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06/06/2016 Paul Kesselman, DPM
When capturing casting for orthotics, should you bill a casting fee? (Robert Steinberg, DPM)
Historically, the HCPCS impression casting code S0395 was developed in order to provide a method by which the practitioner taking the impression could recoup their expenses associated with the materials used during this process. This was obviously in the good old days when plaster was "king" and the only real way to obtain an impression. It may have even prior to the development of foam impression materials. I welcome comments on the history of that as well.
I also agree that the many errors associated with any orthotic fabrication (this is not just limited to foot orthotics) starts with the impression. Having the foot in the wrong or intolerable position should be avoided at all costs. And certainly Dr. Steinberg's remarks about having personnel who don't place the foot properly are well heeded and this is true regardless of what technique is used to capture the foot impression (plaster, STS, etc.). However, that is an issue which could apply to any medical procedure and little if anything to do with the code. Having a poorly trained individual performing any procedure is not a rationale for limiting coding definitions, although it may be for a reimbursement policy.
The issue of updating the S0395 code interpretation has more to do with incorporating modern technology so the practitioner could potentially be reimbursed for an equivalent method of taking an impression to plaster. I agree with Dr. Steinberg concerning the issue of receiving a free scanner as a rationale for exclusion for using this code.
That same would apply for any materials (e.g. plaster, STS, etc.) that are provided free by the lab or anything else which is considered an inducement. There are plenty of anti Stark provisions which apply not just to DME, but to other medical/surgical procedures as well. Certainly, that would also be an abuse of use of this code to be addressed and enforced by the third-party payers and others. It however, is not a coding issue but more of a reimbursement issue.
Most modern orthotic labs today take the plaster impression and digitalize them subsequently fabricating a device based on computer images. As with everything else in this digital age, there are improvements in software and hardware, at lightning speed. Many readers don't have any idea that the devices they order are based on digital images which are made from their hand made plaster casts. Certainly those images and the resultant devices may be far different from those which start with digital scans, but that may be more dependent on the lab than the scan itself.
I leave it to those who know this better to discuss as my main attempt here was to start and continue the discussions on a coding issue regarding S0395.
Personally, I continue to take plaster (and at times foam) impressions of my patients. My comments are to suggest that those days will soon be coming to a close as scanners become less expensive and more accurate and may eventually sometime in the future even more accurate than plaster.
Today scanners are incorporated into other orthotic policies by Medicare (e.g. spinal) so that the scanned image can be used as a basis for a custom fabricated TSLO (spinal) brace. While the TSLO policy does not provide separate reimbursement for casting (or scanning) it simply reinforces the separation between coding and reimbursement. While the anatomy of the spine and foot are significantly different, I expect that there will be more accurate and inexpensive scanners which should address the concerns I have heard on this subject, not just in this forum, but for quite some time.
Paul Kesselman, DPM, Woodside, NY
Other messages in this thread:
06/08/2016 Chris Smith, DPM
When capturing casting for orthotics, should you bill a casting fee? (Robert Steinberg, DPM)
A professional fee for capturing the morphology and alignment of the foot by a foot scan or plaster of Paris is certainly justified, assuming that the foot is properly positioned at the subtalar and midtarsal joints. Dr. Steinberg suggests that only a podiatrist has the skill and knowledge to properly position a foot. I counter this notion because I have seen a complete spectrum of proper and improperly positioned plaster of Paris casts taken by a litany of providers ranging from office staff, chiropractors, physical therapists, podiatrists and other medical professionals. We cannot assume that only a podiatrist can take a true “neutral” cast. However, I firmly believe that generally, podiatrists do provide that service better than others, professional or non-professional. It is an ethical question whether a fee should be incurred if office staff performs the casting (or digitization, if applicable) that the APMA should address. Digital scanning presents a similar question. Weight bearing scanning/impression molding is inherently inadequate because the long axis of the midtarsal Joint is invariably supinated. As far as I know the subtalar Joint should be “neutral” and the midtarsal Joint (both axes) should be be maximally pronated. Should a fee be incurred for an image that is inherently erroneous and incomplete? Dr. Richie states that a “high quality scan taken with an I-phone is entirely incorrect”. Not all “camera/sensors” are equal and, similarly, not all positioning systems are adequate. As far as I know, the Structure Sensor (camera) attached to the I-phone is identical to the Structure Sensor commonly with an I-Pad. Digital imaging requires a reference plane in order to correct any abnormal position of the forefoot to the rearfoot, commonly measured from the sagittal bisector of the heel. With a digital image with only the 5th metatarsal head squarely seated on the transverse plane, the forefoot deviation can be measured relative to the transverse plane and this technique is just as valid as heel bisection. Chris Smith, DPM, Northwest Podiatric Laboratory, Blaine, WA
06/08/2016 Richard Stess, DPM
When capturing casting for orthotics, should you bill a casting fee? (Robert Steinberg, DPM)
As president of the STS Company, I have refrained from entering the discussion regarding casting with plaster, scanning, or casting with the STS casting socks for obvious reasons. When my partner and I, whom were in practice for thirty five plus years and attendings at the VA Medical Center in San Francisco, developed the idea of casting socks and slipper casts for obtaining negative models of the foot it was done to provide practitioners a method that was not only clean and efficient but also accurate.
We knew it would save money because of the reduce time required to cast and clean up but soon learned that there are other factors to make a successful cast for each foot orthotic device and AFOs besides casting time. We have since learned from many podiatric orthotic laboratories that often the impressions whether plaster, STS, or scans that they receive can be un-satisfactory and result in poor outcomes. Evidence has proven to us that often the position that the foot is held during casting process rather than the shape itself dictates a successful device with the desired clinical results.
We also came to understand that often a practitioner did not take the “time” to obtain a satisfactory impression but often relegated this task to assistants whom they did not adequately train. The gift that some of us had in our podiatric education was that we were taught the skills in taking a good consistent negative cast. This skill was not necessary how best to apply plaster but rather the various methods of positioning the patient and maintaining a desired foot position in order to hopefully achieve the type of device that supports or controlled motion/moments of force.
I have observed that the practitioner who possesses this skill can obtain excellent impressions with any of the modalities. Merely obtaining the shape of a foot with an anatomically accurate plaster model or 3D scan does not necessarily guarantee the anticipated clinical outcome. Despite the technology of scanning which can be done by other non- professionals and in other than medical related facilities (i.e. shoe stores, big box stores, pharmacies, etc.) , the reimbursement of the materials in addition to the therapeutic positioning of the foot must be continued.
I know of no studies thus far that have proven that merely scanning a foot shape can provide any significant beneficial therapeutic outcome as compared to neutral suspension casting (STS or Plaster) to achieve a custom functional foot orthosis. Richard Stess, DPM, President, STS Company
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