May 2018 O&P Almanac

Page 1

The Magazine for the Orthotics & Prosthetics Profession

MAY 2018





Preview Performant's Upcoming Audits P.16

Tips for Treating Pregnant Patients




Improving Mobility at Vanderbilt's CREATE Space P.40

Understanding Advance Beneficiary Notices P.60


This Just In: Planning Underway for Health-Care Compliance & Ethics Week P.20







tio forma ore in For m pp.12 & 49 see



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.


MAY 2018 | VOL. 67, NO. 5

22 | Smart Marketing The most effective O&P marketing strategies are individualized to fit a facility’s geography, patient base, referral sources, and competition. Learn how to craft a tailored marketing campaign by defining your brand, identifying your audience, developing content, and determining the delivery channel. Plus, hear from marketing experts who share their facilities’ success stories—from community building to educational seminars to social media initiatives, and more. By Christine Umbrell

PHOTO: Julian Huarte Photography

This Just In 20 | A Toolbox for Ethical

O&P Workplaces

O&P facilities are gearing up for the 2018 Health-Care Compliance & Ethics Week, scheduled for November 4-10. This dedicated time period offers facilities a chance to create, revamp, or promote their compliance programs. AOPA offers several tools to facilitate the celebration, including press releases, daily compliance messages, webinars, and more.



PHOTO: Reach Orthotic and Prosthetic Services



32 | What To Expect When Your Patient’s Expecting

Pregnant patients experience changing body issues that can affect their orthotic or prosthetic needs. Clinicians should be proactive in assisting patients through their pregnancies, both physically and emotionally, by adjusting the fit of devices, providing new componentry when warranted, offering appropriate orthotic devices, and explaining what patients can expect as their due dates draw near. By Christine Umbrell



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PRINCIPAL INVESTIGATOR Karl E. Zelik, PhD ................................. 40

The co-director of the Center for Rehabilitation Engineering & Assistive Technology at Vanderbilt University discusses the future of prosthetics and orthotics and explains his belief that “mobility is livelihood.”

DEPARTMENTS Views From AOPA Leadership..........5 AOPA Board Member Dave McGill discusses AOPA’s influence on coding decisions

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

Upcoming RAC Audits

A detailed look at the orthoses under review by Performant CE Opportunity to earn up to two CE credits by taking the online quiz.


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


Cascade Dafo Dynamics Orthotics & Prosthetics


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

AOPA News.............................................. 48 AOPA meetings, announcements, member benefits, and more

PAC Update............................................... 53 Welcome New Members................... 53 Careers.........................................................54 P.44

Professional opportunities

Ad Index...................................................... 55 Marketplace..............................................56 Calendar......................................................58 Upcoming meetings and events

Ask AOPA.................................................. 60 P.46



Appropriate use of Advance Beneficiary Notices


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

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

AOPA’s Lead on Coding Issues


CPCS. PDAC. CMS 1500. These are not acronyms that send people’s

hearts racing with excitement. The world of coding is confusing, mechanical, and devoid of the compelling storylines that make patient care and groundbreaking technological advances so interesting. But the L codes and the Health-Care Common Procedure Coding System (HCPCS) coding system are undeniably important. By placing a monetary value on the devices and care provided by O&P professionals and, by extension, dictating what amputees and others with mobility impairments have to pay out of their own pockets, L codes are arguably the pumping heart that powers the patient-care and product manufacturing body. Thus, keeping that heart healthy and strong is essential to the future of O&P. And AOPA is committed to doing that. Last year, we saw Performant Recovery, the new Region 5 recovery audit contractor (RAC), publish a new audit issue affecting mechanical knees that would have (a) fundamentally reshaped how O&P professionals have consistently understood and interpreted L5845 and (b) given Performant the ability to apply a new interpretation of that code retroactively, which could have had devastating financial consequences for O&P facilities across the United States. AOPA immediately reviewed Performant’s statement of work and determined that the company was operating outside of the guidelines in that document. AOPA notified the RAC’s medical director and worked with the O&P Alliance to elevate the issue to CMS. Less than a month later, Medicare issued a statement acknowledging that the audit issue had not gone through the appropriate channels for approval, and it disappeared from Performant’s website—ensuring that O&P facilities would not be audited for that reason. Fast-forward to 2018, and AOPA continues to protect O&P companies from adverse coding changes. AOPA provided extensive comments to and met with CMS officials when proposed changes to the code describing directmilled inserts threatened to result in a reimbursement cut and set a dangerous precedent penalizing technological innovation. The result of those efforts? The reimbursement for that code remains unchanged today, an outcome that at the beginning of that debate seemed remote at best. Similarly, AOPA continues to fight for an appropriate definition of “minimal self-adjustment” for off-the-shelf orthoses by relentlessly fighting to get the Medicare O&P Improvement Act passed into law. Coding isn’t fun. It’s not sexy. But if we don’t focus on it, everyone— manufacturers, clinicians, and patients—will suffer. AOPA will continue to work tirelessly to make sure that it protects its members and the people they care about moving forward. Dave McGill is a member of AOPA’s Board of Directors and the 2018 AOPA National Assembly Business Education Workgroup.




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, Betty Leppin, manager of member services and operations, 571/431-0810, Yelena Mazur, communications specialist, 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/Khongtham

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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Women’s Health Trends Nonelderly women report increases in health-care coverage since ACA implementation

The number of women in the United States covered by health insurance has risen since the Affordable Care Act (ACA) was enacted in 2010 and fully implemented in 2015. But women are still more likely than men to delay or forgo health-care services, according to a new report from the Kaiser Family Foundation, “Women’s Coverage, Access, and Affordability: Key Findings From the 2017 Kaiser Women’s Health Survey.” The report features the findings of a survey of women ages 18 to 64 regarding their coverage, use, and access to health-care services.

45 Percent


Approximate number of nonelderly women uninsured in 2017


26 Percent

28 Percent

Do not take any medication on a regular basis

1 in 10

1 in 5

Approximate number of nonelderly women uninsured before ACA took effect

Delayed or went without care in past 12 months, compared to 19 percent of men

Take one or two medications on a regular basis

25 Percent

Reported problems paying medical bills, compared to 17 percent of men

15 Percent

Take three to five medications on a regular basis

20 Percent

11 Percent

31% 69%



The uninsured rate has dropped significantly since implementation of the ACA was completed in 2015. 2013

Private Insurance


Medicaid Uninsured

Insured Part of the Year/Other SOURCE: HCUP Nationwide Inpatient Sample, Healthcare Cost and Utilization Project. Rockville, MD: Agency for Healthcare Research and Quality; data from 2014. *Due to rounding, numbers may not add to 100 percent.



3.1 Million


WOMEN WITH LIMB LOSS Nearly one third of amputation patients are women

Number of women with diagnosed diabetes, compared to 11.3 million men

Number of women with undiagnosed diabetes, compared to 4.0 million men

Skipped a recommended medical test or treatment, compared to 15 percent of men

Take six or more medications on a regular basis

11.7 Million

9% 14% 18% 12% 7% 12%

66% 62%

SOURCE: “Women’s Coverage, Access, and Affordability: Key Findings From the 2017 Kaiser Women’s Health Survey,” Kaiser Family Foundation.

SOURCES: “Women’s Coverage, Access, and Affordability: Key Findings From the 2017 Kaiser Women’s Health Survey,” Kaiser Family Foundation; HCUP Nationwide Inpatient Sample, Healthcare Cost and Utilization Project; “National Diabetes Statistics Report, 2017.”



Happenings TECH TALK

Veterans Test Gait-Focused Audio App ReLoad, an app designed by a team of researchers at the University of Miami Schools of Medicine and Music, is being tested by amputee veterans at the U.S. Department of Veterans Affairs in Miami and at the Walter Reed National Military Medical Center in Bethesda, Maryland. The app was developed to provide audio feedback regarding gait to users in real time. Study participants have been asked to put sensors on their legs, their prostheses, and their lower backs when they walk or exercise. The sensors sync up with the app, which is designed to help users increase awareness of their body position and the way they are walking. The app also leverages music therapy to assist users in improving their gait. Amputees can listen to songs while practicing walking, and will hear a “warp” in the music when they are not walking evenly, as well as suggestions to improve their gait. “It will give you automatic commands to tell you how to improve, just like you were at the physical therapy clinic,” said Robert Gailey, PhD, PT, a University of Miami professor and leader of the research team. Veterans have been testing the app for several months, with many reporting an improvement in gait and a difference in the pain they feel when walking. Researchers will be recruiting more veterans to test the app in the coming months.




Researchers Explore Randomized Controlled Trials in O&P Literature

Researchers at the School of Life Sciences and Education at Staffordshire University in the United Kingdom have published a systematic review of randomized controlled trials assessing the efficacy of O&P interventions. Led by Aoife Healy, a senior research officer with a focus on biomechanics, the researchers conducted literature searches of 14 databases between the years 1995 and 2015 and identified 342 randomized controlled O&P trials, 319 of which were published in English. Only four of the trials focused on prosthetic interventions, while the remaining 338 highlighted orthotic treatments. Though they concluded the scientific literature does not provide sufficient high-quality research to allow strong conclusions on O&P’s effectiveness and cost effectiveness, the researchers were able to identify and categorize studies of orthotic intervention for 12 different medical conditions/injuries. For example, they identified 43 randomized controlled studies focusing on orthotic intervention for arthritis, 26 for fractures, 22 for stroke, 20 for carpal tunnel syndrome, 18 for plantar fasciitis, 16 for anterior cruciate ligament, 15 for diabetic foot, 10 for ankle sprain, five for

cerebral palsy, eight for lateral epicondylitis, and six for lower back pain. While most findings were inconclusive, the review resulted in support for O&P care in some areas. For example, for diabetic foot patients, the review found that orthotic interventions resulted in “some evidence of superior results with lower ulcer incidence/relapse rates. However, when it comes to treating active ulceration, total contact casts show superior results in most of the randomized controlled trials.” Healy and her team also noted that some studies supporting O&P efficacy did not fall within the parameters of the systematic review: “While at present the scientific literature does not provide sufficient high-quality prospective studies to allow strong conclusions on the effectiveness or cost effectiveness of prosthetic and orthotic interventions, there are a number of reports from various organizations in the United Kingdom and United States [that] discuss the positive impact of orthotic and prosthetic service provision.” The research, which was supported by the International Society for Prosthetics and Orthotics, was published in March in PLoS ONE.



CMS Sets Medicare Fee Schedule for Code K0903 CMS has issued a bulletin indicating that the fee schedule for code K0903—the newly created Health-Care Common Procedure Coding System (HCPCS) code used to describe direct-milled, custom-fabricated diabetic inserts—has been set at $43.56, the current Medicare fee schedule for HCPCS code A5513. When K0903 was first announced, CMS indicated that the Medicare fee schedule would be approximately $5 less than the current fee schedule for A5513, which describes customfabricated diabetic inserts molded over a positive model of the patient’s foot. AOPA challenged this position and presented several arguments that supported the direct crosswalk of the Medicare fee schedule for A5513 to the fee schedule for K0903. The decision to provide equitable

reimbursement is a victory not only for what it represents for providers of diabetic inserts, but also for the precedent that it sets for future issues involving the use of scanning and other technology to create alternate manufacturing processes in orthotics and prosthetics, according to AOPA.


DME MACs Update AFO/KAFO Policy The durable medical equipment Medicare administrative contractors (DME MACs) have released a series of revisions to the Medicare medical policy on ankle-foot orthoses (AFOs) and knee-anklefoot orthoses (KAFOs) with an effective date of Jan. 1, 2017. The revisions were predominantly clerical (e.g., include language associated with the 21 Century Cures Act and updating the list of off-the-shelf/custom-fitted braces) and should not have a direct effect on coding, billing, and medical necessity determinations. In addition, the revised policy now states in writing that walking boots (L4360, L4361, L4386, and L4387) are all inclusive and may not be billed with any other add-on codes.



AHA To Suggest Fixes for Medicare Billing Appeals Backlog

Individuals ages 45 to 64 are at highest risk for amputation in the United States.

U.S. District Judge James Boasberg has asked the American Hospital Association (AHA) for suggestions on how the U.S. Department of Health and Human Services (HHS) can reduce the appeals backlog. During a hearing in March, Boasberg sought solutions to the backlog. As of June 2017, the Office of Medicare, Hearing, and Appeals (OMHA) had 607,402 appeals pending, with a current estimated wait time of three years for an administrative law judge to process a provider’s appeal. AHA sued HHS in November 2012 and alleged that the agency was illegally denying hospitals Medicare payments for audited outpatient procedures. During the March hearing,

Boasberg asked that AHA, by June 22, provide a list of recommendations for reducing the backlog. AHA may introduce several possible “fixes,” such as suggesting that CMS impose a financial penalty on recovery audit contractors if the majority of their denials are overturned on appeal, AHA attorney Sean Marotta told Modern Healthcare. AHA also may suggest that HHS eliminate the RACs’ ability to deny claims based on medical judgment, and instead transfer such cases to quality improvement organizations. In addition, AHA reportedly will request that Boasberg order HHS to offer reasonable settlements to providers that want to use mediation rather than the traditional appeal conference.

Age at Amputation 0.2%




AGES AGES 85 1-17 11% AND AGES OLDER 18-44

36% AGES 65-84

46% AGES 45-64

SOURCE: “Limb Loss in the USA,” Amputee Coalition.





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The third annual Össur Women’s Leadership Conference, themed “Do Great Things,” will take place at the Arizona Biltmore Waldorf Astoria Resort in Phoenix, August 23-25. The three-day educational conference will focus on issues relevant to all O&P practitioners. Topics covered will include leadership development, critical industry discussions, and the impact of diversity in the O&P field. Continuing education units will be offered for those eligible. For more information, visit The AOPA Assembly hotel blocks have opened! Start planning your trip to the 2018 AOPA National Assembly, September 26-29, by booking your hotel room. Reserve now to get your first choice at one of AOPA’s five partner hotels. Prices range from $251 to $399 CAD (at press time, approximately $200 to $317 USD). Learn more about the hotels and book our discounted rates at Choose from the following partner hotels: • Pinnacle Harbourfront Hotel, 1133 West Hastings Street, Vancouver, BC, V6E 4R5, $251 CAD • Coast Coal Harbour Hotel, 1180 West Hastings Street, Vancouver, BC V6E 4R5, $270 CAD

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Midwesterners Experience High Prevalence of Diabetes and Related Conditions

FIGURE: Matthew J. Gurka, Stephanie L. Filipp & Mark D. DeBoer

Adults residing in the Midwest are more likely to have metabolic syndrome, diabetes, and obesity than other U.S. adults, according to a new study published in Nutrition & Diabetes. In addition, a high prevalence of metabolic syndrome among black women persists across the United States, according to the study. Mark D. DeBoer, MD, MSc, MCR, associate professor in the Division of Pediatric Endocrinology at the University of Virginia, led a team that analyzed data from nearly 10,000 adults ages 20 to 65. Participants completed questionnaires and underwent measurements of waist circumferences, blood pressure, fasting triglycerides, high-density lipoprotein cholesterol, and fasting glucose. Obesity prevalence overall was highest in the West South Central and East South Central areas, according to the researchers, with lowest prevalence in the Mountain and New England areas. Metabolic syndrome prevalence was highest in the West North Central area and lowest in the Pacific

Prevalence of obesity, metabolic syndrome, and diabetes by U.S. census division

Data shown for prevalence of (a) obesity, (b) metabolic syndrome, and (c) diabetes are among U.S. adults aged 20–65 years, from the National Health and Nutrition Examination Survey, 1999–2014.

and New England areas. Diabetes prevalence was highest in the East South Central and West Central areas and lowest in the New England area. Examining trends across race and gender, the researchers found that white women had a low prevalence of all three conditions in the Northeast and West regions, and white men had a low prevalence of all three in the West region. However, white men

and women had a high prevalence of obesity, metabolic syndrome, and diabetes in the Midwest region. “Further assessments are needed to determine lifestyle and other causes of the increased prevalence of obesity and metabolic syndrome in these geographical areas and whether focused attention can help avoid worsened cardiovascular disease in these populations,” DeBoer said.


OPAF Hosts Dance and Swim Clinics in California


With help from students in California State University—Dominguez Hills’ (CSUDH’s) Orthotics and Prosthetics Department, O&P patients learned to better manage their functional limitations in a fun and active way during First Dance and First Swim adaptive clinics in March. The O&P Society, the student organization at CSUDH’s O&P Department, held the clinics in partnership with the Orthotic and Prosthetic Activities Foundation (OPAF) to offer individuals with amputations, limb differences, and other physical disabilities the opportunity to learn or relearn to dance and

swim with the help of skilled instructors and adaptive equipment. The clinics were partially funded by campaign organized by the O&P Society. During the First Dance clinic, participants learned to tango, waltz, and do the electric slide. The clinic was designed to build participants’ confidence on the dance floor to prepare for attending a wedding, high school reunion, or similar event. At the First Swim clinic, participants learned the adult doggie paddle as well as a free-style swimming technique, and worked their way up to diving into the deep end. O&P ALMANAC | MAY 2018



Stephen T. Hughes, CFo, LO, has joined Allard USA as educational product specialist. He will provide education, clinical support, and expertise for Allard’s staff, the O&P community, and its referral sources on Allard’s products. Stephen T. Hughes, With more than 30 years’ experience in the O&P CFo, LO industry, Hughes has established his abilities as technical staff, product specialist, orthotist/fitter, and, most recently, as director of central fabrication. He specializes in reciprocating gait orthoses, stance-phase control systems, and carbon graphite materials. For the past 20 years, Hughes has been responsible for conducting lectures, workshops, and product demonstrations within the O&P industry.


Staff members from AOPA; the American Board for Certification in Orthotics, Prosthetics, and Pedorthics; and the National Commission on Orthotic and Prosthetic Education convened in Alexandria, Virginia, in April to take part in a walk as part of a fundraiser dedicated to youth with limb loss and limb difference. Jack Richmond, CPOA, president and chief executive officer of the Amputee Coalition, and Dan Ignaszewski, director of government relations and marketing, also participated and donated to the fundraiser. Participants raised more than $4,000 during the event, enough to send two children, at no cost to their family, to the Amputee Coalition’s summer camp program, the Paddy Rossbach Youth Camp. Scheck & Siress Prosthetics Inc.

Scheck & Siress has announced a partnership with

Northwestern University’s Feinberg School of Medicine to fund research in prosthetics and orthotics. The research will be under the direction of Stefania Fatone, PhD, BPO (Hons), who oversees prosthetics and orthotics research at the Northwestern University Prosthetics-Orthotics Center (NUPOC). The decision to partner with Northwestern was spurred by Scheck & Siress’s commitment to investing in the future of O&P to develop improvements in clinical treatment paths and technology to provide enhanced services to those patients in need of prosthetic and orthotic care. “This gift represents both our support of the exemplary work led by Dr. Fatone Prosthetics. Orthotics.



and her team at NUPOC and Scheck & Siress’s goal to help bring meaningful clinical research that improves the quality of patient care we deliver,” said Michael Oros, CPO, LPO, FAAOP, president and chief executive officer of Scheck & Siress. WillowWood has announced a new venture: WillowWorks, an early-stage investment company offering capital, strategic advisory services, and commercialization support to entrepreneurs. Through WillowWorks, WillowWood plans to help entrepreneurs and partners develop, prove, refine, and launch new ideas. “We view WillowWorks as an opportunity to amplify and expand the WillowWood mission of making life better for others beyond the prosthetics market,” said Ryan Arbogast, chief executive officer of WillowWood. “We’re looking to invest in concepts ranging from consumer products to medical devices to technology.” Based in Columbus, Ohio, WillowWorks is pursuing collaborations with entrepreneurs who have big ideas that need nurturing and investment, as well as partners seeking to commercialize an offering to reach a broader audience. “Big, blue sky ideas can come from anywhere, and we’re open to potential collaborations across industries and markets,” said John Choi, general manager of WillowWorks. “Our one criterion is that we support opportunities that deliver positive financial and social impact.”


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Upcoming RAC Audits The latest on Performant’s reviews of LSOs, TLSOs, AFOs, and KAFOs

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.





N OCT. 31, 2016, CMS awarded

contracts to the new recovery audit contractors (RACs), and the Region 5 contract went to Performant Financial Corp. Region 5 is solely dedicated to auditing claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), as well as home health and hospice services. The company began auditing O&P claims in late 2017. Performant is required to publish on its website,, areas of vulnerability/approved issues it intends to audit. In addition, CMS began posting a list of topics that have not yet been approved for RACs to review on a monthly basis. The advance listing provides stakeholders with a chance to prepare for possible audits and to provide any comments, suggestions, or concerns about the proposed areas of review. Currently, there are no new proposed O&P areas listed for the month of May, but the Performant website lists two areas under current review. A complex review of spinal orthoses—lumbosacral orthoses (LSOs) and thoracolumbosacral orthoses (TLSOs)—began on Aug. 2, 2017, and a complex review for the medical necessity for ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs) was posted on July 5, 2017.

With these listings, Performant has provided some details as to what it may be looking for and the basis of its reviews. This information can be confusing at first glance, but once broken down to its core components, it becomes much clearer. This month’s Reimbursement Page focuses on some of the details regarding each of the current audits and provides a picture of what Performant may be looking for in its audits.

Basic Components

The details section of the Performantapproved issues makes several references to the Social Security Act—for example, 42 CFR 414.402, Social Security Act, Section 1842 (p) (4). These references are not too important as they simply list the definitions for orthoses and explain the benefit categories for AFOs or TLSOs, or the payment rules for DMEPOS. More important is the listing of the Medicare manuals. The manuals serve as condensed versions of the Social Security Act, and they offer the guidelines and rules created by CMS for its contractors. The spinal and AFO/KAFO details rely heavily on two Medicare manuals: the Benefit Policy Manual and the Program Integrity Manual—this one


If an item is being replaced due to damage, document the exact event that caused the damage and show that it was not caused by “normal” wear and tear.

being the primary source of information and directions for these audits. The primary focus is on the Benefit Policy Manual, Chapter 15, Section 110.2, and the rules regarding replacement items. One of the primary denial reasons in previous durable medical equipment Medicare administrative contractor (DME MAC) widespread prepayment reviews was that there was not sufficient information to support the reason for replacement (provision of the exact same or similar item and not related to change in patient’s condition); so it is no surprise that this would be an area of interest for Performant. Medicare will cover a replacement item/device if the original is lost/stolen or is irreparably damaged, damage not caused by normal everyday wear and tear. When replacing an item, be sure you have documented that the item was lost or stolen. The documentation could include copies of insurance claims and/or police reports, or could take the form of a statement from the patient or the facility/hospital if the item was lost during an inpatient stay. If an item is being replaced due to damage, be sure to document the exact event that caused the damage and show that it was not caused by “normal” wear and tear;

in this instance, a picture truly is worth 1,000 words. Lastly, always remember to seek verification that the item is still medically necessary and is still needed and being used by the patient. The Program Integrity Manual (Chapter 4, Section 4.26; Chapter 5, Sections 5.2, 5.7, 5.8, and 5.9) references are focused on administrative documentation requirements (orders and proof of delivery) and the documentation requirements for medical necessity. Below is a quick recap of some of the key elements of compliant orders and proof of delivery (POD) slips.

Compliant Orders

Normally, you will have two orders in your files: the initial/dispensing order and the detailed written order (DWO). However, if your initial order has all the elements of a DWO, then you do not need to have both orders in your files. An initial/dispensing order must contain the patient’s and physician’s names, a generic description of the item ordered (e.g., back brace or AFO), the order date, and a signature. The order date and the signature on the initial/ dispensing order are dependent on whether the order was written or if it was a verbal order. For a verbal order, the date should be the date you are contacted by the physician; on a written order, the date entered by the physician is the order date. If the order is verbal, then your signature must be attached to it in the record; for a written order, the order must contain the physician’s signature. The DWO, on the other hand, must contain a detailed description of the items/services you are providing, including quantities provided and any supplies that may be replaced on a regular basis, and an estimated schedule of when they will be replaced. The description may be accomplished in one of three ways: by listing the name, manufacturer, and model number of the item(s) you are providing; by providing a narrative description of the item(s) you are providing; or by listing all of the Health-Care Common Procedures Coding System (HCPCS) codes and their descriptors.

Someone other than the ordering physician may write or create the DWO, but the ordering/referring physician must be the one to sign and date it. For example, you may create the DWO and have the ordering provider (physician, nurse practitioner, physician assistant, etc.) sign it. The DWO must include the patient’s name and the date of the order (the date on the initial order), and this must be separate from the signature date if the DWO was prepared by someone other than the physician. A new order (initial/DWO) is not required when you are providing or replacing minor components or supplies but is required when providing a full replacement or replacement of major components. In addition, a new order is not required for repairs and adjustments as these are covered under the original order for the lifetime of the item. However, if you were not the original biller and you have not obtained a valid copy of the original order form the original supplier, then you will need to obtain a new order for the repairs and adjustments.




Proof of Delivery Forms

PODs must contain the following items to be considered compliant: • Beneficiary’s name • Delivery address • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description) • Quantity delivered • Date delivered • Beneficiary (or designee) signature and date of signature. The delivery address listed on the POD must be the physical address of where the items/services were delivered. The detailed description could simply include the manufacturer’s name, the brand name, and the serial/model number; or it may include a narrative description; or it could be a list of L codes with their complete descriptors. The date of delivery may be entered by the patient or his or her representative, or by you as the supplier, so you may preprint delivery slips and include the date of delivery on them. Just be sure that the date entered on your POD is the actual date of delivery or the date the patient receives the item/service. If your POD has a date entered by you and a date entered by the beneficiary, the beneficiary-entered date is considered to be the delivery date and thus the date of service.

LCDs and PAs

The details section of the approved areas of review will list the appropriate Local Coverage of Determination (LCD) and Policy Article (PA) or Medicare medical policy associated with the items under review. There may be several LCDs and PAs listed because the review period for the RAC is three years, and policies are normally updated on a quarterly basis. Thus, it is important to verify that Performant is using the correct policy to audit your claim, and it should be the policy that was in effect on the date your claim was originally adjudicated and paid. Instead of reviewing all of the LCDs and PAs over the last three years, let’s focus on the overall requirements associated with the codes under review by 18


Performant, which include the following: • Under the AFO/KAFO review: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, and L2128. • Under the LSO/TLSO review: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, and L0640. Since all of these codes are associated with custom braces, we will take a quick look at some of the key coverage criteria in policy for custom orthoses. First, there must be documentation in the physician’s record to support the need of a custom-fabricated brace over a prefabricated brace; failure to include this information is usually the main reason for denials in audit situations. What a physician puts in his or her records is out of your control, but it is not out of your influence. It is acceptable for you to work with and educate your referral sources about the type of information that must be in the patient’s record, as long as the physician is writing/dictating his or her own notes. It also is acceptable for the physician to amend his or her notes to include the appropriate information as long as he or she follows Medicare-approved guidelines for amending records. The information physicians enter can and should be corroborated by the evaluations and findings in your records, as is stated in the policy, so be sure to document your findings

as to why a custom brace is required, and make sure it is in line with the physician’s recommendations. For AFOs and KAFOs, you must first document that the underlying coverage criteria have been met, including ensuring that the patient is ambulatory, that the patient still requires stabilization (at the ankle/foot for an AFO as well as the knee for a KAFO), and that the patient has the potential to benefit. Next, you must focus on the documentation for the custom AFO/KAFO; these requirements are clearly defined as: • The beneficiary could not be fit with a prefabricated AFO; or • The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than six months); or • There is a need to control the knee, ankle, or foot in more than one plane; or • The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or • The beneficiary has a healing fracture that lacks normal anatomical integrity or anthropometric proportions. Only one of these requirements must be met and documented in your records and the physician’s records. In addition, it is not a requirement that you must first deliver or fit a prefabricated brace. However, whenever possible, it is recommended that you document if a prefabricated brace


was originally provided, or why a prefabricated brace would not fit (e.g., measurements outside of normal manufacturer-listed prefabricated sizes). The policy for LSOs and TLSOs doesn’t provide specific criteria for when a custom brace is covered, but you may use the AFO/KAFO criteria as your guide. In addition, be sure to document and meet the overall coverage criteria. The LSO or TLSO must be needed and used in one of the following manners: • To reduce pain by restricting mobility of the trunk; or • To facilitate healing following an injury to the spine or related soft tissues; or • To facilitate healing following a surgical procedure on the spine or related soft tissue; or • To otherwise support weak spinal muscles and/or a deformed spine. In addition, the LSO/TLSO codes under RAC review require verification from the Pricing, Data Analysis, and Coding (PDAC) contractor. If you are providing a brace that is custom

fabricated by a manufacturer or central fabrication facility, be sure you have verified the brace is on the PDAC’s Product Classification List, and document that verification via a notation in the chart, a screen shot of the PDAC site, or a copy of the verification letter. If you custom fabricate the brace in house and provide it directly to the beneficiary, you don’t have to have the item reviewed by the PDAC. However, you must be able to provide a list of the materials that were used and a description of your fabrication process if requested. You may want to have this information on file and ready to go, just in case it is requested. Remember that it is acceptable to enlist other providers and suppliers when it comes to augmenting and supporting your documentation and the physician’s documentation for the underlying medical necessity of the prefabricated brace and, subsequently, the custom-fabricated brace. The Social Security Act, as referenced in the details portion on the Performant site, states: “It is expected that the beneficiary’s medical records will reflect

the need for the care provided. The beneficiary’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other health-care professionals, and test reports.” If you enlist other providers/suppliers, be sure to include their records; these do not need to be signed off on or reviewed by the ordering/ referring physician when you reply to a Performant documentation request. 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:

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This Just In

A Toolbox for Ethical O&P Workplaces Start planning now for 2018 Health-Care Compliance & Ethics Week


AST YEAR, AOPA and its members celebrated the profession’s inaugural Health-Care Compliance & Ethics Week November 5-11, in collaboration with the Health Care Compliance Association. Hundreds of O&P professionals boosted their companies’ compliance efforts by utilizing resources provided by AOPA, including free webinars, opportunities for free CE credits, daily quizzes and prizes, and tools for in-office celebrations. This year, Health-Care Compliance & Ethics Week will be celebrated November 4-10. The event seeks to elevate awareness of the benefits of formal written policies and procedures to ensure all employees understand the laws and the consequences of violating them, know what to do when a compliance issue arises, and learn to cultivate a culture of compliance and ethical conduct within an O&P facility. Ethics and compliance go hand in hand. Taking part in HealthCare Compliance & Ethics Week is an opportunity to reinforce your company’s commitment to the rules of the road—especially in the compliance area, where violations of the Health Insurance Portability and Accountability Act are just one



example of severe penalties imposed if there is a lapse in compliance. Focusing attention on compliance during this dedicated week in November also will help encourage members to review or—if necessary— create a compliance program. The U.S. Department of Health and Human Services Office of Inspector General (OIG) has developed resources to assist health-care providers in creating a compliance program and in establishing internal controls that can help reduce fraud, abuse, and waste. OIG has identified seven elements necessary for an effective compliance program: • Implementing written policies, procedures, and standards of conduct • Designating a compliance officer and compliance committee • Conducting effective training and education • Developing effective lines of communication • Enforcing standards through well-publicized disciplinary guidelines • Conducting internal monitoring and auditing • Responding promptly to detected offenses.

This Just In

Your company may benefit in several ways from participation in the observance. A week-long focus on compliance and ethics will give you an opportunity to introduce and reinforce the compliance and ethics standards your employees are expected to meet. And by demonstrating your facility’s commitment to ethical business practices, your standing within your community may be elevated. AOPA will make available tools to assist in your company’s participation. If you don’t have a compliance officer on staff, this is the opportunity to assign that responsibility. Your company can use the press release template AOPA has developed to let your community know of your organization’s commitment. In addition, a daily “compliance message” will be available for forwarding to all employees over the course of the week. You can sign up employees for

one or all of the online webinars that will be offered during that time. A “compliance question of the day” is another tool your company can leverage during the week; your employees can answer a question each day to earn CE credits and become eligible for daily prize drawings. For more information about Health-Care Compliance & Ethics Week offerings, visit; here you can download whitepapers, cartoons, videos, and other tools to promote compliance and ethics. Nearly all of the materials are made available on a complimentary basis. Plan now to take part in Health-Care Compliance & Ethics Week, and take advantage of the many cost-effective opportunities to instill a sense of a commitment to a value system documented by your written compliance and ethics program. The November celebration is a win/win for your company and for your patients.

A week-long focus on compliance and ethics will give you an opportunity to introduce and reinforce the compliance and ethics standards your employees are expected to meet.

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MARKETING Strategies for attracting patients and referral sources and expanding O&P businesses By CHRISTINE UMBRELL

NEED TO KNOW • Each O&P facility has its own geography, patient base, referral sources, and competition, so effective marketing programs need to directly support each facility’s individual business goals. • Develop a marketing strategy tailored to your facility following a four-step approach: defining your brand, identifying your audience, developing content, and determining the delivery channel. • Consistency is key in marketing efforts targeted toward referral sources—a consistent, repetitive presence may resonate more than one single “big” event. • Some facilities have found success in hosting educational sessions for therapists or physicians as part of their marketing plans. These sessions can provide valuable information about orthotics and prosthetics to referral sources and may be eligible for continuing education credits.



• One patient-care facility has focused on providing tools to help support referral sources and meet their needs—for example, communicating outcome measures test scores and patient successes back to physicians. • Community outreach is another form of marketing embraced at some patient-care companies. Facilities can plan activities for patients to take part in or host an event that all community members may enjoy. • Most facilities are incorporating digital marketing into their promotional strategies since these campaigns can be both costeffective and far-reaching. Facilities can focus their efforts on websites, Facebook, and other types of social sharing.



O TWO O&P FACILITIES are alike, so while

every company needs a well-thought-out marketing plan, that strategy will vary from practice to practice. Because each O&P facility has its own geography, patient base, referral sources, and competition, effective marketing programs need to directly support each facility’s individual business goals. Today’s marketing tools have come a long way from those of previous generations. Traditional methodologies are expanding to digital marketing campaigns that rely heavily on websites, posts on social media, and email messaging. Simple word-of-mouth communication is evolving into community building activities that spotlight O&P patients and their abilities. And clinicians are no longer knocking on the doors of referral sources; now, they are offering educational sessions that teach allied health professionals valuable information about patients with limb loss and limb difference. O&P facilities are embracing these new strategies to boost their patient populations and ensure the profitability of their businesses. Deciding which approach will work best at a given facility is key to marketing success.

J. S





Start With Four Steps

While each facility will need to tailor its marketing strategy to meet its specific needs, all companies can benefit from following a four-step approach to designing that plan, says Karen Lundquist, chief communications officer for the Amputee Coalition and former director of communications for Ottobock. These steps include defining your brand, identifying your audience, developing content, and determining the delivery channel. Following these steps and staying consistent in messaging are the keys to retaining current patients, onboarding new customers, and attracting referral sources. To define your brand, start with “a clear understanding of who you are— the personality of your facility and why someone would come to your facility versus another one,” says Lundquist. “You will attract different types of patients based on your style, so you need to understand your style.” Understanding your style involves examining your competitors, and identifying characteristics that set your facility apart, explains Lundquist. Compare factors such as the products and services you provide, how innovative your facility is, whether

PHOTO: William Iven

your facility presents a very clinical or casual “vibe,” and how you communicate with patients and referral sources. Once you have a clear picture of your brand and how it compares to your competitors, the next step is identifying your audience—your patients and potential patients, as well as your referral sources. Investigate why loyal patients choose to return time and again. “Especially look at who stays with you the longest,” recommends Lundquist, because “that will show you who you’re doing the best with.” When pinpointing your key patient base, determine whether to devote marketing resources to attract patients who are outside of your core audience or to focus instead on retaining current customers and marketing to Karen Lundquist similar types of patients. This decision may not be easy. If you do mostly lower-limb work, for profitable before investing marketing example, do you want to devote your dollars, Lundquist says. “Look at your marketing resources to attract more of audience before you go too far in your the lower-limb patient population—or marketing.” do you want to attract new upperAfter identifying your target audilimb patients? “It may be expensive to ence, the third step is figure out what expand in a new direction,” so detertype of content you want to develop for your marketing efforts. Lundquist mine which direction may be most suggests asking your most loyal customers what they like about your facility and why they stay with you. “Ask your patients to write a recommendation on Facebook or Google. They may post for you—and you can use that content” in the marketing materials you develop, she says. Then look for other types of content that will “speak” to your audience. Finally, determine your delivery channel by deciding how to reach your audience. Speak with patients informally or look at the data from your facility website to figure out where your patients spend their time and how they search for health-care solutions. “There’s so much data out there” to help you select the delivery channels that resonate with your audience, Lundquist says. Digging into the data from your website can help you determine who is visiting your site and which pages get the most traffic.



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Facebook, other social media platforms, and websites, and may include hosting community activities or educational seminars for referral sources—or some combination of all of these.

Be Consistent



PHOTOS: Reach Orthotic & Prosthetic Services

Following the four steps outlined by Lundquist is one way to approach marketing. But she cautions that whatever approach you take, it’s important to be consistent. “If you skip around and try a lot of things, your message gets cluttered,” she says. “Think about the raindrop on the stone—just keep hitting the same message until it makes its mark.” Staff at Reach Orthotic & Prosthetic Services led Playing the long game is especially a community-building activity by arranging for important when marketing to referral the traveling Wounded Warrior Amputee Softball sources, says Elizabeth Mansfield, Team to come to town and compete against the vice president of Clinical Education Newport News fire and police departments. Concepts, a firm that helps companies market their products and services. Lundquist also suggests “asking Planning a single “big event” is not the your patients what they use” to key to relationship building, she says. help them decide where to go for “Rarely are referral sources won over health care. These conversations can with one, giant sweeping deed; usually, take place informally or via patient it’s a series of smaller steps. It takes surveys—for example, via Survey consistent effort to get to know, like, Monkey. “Their answers may be and trust someone.” different than what you expect,” says Clinical Education Concepts Lundquist. While Facebook has a provides full meeting planning services reputation for attracting older users, for O&P state associations, societies, she has found that Facebook users and AAOP chapters, as well as educamay actually skewer younger. “More and more, people are searching on tion-based marketing platforms for Facebook for your presO&P patient-care facilities and vendors. “We like to ence. People are using it describe it as ‘central fab for as a search engine.” Some marketing,’” says Mansfield. facilities leverage other “We create the program for social media venues, such them, and they adjust it to as Instagram and Twitter, their needs. So, we don't but it’s important to identify really ‘do’ events; we assist what will work best for your Elizabeth Mansfield our customers in establishing particular target audience. an ongoing relationship based “Ask your loyal patients on value-added learning.” what they use,” and then package your Mansfield encourages her compacontent in those delivery vehicles that are popular with your audience. ny’s clients to carefully consider what Completing these four steps will the return on investment might be result in a plan that is geared specififor a one-day event like a continuing education seminar at a conference cally for a patient and referral source center. “Medical professionals might population that will be most profitshow up for the CEUs and lunch, able for you to attract, delivered with but time takes its toll and they can messaging that will resonate with the forget who sponsored the event,” she recipients. The end result may be a explains. “People are busy—busier now print or digital campaign, leveraging


than ever. It’s easy to assume that our companies and services are unforgettable, but that would be foolish.” Instead, Mansfield and her team emphasize the value of consistently educating physicians, case managers, and physical and occupational therapists in their offices or at a grand rounds type of setting. “The attendees receive their continuing education credits, and the O&P patient-care facility does not incur costly meeting expenses,” Mansfield says. “A consistent, repetitive presence is the most effective way for our customers to establish credibility with referral sources, while showcasing their expertise. Our customers are credentialed professionals, not meeting Becky Snell planners or catering staff. They are an integral part of the team responsible for the recovery and well-being of folks with limb and functional loss. That is the focus of our marketing platforms.”





PHOTO: Getty Images/Gilaxia

can promote your O&P facility within your community—and doing so may be easier than you think if you work with the Orthotic & Prosthetic Activities Foundation (OPAF). Founded in 1995 to support the Paralympic Games in Atlanta, OPAF develops, implements, partners, and hosts adaptive recreational clinics for those with physical challenges. Facilities can choose from a wide range of sports as the focus of a clinic, including tennis, swimming, scuba diving, dancing, golfing, or rock climbing. The experience provides a hands-on introduction to the sport itself, taught by experienced athletes provided by OPAF, in a safe and secure environment with peers in similar situations. OPAF also offers a clinical education component for those facilities that wish to host members of the rehab team. When an education session is part of a First Clinic, the event lasts a full day and begins with classroom education in the morning, where physical or occupational therapists or other allied health professionals can earn CE credits, followed by lunch and the hands-on clinic in the afternoon—where class participants get the chance to put their learning into action with O&P patients from the community. The clinical education program is offered for four types of clinics: First Stride, an introduction to gait training; First Things First, focusing on falls and recovery; First Swim, an introduction to swimming and aquatic therapy; and First Swing, offered in partnership with the National Amputee Golf Association. O&P facilities that sponsor these events do so as a “give-back” to allied health professionals, patients, and their communities, says OPAF Executive Director Robin Burton. “It demonstrates that the patient-care facility cares about their clientele, and that they want to further educate therapists in their area. This is a great marketing tool, plus it’s a way to show the community that you’re giving back, while showing people with disabilities what is out there sports-wise,” she says. “Not everyone is going to be a Paralympian, but everyone deserves adaptive recreation that is geared toward and designed for them,” adds Burton. For more information on OPAF and the First Clinics, visit




Educate Referral Sources



having patients be advocates to physicians and therapists.” Stresing communicates back to each patient’s physician and therapist not only what device has been provided but also the results of different outcome measures testing. She sends periodic updates to referring practitioners with the results of patient socket comfort scores, AMP Pro/ NoPro testing, and patient satisfaction surveys—“then, we’re all part of the solution,” she explains. Many physicians and therapists “are being rated and graded” by hospitals and other organizations for their patient care—“and their patient care involves us,” says Stresing. “So, doctors feel much more comfortable when they know [the O&P patient] is doing well. That can be a success for the doctors as well as for” O&P clinicians and patients. “Taking the time to understand how physicians and therapists are paid and ranked, and providing tools to help support them,” explains Stresing, has led to Limbionics becoming a critical part of referring health-care professionals’ teams—and has resulted in repeat business and substantial growth for the company.

PHOTO: Getty Images/Hakinmhan

creates a synergy for many opportunities—and is also One patient-care facility our responsibility as true that is seeing positive results partners in our communifrom becoming a “consistent, repetitive presence” to its ties,” says Snell. “There is referral sources is Dankmeyer real value in the hands-on Inc., a company with four approach of education locations in Maryland. During Brittany Stresing, provided to other profesCPO, FAAOP the past six months, the facility sionals. When you are has launched “Dankmeyer communicating directly Academy” as the umbrella for all of its with your markets in a team-based education programs, “but specifically approach, this in turn has a direct to introduce our most recent initiative impact on their own marketing and of a brand new in-service offering,” business development—and, more explains Becky Snell, Dankmeyer’s IT importantly, patient care.” and marketing director. “This series of courses is taught by Expand Dialog With two different clinicians who, as part of Physicians and Therapists the lecture process, are building strong Educating referral sources via orgaprofessional relationships with the nized seminars and courses is not the attendees,” she says. The courses are only way to build your following with targeted toward physical and occuthis population. Brittany Stresing, CPO, FAAOP, has found success in pational therapists, and Dankmeyer building relationships and creating a promotes the sessions as offering CE “team” dynamic with other health-care credits, which have been approved professionals. by the Maryland Board of Physical Stresing founded Limbionics Therapy Examiners and the American of Durham, North Carolina, just Occupational Therapy Association, five years ago, but her practice has says Snell. expanded from one facility to five The current series focuses on locations. She attributes that growth physical therapy education in skilled primarily to “word of mouth and nursing facilities, but the material is valuable for any team that is responsible for O&P patient care outside of the O&P facility or clinic, according to Snell. “We want to tie education in with our patient-care team approach in order to build that bridge between hospital care, skilled nursing and rehab, and the patient’s entry into the clinic environment.” Though the program is new, Dankmeyer already is receiving positive feedback. “We are seeing a significant interest in this new offering detailed on our website, via emails and phone calls, as well as through our own personal outreach to facilities,” says Snell. The Dankmeyer Academy is just one pillar of the company’s overall marketing strategy, which is heavily based in educating patients, referral sources, and staff. “We have always believed that education of these various groups

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Build Community



PHOTOS: Reach Orthotic & Prosthetic Services

For facilities seeking to focus more on community building, Reach Orthotic and Prosthetic Services in Newport News, Virginia, offers an example of effective outreach. “We set out to extend our marketing efforts beyond typical interactions with patient Clinicians at Reach Orthotic & Prosthetic Services created a prosthesis for referrers to the community at large,” an amputee dog as part of the facility's community outreach effort. says Anne Sych, the company’s marfrom free press. Reach Owner John keting coordinator. patient education and case studies that Robb, CPO, appeared on a television Last year, Reach O&P partnered we can share on our website and social and morning radio show, “and our with the local chapter of the Society media channels,” says Sych. Facebook event was further promoted in several for the Prevention of Cruelty to has been “a great way to connect articles and interviews,” says Sych. Animals to create a prosthesis for with our patients, referrers, and the Looking back, Sych says the “Trey,” a rescue dog who community,” she says. WWAST initiative gave Reach was missing a front leg. It The facility publishes new Facebook O&P visibility with “people in took Reach clinicians several post several times a week, “alternating our community that we do not weeks and involved multiple a blend of prosthetic news, patient typically market to, such as office visits to achieve their stories, office happenings, and motivamilitary, veterans, and sports goal. “We took photos and tional quotes,” Sych explains. “We have groups. Including our local first videos of Trey’s treatment, had several new patients say that they responders also brought a lot and reached out to our local found us on Facebook. Anne Sych of support. We were pleasantly newspaper to share our “Patients are becoming more techsurprised by all of the free story with the community,” nologically savvy and doing their own advertising the event produced. All Sych recalls. The press brought a lot of research for their medical care. We attention to the facility—both when the of these efforts are helping us get our are even seeing patients ‘shop around’ name into the community.” In addition, and transfer to us from other pracarticle was originally published and a Reach’s Facebook following increased few months later when a photo of the tices.” In addition to Facebook, Reach by 27 percent last year, “largely canine amputee was republished as has a Pinterest page and plans to because of these initiatives.” one of the “photos of the year.” create educational videos for YouTube Reach O&P also arranged for the and social sharing in the future. Sych traveling Wounded Warrior Amputee says that developing a targeted focus Investing in Digital Marketing Softball Team (WWAST) to come each year helps the company aim Beyond expansive community inito town and compete against the marketing efforts toward a strategic tiatives and referral source outreach Newport News fire and police departgoal while continuing to build its core efforts, almost all facilities are engagpractices. ments. “This was a huge undertaking, ing in some type of digital marketing but worth the investment of our time campaigns. These campaigns can be and resources,” Sych says. In addition both cost-effective and far-reaching. Christine Umbrell is a contributing to providing a fun day for the commuReach O&P, for example, is focusing writer and editorial/production associate this year on “developing more patientnity and raising funds for the WWAST for O&P Almanac. Reach her at Kids’ Camp, Reach also benefitted centric marketing stories, such as


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What To Expect When Your Patient’s Expecting Flexibility to work with both physical and emotional adjustments is a must

NEED TO KNOW: • Expectant mothers undergo physical changes during pregnancy—such as weight gain, fluid retention, and difficulty bending— that can significantly impact their orthotic or prosthetic needs. • Prosthetists should be aware of the weight ratings associated with their patients’ devices and fit new componentry if necessary. They also may need to devise creative solutions to accommodate weight gain, such as switching out liners of different thicknesses or casting with extra socks. • Orthotists may need to fit pregnant patients with devices that are adjustable. Some patients may benefit from support belts, compression hose, or foot orthoses during this time period.



• Clinicians with experience in this patient population suggest scheduling more frequent appointments during pregnancies. They also emphasize the importance of listening to patients’ concerns, providing reassurance, and focusing on positive clinical solutions for patients who express doubts about accomplishing specific parenting tasks. • Both male and female practitioners who are inexperienced with pregnant patients can turn to mentors for advice when treating this population. • Expectant O&P clinicians may require accommodations during their own pregnancies, and should evaluate their workplaces to determine whether to reduce their fabricating duties, take more breaks during the workday, and prepare co-workers to care for their patients while they are out on maternity leave.



brought pregnancy as an O&P patient into the national spotlight, becoming the first U.S. senator to give birth while serving in Congress. Duckworth, a bilateral lower-limb amputee who also has a 3-year-old daughter, has successfully navigated two pregnancies as an individual with limb loss. Though pregnant women may not comprise a large percentage of the O&P patient base, it’s important that expectant mothers’ clinical needs are met. Pregnant patients may experience physical symptoms such as weight gain, fluid retention, tenderness, and difficulty bending. These symptoms should never be taken lightly—especially among women who have limb loss or limb difference.

Shalyn Latorre, CPO, LPO

“Pregnant O&P users are a fairly small patient population, who have specific needs that are important to address,” says Shalyn Latorre, CPO, LPO, clinic manager at Hanger Clinic in Sarasota, Florida. Women who become pregnant “can experience skin changes, ligament changes, perspiration changes, and volume and edema changes,” says Latorre. Devices may have to be adjusted or even replaced, depending on each individual’s clinical needs and how her pregnancy progresses. Changing body issues can affect both prosthetic and orthotic patients, so it’s important for all O&P clinicians to be aware of each patient’s pregnancy, schedule extra appointments when warranted, make appropriate changes to the treatment plan, and be prepared to educate patients about changes that may occur during pregnancy as well as preparations for delivery and motherhood.

Growing Bodies, Shifting Prosthetic Needs

The most obvious change in a pregnant patient’s body is the weight gain

that is an inherent part of the process. Individuals of “normal weight” before pregnancy should expect to gain between 25 and 35 pounds over the course of nine months, according to the Centers for Disease Control and Prevention (CDC). “With weight gain comes a shift in the center of mass, so you have to see the patient more often to check alignment,” says Latorre. With the shift in center of mass, which typically results in leaning forward, come shifts in a patient’s sense of balance and a need for changes in alignment, says Kris Desjardins, CPO, FAAOP, of Ability Prosthetics & Orthotics’ Exton, Pennsylvania, patient-care center. “There’s increased lordosis” affecting the small of the back. “For some of my amputees, I have suggested a maternity [support] belt,” says Nancy Snyder, CPO, LPO, an area clinic manager at Hanger Clinic in Gainesville, Georgia. “Pregnancy puts a lot of stress on the body.” Some patients may require adjustments or new componentry to accommodate weight gain. “Many of our components are weight-rated, so we have to be careful” not to allow patients to remain in a device that doesn’t match their new weight, says Latorre. For patients who experience rapid volume fluctuations as a result of

pregnancy, “you might need to get creative,” says Snyder. For example, a patient may start out a pregnancy using a 9-millimeter gel liner, then transition to a 6-millimeter liner, and switch again to a 3-millimeter liner, suggests Snyder. Similarly, Desjardins has used a thicker, flexible inner liner, “knowing we could remove it,” when working with an above-knee patient. “When we made a socket, we casted her with extra socks,” which could be removed as the pregnancy progressed.

Kris Desjardins, CPO, FAAOP

Patients with microprocessorcontrolled devices also may require special attention. “In addition to overall alignment changes, transfemoral patients may require adjustments to their knees during their pregnancy and after,” says Latorre. “You can make fine-tune adjustments to microprocessor knees to accommodate for your patients’ bodies changing. You can easily save the old settings and return the knee back to those settings when it is appropriate for your patient.” O&P ALMANAC | MAY 2018


In addition, a growing mid-section can lead to problems with donning and doffing. Clinicians can try to ease this process with inventive solutions: Latorre recalls providing a rotator underneath a socket to help one patient get her shoe on. But patients themselves sometimes have their own interesting ideas: “One of my transtibial patients came up with a creative solution to use kitchen tongs to put her liner on,” says Latorre. Other patients may require back support, compression hose, or foot orthoses during pregnancy. “Sometimes patients’ feet change,” says Nicole Keller, CPO, of Bionics O&P in San Diego. Other women may experience skin issues if they are in a restrictive device. Overall, a lot of options exist for making needed adjustments without getting all-new componentry. When clinicians face a particularly challenging pregnant patient, they can turn to other practitioners who have more experience in this arena for guidance— or consult with manufacturers. “A lot of companies that fabricate have seen these issues before,” says Desjardins.

Addressing Orthotic Needs, Safety



cover new devices, she says. She also suggests using Tamarack joints, which allow for a little more “play,” compared to other types of joints.

Brooke Artesi, CPO, LPO

As with prosthetic patients, creativity can go a long way when designing treatment plans for orthotic patients. Desjardins treated one pregnant woman who required a bivalve thoracic lumbosacral orthosis (TLSO) as the result of a car accident. While the fetus was unharmed in the collision, the mother was prescribed the TLSO for the duration of her pregnancy. “It was soft in the belly but harder in the frame, and we put several layers of foam in the belly section when making it, so the patient

could peel off layers as she grew.” It’s also important to consider whether any devices have restrictions regarding use by expectant mothers. Brooke Artesi, CPO, LPO, owner of Sunshine Prosthetics and Orthotics in Wayne, New Jersey, notes that devices with functional electronic stimulation (FES) technology should be temporarily discontinued during pregnancy. One of her multiple sclerosis patients was in an FES-driven WalkAide for foot drop prior to getting pregnant. Artesi switched the patient to a KAFO while pregnant because “the safety of FES for use during pregnancy has not been established,” according to manufacturer Innovative Neurotronics. While the KAFO was a challenge for the patient after being accustomed to the WalkAide, she complied with Artesi’s wear instructions and was able to switch back to her preferred device as soon as her baby was delivered.

PHOTO: Julian Huarte Photography

While the clinical needs of pregnant orthotic patients may appear less drastic than those of prosthetic patients, it’s important to accommodate the changes experienced by brace-wearing patients as well. Weight fluctuations and swelling in ankles and feet can cause discomfort, so using adjustable devices is key to helping these patients adapt as their bodies change. Latorre suggests using an adjustable BOA system in ankle-foot orthosis (AFO) and knee-ankle-foot orthosis (KAFO) closures. Snyder notes that orthotic devices made of plastic may be preferable, as adjustments are easier to make. “I try to make AFOs as adjustable as possible,” to allow for potential swelling and weight gain, adds Desjardins. “Having an AFO that can open up can be really important,” especially because insurance may not

Brooke Artesi, CPO, LPO, has treated pregnant O&P patients and also has experienced pregnancy as a lower-limb amputee.



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Safety in the O&P Workplace Clinicians Share Strategies for Ensuring Their Own Healthy Pregnancies


Diego, avoided all carbon and some glues, plastics, sprays, and adhesives during her pregnancy a year-and-a-half ago. She also made sure to read every label. “I didn’t sand with carbon, and I used a mask when I needed to,” she says. Keller also relied on a facility technician to assist with modifications. “If you have a patient who needs a gait belt or is using a new device, ask for help,” she says.

PHOTO: Julian Huarte Photography

facilities with in-house fabrication areas can be a challenging environment for pregnant clinicians. While there are no explicit guidelines geared specifically toward pregnant O&P clinicians, safety begins with following all of the rules set forth by the Occupational Safety and Health Administration (OSHA) regarding chemical exposures, including wearing appropriate personal protective equipment, such as gloves and masks. “There are many studies that talk about the dangers of being around the chemicals we use” in fabrication, says Nancy Snyder, CPO, LPO, an area clinic manager at Hanger Clinic in Gainesville, Georgia. She has two children and tried to avoid being around chemicals during her pregnancies. “As O&P clinicians, we become desensitized to some of these smells,” she says. “You really have to be careful and wear gloves when using acetone, and be careful with cement and glue.”

Nancy Snyder, CPO, LPO

Shalyn Latorre, CPO, LPO, emphasizes the importance of reading the Material Safety Data Sheets provided by manufacturers of lab materials. “Follow the guidelines,” says Latorre, a clinic manager at Hanger Clinic in Sarasota, Florida. “You need high-quality protective gear” when working with chemicals and laminations, says Kris Desjardins, CPO, FAAOP, of Ability Prosthetics & Orthotics’ Exton, Pennsylvania, patient-care center. Desjardins worked in an O&P facility with in-house fabrication while pregnant with her children, who are now ages 2 and 4. She advocates wearing the personal protective equipment recommended by OSHA, as well as scheduling breaks throughout the day. “And don’t be afraid to ask co-workers to assist,” especially with removing casts and similar tasks. Nicole Keller, CPO, at Bionics O&P in San



Brooke Artesi, CPO, LPO

Brooke Artesi, CPO, LPO, who lost her leg below the knee in a traumatic accident more than 20 years ago, has gone through pregnancy twice and now has a 5-year-old and 16-month-old. When she was pregnant with her older son, she worked at a large facility with in-house fabrication, and cut back her fabrication duties to reduce exposure to chemicals while pregnant. During her second pregnancy, she had started her own company—Sunshine Prosthetics and Orthotics in Wayne, New Jersey—which outsources all fabrication and thus eliminated exposures. Because she is constantly vigilant about safety, Marissa Paley, MPO, CPO, LPO, says she took the same precautions regarding fabrication materials, chemicals, and fumes

before, during, and after pregnancy. And she did not have to alter her work day in regard to seeing patients. “I continued to perform all aspects of patient care, including casting, scanning, measurements, fabrication, adjustments, documentation, and everything in between, and continued to perform all patient care until I went out for my maternity leave,” says Paley, who works at JRK/JRI Prosthetic and Orthotic Laboratory in Edison, New Jersey. She began her maternity leave one month prior to her due date. For some clinicians—especially those who work all nine months of pregnancy—clinical care does become more challenging. As getting down on the floor and moving around becomes more of an effort, Snyder suggests using a casting stand. “You can sit upright and have a patient get on the stand, so you don’t have to bend over,” she explains. “By using the casting stand, it takes stress off your body.” Desjardins says that she spent a little less time on patient care during the last couple of months of her pregnancy, but picked up extra marketing duties, which proved to be less strenuous—and ultimately boosted business at her company. Once a clinician’s baby arrives, orthotists and prosthetists face varying maternity leave policies. Owning her own business meant a unique experience for Artesi: “I really didn’t take one,” she says. “I worked a shortened schedule and strategically scheduled patients in the middle of the day. But I brought my baby to the office,” and also had her mother assist with child care. Other clinicians take several weeks or months of leave. Desjardins encourages pregnant clinicians to take as much time as they are fiscally able for maternity leave, and she suggests preparing detailed notes to assist other staff members in providing optimal care during an absence. “Figure out which patients will be coming in while you’re out and make notes so other clinicians” are properly prepared, says Desjardins. Such an approach helps assure a continuity of care for patients.

O&P professionals occasionally gain new patients when mothers experience complications during delivery, so clinicians should be prepared to act quickly should such a circumstance occur. “I’ve had hospital calls when a mother experienced a nerve injury while giving birth and had drop foot. I had to rush to provide an AFO” for these patients, says Desjardins. One additional consideration for orthoses—and prostheses as well—is to “make it easy to get devices on or off quickly” for more frequent trips to the bathroom, especially during the final months of pregnancy, says Desjardins.

Frequent Appointments, Candid Conversations

Clinicians who have treated pregnant patients say extra attention is key to successful patient outcomes—by seeing patients more often and by more closely monitoring their physical and emotional changes. “Whether it be addressing a pregnant patient with prosthetic intervention, orthotic intervention, or dual interventions, it is important to understand that a patient may require more frequent trips to see you because one day can be different from the next, and a morning can be extremely different than the afternoon,” says Marissa Paley, MPO, CPO, LPO, of the JRK/JRI Prosthetic and Orthotic Laboratory in Edison, New Jersey. “It is important to be ahead of the game with design considerations for management during pregnancy but also during the postpartum timeframe as well,” says Paley. “These design considerations are not just for size/ volume changes but also considering changes in range of motion in relation to the changing center of gravity the patient may experience.” Desjardins and Latorre try to schedule expectant mothers on a

monthly basis, to make adjustments before problems arise. “But pregnant patients have a lot of appointments already,” with obstetricians and other specialists—for complicated pregnancies—says Desjardins. “So, I try to schedule appointments well in advance,” and make it easy to accommodate patients’ work schedules and

Marissa Paley, MPO, CPO, LPO

other physician visits. Snyder also recommends scheduling appointments ahead of time, but, for patients with lower-extremity orthoses, she suggests seeing them every four to six weeks. Extra appointments can be both physically and emotionally healing for patients—especially new moms who are uncertain not only about impending motherhood but also about caring for a baby as an individual with limb loss or limb difference. O&P

clinicians “can come close to understanding what they’re going through and be a positive outlet” for listening to and alleviating their concerns, says Snyder. Some patients may share their fears about caring for a new baby, or their concerns about falling or dropping the baby. Some patients with arm loss also may worry about holding their babies in a safe manner, and congenital amputees may wonder whether their babies may be born with limb loss. Snyder suggests that clinicians take the time to listen to patients about their concerns, provide reassurance, and focus on positive clinical solutions if they express doubts about being able to accomplish a specific parenting task. Snyder recalls one upper-extremity patient who was particularly concerned about holding her baby. “I made her a passive arm and padded the forearm, so she could hold the baby with the passive arm and feed the baby using the sound side,” she says. The patient loved the device and was extremely appreciative of the extra attention to detail on Snyder’s part. Clinicians also should be prepared to discuss how patients can help control their changing O&P needs by addressing the topic of weight—a difficult, but important, talking point. Artesi—who has dealt with these issues herself, as she is both an amputee and a mom of two—advises pregnant patients to try to avoid gaining more weight than is recommended by the CDC, and to stay active during pregnancy. “That’s what any doctor would say to any patient—to stay healthy—but it’s even more important for patients with limb loss,” she says. “You need to be mobile afterwards—you don’t want to end up in a wheelchair.” O&P ALMANAC | MAY 2018


Latorre also advises that, “if patients have concerns about how pregnancy could affect their mobility, clinicians take the time to have encouraging conversations with them about steps they can take to stay as active as possible—empower them with positive conversations.” Whether because of weight gain or other issues, some patients may not be able to use their prostheses toward the latter months of pregnancy. Desjardins, for example, worked with an above-knee patient who had to transition to a wheelchair as delivery approached. Honest conversations and realistic expectations are critical in such situations.

Prepping for Delivery, Life as a Mom

Conversations about pregnancy lead naturally into discussions about delivery and infant care. Snyder and Latorre both encourage their patients to wear shrinkers at nighttime, especially during pregnancy. They also instruct their patients to take their shrinkers and liners to the hospital to help

control fluid retention postdelivery. Lower-limb amputees will want to consider whether to wear their prostheses during delivery, says Artesi. C-section patients who use orthoses may require additional

Prosthetists and orthotists should plan to schedule appointments for new moms a few weeks after delivery, to determine whether adjustments are necessary as patients’ bodies experience additional fluctuations in swelling and weight.

adjustments to their braces right after delivery, due to the water retention associated with the surgery, according to Desjardins. O&P professionals should initiate discussions about device use once the baby arrives and the new mom heads home to care for an infant, often with multiple night feedings. Some clinicians suggest a cradle placed beside the bed so nursing mothers don’t have to get out of bed to feed their babies. “Some patients manage without having to put their prosthesis on” during nighttime feedings, says Latorre. She also notes that patients who don their prostheses “don’t need the ‘perfect fit’ in the middle of the night,” and may choose to skip a liner or sock in these circumstances. Prosthetists and orthotists should plan to schedule appointments for new moms a few weeks after delivery, to determine whether adjustments are necessary as patients’ bodies experience additional fluctuations in swelling and weight. Desjardins tries to see patients two to three weeks after the baby has been born, unless everything is fitting without a problem. “I like to see patients within the first month. I want their safety to be a priority,” she says. Snyder tries to see her patients at the six-week mark. She also enjoys having patients bring their newborns to patient appointments. “We become like their family—I feel like the baby’s aunt,” she says. Clinicians agree that having their previously pregnant patients come in for follow-up visits—usually accompanied by their infants—is a rewarding experience. The extra time, clinical care, and emotional support provided by orthotists and prosthetists throughout an expectant mom’s pregnancy is well worth it when a healthy mom and baby arrive for an appointment. Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at




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Next-Generation Rehab From prosthetic feet to ‘smart underwear,’ Karl E. Zelik, PhD, studies it all Karl E. Zelik, PhD, in his lab at the Engineering Science Building

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.

Karl E. Zelik, PhD, works with students at Vanderbilt University’s CREATE space.


ARL E. ZELIK, PhD, has always



Engineering & Assistive Technology (CREATE), Zelik has spent the last 10-plus years developing multidisciplinary skills in, and refining his knowledge of, engineering, movement biomechanics, wearable technology, biosignal analysis, clinical care, and neural control of movement—continuing to pursue his passion of pushing the human body past its limits.

A Creative Space

Zelik’s greatest responsibilities are his duties as co-director of CREATE, a space that aims to advance science and technology to restore health, mobility, independence, and societal participation to individuals with disabilities.

PHOTO: John Russell/Vanderbilt University

found a way to push the limits of the human body. Growing up in a family of four boys, he loved playing sports and was “quite reckless,” he says. “I broke a lot of bones, and got a lot of stitches.” In college, he discovered biomedical engineering—an academic and “much safer way to explore the limits of the human body.” Zelik eventually fell in love with movement biomechanics and assistive devices—such as prostheses and exoskeletons—during his doctoral studies. Now an assistant professor at Vanderbilt University and co-director of the university’s Center for Rehabilitation


PHOTO: Joe Howell

This goal is accomplished, according to Zelik, by studying the interdisciplinary science of human movement (biomechanics/neuromechanics); designing, developing, and controlling next-generation assistive and rehabilitative technologies, such as prosthetic limbs, robotic exoskeletons, and smart assistive clothing; performing human subject experiments in a motion analysis lab to measure if and how much these technologies help users; and training engineers and scientists to be future leaders and innovators in the fields of biomechanics, biomechatronics, human augmentation, prosthetic and exoskeleton design, and rehabilitation engineering. CREATE comprises two co-located laboratories: the lab that Zelik manages, called the Zelik Lab for Biomechanics & Assistive Technology, and a second lab managed by Michael Goldfarb, PhD, a leader in wearable robotic prostheses and exoskeletons. “Together, Professor Goldfarb and I co-direct CREATE, which consists of our individual labs plus 3,000 square feet of additional shared testing and fabrication facilities,” Zelik explains. The CREATE space is equipped with state-of-the-art measurement equipment, including an infrared motion capture system, force-instrumented treadmill, force-instrumented floor tiles, portable respirometry (oxygen measurement) system, ultrasound imaging, electromyographic (muscle activity) measurement system, and an assortment of additional wearable sensors. “Human movement research,” according to Zelik, “has a lot to offer in terms of objectively quantifying and assessing the relative benefits of different interventions, which is of high interest to payors.” He enjoys studying biomechanics and discovering how biomechanical principles can translate into improvements in assistive devices. “I strive to improve health and mobility for individuals with disabilities, and to enhance human capabilities beyond biological limits, by engineering, measuring, optimizing, and understanding technologies that physically augment human performance,” he says. “I am interested in all applications of biomechanics—prosthetics, exoskeletons, smart clothing, and wearable tech.”

Zelik discusses results with PhD students at Vanderbilt University.

The Influence of Mentors

Originally from Pittsburgh, Zelik earned his bachelor’s and master’s of science degrees in biomedical engineering from Washington University in St. Louis. He initially pursued the field of cardiac bioelectricity, focusing on research and development related to implantable pacemakers and defibrillators, but he was drawn to the O&P field during his engineering doctoral studies at the University of Michigan. “My very first project involved a newly invented energy-recycling prosthetic foot and testing its function on a group of individuals with transtibial amputation,” he recalls. The prosthesis had been invented by engineers at Michigan prior to Zelik’s arrival, including Steve Collins, PhD, who is now associate professor at Stanford University; Peter Adamczyk, PhD, now assistant professor at the University of Wisconsin; and his PhD advisor, Arthur Kuo, PhD, now the Benno Nigg Chair in Biomechanics, Mobility, and Longevity at the University of Calgary. “When I arrived at Michigan, I helped lead human subject testing and perform gait analysis to understand if and how prosthesis users could benefit from this new type of foot that restored more natural ankle push-off capabilities during walking,” he says. “This principle of increasing ankle push-off to restore

limb function has since been applied to commercially available bionic foot prostheses.” Experiments were carried out at the U.S. Department of Veterans Affairs Hospital in Seattle, in conjunction with a group of clinical and engineering researchers in its Center of Excellence for Limb Loss Prevention and Prosthetic Engineering. “In retrospect, I was unbelievably lucky to begin my O&P experience with such an interdisciplinary and world-class set of mentors and collaborators from both Michigan and Seattle,” he says. Zelik and his wife, Tiffany, also spent two years in Italy while he completed his postdoctoral research at the Santa Lucia Foundation Rehabilitation Hospital in Rome. “During that time frame we traveled a lot, to about 35 countries, and enjoyed a lot of Italian sunshine, food, wine, and culture,” he says. They moved to Nashville in 2014 when Zelik joined the mechanical engineering faculty at Vanderbilt. He now has two children and feels right at home among the food, music, and vibrancy of Nashville. “We still enjoy traveling, when we can, with the little ones.”

Making an Impact

Since joining the Vanderbilt faculty, Zelik has led a variety of research initiatives, all aimed at improving mobility. O&P ALMANAC | MAY 2018



Zelik works with students and study participants at the CREATE space.



this understanding to underlying muscle-tendon mechanics. “We then work to translate these biological insights into bionic devices that better interface with and augment human movement, in order to restore mobility to individuals with disabilities and to enhance human capabilities beyond natural biological limits,” he explains. Recent projects have included studying multiarticular (multijoint) muscle biomechanics, studying ankle and foot dynamics, exploring neuromuscular adaptations during barefoot gait, quantifying the effect of footwear on walking and running performance, employing ultrasound imaging to peer under the skin at how muscle-tendon dynamics facilitate human movement, and exploring how to use wearable (accelerometer-based) sensors to track walking performance outside the lab—for example, to monitor gait of lower-limb prosthesis users and provide prosthetists with objective data to help them fit and align devices. Wearable technologies—such as exoskeletons and smart clothing—is another area where Zelik has focused some of his research efforts. “Innovative human augmentation devices could dramatically

improve the health and mobility of individuals” living with physical disabilities or neurological impairments, he says—but only if properly designed and integrated with the human body. “Even for healthy individuals, human augmentation technologies could be developed to enhance their capabilities beyond normal biological limits, which could improve productivity and reduce workplace injuries,” Zelik says. “Our lab is interested in the ubiquitous challenges associated with integrating technology—exoskeletons, smart clothing, and other wearable orthoses—with the human body to augment movement.” Recent research initiatives have included studying the physical human-exoskeleton interface dynamics, developing new ways for comfortably integrating assistive technologies with the body, and creating and testing wearable assistive devices that aim to enhance performance and reduce injuries. Zelik’s most visible wearable tech project has been his lab’s “smart underwear” invention, which debuted last year and led to one of his students winning the Young Scientist Award at the International Society of Biomechanics conference in Brisbane, Australia, in 2017.

PHOTO: John Russell/Vanderbilt University

In the area of lower-limb prosthetics, for example, he has been involved in studies related to developing innovative ways to couple prosthetic limbs to the human body to improve force and power transmission, such that users get more benefit from their prosthesis. He also has been exploring how adding toe joint dynamics in prosthetic feet can benefit users who are navigating different terrains and performing various daily activities. In addition, he has been investigating how to build human-like reflexes into robotic prosthetic knees, so that individuals with transfemoral amputation can recover from stumble and foot scuff perturbations—and reduce the incidence of falls and resulting injuries. Zelik also performs biomechanics research related to gait analysis, both in the laboratory and using wearable sensors. “We seek to develop a deeper understanding of biomechanical mechanisms underlying legged locomotion by studying how humans move and why we move the way that we do,” he says. His research team places a strong emphasis on a multiscale biomechanical understanding of movement—connecting whole-body dynamics to joint- and segment-level kinetics, then connecting

“We developed, and are now continuing to refine and test, this new smart clothing device that can reduce low back stress during lifting and leaning tasks, in an effort to reduce back pain and injury risks,” he says. “The media has affectionately dubbed our device ‘smart underwear’ since the key feature that distinguishes our approach from other wearable exoskeletons is that it can be concealed within or worn under clothing to make the solution practical for people who either cannot, or for various reasons will not, wear a device on top of their clothes in their daily lives.” The device fits like clothing, assists like an exoskeleton, and can be engaged/ disengaged on demand by simply tapping a sensor on the clothing to reduce stress on the low back during heavy lifting or prolonged leaning, according to Zelik. The invention recently won the Fan Favorite Award in the Innovation Challenge at the Wearable Robotics Association Conference in Phoenix.



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NETWORKING It’s not just who you know, it’s who others know. Networking is powerful.

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A Brighter Future

Zelik believes his self-evolution—from an energetic and often-injured child with broken bones and casts, to a prominent researcher developing solutions for the mobility-challenged population—is far from over. He continues his work at CREATE, funded by a combination of grants from government agencies, industry, and private foundations, as well as Vanderbilt’s institutional support. He believes the work he is doing will result in improved mobility and a better quality of life for prosthesis users and for other individuals with musculoskeletal disorders or neurological injuries, such as stroke and spinal cord injury patients. “I believe that ‘mobility is livelihood,’” Zelik says. He enjoys “the challenging and interdisciplinary nature of this research— combining expertise from engineering, science, medicine, and specifically the O&P discipline, with input from end users in order to address pressing societal problems.” And like any good researcher, Zelik thrives on “the joy and exhilaration of discovering something new, coupled with the humility of realizing how little we actually know, and how much more there is to figure out!”

HAVE A VOICE Gain a say in what happens in government through AOPA’s advocacy efforts.


Improve documentation with coding, billing, and audit resources and research so you get fairly paid for services while providing excellent patient care.


Let your business stand out and get noticed by peers, patients, and your community. Mobility Saves Lives & Money.

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JOIN US! Call 571-431-0876 or email


Learn more at





Cascade Dafo


Lightening the Load Manufacturing company debuted orthoses made of thinner, more flexible plastic





Don Buethorn, CPO, works with a pediatric patient.

COMPANY: Cascade Dafo OWNERS: Don Buethorn, CPO, and Candace Buethorn LOCATION: Ferndale, Washington HISTORY: 36 years

A pediatric patient wears orthoses from Casade Dafo.

for the hand, elbow, and knee, as well as knee-ankle-foot braces. The main concept, says Sheldon, is to keep the level of support well matched to the patient, the least amount of support to get the job done. “We don’t want to interfere with any movement patients can do on their own. That’s why we have so many designs.” The company’s manufacturing facility in Ferndale, Washington, occupies about 50,000 square feet, employs 300 workers, and serves clients worldwide. “Many people don’t know we also make adult braces,” says Sheldon. “But the first DAFO is over 33 years old, and those children have grown up!” Buethorn stuck with his vow not to quit until a brace is 100 percent satisfactory, and he will remake a device until the patient is happy. Customers have come to appreciate the company’s warranty, says Sheldon. “It doesn’t have to be anything we did wrong; if fit and function aren’t happening, we will make it over again. That is our No. 1 priority… . What the patient

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

PHOTOS: Cascade Dafo

CPO, planned to become a physical therapist—then he learned about orthotics and prosthetics and became fascinated with the profession. He moved into the O&P field and, as an intern, was frustrated when his facility owner insisted he make do with orthoses that did not fit his patient properly. When Buethorn and his wife, Candace, opened an O&P facility in Bellingham, Washington, in 1982, he vowed not to quit until a brace was 100 percent perfect. At the time, ankle-foot orthoses were made of rigid, thick plastic that did not wrap around the limb. Buethorn was working with a physical therapist who wanted something better—a thin, flexible, wraparound brace. Buethorn “explained patiently that that was not how braces were made,” says Loretta Sheldon, director of business development and education for Cascade Dafo. But the physical therapist insisted, and Buethorn eventually created the first dynamic ankle-foot orthosis, or DAFO. “It was made of thin plastic that was light and flexible but returned to the position intended,” says Sheldon. “And because the whole foot was wrapped, pressure was spread out over the whole device instead of hitting a few pressure points that could become irritated.” Buethorn’s invention led to the creation of a new business, Cascade Dafo, in 1996, and his product line has expanded to include 23 different custom designs and 10 prefabricated orthoses. Most are lower-limb devices, but the company also makes orthoses

experiences is what matters— improved mobility and meeting their physical therapy goals.” The company was one of the first to involve children in the process of getting a brace. Candace Buethorn is an artist, and she devised special trims that are sewn to the straps of the device. A section on the company website, The Creation Station, allows children to select their own patterns and colors for their brace, which boosts compliance with wear instructions, Sheldon says. Clinicians can sign up for free online courses through the Cascade Dafo Institute on the company’s website and can earn up to 12.25 continuing education credits approved by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics. Online video case studies and how-to videos help clinicians with selecting appropriate designs and ensuring appropriate fit. The company markets through live presentations at industry trade shows and has four account representatives who can visit clinicians in person to show them DAFO samples and explain support offered by the company. Cascade Dafo encourages everyone on staff—not just clinicians—to connect to the patient experience, says Sheldon. Some visit clinics to observe the process, while others gain experience through videos and onsite education. That commitment to patients—getting it right no matter what the cost and understanding what patients experience and want—was the inspiration behind the creation of Cascade Dafo, and it continues to be the company’s foundation.

Customizable Accreditation Brochures Your patients, referral sources and insurers probably don’t know how hard you worked to attain ABC Facility Accreditation. Isn’t time you tell them! Take advantage of our Customizable Accreditation Brochures. We’ve done all the work for you, all you need to do is place an order.


Dynamics Orthotics & Prosthetics

Inclusive O&P Los Angeles facility serves area hospitals and caters to a diverse O&P population





Sue Sean, CP, CMF, and resident Christian Meier work with a patient.

FACILITY: Dynamics Orthotics & Prosthetics LOCATIONS: Los Angeles, Torrance, Mission Hills, and Apple Valley, California OWNER: Peter Sean, CPO HISTORY: 28 years

Peter Sean, CPO

practitioners, technicians, and billing and administrative staff. In addition to its L.A. headquarters, which features a fabrication facility, the practice has satellite offices in Torrance, Mission Hills, and Apple Valley, California. The company offers a full range of O&P services, including pedorthics, mastectomy and lymphedema fittings, cranial helmets for infants, spinal bracing, and halos. The company also maintains an active partnership with the 600-bed Los Angeles County + University of Southern California Medical Center, or Los Angeles County General, one of the largest public hospitals in the country. For that hospital and others in the area, practitioners commit to call rotations so Dynamics clinicians can be available 24 hours a day, seven days a week.

Dynamics O&P, which is certified as a learning center by the National Commission on Orthotic and Prosthetic Education, has a steady stream of residents, in large part because of the variety of cases that the company handles. Students from nearby CSUDH, for example, train at Dynamics on a regular basis. The facility conducts outreach and marketing through regular in-service activities at hospitals, holding learning lunches with physical therapy and nursing staff, for instance, to review the devices that hospital physicians order from the company. “Whenever therapists ask, we’ll meet with them to train them on devices and help them get the most function for their patients,” says Sue. The company also will accompany doctors on weekly rounds and clinics, she adds, so O&P clinicians can update physicians on the patients they referred to the facility. Dynamics staff members strive to be patient advocates, taking the necessary time to collect the proper documentation—and pushing hard against insurance denials, Sue notes. “We listen to patients to accommodate what they need. We will fine-tune a custom device to meet the patient’s needs and abilities.” With its current volume and range of services, Dynamics O&P has no immediate plans for dramatic growth, says Sue. “We have a pretty full plate right now, with the challenges of documentation and keeping up with our on-call services to hospitals, but we’re always working on improving our services—and being ‘dynamic’ and embracing change.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at

PHOTOS: Dynamics Orthotics & Prosthetics Inc.

based in Los Angeles, is a large full-service facility whose staff mirrors the diversity of the broad geographic area it serves. That was the plan from the start, when Korean-American Peter Sean, CPO, founded Dynamics in 1990. Sean had worked in orthotics and prosthetics with the U.S. Army for 11 years, where he sought out every opportunity to improve his skills. He also is a graduate of the O&P program at California State University—Dominguez Hills (CSUDH). The company began in a tiny space in Koreatown, Los Angeles, just down the block from its present location. Sean’s vision for the facility was to become a resource for patients of all backgrounds, ethnicities, and income levels. “He worked hard to gain as many contracts as he could with area hospitals and Medicaid to provide a place where anyone could come and receive care,” says head prosthetist Sue Sean, CP, CMF, Peter’s daughter. With staff members from a variety of ethnic backgrounds, the company can accommodate nearly every language requirement, including Spanish, Korean, Chinese, and Vietnamese. “We pride ourselves on building a community that encompasses not only our patients, but also our affiliation of caregivers, social workers, therapists, nurses, and physicians,” she says. Today, Dynamics O&P has about 50 employees, including



How Does Your Business Measure Up? AOPA’s 2018 Operating Performance Survey


BENCHMARKING: the process of comparing one’s business processes and performance metrics to industry bests.



Participate in O&P’s largest company performance benchmarking survey before the June 28th deadline!

Gross Margin





Needs Work

Sales Generat ed Per Employee

Cost of Goods


AOPA 2018 Annual Operating Performance Report • Identify where your O&P facility needs to improve. • Know how your company’s financial performance compares with industry leaders and others in similar markets.




• Make informed business decisions using your company’s benchmarking data.





This survey is FREE for AOPA patient care facility members.




(Reporting on 2016 Results)

It’s CONFIDENTIAL. Data collection is managed by Industry Insights. Participants receive a confidential company report plus the final published report.


AOPAversity Webinars JUNE 13


Audits: Know the Types, Know the Players, and Know the Rules

With the addition of the Target, Probe, and Educate (TPE) TARGET program come new questions about audits and their resolutions. Take part in the TPE Program June 13 webinar to gain an understanding of the different PROBE audits and what happens during each. AOPA experts will share their knowledge on the following topics: • How many claims can a zone program integrity contactor (ZPIC) audit review? • How can we be removed from a TPE audit? • Who conducts the comprehensive error rate testing (CERT) audit? • What restrictions do the recovery audit contractors have? • What are my options when audited?

Your source for advanced learning EARN CE CREDITS 48



Administrative Documentation: What Is Always Needed and What Is Sometimes Needed? Distinguishing “must-have” documentation form documentation that is needed in certain circumstances can be a challenge for O&P professionals. Plan to listen in to the July 11 webinar on “Administrative Documentation: What Is Always Needed and What Is Sometimes Needed?” You’ll learn important information on the following topics: • When to use an Advance Beneficiary Notice • What to include on a proof of delivery slip • When two orders/prescriptions may be required • When and how often HIPAA forms need to be signed • Who can complete the certifying statement for therapeutic shoes.

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. Sign up for the entire series and get two conferences free. All webinars that you missed will be sent as a recording. Register at


n ovatio n n I t to n! sspor a P r ucatio d You E h g t h ro u R EMBE SEPT




Earn more than

40 CE



REGISTER AND LEARN MORE BY VISITING The 2018 AOPA National Assembly will take place in

Vancouver, Canada. Do not miss out on the most anticipated meeting for orthotic, prosthetic and pedorthic professionals. AOPA’s National Assembly features the best that OP&P has to offer worldwide. What does this mean for you? Get access to the best in business education, and advanced clinical programming from physicians, including highlevel researchers and top practitioners. Did we mention our premier Exhibit Hall that contains a vast array of suppliers from around the globe to meet any and all your needs? All this and more in the beautiful city of Vancouver! For information about the show, scan the QR code with a code reader on your smartphone or visit

OPA the A

s for n Join ual Assembly o018. n Natio ber 26-29, 2 m e t p Se

Who Should Attend? Practitioners, physicians, technicians, fitters, students, educational instructors, facility owners, marketing personnel, residents, office managers, billing specialists, researchers, manufacturers, distributors and suppliers of OP&P products and services must come to Vancouver to learn about the latest in OP&P products, education, legislation/ regulation, business management and so much more. Interact with fellow healthcare and OP&P professionals gathered from around the world. Earn more than 40 CE credits by attending the AOPA National Assembly.


Join us

for the AOPA National Assembly on September 26-29, 2018.



Sarah Reinertsen tests the Nike Sole, developed by Tobie Hatfield of Nike.

TOBIE HATFIELD is Director of Innovations for Nike. Hatfield joined Nike in 1990 and worked in the corporation’s research and development center in Taiwan for five years and was promoted to senior engineer of advanced projects. The renowned designer developed some of Nike’s signature models including the Michael Johnson Olympic “Gold Shoe,” the ACG Trail Running Line, the Nike Free, and PV Lite. He helped launch Nike’s celebrated Innovation Kitchen in 2000. Today, Hatfield works closely on product design with many sports superstars, including Maria Sharapova, Sarah Reinertsen, and Tiger Woods. But, perhaps even more exciting than that is Hatfield’s involvement in driving a number of the company’s significant advances in sneaker and apparel technology. He most recently developed a cutting-edge wrap-around zipper system in sneakers for physically challenged athletes.


Paralympic medalist (1 gold, 1 silver) PyeongChang 2018 Paralympic Winter Games, gold (snowboard-cross), and silver (banked slalom). Schultz has been a lifetime lover of action sports. In 2008, during a snocross race accident he suffered from a severe compound fracture to his knee and after multiple surgeries had his leg amputated above the knee. After engineering his own prosthetic knee, Mike earned a motocross adaptive silver medal at the X games. It was after this that Mike realized the need for advancements in high impact adaptive sports prosthetics and founded BioDapt, Inc. Currently more than 100 wounded soldiers, extreme athletes and amputees wanting to return to an active lifestyle are using Mike’s prosthetics.

Amazing General Sessions featuring innovative and inspirational speakers such as Tobie Hatfield, Director of Innovation for Nike and Mike Schultz, Paralymic Gold Medalist.

World Health Organization standards for P&O will be featured during a special update from the International Society of P&O (ISPO).

Business Education on Compliance, Best Business Practices, Finance, Overhead Reduction Strategies, Navigating the Medicare Appeal Process, HIPAA, Cybersecurity, Contract Negotiations, Change Management and State Level Legislative Activism.

Special Regulatory update to include the 2018 Social Security Act Amendment making the orthotist/ prosthetist notes an official part of the patient’s medical record for purposes of determining the reasonableness and medical necessity.

Orthotic Education highlights include Lower Limb Movement Disorders, the Role of Spasticity in Diplegic Cerebral Palsy, Optimizing Pediatric Outcomes, and Rehabilitation of the Paretic Arm.

Prosthetic Education topics include Technology for Geriatrics, Socket and Suspension Design, Gait Deviation Detection and Correction for LL Amputees, and Evidence of Benefits of MPK for Limited Community Ambulators.

Outcomes and Evidence-Based Practice in P&O: How Are You Documenting Value in Your Clinic and Using it to Improve Reimbursement?

Pedorthic Education on Prevention, Diagnosis and Management of Common and Rare Conditions, Preventing the Destruction of the Diabetic Foot, Making and Keeping Your Pedorthic Practice Successful and more.

Technical Education on lean manufacturing, fabrication techniques and more.

Business Certificate Programming

SCHEDULE AT A GLANCE TUESDAY SEPTEMBER 25, 2018 10:00 AM – 6:00 PM 1:00 – 5:00 PM

Exhibitor Set-up Pre-Show Hands-on Workshop



The Impact of Professional Women in O&P—Panel Program and Brunch

• •

Thranhardt Golf Classic

Pre-show Workshop—Contemporary Overview of LL Prosthetic Impression Techniques

• • •

Day Trips and Tours of Vancouver

Slap Shot Hockey Game sponsored by Alps South LLC

• •

Welcome Reception

Party with a Purpose—1970s Disco and Dinner

1:00 – 3:00 PM 1:00 – 5:00 PM 1:00 – 5:00 PM 3:30 – 5:30 PM 5:30 – 7:30 PM 5:30 – 7:30 PM

Manufacturers’ Workshop – Tier D Business Certificate Program Manufacturers’ Workshop – Tier E Manufacturers’ Workshop – Tier F Welcome to Vancouver: Opening Reception Exhibit Hall Open

7:15 – 8:30 AM


Step it Up Challenge sponsored by MD Orthopaedics

8:30 AM – 10:00 AM 8:30 AM – 5:00 PM 10:00 AM – Noon Noon – 1:30 PM 1:30 – 3:00 PM 3:00 – 3:15 PM 3:15 – 5:00 PM 6:30 – 9:30 PM

Opening General Session: Keynote Address with Tobie Hatfield, of Nike, followed by Thranhardt Lectures Break in Exhibit Hall Exhibit Hall Open Concurrent Education Lunch in Exhibit Hall Concurrent Education Break Concurrent Education Party with a Purpose

FRIDAY SEPTEMBER 28, 2018 7:15 – 8:30 AM

Technical Fabrication Contest ORTHOTIC

Registration Open Exhibitor Set up Manufacturers’ Workshop – Tier A Manufacturers’ Workshop – Tier B Manufacturers’ Workshop – Tier C Thranhardt Golf Classic (Buses depart from the convention center at Noon)


Discounted Alaskan Cruise Option


7:00 AM – 6:30 PM 8:00 AM – 3:00 PM 8:00 AM – Noon 8:00 – 10:00 AM 10:30 AM – 12:30 PM 1:00 – 5:00 PM




EXHIBITS There is no better place to evaluate and compare the latest technology, see product demonstrations and to ask detailed questions. You will have the opportunity to visit and learn from 150 suppliers showcasing the latest devices, tools, componentry and solutions over the course of the Assembly.

8:30 – 10:00 AM 8:30 AM – 6:00 PM 10:00 AM – Noon Noon – 1:30 PM 1:30 – 3:00 PM 3:00 – 3:15 PM 3:15 – 5:00 PM 5:00 – 6:00 PM

General Session: AOPA Membership Meeting followed by ISPO Presentation Break in Exhibit Hall Exhibit Hall Open Concurrent Education Lunch in Exhibit Hall Concurrent Education Break Concurrent Education Happy Hour in Exhibit Hall

SATURDAY SEPTEMBER 29, 2018 7:15 – 8:30 AM 8:30 – 10:00 AM 8:30 AM – Noon 10:00 AM – Noon Noon – 1:00 PM 1:00 – 5:00 PM

General Session: Paralympic Gold Medalist, Mike Schultz, followed by Orthotics 2020 Break in Exhibit Hall Exhibit Hall Open Concurrent Education Lunch on Own Workshops

Visit for a comprehensive education schedule. *Times are subject to change.

A FEW REASONS WHY? Consider just a few reasons why you should plan a trip to Vancouver:

Gateway to Adventure Spectacular & Safe Setting Majestic mountains, sparkling ocean, rainforests and beautiful foliage throughout all four seasons make Vancouver one of the most beautiful cities in the world.

With quick and easy access to Whistler, the Canadian Rockies, Victoria, Vancouver Island, and of course, endless yearround water and land sports, you’ll find your personal adventure here. Only have one evening to explore? Take advantage of the free shuttles to Grouse Mountain and Capilano Suspension Bridge. Vancouver also is the home port for Alaska cruises May through October.


R 26



Superior Service & Value A priority of Vancouver’s businesses is providing friendly assistance every step of the your trip. And with a consistently advantageous exchange rate on the Canadian dollar, you can have a world-class experience with superior value for your money!

Exciting Activities Catering to any interest throughout the year, you can enjoy world class shopping, gourmet meals, outstanding live entertainment, sporting events, theatre, outdoor adventure, spectacular sights and attractions - it’s all waiting for you in Vancouver.

Welcoming & Accessible Just as Vancouver welcomed the world in 2010 for the Olympic and Paralympic Winter Games, we’re ready to welcome you as well! A vast multicultural population, endless activities, and excellent infrastructure, Vancouver is welcoming to all! The Vancouver International Airport has consistently been rated as a top North American airport providing easy access from all over the world. The city has a public transportation, but given how walkable Vancouver is, just might never use it! A great walking city, Vancouver is clean, green, safe, and easily accessible!


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 would like to thank the following individuals for their contributions to a candidate’s fundraiser and/or to an O&P PAC-sponsored event: Wendy Beattie, CPO, FAAOP Rudy Becker Curt Bertram, CPO, FAAOP Amit Bhanti, CPO David Boone, MPH, PhD, BSPO Jeffrey Brandt, CPO Charles Dankmeyer, CPO Traci Dralle, CFm Steve Filippis, CP Thomas F. Fise, JD Rick Fleetwood, MPA Jim Kaiser, CP Teri Kuffel, JD

Dave McGill Michael Oros, CPO, FAAOP Jack Richmond, CPOA Rick Riley Manuel Rivera, CP Scott Schneider Chris Snell, BOCP Clint Snell, CPO Frank Snell, CPO, FAAOP Peter Thomas, JD Jim Weber, MBA

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

Make plans now to celebrate at the “Party With a Purpose” during the 2018 AOPA National Assembly, September 26-29, in Vancouver. Be there or be square, and wear your grooviest threads! Stay tuned for more information on the event, including how to secure your spot, or contact Devon Bernard at



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

Ability Prosthetics & Orthotics of Nevada LLC 309 Kirman Avenue Reno, NV 89502 775/333-9255 Member Type: Patient-Care Facility Tina Humphreys, CFm

Lone Star Prosthetics 2201 Brookhollow Plaza Drive, Ste. 350 Arlington, TX 76006 817/649-8144 Member Type: Patient-Care Facility Bryan Pettit

Kid Ortho 98 Bis Avenue de Saige Pessac, 33600 France 33 556461404 Member Type: International Jean Marc Bérodier

TheraTogs Inc. 305 Society Drive Telluride, CO 81435 888/634-0495 Member Type: Supplier Level 1 Lee Taylor





Opportunities for O&P Professionals


Certified Prosthetic/Orthotic Clinicians

Job location key:

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 are available.

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

Hire employees and promote services by placing your classified ad in the O&P Almanac. When placing a blind ad, the advertiser may request that responses be sent to an ad number, to be assigned by AOPA. Responses to O&P box numbers are forwarded free of charge. Include your company logo with your listing free of charge. Deadline: Advertisements and payments need to be received one month prior to publication date in order to be printed in the magazine. Ads can be posted and updated any time online on the O&P Job Board at 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.


Inter-Mountain Assets For Sale

Recently Retired Mid-Texas CPO Selling Assets

Recently retired CPO/LPO wishes to sell office furnishings, equipment, tools, and inventory. $12,500 cash plus shipping or you load and ship to your location. Ready to ship from storage. Contact John G. Craig, CPO, LPO, with name, credentials, and contact information for specifics at Contact: John G. Craig, CPO, LPO Email:

O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Nonmember $678 $830

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

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

ONLINE: O&P Job Board Rates Visit the only online job board in the industry at Job Board

Member Nonmember $85 $150

For more opportunities, visit:


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




Certified Orthotist

Fredericksburg, Virginia An orthotic and prosthetic company in Fredericksburg, Virginia, is seeking an ABC-certified orthotist. The ideal candidate needs to be motivated and dedicated to providing the best patient care possible. This person will be responsible for patient care, assessment/formulation of treatment plans, documentation, education, fabrication, and ordering proper components and supplies. We are a busy, growing prosthetic and orthotic company looking for the right person so that we may continue to expand our practice. This is a great opportunity for the right person to add to our orthotic department, which is very active with pediatrics to geriatrics. We offer a competitive benefits package and look forward to hearing from you. Interested candidates please email your résumé to Chris Taylor at Contact: Chris Taylor Email:

CAREERS O&P Services


An Orthotics and Prosthetics Billing Company A full-service billing company providing initial insurance verification through final payment posting, including any denial management or appeals necessary. Consultants committed to providing the service you need to be successful!

Altru Health System located in Grand Forks, North Dakota, is seeking an CO/CPO. Altru is a regional integrated health system focused on delivering World Class Care to the residents of our region. As a member of the Mayo Clinic Care Network, we work together and share a common philosophy, commitment and mission to improve the delivery of health care through high quality, data driven, evidence-based medical care and treatment. We are a hospital based practice that has been in business for over 40 years. Strong interest in Cranial shaping helmets preferred as we are a Star Scanner facility with a large pediatric population. Fully staffed on site fabrication facility to support your practice. Candidates must be ABC certified with five years of related experience preferred. Grand Forks offers excellent school systems, year-round outdoor recreation, sporting events, fine arts and a vibrant downtown.

Prudential Billing and Consulting

Contact: Phone: 888/862-9377 Email: EOE


Advertisers Index Company ALPS



15 800/574-5426

American Board for Certification for Orthotics, Prosthetics, & Pedorthics Inc. 45




29 800/356-3668

Cailor Fleming Insurance



Coyote Design



Custom Composite



Fabtech Systems LLC




1 800/301-8275

Naked Prosthetics



3 800/233-6263

Ottobock Spinal Technology Inc.


C4 800/328-4058 7

800/253-7868 www.npdevices.copm




Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email Visit for advertising options.

ALPS Anterior Posterior Tapered Liner ALPS AP Tapered Liner is gradually tapered from the anterior to the posterior to provide superior comfort. This liner is available in a pin-and-lock system or suction suspension. The AP Tapered Liner features our black high-performance fabric with gel to assist in reducing bunching in the popliteal region. For more information, contact ALPS at 800/574-5426 or visit

Coyote Design Quik Glue New name, same great adhesive. 50 cc or 220 cc. Available in 30- and 60-second set times. • Great for attaching componentry • Multiple repair uses • Very quick set with no sag. They ship nonhazardous and are safe with no odor. For more information, contact Coyote Design at 208/429-0026 or visit

Fabtech Systems 3-D-Printing Capabilities Fabtech Systems and Extremiti-3D provide the highest quality 3-D-printed prosthetic devices to the O&P industry. Products provided: Protective covers, above-knee and below-knee sockets. Features: • Precise form, fit, and functionality your patients deserve • Twenty industry standard skin tones and 16 custom protective cover designs • Reformable definitive for individual customization • Carbon additives provide long lasting durability • Eliminates pulling deformities encountered with manual fabrication • 3-D printed to your exact measurements. For more information, call 800/322-8324 or visit



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

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.

MARKETPLACE Ottobock Microprocessor Feet (MPF) Ottobock’s advanced microprocessorcontrolled foot technology allows your patients to experience life with fewer restrictions and provides a wide range of functionalities. With Ottobock Microprocessor Feet (MPF), patients have access to a unique “Relief” function that enables full-surface contact with the floor, and a more natural foot appearance. Empower® is the only prosthetic foot with powered propulsion, which emulates the function of lost muscles and tendons and delivers energy rather than consuming it, with each step. Empower also reduces stress on joints and offers patients the combination of power, control, and stability. Learn about our full MPF portfolio at

Ottobock Omo Neurexaplus Shoulder Orthosis Redefine recovery with Ottobock’s Omo Neurexaplus. The shoulder orthosis facilitates active rehabilitation by correctly positioning the arm and promoting movement for patients with shoulder subluxation. The Omo Neurexaplus inhibits pathological movement patterns, improves body posture and gait, and can be applied by patients themselves with one hand. For more information, call 800/328-4058 or visit

Spinal Technology Spinal Technology Inc. is a leading central fabricator of spinal orthotics, upper- and lowerlimb orthotics, and prosthetics. Our ABC-certified staff orthotists/prosthetists collaborate with highly skilled, experienced technicians to provide the highest quality products and fastest delivery time, including weekends and holidays, as well as unparalleled customer support in the industry. Spinal Technology is the exclusive manufacturer of the Providence Scoliosis System, a nocturnal bracing system designed to prevent the progression of scoliosis, and the patented FlexFoam™ spinal orthoses. For information, contact 800/253-7868, fax 888/775-0588, email, or visit

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.





June 1

May 4–5

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

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

June 1

May 7–12

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

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

June 13

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

May 9

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

July 11

May 18–19

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

Administrative Documentation: What Is Always Needed and What Is Sometimes Needed? Register online at For more information, email Ryan Gleeson at WEBINAR

Apply Anytime!

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

Calendar Rates Let us


your next event!



Free Online Training

Cascade Dafo Institute. Cascade Dafo Institute offers eight free ABC-approved online continuing education courses for pediatric practitioners. Earn up to 12.25 CE credits. Visit or call 800/848-7332.

CE For information on continuing education credits, contact the sponsor. Questions? Email


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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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 Seminar Coding & Billing Techniques Seminars. St. Louis. Register online at For more information, email Ryan Gleeson at

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 7–9

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

November 12–13

August 8

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

August 10–11

The Texas Chapter of the American Academy of Orthotists and Prosthetists 2018 Annual Meeting. Westin Galleria, Dallas. For information and registration, visit

September 12

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

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

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

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


October 18–20

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

2020 September 9–12

AOPA National Assembly. Mandalay Bay, Las Vegas. For general inquiries, contact Betty Leppin at 571/4310876 or, or visit




All About the ABN What are a clinician’s responsibilities regarding an Advance Beneficiary Notice?

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


Is the Advance Beneficiary Notice of Noncoverage (ABN) form all or nothing, or may it be used for individual claim lines?


The ABN may be used either for an entire claim or for a single claim line. Whenever you, as the supplier, have a strong belief that Medicare may deny a covered claim or line item (e.g., addition codes) for medical necessity reasons, you may ask the patient to sign an ABN.


Is the ABN required when providing a noncovered item to a Medicare beneficiary?


When you are providing an item that is statutorily noncovered because it is not considered a Medicare benefit, you are not required to have the patient sign an ABN. However, you may choose to have the patient sign the ABN as a record to indicate that you told the patient the item/service you are providing is noncovered and he or she will be responsible for payment.





Must the ABN be delivered in person?

The ABN must be presented to the patient before that patient receives the care that may be denied, and the patient must have time to make an informed choice about the care. The preferred method of delivering the ABN is in person, but it also is acceptable to send a copy to the patient by traditional mail or email. It is even acceptable to deliver the ABN over the phone.


If the patient refuses to sign the ABN, am I obligated to provide care and services?


If you issued a proper ABN and the patient makes the choice not to sign it, you are not obligated to provide care or services. If the patient


refuses to sign the ABN and you elect not to provide care, you should document this in the record and annotate the ABN to indicate the patient refused to sign. It is a good idea to list any witness to the event. If the patient refuses to sign the ABN, but I still wish to provide the service or item, what modifier should I use on the claim?


If the policy requires a KX modifier, you would not use the KX because it is likely that coverage criteria have not been met—or you would not have requested the patient to sign the ABN. You would not use the GA modifier because the patient did not sign the ABN, and you would not use the GY modifier because the items are not noncovered. Instead, you would use the GZ modifier. The GZ modifier indicates that you are aware the item may not be considered medically necessary but you don’t have an ABN on file. Keep in mind that the GZ modifier will cause the claim line or claim to be automatically denied, but you may appeal the denial and demonstrate the medical necessity for the item or service.



Do Medicare Advantage plans use the ABN?

The ABN is strictly used for traditional fee-for-service Medicare and is not used for items or services provided under Medicare Advantage plans. The ABN form also is not used with private payors; however, it is possible for private payors or Medicare Advantage plans to have a similar method of protecting the financial liability of a provider/supplier.


AOPA Coding Experts Are Coming to

St. Louis July 23-24


FEB. 26-27 | 2018


ESSENTIAL CODING & BILLING TECHNIQUES SEMINAR Join AOPA July 23-24 in St. Louis to advance your 14 CEs 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

Top 10 reasons to attend: 1.

Get your claims paid.


Increase your company’s bottom line.


Stay up-to-date on billing Medicare.


Code complex devices


Earn 14 CE credits.


Learn about audit updates.


Overturn denials.


Submit your specific questions ahead of time.


Advance your career.

10. AOPA coding and billing experts have more than 70 years of combined experience. The Westin St. Louis 811 Spruce Street St. Louis, MO 63102 Book your hotel by July 6 for the $149/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 .

Redefining recovery.


Omo Neurexaplus

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WalkOn® Reaction




Increase comfort, improve outcomes.

Redefine what recovery means to your patients. Our suite of stroke solutions provides you with better tools, better care, and better outcomes for your patients – from head to toe. Facilitate active rehabilitation for patients with shoulder pain and dislocation with the Omo Neurexaplus orthosis, and improve gait stability for individuals with drop foot to walk more naturally with the WalkOn® AFOs.

• Learn more at

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Hesse 2013 Pradon 2011

3/18 ©2018 Ottobock HealthCare, LP, All rights reserved.

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