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

Other messages in this thread:

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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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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