Product or Service?

O&P is viewed by insurers as a product-driven industry-as in, we deliver products to patients. But there is also a service component. Medicare requires that beneficiaries receive three months of follow-up care and adjustments at no cost to the patient. These three months of free care have been given away by O&P providers for years, without thought to what these services actually cost to provide. But that three months of free care is costing O&P providers and costing them plenty. Let's examine cranial remolding. The Healthcare Common Procedure Coding System (HCPCS) code S-1040, used by some commercial and state Medicaid agencies, describes the main product, the helmet; and L-0984 describes an additional product, the sock. After delivery of these products, the patient will need three to six months of follow-up appointments for measurements, and adjustments due to growth and skull correction. Depending on the O&P provider's protocol, these follow-ups could be performed weekly, biweekly, or monthly, in addition to any emergency appointments. Over the course of treatment, these appointments could exceed ten hours. Have you calculated how much your time is worth? Subtract your hourly rate for these appointments, the central fabrication costs, and overhead from your reimbursement. How much is left? When I did the calculation and ran the reports that showed how much I was losing, I decided to reexamine the HCPCS codes and their descriptions. What I came up with is "aftercare." Aftercare separates O&P products from the services orthotists and prosthetists provide. Cranial remolding orthoses and perhaps prosthetics are the most obvious examples of care needed after delivery. These two products often involve multiple appointments for anatomical changes, fitting, and use issues, among other reasons. The time each appointment takes can vary and can exceed two hours. Why should we, as trained practitioners, give away this time for free? I'm not referring to the three months of follow-up care that Medicare requires after device delivery. Rather, I'm discussing the fear that charging for our professional time will somehow alienate the patient or referral source. Providing this care for free may have worked in the old days, but in today's environment it spells disaster. Continuing with the cranial helmet example, the product description for S-1040 says "includes fitting and adjustment(s)." I interpret that to only pertain to the date of delivery. All fitting and adjustments of the cranial helmet to obtain a proper fit are done at that one appointment. Aftercare consists of the follow-ups, adjustments, emergency calls, pads, measurement interpretation, and an end-of-treatment scan, among other things. All of this care is performed after the delivery of the product. In prosthetics, aftercare would include gait assessment, microprocessor programming, reassessment after adjustments, evaluation of a component, and routine servicing. The HCPCS coding book has several codes that may be applicable to aftercare: S-0316 (disease management program, follow-up/reassessment), A-9270 (non-covered item or service), and L-9900 (orthotic and prosthetic supply, accessory and/or service component of another HCPCS L-Code). Use of these codes will understandably raise questions from insurers. But, use of these codes, along with an accompanying description of the services provided, will push the envelope and create discussion of the additional treatment patients receive after product delivery, which has gone unreimbursed for too long. Anthony J. Cappa, BS, CPO, is the director of the N~i.C. BAND™ Program cranial remolding service at Bay Orthopedic and Rehabilitation Supply's patient care centers throughout Long Island and Queens, New York.

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