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  • CMS Considers Upgraded Requirements for Orthotics and Prosthetics Providers

    A proposed new rule from the Centers for Medicare and Medicaid Services (CMS) would include qualified physical therapists (PTs) among the providers who could furnish and bill for custom orthotics and prosthetics; however, the CMS definition of "qualified" may have administrative and financial implications for PTs.

    The proposed rule, issued on January 11, aims to tighten up requirements around who CMS will work with when it comes to making and furnishing devices ranging from glass eyes to exoskeletal systems and finger orthotics. In addition to an estimated 900 PTs who could be affected by the proposed rule, the provisions would also have an impact on facilities including skilled nursing facilities (SNFs) and rehabilitation agencies.

    For PTs, the most notable parts of the proposed rule have to do with how a provider would become qualified to participate in the system. According to a fact sheet from CMS, while PTs are among the providers who could participate, they would need to be "licensed by the state [as a qualified provider of prosthetics and custom orthotics], or … certified by the American Board for Certification in Orthotics and Prosthetics … or by the Board for Orthotist/Prosthetist Certification." These requirements would need to be met within a year after CMS posts its final rule, or at the time of the provider's reaccreditation cycle, whichever is later.

    CMS is accepting comments on the proposed rule until March 13, 2017. APTA regulatory affairs staff is preparing comments to CMS and will post a fact sheet on the proposal in the coming weeks.

    Comments

    • I have been casting for pediatric orthotics for 30 years. I send them to an orthotist for fabrication, but then I bill for them and fit them upon completion. How is this going to affect my ability to continue providing these orthotics for my patients? What kind of certification would be necessary? Sheri

      Posted by Sheryl Simkins on 1/18/2017 4:59 PM

    • This has come up before and successfully defeated as it is truly a bad idea. PTs are more than qualified to prescribe and apply orthososes which is well within our scope of practice. We need to fight this as it would require PTs to obtain a certification outside of the PT profession to do what we already do well, based on sound knowledge and expertise.

      Posted by Cindy Armstrong on 1/18/2017 5:04 PM

    • Hello, I am a PT and have been casting for and ordering custom foot orthotics since 2003. I had special training in 2003 and now have 13 years of experience. This is very disturbing to hear that we may no longer be able to do this. I hope that we can be part of developing the requirements and take into consideration the impact this may have on communities. My town consists of 9000 people, on an island, in Southeast Alaska. As a PT, I am the only provider of custom foot orthotics for our population. If people have to fly to a larger city to get these devices, it will create an increased cost and burden of travel. Please let me know if there is anything else I can do to be involved with this. Thank you.

      Posted by Kay Turner on 1/18/2017 5:16 PM

    • Wondering if having custom orthosis fabrication specified in our practice acts will be enough. Several bills were introduced last session on this, but none of them made it out of committee-how did O & P manage an end run around Congress straight to HHS?

      Posted by Marsha Lawrence -> ?GQ_? on 1/18/2017 6:32 PM

    • Great questions about how this rule might affect PTs. This rule affects those providers and suppliers who specifically bill for and furnish custom fabricated orthotics and prosthetics by mandating that these practitioners and entities such as SNFs and rehab agencies meet certain standards and qualifications. CMS estimates this would affect approximately 900 PTs who currently bill and furnish custom O and P. APTA is aware that this proposal would cause significant issues for PTs, and the additional requirements for accreditation and undefined quality standards is problematic; therefore, we will advocate and comment on the rule accordingly. We will post a fact sheet with detailed information in the coming days and would love your input on how this proposed rule would impact your practice as this would help to strengthen our advocacy efforts.

      Posted by APTA Staff on 1/20/2017 8:28 AM

    • As a practicing PT for 51 years I have emphasized the value of proper ankle/foot mechanics as an integral element of care plan decision making for treatment of a large variety of mechanical back or leg pain/dysfunction syndromes. Adequate corrective insole arch supports were often unavailable, hence I completed laboratory training prescription casting instruction with a national vendor & follow-up fitting of custom insole orthotics. Having experienced very high patient satisfaction during the past 11 years I do not feel that additional certification is merited. I further believe that CMS would realize a very positive impact in the comprehensive care costs attributed to ankle/foot impairments, risk of falls included, by establishing billing authority by PT's for the custom orthotic insoles. We are currently authorized to evaluate for functional deficiencies that provide indication for custom orthotics & follow-up "check-out for proper use/benefit", but the client must personally pay for the orthotics.

      Posted by Gary D. Vande Kamp, PT on 2/3/2017 2:43 PM

    • I have been providing custom foot orthoses for the last 30 years, with many of these orthoses being provided to patients who have Medicare health insurance, and some with Medicaid. My referral sources include orthopaedists, podiatrists, and a wide variety of other physicians. I roughly estimate that I have fabricated over 9,000 pairs of these appliances over the past 30 years. I have traveled the US and internationally teaching other clinicians how to examine patients to determine if they are foot orthotic candidates and also teaching how to fabricate the orthoses. I definitely do not feel as though I need some special certification to have all of this be part of my physical therapy practice.

      Posted by Michael T. Gross, PT, PhD, FAPTA on 2/14/2017 1:55 PM

    • As a board certified clinical specialist in sports physical therapy who established a practice 28 yrs ago on the delivery of all aspects of available care. It is if grave concern that my other PT specialists and OT specialist can be told not to practice a skill well within the scope of their practice!! I would argue training specialty and impact to the level of care in orthopedics is being unfairly challenged Custom orthotics became a calling card leading my partner (also board certified) to build and fabricate our own devices some 25 yesrs ago. Since then several thousand people from diabetics to infants have relied on us for solutions to their foot and ankle problems. For 25+ years we have set a standard of musculoskeletal care in our area. We have taught and presented on a national level sharing what we have learned and learning what others have shared - MDs DPM and OP. To take away our ability to treat is a grave CMS mistake!

      Posted by Patrick Wempe on 2/14/2017 2:35 PM

    • DME needs is an important component in our physical therapy curriculum. Requiring an extra level of certification would be redundant and costly. Many of us cannot afford to lose more time with patients nor is it financially feasible for us to acquire an extra certification. Taking away our ability to provide any tool to a patient is detrimental to their ability to function. Physical therapists above all other professions are the most qualified to apply the most appropriate device to assist their patients with functional mobility.

      Posted by Dr Denise Didio Buher on 3/3/2017 11:41 AM

    • I believe that part of the issue is fabrication of prosthetics. I am unaware of a PT program that teach PTs how to fabricate prosthetics. Foot orthotics are one thing that we all have been doing for many years. Equating prosthtetic fabrication to orthotic fabrication is creating the problem.

      Posted by Melissa Wolff-Burke -> BFW[ on 3/3/2017 12:04 PM

    • As a 37 year licensed PT I have taken an custom orthotics course and have been evaluating patients and casting for orthotics for over 35 years. The scope of our practice covers our expertise in evaluation of musculoskeletal disorders and treatments that may require custom orthotics. Changing the requirements would effects many patients who have successful treatment from physical therapists which custom orthotics was an integral part of their recovery and prevention of future injury. Not allowing PT to perform and bill for this service would significantly raise the cost and access to care

      Posted by Mike Miller PT on 3/3/2017 3:24 PM

    • when will they make a final decision?

      Posted by Andrea on 3/7/2017 12:25 PM

    • This is pretty amazing, as we now see hundreds of different types of over the counter orthotics that people buy on their own accord at affordable prices. Some work well adn others don't . I would still always use the prosthetist for those items that are truly"custom" made to fit for more complicated situations. What we don't even factor in would be what will 3d printer applications do to this market. We have found that those who have the most public access to 3 D printing are the science teachers and the students in our junior high schools. somehow they are able to get amazing printers and have the time to think the applications through. We ought to let the free market decide how this goes.

      Posted by Kathy Hammer on 3/15/2017 6:23 PM

    • I am a prosthetist/ orthotist with 3 decades of experience. Many of the responses show a misunderstanding of who this rule may affect. Functional 'foot orthoses' are not covered by Medicare unless they are attached to a brace. Since they are excluded from payment, PTs will certainly be able to continue to provide them to their clients. Medicare does pay for 'accommodative' diabetic inserts with necessary documentation from diabetic attending physician. This affects devices like AFOs, Knee bracing, and spinal orthoses. Many health care providers can supply an orthosis, with widely varying results, but orthotists and few others have the machinery and materials to make necessary adjustments to keep a device relevant and comfortable. Our practice sees patients back for follow up and adjustment (according to Medicare regulation) free of charge for 90 days after delivery. We then see patients every 3-6 months to insure proper fit and function. If nothing is adjusted, we do not bill anything. Medicare is clear that they will not pay for 'evaluation', so we do this to provide excellent care as orthotists or prosthetists. Obviously, the billing is on the front end of delivery. Those PTs that go to these same lengths of post-care are applauded for their professionalism.

      Posted by Jeffrey Roy on 3/29/2017 8:24 AM

    • I am a American board certified orthotist, Florida licensed. I was a registered physical therapist assistant, Florida licensed for 10 years prior to going back for my orthotics certification and subsequent state license. I know many of you have taken the weekend continuing Ed classes and learned from a manufacturer to cast for functional shoe orthotics. I do think if PTs are granted the ability to bill Medicare for Orthotics and Prosthetics they should be required to get the additional certification to do so. The responsibility and scope of knowlege is much greater than a pair of Shoes Orthotics. The entry level for O&P is now a Masters. I do think you have the ability to evaluate for need based upon PT training and let us know when adjustment may be required. PTs do not have training in fabrication, adjustments and facility accommodation for ongoing care which is required, most of you. Medicare requires facility accreditation in addition to practitioner certification to obtain a provider number. Most of you we're talking about losing the privilege of billing shoe orthotics. I don't see why you can't continue, Medicare doesn't cover them anyway. Just as something to consider. We have one billable event per patient and that is the date of actual delivery. We are globalized meaning we get one fee for the evaluation, purchasing all the parts, fabricating the orthosis and fitting and training...Plus 90 days of PRN adjustments free of charge. By the way 90 day clock does not start until a suscessful fittimg. Just so you know if you get the ability to bill Lcodes fitting and training are inclusive of the Lcodes and cannot be billed separately. Be careful what you ask for...when you get it you may not want it.

      Posted by Peter King on 4/9/2017 12:28 PM

    • As an orthotist, I believe that this should be regulated. I completed a masters degre and a 2 year residency learning proper evaluation skills, material selction, and contraindications/indications for custom orthotics. I have worked with many physical therapists that do not know how to properly evaluate for custom orthotics. There are many factors that go into prescribing these devices. For instance, If a patient is right side hemi, has plantar fasciitis, is diabetic, and has had mutiple surgeries/ulcers in the past, how would a physical therapist know how to treat.? They don't understand all the considerations that need to be taken. It needs to be left to someone who has the proper training. I don't try to integrate therapeutic exercise into my practice and I would expect the same from a PT. Respectfully, Dustin, MS, BOCO, CO, ATC, R-EP

      Posted by Dustin on 4/28/2017 1:26 AM

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