© 2015 Matrix Healthcare Services, Inc. All rights reserved

Orthotics for Upper and Lower Extremities

Agenda

1. Introduction to Orthotics

2. Benefits and Precautions

3. Types of Orthotic Devices

4. Utilization

5. Brand manufacturers

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Learning Objectives

• Discuss types of orthotics, braces, and supplies

• Understand benefits and precautions of orthotics

• Distinguish between different brand devices

• Review orthotic billing codes

• Review common injuries

• Discuss stock and bill programs, concerns, and Ancillary solutions

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Introduction to Orthotics

What are Orthotics?

– Orthotics are the practice of addressing medical conditions of the spine, lower, and upper limbs.

– An orthosis is a device that is intended to be fitted to a person to correct , or to provide support to a person who has a disability.

– Orthotic devices can be fabricated by a trained and certified orthoptist or an off the shelf brace.

– Aid patients in daily living by supporting weakened or

abnormal limbs and joints.

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Introduction to Orthotics

Common Classifications

Custom fabricated orthosis – individually made for a specific patient. – This can be created using an impression generally of plaster or fiber cast,

a digital image using computer-aided design-computer aided manufacturer (CAD-CAM) systems software or a direct form of the patient.

Prefabricated orthosis – a device manufactured in quantity without a specific patient in mind. – The device requires some assembly, fitting or adjustment or other

modification to fit a specific patient.

Soft orthosis – an orthotic device made from fabric or elastic components (e.g., pressure gradient hose, corset, cervical collars and trusses)

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Introduction to Orthotics

HCPCS: – Healthcare Common Procedure Coding System

– The HCPC system is established and maintained by Medicare as a standardized way to ensure consistent processing and billing of products and services.

Levels:

– HCPCS Level I: CPT (Current Procedural Terminology)

– HCPCS Level II: DMEPOS (DME, O&P, Supplies)

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Introduction to Orthotics

HCPCS Level II: DMEPOS (DME, O&P, Supplies):

• Development and use of level II codes began in the 1980’s.

• In 2003, CMS was given authority to maintain and distribute level II codes.

• Five digit alpha-numeric code consisting of one letter and four numbers.

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Introduction to Orthotics

HCPCS Level II: O&P L-Code

• L-Code Facts:

• Products can be assigned one or more codes

• L-codes are often determined during an evaluation

• One brace can be made up of many codes

• L-codes are typically needed to price a product

• Providers may unbundle a product for billing purposes

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Introduction to Orthotics

Who are the Medical Professionals?

Certified Orthotist:– An orthotist is a person who measures, designs,

fabricates, fits, or assists in the formulation of orthoses

– A bachelor’s or associate degree with a major in orthotics, or orthotics and prosthetics

– Successful course completion in areas related to the practice of orthotics and prosthetics with in a facility

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Introduction to Orthotics

Role of a Certified Orthotist

Patient Assessment:– Ascertain physician/clinician diagnosis; gather

information; examine patient and evaluate

– Determine patient’s realistic expectations; consult with clinician as appropriate

– A clinician is defined as any healthcare provider who has the legal and/or licensed authority in the state to order or prescribe medical care

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Introduction to Orthotics

Role of a Certified Orthotist

Application of Bracing:– Select appropriate orthosis, device(s); create

appropriate models; fabricate, measure, assemble and apply orthosis to patient

– Modify, adjust and conduct trial fittings; facilitate patient’s understanding; and conduct appropriate follow-up

– Orthotists are authorized to treat primary diagnoses as provided by the physician/clinician

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Introduction to Orthotics

Who are the Medical Professionals?

A Certified Orthotic Fitter:

– Will have a minimum of 1,000 hours of documented patient care

– Completed entry level education program typically sponsored by manufacturers

– Fits prefabricated orthotic devices designed to provide for the support, alignment, prevention, and/or correction of neuromuscular or musculoskeletal disease, injury or deformity

– Draws on knowledge of biomechanics and a variety of devices and components,

– The Orthotic Fitter may measure, fit and adjust prefabricated orthoses appropriate to the conditions presented

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Benefits of Orthotics

Benefits:Control, guide, limit and/or immobilize

an extremity, joint or body segment for a particular reason

Restrict movement in a given directionReduce weight bearing forces for a particular

purposeAid rehabilitation from fractures after the removal

of a castCorrect the shape and/or function of the body, to

provide easier movement and reduce painMay be used to optimize performance in sports

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Precautions of Orthotics

Precautions of Use: Ensure an accurate diagnosis of the injury Generally, splints are for short-term use Excessive, continuous use of a brace or splint can

lead to chronic pain and stiffness of a joint or muscle weakness

Close follow-up after bracing or splinting is essential to ensure proper fit and use

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Use & Maintenance of an Orthosis

Proper Use:• The orthotist provides specific instructions for donning and doffing

with the least difficulty

• A wearing schedule is often provided for the patient to gradually grow accustomed to the orthosis

• Orthotist provides instructions regarding the need to monitor skin for possible breakdown

Orthosis maintenance:

• May include resetting joint angles

• Screws in joint mechanisms also may loosen occasionally, and tightening can usually be done by the patient or caregiver at home

• Maintenance may vary depending on the type of orthosis

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Classifications

Types:

• Upper Limb Orthosis

• Spinal Orthosis

• Lower Limb Orthosis

Orthotics can be described by an acronym that identifies the joints which they affect and the body part they support

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Upper Limb Orthosis

Acronyms:

WO : Wrist Orthosis

WHO: Wrist Hand Orthosis

EO: Elbow Orthosis

HO: Humeral Orthosis

SEWHO: Shoulder Elbow Wrist Hand Orthosis

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Typical Joint Applications

Upper Limb Orthosis & Common Injuries

– Rotator Cuff Tears

– Fractures

– Bursitis, where there is inflammation of the bursa sacs

– Nerve injuries

– Tendinitis

– Joint injuries

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Upper Limb Orthosis Functions

– Increasing range of motion (ROM)

– Immobilizing an extremity to help promote tissue healing

– Applying traction either to correct or to prevent contractures

– Helping to provide enhanced function

– Serving as an attachment for assistive devices

– Helping to correct deformities

– Blocking unwanted movement of a joint

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Upper Limb Orthosis Devices

Upper Limb Orthosis– Mechanical or electromechanical devices applied externally to

the arm or segments thereof in order to restore or improve function, or structural characteristics of the arm segmentsencumbered by the device

Static:– These devices do not allow motion

– They provide rigid support for fractures, inflammatory conditions of tendons and soft tissue, and nerve injuries

Dynamic:– These devices permit motion, on which their effectiveness

depends.

– These types of upper-extremity orthoses are used primarily to assist movement of weak muscles. Help to improving ROM

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Upper Limb Orthosis Devices

Clavicular and shoulder orthoses

Figure-8 harness/clavicular brace:

– This is used to restrict motion in patients with clavicular fractures.

– Allows tissue healing and bone remodeling

Shoulder sling:

– This is used to restrict motion in the shoulders by providing chest straps and a humeral cuff

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Upper Limb Orthosis Devices

Elbow orthosesPosterior elbow splint:

– This is used particularly for elbow immobilization

– Typically applied after elbow surgery or experienced inflammation

Serial cast:– This is used for preventing or correcting

contractures

– Helps with promotion of soft-tissue stretch and passive range of motion

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Upper Limb Orthosis Devices

Elbow orthosesAir splint:

– This is a form of circumferential inflatable sleeve,

– Used to maintain or increase elbow extension

– Used for contractures and elbow immobilization

Dynamic elbow flexion orthosis– This is used to maintain the elbow in

flexion in cases of elbow contractures, burns, and fractures

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Upper Limb Orthosis Devices

Forearm-Wrist:These are used for immobilization in

patients with:

– lateral or medial epicondylitis

– wrist sprain

– wrist or forearm fracture

– postoperative wrist fusion

Examples :– Wrist cock-up splint

– Wrist extension splint

– Ulnar gutter splint

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Upper Limb Orthosis Devices

Forearm-Wrist-ThumbIndications for the use are as follows:

– Maintenance of thumb range of motion (ROM) in patients who have had burns

– Restriction of motion in patients with arthritis

– Serial static stretching (as in contractures and burns)

– Stabilization in patients who have undergone tendon transfers or repairs or arthroplasty

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Lower Limb Orthosis

Acronyms:

FO: Foot Orthosis

AFO: Ankle Foot

PLS AFO: Posterior Leaf Spring AFO

CROW: Charcot Restraint Orthotic Walker

PTB AFO: Patella Tendon Bearing AFOKO: Knee OrthosisKAFO: Knee Ankle Foot

HKAFO:Hip Knee Ankle Foot HO: Hip Orthosis

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Typical Joint Applications

Lower Extremity Orthosis

Common Injuries: • Knee injuries - torn ligaments, cartilage, torn

meniscus, anterior cruciate ligament (ACL), medial collateral ligament (MCL), or patellar tendon

• Ankle injuries• Foot injuries - Tarsal Tunnel Syndrome & Plantar

Fasciitis (a dysfunction of the long ligament at the bottom of the foot).

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Lower Extremity Orthosis Devices

Lower Limb OrthosisAn external device applied to a lower-body segment to improve function by controlling motion, providing support through stabilizing gait, reducing pain through transferring load to another area, correcting flexible deformities, and preventing progression of fixed deformities.

• Static:– These devices do not allow motion– They provide rigid support for fractures, inflammatory conditions of

tendons and soft tissue, and nerve injuries

• Dynamic:– These devices permit motion, on which their effectiveness depends– These types of upper-extremity orthoses are used primarily to assist

movement of weak muscles, helps to improving ROM

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Lower Extremity Orthosis

Functions: – To lend stability to a weak joint– Correct or maintain alignment– Control motion in the presence of abnormal

tone– Immobilize a body part– Protect an inflamed joint– Ideal for individuals who have inflammatory

joint diseases, sports injuries, or skeletal deformities

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Lower Extremity Orthosis Devices

Foot Orthosis(FO)Provide support for the foot by distributing pressure or realigning foot joints while standing, walking or running. Comprised of a specially fitted insert or footbed to a shoe.

Types:• Semi-Rigid:

• Constructed from flexible plastics, high density rubber and other thermoplastic materials

• Treats forefoot deformities, hyperpronation, shin splints, knee pain, hip pain, lower back pain and sciatica

• Rigid:• Made of a firm plastic material and is used primarily for a dress

style shoe• Rigid custom made foot orthotics are designed to control

motion in the major joints of your foot

• Soft:• Designed to absorb shock, increase balance, and take pressure

off uncomfortable, sore spots• They are particularly effective for arthritic and deformed feet

where there is a loss of protective fatty tissue

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Lower Extremity Orthosis Devices

Ankle Foot Orthosis (AFO)Surrounds the ankle and at least part of the foot. AFOs are externally applied and intended to control position and motion of the ankle, compensate for weakness, or correct deformities.

– Most commonly-used orthoses, 26%

– Generally constructed of lightweight plastic in the shape of an “L”

– AFOs are commonly used in the treatment of disorders affecting muscle function

– Position a limb with contracted muscles into a more normal position

– AFOs are also known as a foot-drop brace

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Lower Extremity Orthosis Devices

Knee Orthosis (KO)A brace that extends above and below the knee joint and is generally worn to support or align the knee.

– In the case of conditions affecting, a KO can provide stabilization to the knee by replacing the function of the ligaments or cartilage of the knee’s injured or damaged parts

– A knee brace may help an individual to stay active by enhancing the position and movement of the knee or reducing pain

– In the case of diseases causing neurological or muscular impairment of muscles surrounding the knee, a KO can prevent flexion or extension instability of the knee

Types of Knee Braces:– Knee Sleeve– Functional– Rehabilitation

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Lower Extremity Orthosis Devices

Knee Orthosis (KO)

Knee Sleeve: are used primarily by athletes participating in contact sports– Knee supports are really simple to use, cheap, and provide some

support and warmth to the knee– Short term use after minor injuries– Longer term use with ongoing knee conditions causing mild to

moderate pain– They are not suitable for moderate to severe instability and pain

Types:– Full Sleeve: provides support all around the joint and retains heat

– Open Sleeve: Has a hole and support buttress at the front and reduces the pressure on the patella and pain at the front

– Wrap Around: Supports have adjustable straps so you can fit them to your own unique shape and they work well with the changing sizes of swollen knees

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Lower Extremity Orthosis Devices

Knee Orthosis (KO)Functional braces: are designed for use by people who have

already experienced a knee injury and need support to recover from the injury

– Short term use after minor injuries

– Intended to reduce the rotation of the knee and support stability

– Reduce the chance of hyperextension, and increase the agility and strength of the knee

– They fit snugly providing some compression to the knee which helps support the soft tissues (muscles and ligaments)

– Reduce the forces going through the patella by improving patellar tracking (how the kneecap moves)

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Lower Extremity Orthosis Devices

Knee Orthosis (KO)Rehabilitation braces: are used to limit the movement of

the knee in both medial and lateral directions

– Adjustable range of motion to stop potential for limiting flexion and extension

– Larger in size than other braces due to their function

– Primarily used after injury or surgery to immobilize the leg

– Provide maximum stability to prevent giving way

– Some braces can be locked to restrict movement

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Utilization

An orthosis may be prescribed in conjunction with some or all of the following products:

• Cold therapy devices

• CPM

• Ambulatory walking device

• Minor wound care (dressings, bandages, etc.)

• Hot therapy (heating pads)

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Utilization

Stock and Bill Programs:– Orthotic devices are often subject to stock and bill

distribution

– manufacturerrs will partner with a physician’s office or therapy clinic to stock supply closets with brand devices

– Doctors will dispense these products to patients

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Utilization

Stock and Bill Concerns:

Stock and bill programs can create numerous concerns for payers, including:

– High prices

– Unauthorized distribution

– Product supplied by a fitter (Certified?)

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National manufacturers

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Brand Units Type

Bledsoe Bracing & Cold therapy Stock and bill program

Don Joy Global Bracing, Cold therapy, Bone Stim and Electro-therapy

Stock and bill program

Breg,Inc.Bracing & Cold therapy Stock and bill program

VQ OrthocareBracing, Cold therapy, Bone Stim and Electro-therapy

Stock and bill program

OttobocK Bracing, Cold therapy, Bone Stim and Electro-therapy & CPM

Stock and bill program

Utilization

Utilization ManagementIn order to manage these concerns for payers, benefit managers have established some processing procedures to limit brand utilization, including:– Requiring current Rx

– Reprocessing of billing

– Contracting directly with manufacturers

– Controlled brand distribution

– Mandated conversion to generic products

– Business models to drive specific requests through network partnerships to drive down costs

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Questions?

Chuck Sweat

Vice President of Ancillary Development

csweat@mymatrixx.com

(615) 358-5351

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