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| Kirsten Simonsen, BSc, CP(c) |
In the summer of 2004, history was made during a Canadian Association for Prosthetics and Orthotics (CAPO) conference: At the first town hall meeting ever held to discuss the need for a unified national nomenclature for O&P, the room was overflowing with professionals who resoundingly agreed to create a document that would give a single voice to Canadian O&P.
Since 2004, Kirsten Simonsen, BSc, CP(c), who practices in Eastern Canada, has been involved in orchestrating the development of that document-the Compendium of Prosthetic and Orthotic Treatment (CPOT).
At the grassroots level, CAPO members recognized the importance of how the profession and its care of patients are represented to funding agencies. Members voted enthusiastically to have their professional dues increased in order to support the project, Simonsen, CPOT project manager, remembers. CAPO members recognized the need for a document created by the profession about the profession. Simonsen says that CAPO members felt such a document was important for patients and for the survival of the profession.
With little money and a lot of commitment, conviction, and creativity, countless volunteers have made progress that has captured the attention of the rest of the O&P world. "It's amazing how fast and how far you can get...if you put your mind to it," she muses.
She gives credit for keeping costs low to the mentorship of Otto Bock's Mark Agro, CO(c), FCBC, and Jean-Pierre Gibeault of Ortoped, Montreal, Quebec, Canada, as well as Adele Fifield and Josée Roy-Pilon of the War Amputations (War Amps) of Canada.
"Our goal was to create one voice with one mandate, and to protect our patients' right to care.
"Unlike the United States, where you have one system for coding and reimbursing, we have hundreds," Simonsen explains. "Every insurance company, group policy, province, and social service-and two federal programs, as well-[use] a different system of identifying reimbursable O&P services. This confusion is compounded by a profession that does not use one common language to describe what it does."
Since healthcare in Canada is under provincial jurisdiction, each province's O&P fee schedule must be negotiated individually by the profession, and each one is different. Thus, even large private insurance companies that serve Canada nationwide often find that their reimbursement rates vary widely across the provinces. The problem is largely due to difficulties with terminology, Simonsen believes. "When we file insurance claims, we most often use words instead of codes, which leaves us with the question of what to call an item: Is it a silicone interface? Is it a liner? Do you use product names? Is it an Iceross? Using these different terms interchangeably to refer to the same item can be very confusing for claim analysts and adjudicators.
"We're so small; and resources for educating government as well as insurance are inadequate," she continues. "It became apparent that we needed to develop one common nomenclature and a system for using it consistently."
Simonsen and the CPOT team began the process by examining how other countries have approached this problem and studying the comparative effectiveness of their diverse systems. In addition to input and guidance from other mentors in the United States-notably John Michael, CPO, FISPO, FAAOP; Mark DeHarde of the National Association for the Advancement of Orthotics & Prosthetics (NAAOP); and Joe Miller, CP, MS-the team also scrutinized systems in South Africa, Germany, Great Britain, and Sweden. They gathered information from the American Academy of Orthotists and Prosthetists (the Academy) and the American Orthotic & Prosthetic Association (AOPA). They also investigated the American Medical Association's (AMA) fee-for-service-style Current Procedural Terminology (CPT®) coding system.
"We started to ask questions like, ‘Who out there provides treatment to patients that involves an object or device?'-for example, orthopedic surgeons who do hip or knee replacements and orthodontists, dentists, optometrists-and we looked at nursing in terms of best-practice guideline development."
Early on, they identified a significant drawback in the United States' L-Code system: L-Codes are device-oriented; they are not accurate because they only describe items and not the comprehensive treatment that prosthetists and orthotists often provide.
"In fact," she reflects, "nowhere in the world could we find any model that identified in detail what we do with the patient in terms of patient care [that doesn't involve providing] a device.
"It was highly recommended," Simonsen says, "that we look at splitting device from procedure. Prosthetists and orthotists have evolved into service or treatment providers, rather than ‘dispensers' of goods. A large amount of our time is spent on patient services and not just on the dispensing or giving of the device."
Simonsen is fierce in her objection to terms like "dispense" and "fit"-"dispense" because it makes providers sound like supply clerks ("It's awful," she says, "the worst possible word to use to describe what we do to treat a patient!"); and "fit" because it is such a broad term that it fails to adequately describe the specific action that was taken.
"Certain words that cover too much-like ‘fit'-should be eliminated from your terminology," she believes. "Take them out of your charting and your conversations with patients or healthcare colleagues, and substitute more precise, descriptive words."
Compendium Structure
The CPOT organizes treatment into four distinct categories:
I. Patient care procedures. These procedures can be direct and indirect. "It's basically everything that you do that can be related to the patient, rather than a thing," Simonsen says. "For example, do you treat the patient for atrophy, or do you adjust the socket? Arguably, you do both." She explains that while the socket adjustment may only involve five minutes to add a pad, treating the patient for atrophy involves the patient calling Simonsen's office and explaining his or her symptoms to a staff member who triages him or her. This is followed by an office visit, during which Simonsen assesses the patient qualitatively and quantitatively to render a diagnosis about what is happening with the patient/prosthesis interface. "I determine the method of treatment, and then I actually do it," Simonsen says. "Before the patient is discharged for the day, I assess that the outcome is satisfactory via subjective and objective measures," which, she explains, goes further than just asking the patient about his or her level of satisfaction.
"But in my world, before I started thinking this way and identifying the steps in the patient care process, I ‘adjusted socket' and signed my name," Simonsen adds.
II. Conditioners, modifiers, and statistical information. The profession can use this information "to improve our understanding of how we care for patients," Simonsen says, by developing it into a database. To use a U.S. example, a patient might reasonably expect his cost for O&P service in an urban area such as San Francisco to be higher than if he or she were treated in a smaller suburban or rural town in the Midwest because of the higher regional/urban business costs to the provider. Likewise, a practitioner with a master's degree and 20 years of experience might warrant a higher reimbursement rate than a resident, she points out. "Most importantly, these codes will include pathologies, comorbidities, and other factors that define complex cases, legitimizing more lengthy or complicated treatment. This will allow a patient with shin splints to be separated from a patient needing ulcer management, [even though] both require a pair of foot orthoses."
III. Fabrication procedures. Once upon a time, most prostheses and orthoses were fabricated in virtually identical ways. Today's high-tech devices require increasingly varied and complex fabrication procedures. "Thus," explains Simonsen, "the types of procedures that we use for fabrication need to be identified. We understand this category quite well; every central fabrication facility in the country has fantastic codes on how it charges for...fabrication. As O&P professionals, we're accustomed to thinking about what it takes to fabricate the prosthesis or orthosis. We tend not to think about what we invest in [doing so], however-the time we spent in the car on our way home trying to design a prosthesis or orthosis and a treatment plan that may involve advanced gait training. If we were another [type of] healthcare professional, we'd actually be sitting in our office, recording and billing for that time. That's where we need to retrain our thinking [about] how we treat our patients."
IV. Components, materials, and devices. This covers items such as supplies used by patients and orthoses that are purchased from a manufacturer and provided to the patient (although the time to assess, measure, and establish satisfactory outcomes will fall into category I). The composition of the device design; e.g., components and the materials used in fabrications procedures (category III), will also be listed here.
Codes will exist within each of the four categories, and subcategories will also be created, as needed.
"We're going into super-detail, knowing that there's a probability that if this effort was looked at in terms of reimbursement, we'd have to lump things together," she notes. "For now, however, there are probably a hundred different ways in which we assess patients, and we're trying to identify and describe all of them specifically so that we can defend their recognition by third-party payers."
A Globally Unique Milestone
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| From left: Allan Bly, CO(c), CBCPO past president; CPOT teammember Al Moore, BA, CO(c); and Simonsen. |
To the best of Simonsen's knowledge, the CPOT is a unique approach to identifying and clearly defining all aspects of O&P service and providership.
"Under CPOT's philosophy, if I assess a patient to determine if he or she would benefit from an orthosis or...a new prosthesis, and no device or adjustment is required-only education-I could say that I actually did something with the patient because I performed an assessment, provided a recommendation, and offered education. Today, I have to provide an item or device in order to be reimbursed for my service, and as a profession we have difficulties in recognizing that assessing, providing recommendations, or educating is valuable patient care and legitimizes our expertise in the field of O&P."
The CPOT also has implications for scope of practice, best practice, ethics, and education. "It will record what we do with patients in terms of actual clinical and technical procedures," Simonsen says.
"This is important for the future, as it will be a mechanism for the definition and growth of the profession. As the market requires us to elevate our level of care, or, as innovators on the cutting edge, develop new procedures, there will be applications for inclusion of these procedures and associated skills/ knowledge in the CPOT."
Can acceptance of the system by paying agencies be enforced? "No," Simonsen says, "but we will use it as a tool to negotiate, defend, and educate governments and insurance."
"We're not doing this for ourselves or our practices," Simonsen stresses. "At every level we can see the ramifications of poor representation by us and our patients regarding the treatments that we provide. The CPOT is more about changing our own culture so that we can best represent our patients and their right to care."
Simonsen reports that the first category of the model is largely completed, but they still have a long way to go. "We would like to have a draft presentable by 2010. As far as the implementation- I guess if you don't look at it as a reimbursement scheme, it's being implemented right now."
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.
