Watch this video on YouTube.

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Watch this video on YouTube.

ASOP Members in good standing can receive up to .25 CEU credits by reviewing the video.

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Recently in the British Medical Journal, there was a very interesting randomized study for the treatment of chronic low back pain that was performed in Norway.^[1] The investigators recruited 116 patients with chronic low back pain and randomly assigned them into 3 groups. The active treatment group received epidural injections of cortisone; the control group received 30-mL epidural injections of saline; and the third group received a sham treatment of 2 mL saline injected subcutaneously. This was a severely disabled group of patients. The majority of patients were men and, on average, they had between 64 and 160 weeks of chronic low back pain. They had an average of 32-37 weeks of absence from work because of low back pain. The primary endpoint of this study was the Oswestry Disability Index score, which measures the impact of low back pain. The secondary endpoints were scale scores for back pain and leg pain, and the investigators also used quality-of-life measurements. Endpoints were measured at 6, 12, and 52 weeks.

As it turned out, there was no difference between the 3 treatment groups. This was true for all timepoints. All patients improved, but the epidural injection of prednisone did not lead to a better improvement than, for example, a sham injection. This study is very important when we talk to our patients who have low back pain. I think we can tell them that this invasive procedure is not better than placebo treatment. Our advice should be to stay with conservative treatments like regular exercise, physical therapy, and if necessary intake of nonsteroidal anti-inflammatory drugs and behavioral therapy.

Related posts:

1. Randomized Trial Brace v. Casting in Children’s Low-Risk Ankle Fractures
2. Focused rigidity casting: a prospective randomised study
3. To Cast Shoe Or Not To Cast Shoe. That Is The Question.

Information from Medscape, edited for our orthopedic membership

October 10, 2011 — A watchdog agency in the US Department of Health and Human Services (HHS) wants to know how many office visits, consultations, eye exams, skin grafts and other services (casting) are performed by unqualified nonphysicians under Medicare’s “incident-to” billing rules.

This is just one new investigation that the HHS Office of Inspector General (OIG) plans to conduct next year, according to its annual work plan, which was published last week.

Incident-to billing in Medicare creates a financial incentive to delegate clinical duties, but the complicated rules governing such claims trip up the best intentioned. A physician can bill for an employee’s work as if the physician had performed it, as long as it is “incident to” the physician’s services.

Low-level office visits, drug injections, and blood draws are common examples of services that are billed incident-to and paid at 100% of Medicare’s physician fee schedule. However, for these claims to be up to snuff, the incident-to service must follow up on patient care initiated by the physician, who also must be on the premises to provide supervision and assistance (in group practices, a partner can suffice).

Busy physicians have drawn much of their Medicare reimbursement through incident-to billing. An OIG study in 2009 revealed that when Medicare allowed physicians to bill the program for more than 24 hours of service within a single day, nonphysicians had performed half the services.

The OIG finds no fault in that pattern. What bothers the OIG is that for 21% of the services that nonphysicians performed, the nonphysicians were not qualified to render them: They lacked needed licenses or certifications, verifiable credentials, or the appropriate training, according to the OIG.

In its 2012 work plan, the OIG stated that incident-to billing “may be vulnerable to overutilization and expose Medicare beneficiaries to care that does not meet professional standards of quality.” The OIG intends to determine whether incident-to claims have a higher error rate than ordinary ones, as well as assess the ability of CMS to monitor incident-to services, which are not identified as such on claims.

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1. NEW MEDICARE BRACING SUPPLIER RULES!!!!
2. To Cast Shoe Or Not To Cast Shoe. That Is The Question.

A Randomized, Controlled Trial of a Removable Brace Versus Casting in Children with Low-Risk Ankle Fractures

Boutis K, Willan AR, Babyn P,
Narayanan UG, Alman B, and Schuh S.
Pediatrics. 2007;119(6):e1256-63.

Summary

The authors review other studies demonstrating that distal fractures of the fibula are the most common isolated fracture of the lower extremity. The current usual care approach would be to cast these fractures for immobilization for 3-4 weeks.

The authors completed a randomized trial to compare outcomes in children with distal fibula fractures with casting vs a removable brace. The authors also conducted cost-effectiveness analyses as part of the project.

The subjects were enrolled after presenting to a single pediatric emergency department over a roughly 2-year period. Subjects were 5-18 years old and could enroll in the study if the fracture was less than 72 hours old. All subjects were generally healthy otherwise, with no bone or developmental problems that would affect assessment. Patients with multiple fractures were excluded.

All emergency department providers underwent training specific to identifying the type of low-risk fibula fractures to be evaluated in this study, and radiographs were obtained as part of the diagnosis.

After establishing the diagnosis, patients and parents were offered the opportunity to enroll and were randomized if they accepted. Children who were in the casting group received a fiberglass cast that ended below the knee. Patients randomized to the brace group were provided with the brace, shown how to put it on, and were encouraged to wear sock and shoe with it. All subjects were instructed to refrain from weight-bearing activities for 5 days after enrollment, after which they could ambulate with crutches or without at will.

Subjects wearing the braces were allowed to discontinue use when they self-determined that it was appropriate. Children with a cast were required to make a follow-up visit at approximately 3 weeks to have the cast removed.

Investigators contacted the families by phone at weekly intervals for 4 weeks to assess return of function (parental diaries provided most of these data). At 4 weeks after the respective injury, a research physiotherapist assessed function in the patients’ homes by a standardized, validated function scale. This investigator was unaware of treatment group, and parents and patients were reminded not to reveal this allocation during the evaluation.

The authors enrolled and randomized 111 subjects, and 104 completed the study and are included in this report. The mean age of the subjects was approximately 10 years, and the 2 groups were not different in measures of initial pain and function.

On the 4-week post injury function assessment, the brace group scored significantly higher than the casted group (91.3% score vs 85.3%). This difference was within the accepted range for this noninferiority trial, and the difference actually favored the brace approach anyway. One third of the cast group compared to only 7.4% of the brace group had at least 1 unscheduled healthcare visit.

The majority of subjects in the brace group were “very happy” with their method of treatment (52.8%) compared to only 18% of the cast group. The percentage of patients who could bear weight without pain at 4 weeks was not different in the 2 groups at just over 75%. However, 81% of the brace group compared to only 60% of the cast group had returned to pre-injury activity levels.

The authors conclude that children with distal fibula fractures can be treated equally well and at lower cost by using the ankle brace. Patient satisfaction is greater with the removable brace.

Viewpoint

The authors point out some very good reasons why community practitioners might not want to immediately begin placing patients in braces and skip the orthopedic referral. To begin, the emergency department (ED) physicians were specifically trained to recognize these low-risk fractures, and higher rates of misdiagnoses may be expected in a non-study setting. In addition, the frequent contact of the investigators with the parents likely helped assure adherence to using the brace. This study is sound enough, however, to demonstrate that this is a valid option worth further testing and consideration. The diminished cost to the healthcare system is a nice bonus on top of the potentially better patient functional outcomes.

Related posts:

1. Are Serial Radiographs Needed in Torus Fractures in Children?
2. Focused rigidity casting: a prospective randomised study
3. What they are saying about ASOP Casting Workshops!

Part-time ( 3 days/week) Ortho castingtechnician for hand surgery office in BeverlyHills, CA.   Must have experience.  Assist physician in backoffice with splinting, casting, dressing changes, suture removal, drawing blood along with placing orders for casting and splinting supplies.

Please send resumes to:pmoyer@handexperts.com 
Tech needed In Dallas, TX

Ortho Tech needed in Dallas for big practice, splinting and casting a plus.

Duties will include patient care, splinting, casting and applying DME etc.

Call Mike Powers 214-720-9333 or send resume to mpowers@wbcarrellclinic.com

Tech Needed in Tampa, Florida 

The USF Physicians Group is currently seeking an experienced Orthopaedic Technician to assist physicians, PAs, residents and medical students with the care and treatment of patients in the orthopaedic clinics. The successful candidate will demonstrate interpersonal skills in dealing with patients, physicians, other staff and faculty members and outside organizations while emphasizing teamwork and cooperation within the organization.  The Orthopaedic Tech will be expected to be proficient in the application and removal of casts, braces and splints. They should be experienced in working with both plaster and synthetic cast materials and be comfortable in assisting the physicians with the preparation, set up and application of various traction techniques.

For consideration, please apply online at https://usfpgcareersource.health.usf.edu

Other duties of the Orthopaedic Technician will include fitting and applying pre-operative braces, crutches, orthotics and other soft goods; removing sutures; providing wound care; assisting with orthopedic procedures, including aspirations, minor surgical procedures and fracture reductions.  They will also be expected to be able to provide patients with instructions concerning cast care and the use of orthopedic appliances. The Orthopaedic Tech will be responsible for the cleanliness and stocking of the cast and soft goods room, along with ordering appropriate supplies and equipment.

Candidates must possess 2-3 years’ experience in an orthopedics environment, as well as a strong knowledge of anatomy, physiology and medical terminology and expertise in the different materials and equipment involved in casts, splints and braces and the ability to provide direct patient care required. The position requires physical effort, including the abilities to sit or stand for an extended time and to push, pull, squat, twist, turn, lift, bend, stoop and reach overhead. Graduation from an approved/accredited technical institute as an Orthopaedic Tech (certified), LPN, or MA with orthopedic surgical experience preferred.

USF Physicians Group offers a competitive benefits package for F/T positions.

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With plaster casts, the rubber heel was applied at no charge and was considered part of the treatment. Medicare considered it part of the treatment & there was no separate charge for the rubber heel. This policy was continued when cast shoes were introduced. If you billed a treatment code that included a weight bearing cast, you provided the means to walk on the cast, the cast shoe. Not only did the shoe protect the bottom of the cast from breakdown, it also provided a rocker bottom to a allow for a more normal gait by the patient.

Several years ago I spoke to an official at CMS (The Center for Medicare/Medicaid Services) and they informed me that it was their policy that the cast shoe had just replaced the rubber heel and was required to be supplied by the provider billing for the treatment just as the rubber heel had been supplied. The provider could also not give a script to the patient and have the cast shoe provided by another DME source. since this increased the cost to Medicare.

As an orthopedic professional it is our duty to treat the patient as best our abilities and knowledge allow for. There is an old saying, SOLID ANKLE, ROCKER BOTTOM. If we put the patient in a cast or a brace that limits the motion of the ankle in flexion or extension, we must allow for a more normal gait by providing a rocker bottom shoe. This also meets the expectation of the patient that we will “DO NO HARM”, the first rule of medicine.

A rocker bottom cast shoe helps prevent other problems (knee & back pain) that can arise from a weight bearing cast. To routinely provide a flat post-op shoe may cause the patient harm by not allowing for a more normal gait. To send the patient elsewhere for a cast shoe may also violate Medicare laws.

I look forward to reading your responses.

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1. The Toe Plate for the Lower Extremity Cast
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N. Trieste, RN, MBA Geisinger Medical Center Dept of Orthopedics
Positive aspects of the course:

• Hands on demonstration was very beneficial; opportunity to practice several times and in different combinations
• Learned a lot of new and updated casting techniques and basic tricks of the trade that make casting quicker and more efficient even for those that had never casted before
  • Cutting to fit around thumb
  • Body fossa molding
  • Spray bottle
• Very informative
• Practical knowledge that will allow non-cast techs to help when needed
• Small group with a variety of experience

Instructor feedback:

• Kyle was very informative, helpful and enthusiastic; very experienced in quality patient care; helped to pass his knowledge and experience onto the group; reminded the participants to treat patients the way they would want to be treated with a cast
• Stayed extra on the second day to help a few participants work on a casting technique that is beneficial for their clinic

Other comments:

• Course was a wonderful experience and showed the participants the “right” way to cast
• Would recommend course to others to help improve or just simply to learn casting skills
• Kyle gave a lot of information that is on the certification test and some interesting trivia about ortho and his experiences
• Feel much more confident with casting skills
• Happy to have the opportunity to sit for the ROT exam, receive 1 yr membership to ASOP and study materials, etc.
• Interest in other ASOP courses, such as the Orthotic Fitters Class
• Would recommend having future courses

Teresa Terry, Texas
The workshop here in Houston was GREAT! Kyle did a fantastic job and I would recommend this workshop to everyone in the Orthopedic field. I picked up many helpful ideas from Kyle and appreciate his patience.

Ken Ockunzzi, Florida
Thank you so much Charles. I had a great time at the course last week. You really kept things interesting and fun. I learned a bunch and had a good time doing it.

Agnes Freeman, Chicago
Can’t wait to try out the new techniques I learned this weekend. I thank you so much for the extra time you gave me to practice. I attended another organizations casting course last year. I was very disappointed that it was mostly demonstrations and hardly any hands-on. Thank you Charles for not letting me down. You are right, your workshop is a lot of work! I am sure my Doc will be happy with my improved skills.

Dianne Joyner, R.T.(R) Peace Health Orthopedic, Oregon
I just wanted to send a quick note regarding the casting workshop I attended in Portland this past weekend. I had a great time learning and Jack Hart was a fabulous instructor. He created and maintained a fun, active and very educational atmosphere. I actually was sad we didn’t have more time to soak up more of his energy and knowledge. Thank you and please let Jack know that his efforts were well received and appreciated. I look forward to future classes that you may have in our area.

Over 1100 Orthopedic Preactices have used the ASOP workshop for fracture casting training in just the last three years.  See them all here 

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1. Private & Semi-Private Workshops now available from ASOP
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