Get on the fast track for a profitable practice with orthotics. This secondary profit center will increase your patient base and improve patients’ postural base.

Are you feeling the pinch of managed care and a slow economy? Finding ways to provide optimum care, affordable products, and great service is critical to your patients’ health as well as the health of your practice. Ancillary products provide a steady stream of residual income to your practice. Establishing a profit center using orthotics is one of the easiest ways to improve patient results and bring instant profit.

Why? Because 80% of your patients are likely to have some sort of foot problem by age 20. Whether caused by hyperpronation, hypersupination, or asymmetrical differences between the feet, these imbalances interfere with proper alignment of the musculoskeletal system.

Fishing for Complements
Orthotics are a natural complement to your adjustments. Studies show that custom-made, flexible orthotics have a positive influence in promoting balance and proprioceptive symmetry.² According to a 2003 survey³ conducted by McDonald et al, 97.8% of chiropractors deem orthotics as appropriate in their scope of practice—surpassing vitamins, collars, massage, and clinic-based exercise.

Look for an orthotic that works with your goals for your patients, one that enhances biomechanical stability of the entire body, not just corrects foot problems or provides pain relief. Over-the-counter orthotics can provide some comfort and perhaps some pain relief, but they do not adequately address your patient’s unique problems.

In addition, make sure the orthotics you recommend are based on weight-bearing casts or scans. Just as with weight-bearing x-rays, you will want to make sure your orthotics address the body in a position of function. Most orthotic labs design rigid products taken in the subtalar neutral position. Research has found that the subtalar position cannot be effectively located nor provide the most accurate information for a laboratory to make an orthotic.⁴

Once you have decided on an orthotic, you will find that vendors can provide a wealth of resources, such as start-up kits that contain everything needed (from patient literature to insurance forms), to set up your office.

Encourage patient interest and questions by maximizing orthotics visibility in your office. For example, an orthotic display can have samples and brochures in full view for patients. It is an excellent use of space and gives your patients information to make good decisions about their health. Other useful tools are posters and patient catalogs.

Spend some time making sure everyone in your practice understands the orthotic protocols, from the chiropractic assistant to the insurance specialist. In many practices, the staff handles all aspects of orthotic ordering including the casting.

Have specific objectives in place and reward your staff when those objectives are met. One example of a year-long group reward program can focus on a goal of getting 75% or more of orthotic-wearing patients to return for an annual orthotic re-examination (to confirm the orthotics are still providing proper support). A monthly objective can be set at seeing 75% of the eligible patients for that month; the reward for meeting or exceeding that objective could be a staff meal at a restaurant or some other activity that would appeal to your staff. Incentive programs can be a positive factor in your practice’s success.

The First Step
Once you have committed to using orthotics in your practice, new patients should be screened automatically as you begin orthotic implementation. Invite previous patients in for a visit. Schedule these visits for slow days so you can keep the busier days for your active clients. By helping all of your patients understand the importance of a balanced body, you can increase patient visits and provide a valuable service.

Figure 1: Five signs of postural foot distortions.

A quick step-by-step foot examination should take place as part of your initial patient exam protocols. Observe your patients for a few moments as they walk in your office. Five red flags that are signs for postural foot distortions are (Figure 1):

1. excessive foot flare (greater than 10°);
2. internal knee rotation;
3. medially bowed Achilles tendons;
4. flat foot; and
5. uneven shoe wear (significant lateral heel wear is a classic sign of hyperpronation).

Show patients how their feet affect the foundation of the spine. Describe how foot problems can affect the feet, ankles, knees, hips, pelvis, and spine. Let them know how stress due to imbalance can permanently stretch connective tissues over time, which adds stress to the body’s structural alignment.

An easy example that most patients understand is fallen arches: If the feet are unbalanced, the pelvis shifts providing an asymmetrical base for the spine. The stretching of the ligaments that help support the feet is permanent so adjustments alone are usually not enough to restore normal arches. Tell your patients that orthotics can help stabilize the foundation and keep the body in structural alignment between adjustments.

It Takes Three
The orthotic process involves three visits: screening and casting, issuing orthotics, and orthotic checkout.

Screening and casting. During this visit, a problem-focused history and examination is conducted and documents the medical necessity for the orthotics (CPT code 99002). Make a radiological examination where a bone spur or other anomaly is suspected (CPT code 73620).

After determining which orthotics are best for your patient, cast or scan him and order the orthotics (CPT L3020 or some insurance companies prefer 99070) Use this code twice, one for each foot. In some cases, the cost of shipping and handling can be covered using CPT code 99002.

When completing the form, the patient’s diagnosis should include the specific spinal condition, as well as the associated extremity condition. For example, an 839.20 lumbar subluxation is a result of a 754.61 flat foot.

Include a letter of necessity with your CMS form: (Patient’s name) has been diagnosed as having a spinal condition related to instability of (the feet, lower extremities, pelvis, and/or spine). This causes an inability to equally distribute weight when standing, walking, and/or working, thus increasing spinal biomechanical stress and strain. I have prescribed and cast this patient for bi-lateral custom-made orthotics to stabilize this condition. These custom-made orthotics are specifically designed for this patient to improve structural stability of the spine and lower extremities.

What do you charge your patient for the orthotics? A 50% to 100% markup on custom products is recommended to earn a fair profit on dispensing these products and services. An office applying a 100% markup to a $125 orthotic can realize a $6,500 increase in profits every year by fitting one patient per week. With up to 80% of your patients manifesting postural issues, you can increase your profits and help patients.

Issuing the orthotics. This visit includes the orthotics fitting and training (CPT code 97504). During this visit: a) show how to insert the orthotics into the shoes; b) tell patients the orthotics will last longer if removed from their shoes at night; c) discuss proper shoes for the orthotics; and d) show how to ease break-in by rolling their foot over a golf ball. This should be done in the mornings and evenings until the fixations in the foot are broken up and adaptation to the orthotic is complete. You may also want to recommend therapeutic exercises to develop strength and endurance (CPT code 97110).

Orthotic checkout. Spend time examining your patient’s break-in progress (CPT code 97703). Conduct a problem-focused history and exam to evaluate the post–break-in period, including how the orthotic use is tolerated and whether the desired outcomes are being achieved (CPT code 99212).

The successful chiropractic entrepreneur offers valuable chiropractic products and services, not because of sheer profit potential, but because it is the right thing to do for both the practice and its patients. Achieving balance in your chiropractic practice can be challenging. On the one hand, you have the clinical skills to make a patient better. On the other hand, you have the business savvy to run a practice Offering orthotics can be a defining element in your practice’s success and keeps its clinical and business elements of your practice in perfect flux. CP

Kirk Lee DC, CCSP, practices in Albion, Mich. A 1980 graduate of Palmer College of Chiropractic (PCC), he is a member of the PCC postgraduate faculty and has lectured nationally on sports injuries and the adolescent athlete. Lee can be reached via email: kaleedcccsp@hotmail.com.

References
1.    Schafer RC. Chiropractic Management of Sports and Recreational Injuries. Baltimore, Md: Williams & Wilkins; 1982:17.
2. Stude DE, Brink DK. Effects of nine holes of simulated golf and orthotic intervention on balance and proprioception in experienced golfers. J Manipulative Physiol Ther. 1997;20(9):590–601.
3. McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice: The Survey of North American Chiropractors. Ada, Ohio: Institute for Social Research; 2003:17.
4. Ball KA, Afheldt MJ. Evolution of foot orthotics—part I: coherent theory or coherent practice? J Manipulative Physiol Ther. 2002;25(2):116–124.