Please be sure to include the following for all orders:

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Roy McGee
5 years ago
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1 Cheat Sheet Index* 2339 Weldon Parkway A. Electrotherapy/Stims 1. Intensiy 10, InTENity IF/Combo, and InTENsity Twin Stim III for pain control (E0730/ E0720 for Medicare) 2. InTEnsity Twin Stim III for disuse atrophy (E0745) 3. Osteogenesis Bone Stim for spinal (E0748) 4. Osteogenesis Bone Stim for long bone (E0747) 5. Conductive garment for use with TENS/IF/EMS device (E0731) B. Cervical Spine 1. Cervical Traction (L0849) C. TLSO 1. Aspen Horizon 456 (TLSO - L0456/L0457 for Medicare), Aspen Horizon 464 (TLSO - LO464/L), and Medi USA Spinomed IV (TLSO - L0456/L0457 for Medicare) D. LSO 1. Aspen Horizon 627 (LSO - L0627/L642 for Medicare), Aspen Horizon 631 (LSO - L0631/L0648 for Medicare), Aspen Horizon 637 (LSO - L0637/L0650 for Medicare), DDS 500 Lumbar Traction Belt (LSO - L0631/L0648 for Medicare) E. Upper Extremty F. Lower Extremity 1. Step-Smart AFO (L1971) 2. Patellofemoral Knee (L1820, L1832, L1843/K0901 for Medicare, L1845/K0902 for Medicare) 3. Post-Op Knee (L1832) 4. Osteoarthritis Knee (L1832, L1843/K0901 for Medicare, L1845/K0902 for Medicare) 5. ACL/Ligament Knee (L1832, L1845/K0902 for Medicare) Please be sure to include the following for all orders: 1. PRESCRIPTION 2. MEDICAL RECORDS/CHART NOTES supporting medical necessity of equipment. Also include any X-rays or MRI reports (if applicable). 3. DEMOGRAPHICS & INSURANCE INFORMATION

2 A. Electrotherapy/Stims 1. TENS Unit (Pain Control) o Chronic pain for 3 months or greater o No low back diagnosis codes are covered (Medicare or plans that follow Medicare guidelines) : o Ordering a 2 Lead TENS unit to treat the pain symptoms associated with the Dx, patient to follow up in 5-6 weeks for re-evaluation o Location and severity of pain o Treatment modalities tried and failed (previous chart notes) C. 30 day face-to-face reevaluation (Medicare): At the end of the 30 day rental period (30 days from when the patient was set up) the patient must go back to the prescribing physician to complete a reevaluation for the purchase of the TENS unit. A certificate of medical necessity must be signed and the following must be dictated in the chart notes after a 30 day trial has been completed: o How often the TENS unit is used on a daily/ weekly basis and the duration of use for each treatment session. o Effectiveness of TENS therapy o A continued use recommendation 2. EMS (Disuse Atrophy) o Dx Code (Disuse Atrophy) : o Ordering a neuromuscular stimulator for disuse atrophy due to. (examples: casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, hip replacement surgery, and ACL surgery) 3. Osteogenesis Bone Stim - Spinal o Failed fusion, where a minimum of 9 months has elapsed since the last surgery; o Previous fusion at same level o Multiple level fusion. A multiple level fusion involves 3 or more vertebrae (e.g., L3- L5, L4-S1, etc). B. chart notes must dictate: o Ordering spinal bone growth stimulator for assistance with the healing process given. ie: the multi-level fusion, failed fusion, or repeat single level fusion. 4. Osteogenesis Bone Stim - Long Bone :

3 o Nonunion of a long bone fracture defined as radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator, or o Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery, or o Congenital pseudarthrosis. o Ordering bone growth stimulator for the non-union of fracture to promote healing. The patient should use the bone growth stimulator daily until healing. There is radiographic evidence of the non-healing for approximately months. (Radiographic evidence must be included in the patient s records.) 5. Conductive Garments o Use of electrotherapy is so often that electrodes become unusable before 1 month. o The patient cannot reach the area to be stimulated. o Documented skin condition o Electric Stimulation needs to be delivered under a cast : o Ordering a conductive garment because the patient requires the conductive garment due to the large area/large number of sites to be stimulated, the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes and lead wires. Or; o Ordering a conductive garment because the patient cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas of the site to be stimulated are inaccessible with the use of conventional electrodes, adhesives tapes, and lead wires. The patient cannot reach the area to be stimulated without assistance; therefore, the patient cannot get the full benefits of the electrical stimulation. Or; o Ordering a conductive garment because the patient has a documented medical condition, such as skin problems that preclude the application of conventional electrodes, adhesive tapes, and lead wires. Or; o Ordering a conductive garment because the patient requires electrical stimulation beneath a cast to treat chronic intractable pain. B. Cervical 1. Cervical Traction (both a and b are requirements and one of 1, 2, or 3) a. The patient has a musculoskeletal or neurologic impairment requiring traction, and; b. The appropriate use of home cervical traction device has been demonstrated to the patient and the patient tolerated the selected device.

4 2339 Weldon Parkway 1. The patient has a diagnosis of temporomandibular joint (TMJ) dysfunction, and has received treatment for the TMJ condition. 2. The patient has distortion of the lower jaw or neck anatomy (e.g. radical neck dissection) such that a chin halter is unable to be utilized 3. The treating physician orders and/or documents the medically necessity for greater than 20 pounds of cervical traction in the home setting : o Due to Dx: (c- spine diagnoses), I am recommending a supine home traction to lbs. 1x/ daily. Anything less than 20 lbs. would not provide sufficient enough force to relieve pain (and/or) radiculopathy. C. Thoracic Spine 1. TLSO o Thoracic diagnosis code o Ordering LSO to reduce pain associated with (Dx: ), by restricting mobility of the trunk. or o Ordering TLSO to support weak spinal muscles and/or a deformed spine due to (Dx: ). or o Ordering TLSO to facilitate healing following following an injury or surgical procedure on the spine or related soft tissue D. Lumbar Spine 1. LSO o Lumbar diagnosis code o Ordering LSO to reduce pain associated with (Dx: ), by restricting mobility of the trunk. or o Ordering LSO to support weak spinal muscles and/or a deformed spine due to (Dx: ). or o Ordering LSO to facilitate healing following injury or surgical procedure on the spine or related soft tissue E. Upper Extremity* F. Lower Extremity 1. Step-Smart AFO o Foot drop, Dx code: o Ordering an ankle foot orthosis to assist foot drop and help during ambulation 2. Patellofemoral Knee Bracing

5 (Medicare Patients must have each qualification) o Patellar Subluxation/Dislocation or Chondromalacia o Knee Instability / Joint Derangement o Ordering a patellar stabilizer knee brace to assist in proper joint tracking and stabilize the knee joint and shows positive for instability (Medicare Patients) 3. Post-Op Knee (Medicare Patients must have each qualification) o ACL Tear, or MCL Tear, o Knee Instability / Joint Derangement, o Ordering a functional knee orthoses to assist in proper joint tracking and stabilize the knee joint and 4. Osteoarthritis Knee Bracing (Medicare Patients must have each qualification) o Knee Osteoarthritis o Knee Instability o Ordering an unloading knee brace to treat the pain symptoms associated with the knee OA and to stabilize the joint and 5. ACL/Ligament Knee Bracing (Medicare Patients must have each qualification) o ACL Tear, or MCL Tear, o Knee Instability / Joint Derangement, o Ordering a functional knee orthoses to assist in proper joint tracking and stabilize the knee joint and G. Temperature therapy* *If you do not see a specific product or category from our prescription form listed on the cheat sheet, then there are no specific requirements needed. Just be sure to include a script with a related diagnosis code, chart notes that supports the need for the product, and patient demographics and insurance information.

Insurance Guideline Summary

Insurance Guideline Summary Foot/Ankle: Soft Goods- Ankle lace-up, Velocity, PTTD $83.00 Had an injury, surgery, or chronic instability (will not be covered for osteoarthritis unless you document instability