|
Freehand
|
|
|
PRICE, PT, Ace Wrap, Padding
|
|
|
PRICE / Generic Conservative Modalities Recommended
|
|
|
1) Click to Add Heel Pain Discussion
|
|
|
2) Physical Therapy Referral Sent?
|
|
|
3) Stretching Recommended?
|
|
|
4) Ice & Elevation Recommended?
|
|
|
5) Ace Wrap Applied?
|
|
|
6) Any Accommodative Padding Applied?
• • •
|
|
|
|
|
|
Medications Recommended
|
|
|
Medications Recommended?
|
|
|
NSAID, Steroid Prescribed
• • •
|
-or- OTC NSAID recommended?
|
|
Compound Cream Prescribed
|
|
|
Other Meds Recommended
|
|
|
|
|
|
Strapping Applied
|
|
|
Click if Strapping Applied
|
|
|
a) Foot Strapping
|
|
|
Left Foot Strapping
|
Right Foot Strapping
|
|
Bilateral Foot Strapping
|
|
|
|
|
|
b) 1st MPJ Strapping
|
|
|
Left 1st MPJ Strapping
|
Right 1st MPJ Strapping
|
|
Bilateral 1st MPJ Strapping
|
|
|
|
|
|
c) Toe Fracture Strapping
|
|
|
Left Hallux Fracture Strapping
|
Right Hallux Fracture Strapping
|
|
Left 2nd Toe Fracture Strapping
|
Right 2nd Toe Fracture Strapping
|
|
Left 3rd Toe Fracture Strapping
|
Right 3rd Toe Fracture Strapping
|
|
Left 4th Toe Fracture Strapping
|
Right 4th Toe Fracture Strapping
|
|
Left 5th Toe Fracture Strapping
|
Right 5th Toe Fracture Strapping
|
|
|
|
|
Wraps/Unna Boot/Casting/Splinting Applied
|
|
|
Wraps/Casting/Splinting Applied?
|
|
|
a) Multilayer Compressive Wrap Applied
|
|
|
Left Multilayer Wrap
|
Right Multilayer Wrap
|
|
|
|
|
b) Unna Boot Wrap Applied
|
|
|
Left Unna Boot Wrap
|
Right Unna Boot Wrap
|
|
|
|
|
c) Cast Applied
|
|
|
Private Insurance (except UHC)
|
|
|
Left Leg Cast
|
Right Leg Cast
|
|
Medicare or UHC
|
|
|
Left Leg Cast
|
Right Leg Cast
|
|
|
|
|
d) Posterior Splint Applied
|
|
|
Left Leg Posterior Splint
|
Right Leg Posterior Splint
|
|
|
|
|
In-Office Dispensing (cash products)
|
|
|
In-Office Dispensing
|
|
|
Ancillary Services Recommended
• • •
|
|
|
Other Ancillary Services
|
|
|
|
|
|
Injection Administered
|
|
|
Steroid/Amniotic Injection Administered
|
|
|
Joint, Nerve, Trigger Steroid Injection
|
|
|
Ken40, Dex, Marcaine 2cc Injection
|
Dex, Xylocaine 1cc Injection
|
|
|
B12, Lidocaine 1cc Neuroma Injection
|
|
|
Sclerosing Neuroma Injection
|
|
Plantar Fascia Injection (Kenalog and Dex)
|
|
|
a) Medial Calcaneal Tubercle w/out US (20550)
|
|
|
Left Foot
|
Right Foot
|
|
Bilateral Feet
|
|
|
|
|
|
b) US-Guided Medial Calcaneal Tubercle (76942/20551)
|
|
|
Left Foot
|
Right Foot
|
|
Bilateral Feet
|
|
|
|
|
|
Trigger Point Injection (Ken and Dex)
|
|
|
a) Trigger Pt Injection w/out US 20550 (tendon, lig, muscle)
|
|
|
Left Trigger Point Injection Location ("into the____")
|
Right Trigger Point Injection Location ("into the____")
|
|
|
|
|
b) US Guided Trigger Pt Injection 76942/20550 (tendon, lig, muscle)
|
|
|
Left US Trigger Point Injection Location ("into the____")
|
Right US Trigger Point Injection Location ("into the____")
|
|
|
|
|
Joint Injection (Ken and Dex)
|
|
|
1a) 1st MPJ Hallux Limitus w/out US (20605)
|
|
|
Left Foot
|
Right Foot
|
|
Bil Feet
|
|
|
|
|
|
1b) US Guided 1st MPJ Hallux Limitus (76942/20605)
|
|
|
Left Foot
|
Right Foot
|
|
Bil Feet
|
|
|
|
|
|
|
|
|
2a) Other Intermediate Joint w/out US (20605)
|
|
|
Left Joint Injection Location ("into the____")
|
Right Joint Injection Location ("into the____")
|
|
|
|
|
2b) US Guided Other Intermediate Joint (20606)
|
|
|
Left Joint Injection Location ("into the____")
|
Right Joint Injection Location ("into the____")
|
|
|
|
|
Neuroma/Nerve Injection (Ken and Dex)
|
|
|
1a) Neuroma Injection (64455)
|
|
|
Left Neuroma Injection (64455)
• • •
|
Right Neuroma Injection (64455)
• • •
|
|
|
|
|
1b) US Guided Neuroma Injection (76942/64455)
|
|
|
Left Neuroma Injection (64455)
• • •
|
Right Neuroma Injection (64455)
• • •
|
|
|
|
|
Peripheral Nerve Injection (64450)
|
|
|
Left Periph Nerve Injection (64450)
• • •
|
Right Periph Nerve Injection (64450)
• • •
|
|
|
|
|
Plantar Fascia Injection (Dex & Xylocaine)
|
|
|
Medial Calcaneal Tubercle (20550)
|
|
|
Left Foot
|
Right Foot
|
|
Bilateral Feet
|
|
|
b) US-Guided Medial Calcaneal Tubercle. (76942/20551)
|
|
|
Left Foot
|
Right Foot
|
|
Bilateral Feet
|
|
|
Trigger Point Injection (Dex and Xylocaine)
|
|
|
Trigger Pt Injection 20550 (tendon, lig, muscle)
|
|
|
Left Trigger Point Injection (20550)
• • •
|
Right Trigger Point Injection (20550)
• • •
|
|
b) US Guided Trigger Pt Injection 76942/20550 (tendon, lig, muscle)
|
|
|
Left Trigger Point Injection (20550)
• • •
|
Right Trigger Point Injection (20550)
• • •
|
|
Joint Injection (Dex and Xylocaine)
|
|
|
1st MPJ Hallux Limitus (20605)
|
|
|
Left Foot
|
Right Foot
|
|
Bilateral Feet
|
|
|
|
|
|
Other Intermediate Joint (20605)
|
|
|
Left Intermediate Joint Injection (20605)
• • •
|
Right Intermediate Joint Injection (20605)
• • •
|
|
Neuroma/Nerve Injection (Dex and Xylocaine)
|
|
|
Neuroma Injection w/out US (64455)
|
|
|
Left Neuroma Injection (64455)
• • •
|
Right Neuroma Injection (64455)
• • •
|
|
|
|
|
Peripheral Nerve Injection (64450)
|
|
|
Left Periph Nerve Injection (64450)
• • •
|
Right Periph Nerve Injection (64450)
• • •
|
|
|
|
|
|
|
|
Neuroma (B12/Lido)
|
|
|
Neuroma Injection (64455)
|
|
|
Left Neuroma Injection (64455)
• • •
|
Right Neuroma Injection (64455)
• • •
|
|
|
|
|
Neuroma- Sclerosing Injection
|
|
|
Sclerosing Neuroma Injection
|
|
|
Left Sclerosing Neuroma Injection
• • •
|
Right Sclerosing Neuroma Injection
• • •
|
|
|
|
|
Intralesional Injection
|
|
|
Intralesional Injection (11900)
|
|
|
a) Intralesional Injection Amount
|
b) Intralesional Injection Location**
• • •
|
|
|
|
|
Amniotic Injection
|
|
|
Amniotic Injection
|
|
|
ClarixFlo (25mg) Injection
|
|
|
Left ClarixFlo 25mg w/out US
|
Right ClarixFlo 25mg w/out US
|
|
US- Guided Left ClarixFlo 25mg
|
US- Guided Right ClarixFlo 25mg
|
|
Epifix Injection
|
|
|
Left EpiFix Injection
• • •
|
Right EpiFix Injection
• • •
|
|
Ascent
|
|
|
Ascent (7.5mg)
|
|
|
Left Ascent (7.5mg) injection w/out US Location (to the left___)
|
Right Ascent (7.5mg) injection w/out US Location (to the right___)
|
|
Ascent (15mg)
|
|
|
Left Ascent (15mg) injection w/out US Location (to the left___)
|
Right Ascent (15mg) injection w/out US Location (to the right___)
|
|
Ascent (30mg)
|
|
|
Left Ascent (30mg) injection w/out US Location (to the left___)
|
Right Ascent (30mg) injection w/out US Location (to the right___)
|
|
Flower Amniotic
|
|
|
Flower Amnio 1cc
|
|
|
Left Flower (1cc) injection w/out US Location (to the left___)
|
Right Flower (1cc) injection w/out US Location (to the left___)
|
|
Flower Amnio 2cc
|
|
|
Left Flower (2cc) injection w/out US Location (to the left___)
|
Right Flower (2cc) injection w/out US Location (to the left___)
|
|
Biolabs Amniotic
|
|
|
Biolabs Amnio 1cc
|
|
|
Left Biolabs (1cc) injection w/out US Location (to the left___)
|
Right Biolabs (1cc) injection w/out US Location (to the left___)
|
|
Siegel Additional Information (ie boot applied)
|
|
|
Other Type of Injection?
|
|
|
|
|
|
Orthotics (Custom & PreFabricated)
|
|
|
Orthotics Recommended
|
|
|
Custom Molded Orthotics
|
|
|
Orthotics Casting Today (MFA)
|
Orthotics Scanned TODAY (APG)
|
|
a) L3000 - BCBS, UMR, Ambetter, Oscar (w/ S0395, A4580)
|
|
|
b) L3000 - Aetna, Cigna, Tricare Prime (w/ 29799 & A4580)
|
|
|
c) L3000 - UHC (w/ S0395 Only)
|
|
|
d) L3000 - Simply, Devoted (w/ 29799)
|
|
|
e) L3000 - Tricare ACTIVE DUTY (2 pairs w/ 29799 casting code)
|
|
|
f) L3000 - Add'l Pair thru INSURANCE (NO CASTING)
|
|
|
g) Cash Pay Orthotics - 1st Pair
|
|
|
h) Cash Pay Orthotics - Add'l Pairs
|
|
|
i) MCR L3000 -GY Modifier w ABN
|
|
|
|
Cstm Orthotics-1st Pair INSURANCE w/ 225 deposit
|
|
|
Cstm Orthotics-1st Pair INSURANCE NO Deposit
|
|
|
Cstm Orthotics Scanned 1st Pair, CASH
|
|
|
Tricare Orthotics Active Duty (2 Pairs)
|
|
|
Cstm Orthotics- Add'l Pairs INSURANCE
|
|
|
Cstm Orthotics- Add'l Pairs CASH
|
|
|
MCR L3000 -GY Modifier w/ ABN
|
|
j) L5000 INSURANCE (Left)
|
L5000 INSURANCE (Right)
|
|
L5000 INSURANCE (Bilateral)
|
|
|
|
|
|
|
|
|
|
|
|
Orthotics at a Later Date
|
|
|
a) Custom Orthotics- Will Check Insurance
|
|
|
b) Custom Orthotics Later Date- CASH
|
|
|
c) Custom Orthotics- Add'tl Pairs Will Check Insurance
|
|
|
|
|
|
PreFab Orthotics (Footsteps, PowerSteps)
|
|
|
PreFab Orthotics Today
|
-or- Recommend PreFab Orthotics, Pt Will Wait
|
|
Diabetic Shoes
|
|
|
Recommend Extra Depth Shoes
|
|
|
Medicare (Billing later at pickup)
|
Private Insurance/Medicare Advantage (Billing today)
|
|
1) Sending DM Letter to PCP Today
|
Ordering and BILLING Today
|
|
1a) Diabetic- Shoes Only (Medicare)
|
Diabetic- Shoes Only (Private)
|
|
1b) Diabetic- Shoes w 3 Cstm Inserts Today (Medicare)
|
Diabetic- Shoes Insurance w 3 Cstm Inserts Today
|
|
1c) Diabetic- Shoes w 3 Pre Fab Inserts Today (Medicare)
|
Diabetic- Shoes Insurance w 3 PreFab Inserts Today
|
|
1d) Non Diabetic- Shoes CASH w/ 3 Custom Inserts Today
|
Non Diabetic- Shoes CASH w/ 3 Cstm Inserts Today
|
|
1e) Non Diabetic- Shoes CASH w/ 3 Prefab Inserts Today
|
Non Diabetic- Shoes CASH w/ 1 Cstm Insert Today
|
|
|
Non Diabetic- Shoes CASH w/ 3 Prefab Inserts Today
|
|
|
|
|
2) Pt will decide later about shoes (medicare)
|
Ordering Later (Non-Medicare)?
|
|
Durable Medical Equipment
|
|
|
DME Recommended
|
|
|
1) New DME Dispensed/Ordered Today
|
|
|
Pre-Fabricated DME Dispensed Today [Choose all applicable]
|
|
|
Pre-Fabricated Device Dispensed
|
|
|
L Foot Prefab DME
|
R Foot Prefab DME
|
|
L Surgical Shoe (L3260)
|
R Surgical Shoe (L3260)
|
|
L Tall CAM Walker (L4361)
|
R Tall CAM Walker (L4361)
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
Previous L4361/L4360 --> New L4361 Medical Necessity
|
|
|
Previous L4397 --> New L4361 Medical Necessity
|
|
|
Previous L1902 --> New L4361 Medical Necessity
|
|
|
|
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
|
Previous L4361/L4360 --> New L4361 Medical Necessity
|
|
|
Previous L4397 --> New L4361 Medical Necessity
|
|
|
Previous L1902 --> New L4361 Medical Necessity
|
|
|
|
|
L Short CAM Walker (L4361)
|
R Short CAM Walker (L4361)
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
Previous L4361/L4360 --> New L4361 Medical Necessity
|
|
|
Previous L4397 --> New L4361 Medical Necessity
|
|
|
Previous L1902 --> New L4361 Medical Necessity
|
|
|
|
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
|
Previous L4361/L4360 --> New L4361 Medical Necessity
|
|
|
Previous L4397 --> New L4361 Medical Necessity
|
|
|
Previous L1902 --> New L4361 Medical Necessity
|
|
|
|
|
L Gauntlet (Lace-Up) Brace (L1902)
|
R Gauntlet (Lace-Up) Brace (L1902)
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
Previous L4361/L4360 --> New 1902 Medical Necessity
|
|
|
Previous L4397 --> New L1902 Medical Necessity
|
|
|
|
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
|
Previous L4361/L4360 --> New 1902 Medical Necessity
|
|
|
Previous L4397 --> New L1902 Medical Necessity
|
|
|
|
|
L Ankle Stirrup (L4350)
|
R Ankle Stirrup (L4350)
|
|
L NightSplint (L4397)
|
R NightSplint (L4397)
|
|
CMS: Nightsplint med necessity*
|
CMS: Nightsplint med necessity*
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
Previous L4361 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
Previous L1902 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
Previous L4397 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
|
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
|
Previous L4361 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
Previous L1902 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
Previous L4397 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
|
|
BILATERAL NightSplint (L4397)
|
|
|
CMS: Nightsplint med necessity*
|
|
|
MEDICARE ONLY, if applicable - Same or Similar Exception
|
|
|
Previous L4361 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
Previous L1902 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
Previous L4397 ---> New L4397 (Night Splint) Medical Necessity
|
|
|
|
|
|
Other DME Device or WB status
|
|
|
-------------------------------------------------------------------------------------
|
|
|
Custom DME
|
|
|
Custom AFO
|
|
|
Private Insurance (Bill out today)
|
|
|
L Foot
|
R Foot
|
|
Bilateral Moore Balance Brace (L1940, L2330, L2820)
|
|
|
L Richie Brace (L1970, L2820)
|
R Richie Brace (L1970, L2820)
|
|
L Richie Dynamic Assist Brace (L1970, L2210, L2820)
|
R Richie Dynamic Assist Brace (L1970, L2210, L2820)
|
|
L Richie Brace w/ arch susp (L1970, L2275, L3480, L2820)
|
R Richie Brace w/ arch susp (L1970, L2275, L3480, L2820)
|
|
L Richie Gauntlet (L1940, L2275, L2330, L2820)
|
R Richie Gauntlet Brace (L1940, L2275, L2330, L2820)
|
|
L Richie California AFO (L1940, L2275, L2280, L2820)
|
R Richie California AFO (L1940, L2275, L2280, L2820)
|
|
L Richie Solid AFO (L1960)
|
R Richie Solid AFO (L1960)
|
|
Private Insurance Medical Necessity DME
|
|
|
|
|
|
-------------------------------------------------------------------------------------
|
|
|
Medicare (Bill out on day of dispense)
|
|
|
Med Necessity Form
|
|
|
L Foot
|
R Foot
|
|
Bilateral Moore Balance Brace (L1940, L2330, L2820)
|
|
|
L Richie Brace (L1970, L2820)
|
R Richie Brace (L1970, L2820)
|
|
L Richie Dynamic Assist Brace (L1970, L2210, L2820)
|
R Richie Dynamic Assist Brace (L1970, L2210, L2820)
|
|
L Richie Brace w/ arch susp (L1970, L2275, L3480, L2820)
|
R Richie Brace w/ arch susp (L1970, L2275, L3480, L2820)
|
|
L Richie Gauntlet (L1940, L2275, L2330, L2820)
|
R Richie Gauntlet Brace (L1940, L2275, L2330, L2820)
|
|
L Richie California AFO (L1940, L2275, L2280, L2820)
|
R Richie California AFO (L1940, L2275, L2280, L2820)
|
|
L Richie Solid AFO (L1960)
|
R Richie Solid AFO (L1960)
|
|
Medicare Medical Necessity DME
|
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
2) DME Recommended, but will check benefits first
|
2a) DME Recommended
• • •
|
|
|
|
|
3) Continue Previous DME
|
WBing Status with old DME?
|
|
|
Previously Dispensed DME**
• • •
|
|
|
|
|
Imaging
|
|
|
Imaging Ordered
|
|
|
a) Imaging Studies Ordered?
• • •
|
|
|
b) **Of What Part?**
• • •
|
|
|
Other Imaging
|
|
|
Weightbearing and Activity
|
|
|
Weight Bearing Status
|
|
|
Activity Level
• • •
|
|
|
Excusal Note Provided
|
|
|
If Symptoms Fail to Improve, Next Visit Plan
|
|
|
If symptoms fail to improve by next visit
• • •
|
|
|
New Referral Sent
|
|
|
New Referral Sent
• • •
|
|
|
Other Modalities Not Listed
|
|
|
Other Conservative Therapy Not Listed
|
|
|
When to Return?
|
|
|
How many months?
|
2 months
|
|
How many weeks?
|
1 month
|
|
How many days?
|
3 weeks
|
|
|
2 weeks
|
|
|
1 week
|
|
|
PRN
|
|
|
When Orthotics are Ready
|
|
|
When Shoes are Ready
|
|
|
After Imaging
|
