O&P Match Game

Deciding on the best prosthetic or orthotic device is not always a simple task, especially with payer issues and patient input.

When fitting patients with orthotic and prosthetic devices, O&P practitioners search through a variety of options before making a choice. Any number of issues may affect that initial decision, however. Practitioners must consider these factors and additional patient circumstances to find the best match.

O&P criteria

O&P practitioners have their own ways of determining the best course of action for their patients. When it comes to choosing prosthetic and orthotic devices, they use certain established guidelines.

The first factor in deciding on the best prosthetic device for a patient is the condition of the residual limb, Robert F. Silvestri, CPO/L, director of JFK/JRI Prosthetic and Orthotic Lab in Edison, N.J., told O&P Business News.

“If they have skin grafts, or if a transtibial amputee has a contracture of the knee, if there are any fractures … that is going to modify the way that we think about our recommendation for a prosthesis,” he said.

Jonathan D. Day, CPO/LPO, chief of orthotics and prosthetics in the department of orthopedic surgery and rehabilitation at the University of Oklahoma Health Sciences Center in Oklahoma City, on the other hand, first looks at whether or not the patient will meet weight restrictions for certain components. As the number of obese people in the United States steadily increases, O&P practitioners begin to find a large patient population that exceeds weight limits, Day said.

Next, Silvestri, president of the New Jersey Chapter of the American Academy of Orthotists and Prosthetists, determines the manual dexterity of his patients, as well as their access to family help or home care. If a patient will not be able to don and doff a complicated device, then the benefit of certain prosthetic components is not the most important factor.

He also establishes the patients’ activity level. If a patient already is an amputee and has had a prosthesis, in what type of activities has he or she participated? If the patient is a new amputee, then what activities would he or she like to work toward? The answers to these questions guide Silvestri’s recommendations for feet and for knees for transfemoral amputees.

In Oklahoma, many of Day’s patients enjoy hunting, fishing or boating, activities that may affect an amputee’s prosthetic device. For this reason, he questions all of his patients about their work history, vocational and avocational activities, and their personal and occupational goals.

Finally, many patients may have any number of cognitive issues that affect their use of prosthetic devices. Older amputees may be dealing with stroke or Alzheimer’s disease, both conditions that could present challenges in their understanding of the prostheses and of how to properly care for the devices.

O&P Match Game
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The most important factor in determining a prosthetic device for a patient is listening to that patient. Patients know better than anyone else what kind of activities and work their legs and feet will need to able to handle throughout the day.

Often, prosthetists find there are multiple feet or multiple knees that meet a patient’s needs. In these cases, Day said it may be feasible for the patient to make the final decision. However, it is up to the prosthetist to provide enough information about the pros and cons of each component so that the choice the patient makes is the right one.

“I think if you do an appropriate history, you then become the guide,” he said.

Prosthetic mismatch

Just because patients choose certain devices does not mean that they are good candidates for them. Silvestri recalls a woman who spent most of her time in a wheelchair because she was unsteady on her preparatory prosthesis. When it came time to fit her for a permanent prosthesis, she requested a microprocessor knee. He informed her that the microprocessor would be heavy and requires too much maintenance for her functional level.

In the end, Silvestri fitted her with a polycentric stance control knee in her prosthesis, which provided her with more stability and less tendency for her knee to buckle.

Another challenge practitioners face is correcting the influx of information patients get from television and the Internet, Day told O&P Business News. Although they are great sources of knowledge for patients and help to spread the word about orthotic and prosthetic breakthroughs, they can make for difficult requests from people who set their hearts on devices that are not fit for them.

In one example, Day had to tell an obese patient that he exceeded the weight limit for the microprocessor knee he read about on the Internet, and would lose the warrantee on the device if fitted.

Silvestri, too, has had to educate someone about a potential prosthesis. He received a phone call from an amputee looking to be fitted with the C-Leg from Otto Bock HealthCare. Silvestri asked him to describe his residual limb and he learned that the patient was a transtibial amputee, and would not need the microprocessor knee.

Device specifications

Regardless of what patients need, most O&P treatment options ultimately are guided by payments from Medicare or another third party payer. Under Medicare regulations, patients must fall into different functional categories in order to recieve certain prosthetic components.

“In order to get a lot of these components, you have to either be at level three or have the potential to get to level three,” Silvestri said. “A lot of patients may be at level two, but they may need that component, say a microprocessor knee, to be able to get to that next level. In order to get microprocessor knees, hydraulic knees and certain types of energy-storing feet, they need to be at level three or above.”

When patients fall into that gray area between the second and third levels, practitioners need to do their homework to provide patients with the top devices.

“We have to justify that someone at a level two has the potential to get to level three,” he said.

Payer issues

Medicare and other third party payers often cause issues in providing the best care for patients. On the opposite side of the issue of patients not understanding what is appropriate is the issue of Medicare and other payer denials.

“Sometimes patients want devices and they are appropriate candidates for them, but their insurance policies either are capped and the annual amount of money the policy permits them to spend on prostheses won’t scratch the surface, or the insurance company has deemed [certain devices] experimental,” Day said. “For financial insurance reasons, we have to tell them the devices are appropriate, the patients could benefit from them and I have written every letter, but the reality is they cannot afford to pay for it themselves and their insurance companies say no.”

Through the O&P practice at the University of Oklahoma Health Sciences Center, patients receive financial counseling prior to receiving care. This way, patients know exactly how much they can afford to spend on prosthetic or orthotic devices before they even find out what they need.

“There are way too many patient situations where it is medically appropriate [for them to get a certain prosthesis], based on their work and avocational needs and they have the ability to use the device, and yet the insurance company will still deny that care,” Day said.

Silvestri points out that practitioners can do their part to decrease these denials.

“Third party payers always point to that there is not enough evidence in the literature to say [these devices are] beneficial,” he said.

As the profession increases its use of evidence-based practice models, fewer patients should be denied care for these reasons.

Level II Modifiers

Level II or “K-Modifiers” help organize components and amputees’ access to them based on the patient’s rehabilitation potential as determined by the prosthetist and ordering physician. Criteria considered for assessing the functional level include the patient’s history, current condition including the status of the residual limb and the nature of other medical problems, and the patient’s desire to ambulate.

Classification levels

Classification levels are:

K0 (Level 0): Patient does not have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance the quality of life or mobility.

K1 (Level 1): Patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. This is typical of the limited and unlimited household walker.

K2 (Level 2): Patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces, as is typical of the limited community walker.

K3 (Level 3): Patient has the ability or potential for walking with variable cadence. This is typical of the community walker who is able to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic use beyond simple walking.

K4 (Level 4): Patient has the ability or potential for prosthetic use that exceeds basic walking skills, exhibiting high impact, stress or energy levels, typical of the prosthetic demands of the child, active adult or athlete.

Determination of coverage for selected prostheses and components with respect to potential functional levels represents the usual case. Exceptions are considered in individual cases if additional documentation is included that justifies the medical necessity. Prostheses are denied as not medically necessary if the patient’s potential functional level is “0.”

Information reprinted with permission of the Amputee Coalition of America.


Patient reactions

Additionally, the variety of choices in O&P care also can result in difficult circumstances for practitioners and patients.

“I’m old enough that when I first got into the field, there were maybe five choices for feet and maybe the same for knees. There weren’t a lot of choices for components. Now there are so many,” Silvestri said. “It actually makes our job somewhat difficult because until you try a lot of these feet, and even knees, we don’t know how they are going to work with certain individuals. We may recommend one and it may not work out for them.”

The easiest way for practitioners to avoid these back-and-forth situations is to listen to their patients. Beyond their initial recommendations, practitioners need to provide patients with the best fit for their bodies and their lives. Otherwise, the patients might not wear the devices, and that results in a waste of time and money for both patients and practitioners.

“Once patients get that foot and they wear it for a year and decide they don’t like it, then they are kind of stuck with it,” he said.

Keeping patients informed and pleased with their choices is important to the process, and that means ensuring they do not thwart their own prosthetic or orthotic success. Day wants his patients to make the important choices involved with their O&P care, but not at any detriment to their health.

“I like to empower patients through education and then allow them to have some input on ultimate decisions,” he said. “But I’m not going to allow them to do harm to themselves or make a terribly inappropriate choice.”

Proper fit

Silvestri makes every effort to fit patients with the right devices on the first try, but also adjusts care options as necessary. In situations where Silvestri has fit a patient with a socket, for instance, and that socket turns out to be a less-than-optimal fit for that particular person, he will change the design to get the patient in a socket better suited to the individual’s needs.

In the end, the main point of this issue is that practitioners must ensure that their patients receive the best possible care, regardless of the factors involved in the process.

“Ultimately, they are going to be the end users, so my perspective is pretty simple: It is my job to morally and ethically guide them through the process,” Day said.

After reviewing all their options, he leaves the big decisions to them.

“I have guided them. I have told them the consequences of choices, the benefits of other choices and what the limitations may be if they choose one thing over the other. But I don’t want to lose sight of the fact that these are the end users and these are their prosthetic limbs that I’m going to provide,” he said.

Only once in Day’s years in the O&P profession did he tell a patient that he could not provide a service. His professional opinion was that the decision was inappropriate for the patient and he suggested that the patient seek services elsewhere.

“I think it boils down to being the professional medical care provider over the salesman. I think it is appropriate to say no sometimes,” he said. “If all we are doing is getting a prescription that says below-knee prosthesis, and we apply the components that yield us the greatest profit margin to every patient, then we are salespeople focused on the profit. That, to me, would be the greatest disservice to the public.”

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