to-date on billing Medicare. 4. Code complex devices 5. Earn 14 CE credits. 6. Learn about audit updates. 7. Overturn denials. 8. Submit your specific questions ahead of time. 9. Advance your career. 10. AOPA coding and billing experts have more than 70 years of combined experience.

The San Antonio Marriott Riverwalk 889 E Market St San Antonio, TX 78205

Book your hotel by April 6 for the $179/night rate.

Find the best practices to help you manage your business.

Participate in the 2018 Coding & Billing Seminar!

Register online at

For more information, email Ryan Gleeson at .

Cyberspine TLSOx4 Universal sizing now available

Easy to don and doff

Universal sizing reduces inventory and overall costs Tool free adjustment and low-profile design

14541 - 1/18 Š2018 Ottobock HealthCare, LP, All rights reserved.

Patented Mechanical Advantage Pulley System maximizes spinal stabilization and abdominal compression

March 2018 O&P Almanac  
March 2018 O&P Almanac