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12/23/2009    

CODINGLINE CORNER

Query: Hallux Valgus Repair


We are trying to the locate the appropriate code(s) for a hallux varus repair by capsulotomy and Mini-TightRope.


Joy Constanzo, Billing Supervisor, Office of Kirk Koepsel, DPM,

Houston, TX


Response: There is no specific code for this service. You should bill for the actual procedure(s) performed. It this case, your options could include CPT 28270 which is capsulotomy metatarsal-phalangeal joint, or CPT 28313 (reconstruction angular deformity of toes, soft tissue procedure only).


There is no code for the TightRope use. It is a product used in the primary repair procedure. If you feel the work done was significant enough, append a "-22" modifier. The op report should clearly document that work. Be sure to include a letter of explanation.


Tony Poggio, DPM, Alameda, CA


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Other messages in this thread:


12/02/2016    

CODINGLINE CORNER


Query: Hospital Consultation Coding Issue


 


We have a patient whom we did a consult on at the hospital. We billed it as CPT 99223 (initial hospital consult) to the patient's insurance -- in this case, the patient has Bluecare (Tenncare/Medicaid plan). They are denying the claim, stating there's a more "appropriate code" that we need to bill. I pulled records from the hospital and the only thing I can figure is that the hospital had the patient marked as "OBSERVATION" the entire time she was there (08-10-2016 16:31pm to 08-11-2016 21:55pm). So, we think that would mean they want us to bill a CPT 99218-99220 code for "hospital observation". However, we did NOT admit this patient and the way that those codes read, they are only to be billed by the physician who actually admitted the patient. Does anyone have any insight on this? Are we correct on our CPT 99223 coding? Do I need to file an appeal or can we bill the observation code? 


 


Jennifer P. Memphis, TN


 


Response: CPT 99223 is a very high level consultation code. The payer may have an edit in place against podiatrists or other specialists using this code. There are many things required to satisfy a CPT 99223 level E/M service. Among them is that you perform 10 Review of Systems that are appropriate for the problem you are evaluating. These systems include GI, GU, Eyes, ENT, CV, Respiratory, and others. 


 


Also required is a full organ system exam. When you look through all the full organ system exams, most require opthalmoscope, otoscope, and other things most podiatrists aren’t doing as a consultant. Even the musculoskeletal full organ system exam requires skin inspection, muscle strength, and range of motion of both upper extremities. Take a close look at ALL of the requirements of CPT 99221, CPT 99222, and CPT 99223 before choosing your code. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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11/29/2016    

CODINGLINE CORNER


Query: CPT 99212 or 99213?


 


When billing for a chief complaint of bunion, heel pain, or hammertoe, when the evaluation/medical decision-making is straightforward with one chief complaint and the plan only involves educating the patient of the deformity (no prescription given and no therapy/treatment ordered), should this be CPT 99212 or CPT 99213? 


 


Danielle LaLonde, Belvidere, NJ


 


Response: There are office visits where counseling is the primary service performed - patient education about their condition, treatment options, risks, etc. In these cases, use "time" as the basis for selecting your E/M service. In the CPT book, each E/M code for any place of service has time period associated with it. If over 7.5 minutes is spent with a patient in counseling/coordination of care (over 50% of the encounter time was spent in counseling) during a 15 minute face-to-face encounter, then CPT 99213 would be appropriate, as long as your documentation is clear regarding the issue(s) discussed and the medical necessity for the counselling. Both times should be documented within the medical record. 


 


Tony Poggio, DPM, Alameda, CA


 


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11/25/2016    

CODINGLINE CORNER


Query: Coding Laser Treatment of Neuromas


 


I want to offer laser treatment of neuromas. Guidelines for the laser use suggested up to 10 treatments 3 to 4 days apart. How would this best be billed? I'm think about billing E/M codes until symptoms are relieved, then code CPT 28080 (excision, interdigital [Morton] neuroma, single, each) or CPT 64776 (excision of neuroma; digital nerve, one or both, same digit) if the laser treatments fail to work. 


 


PM News Subscriber


 


Response: Why would you use a code for neuroma excision if you are not actually excising the neuroma? I think you may be asking for an audit, especially if the patient complains. Do you actually make an incision? If not, then you can't bill for one. If the laser treatment of the neuroma is off-label, be sure to get a separate consent clearly spelling this out for the patients. 


 


Vince Marino, DPM, San Francisco, CA


 


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11/22/2016    

CODINGLINE CORNER


Query: Coding Revision Surgery


 


I will be removing a Silastic implant from the first metataral-phalangeal joint, and fusing the joint with a bone graft. How do I bill the procedures? 


 


Jeffrey Klein, DPM, Waterford, MI


 


Response: I suggest CPT 28750 (arthrodesis, great toe; metatarsophalangeal joint). The removal of the implant is not separately billable because it is considered to be part of the dissection for the fusion. If you feel the extra work performed to remove the implant was substantial, you can add a "-22" modifier to indicate the work performed was substantially greater than what is typically required with this code. Submit the necessary supporting documentation. 


 


If you obtained the bone graft yourself from another site, you can also code CPT 20900 (bone graft, any donor area; minor or small [e.g., dowel or button]). CPT 28750 does not include the harvesting of the graft or implant from a separate site. If you used allograft, nothing should be coded relative to the use of that graft. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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11/19/2016    

CODINGLINE CORNER


Query: CPT 28510 Global Days


 


What is the global period for CPT 28510 (closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each) with Medicare? 


 


Danielle LaLonde, Belvidere, NJ 


 


Response: The Medicare global period is 90 days for CPT 28510. You can, however, bill any medically necessary follow-up x-rays you perform during the global period. 


 


Katherine Sharp, Woodbury, TN


 


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11/15/2016    

CODINGLINE CORNER


Query: Pre-Operative History and Physical


 


I billed CPT 99214 for a pre-op history and physical encounter since I spent about 30 minutes face-to-face with the patient. Now Medicare is requesting my notes. The pre-op visit was on March 31 and the surgery was performed April 2. I documented my start and finish time for the entire encounter, as well as the counseling time of 18 minutes. Did I code correctly? Is it reasonable to code CPT 99214? Should I change the visit to CPT 99213? Should I not charge for the pre-op which may or may not have a family member who will be caring for the patient sitting in and hearing about the procedure, complications, risks, and post-operative care? 


 


Codingline Archive Question


 


Response: The reimbursement for a surgery is calculated by taking into account the normal pre-operative care, surgery, and normal post-operative care. A normal pre-op history and physical encounter should not be billed in addition to the surgery. 


 


Medicare considers a one-day pre-op global fee period, so the reason you were paid is because it was 2 days prior to the surgery. If Medicare determines that it was a normal pre-op and they suspect that you did it 2 days prior so that you could bill separately for it, they will ask for money back on it - regardless if you billed a CPT 99213 or a CPT 99214. 


 


Don Self, Whitehouse, TX 


 


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11/08/2016    

CODINGLINE CORNER


Query: Achilles Lengthening Coding


 


Can you please tell me the proper code to use for percutaneous Achilles lengthening? 


 


Danielle LaLonde, Belvidere, NJ


 


Response: Consider 


 


1) CPT 27605 (tenotomy, percutaneous, Achilles tendon [separate procedure]; local anesthesia); or 


 


2) CPT 27606 (tenotomy, percutaneous, Achilles tendon [separate procedure]; general anesthesia). 


 


Joseph Borreggine, DPM, Charleston, IL 


 


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11/07/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Elliot Udell, DPM


 


Many insurance companies have tricks they play on providers when it comes to orthotics. We have had cases where they tell the patient and us that the patient is fully covered for custom orthotics. When we cast them for orthotics and dispensed them, we received a "big" check for twenty six dollars and fifty cents. This didn't even come close to what the lab fees were. So, we learned not to make custom orthotics for certain patients with certain insurance plans. 


 


One other time, we got burnt was when a patient insisted on us making him custom sports orthotics so that he could play tennis better. He insisted that he would pay cash for them .We accepted and six months later his wife called us patched into the insurance company complaining that we had no right to take money from her husband for custom orthotics and the insurance company said we were only entitled to twenty six dollars. We were forced to give the patient a full refund. 


 


The bottom line is that we all must be aware of what certain plans pay for orthotics and if you are participating with a plan, don't expect a patient to pay out-of-pocket. The "$64,000" question is how do you properly manage a patient who medically needs custom orthotics and the insurance company is only going to pay a substandard fee?


 


Elliot Udell, DPM, Hicksville, NY

11/04/2016    

CODINGLINE CORNER


Query: Orthotics and Diagnoses


 


What diagnosis codes besides plantar fasciitis and diabetes are billed for foot orthotics? 


 


Amannda Richline, DPM, Belvidere, NJ


 


Response: Each payer has their coverage policy for foot orthotics in terms of benefit and utilization. Unfortunately, there are no set codes that fit all payers. You should check any published policy/guidelines from the specific payer in question. Check to see if they have a published list of approved diagnosis codes. Having said that, consider those conditions you feel custom foot orthotics would be most appropriate and medically necessary. This would include many musculoskeletal conditions in the foot such as plantar fasciitis, tendinitis, instability, symptomatic or limiting pes planus, etc. Document medical necessity and the need for orthotic therapy. 


 


Diabetes alone does not necessarily guarantee coverage even under the Medicare therapeutic shoe program for diabetic patients. With that program, the patient still needs to meet one or more of the listed lower extremity conditions, along with diabetes to qualify (plus the other requirements necessary). 


 


Tony Poggio, DPM, Alameda, CA


 


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11/04/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Michael M. Rosenblatt, DPM


 


For NH podiatrists, a great deal of time and effort is made on issues of "coding." While coding properly is a must, the REAL issue is the quality of your charting. The challenge is that many of the procedures that you do in the nursing home are the same for each patient. However, their health histories are often completely different. There may be diseases and previous injuries to the NH patient that you are unaware of. You will not know what they are until you thoroughly read their intake, H&P, and treatment history. 


 


Some patients have a wasting disease, like cancer or a chronic infectious disease. Some are on the terminal watch list. Others have decubitus ulcers and severe contractures. Many patients have draining lesions between their toes, sometimes from associated pressure of a hypertrophic, fungused nail against it. In NH charting, there is a tendency for DPMs to...


 


Editor's note: Dr. Rosenblatt's extended-length letter can be read here.

11/03/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Gary Hoberman, DPM


 


As to Dr. Poggio’s response to the query regarding billing a new patient E&M NH visit when all that is needed is nail/corn/callus care, I’m hoping for more clarification: 1. How does one know that’s all that is needed until the H&P is performed? 2. Since the lowest level E&M pays more in many cases than the RFC, if only the procedure code or the E&M code is warranted, shouldn’t the E&M be billed? (Just a reminder, 11719-Q8 pays about $12.50) 3. Dr. Poggio states guidelines are “just like in the office.” Does this mean that we should NOT bill a new patient visit in the office in combination with the procedure code on patients’ whose history and physical determine that they qualify for, but ultimately only need nail/corn/callus care covered routine foot care? 


 


Gary Hoberman, DPM, Chicago, IL

11/02/2016    

CODINGLINE CORNER


Query: Destruction of Benign Lesion


 


We are getting denials every time we bill CPT 17110. Can anyone please advise which ICD-10 code(s) you are billing with this procedure code? 


 


Ellyn Black, Greenville, TX


 


Response: If you are using this for destruction of a plantar wart, I suggest B07.0, (plantar wart). I also suggest adding a secondary code of “pain” if it is appropriate. 


 


Those codes include: M79.671 Pain in right foot, M79.672 Pain in left foot, M79.674 Pain in right toe(s), M79.675 Pain in left toe(s). 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 


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10/31/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Bryan C. Markinson, DPM


 


I believe that Dr. Poggio's response regarding modifier-25 on initial visits is incorrect. Although the definition does require a separately identifiable diagnosis (at least in New York), that requirement is suspended on and only on the initial visit. It has been this way for years.


 


Bryan C. Markinson, DPM, NY, NY

10/28/2016    

CODINGLINE CORNER


Query: New Patient Visit in Nursing Home


 


I understand that you can bill an E/M code plus a procedure code (e.g., nail care) for new patients in nursing homes for routine foot care. Do you need a separate, diagnosis other than onychomycosis and peripheral vascular disease (along with class findings) to support the E/M coding, or do I have to find something like hammertoes or foot pain with a separate treatment plan to justify the E/M billing? 


 


Troy Harris, DPM, Swansboro, NC


 


Response: Billing for routine foot care and a possible E/M service (or any procedure with an E/M service) is no different in a nursing home than it is in the office setting. The E/M service has to be "significant and separately" identifiable from whatever procedure you are doing (just like in the office). 


 


You do not get an E/M service just by going to the facility like a service call. If all you are doing is nail/callus care, then that is all you should bill for. If the patient or family had questions about nail and callus care and you did a more intense work-up or discussed other treatment options, then an E/M service MAY be warranted per your documentation. 


 


Tony Poggio, DPM, Alameda, CA 


 


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10/25/2016    

CODINGLINE CORNER


Query: Bilateral Strapping Denials


 


We have had two patients recently who have had both feet strapped. We billed one on two lines, CPT 29540-RT, CPT 29540-LT and the other on one, CPT 29540-LT-RT. Both were denied by Excellus Blue Cross Blue Shield. Any suggestions on how to bill this correctly? 


 


Linda, Billing, Office of Lewis Giglia, DPM, Fairport, NY


 


Response: Try billing one line and using the "-50" modifier. This represents a bilateral procedure. Check the APMA Coding Resource Center for CPT 29540. You will see, at least for Medicare, that the strapping code requires a "-50" modifier. 


 


Tony Poggio, DPM, Alameda, CA


 


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10/22/2016    

CODINGLINE CORNER


Query: Bilateral Diagnosis


 


When coding a patient who has hammertoes bilaterally, do you have to use both M20.41 and M20.42 (other hammer toe(s) (acquired), right foot and left foot, respectively)? Obviously, dealing with feet, we have many patients with bilateral problems. Can anyone shed any light on this for me? 


 


Ellyn Black, Greenville, TX


 


Response: Yes, Ellyn,you do need to use both codes if coding for bilateral hammertoes. In the updated ICD-10 for 2017, we have a few bilateral codes added, but not for hammertoes. So, I would use both the M20.41 and M20.42 if coding for bilateral hammertoes. Be sure to link the proper laterality to the proper treatment rendered for each, when indicated. 


 


Mike King, DPM, Alpharetta, GA


 


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10/20/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Michael G. Warshaw, DPM, CPC


 


After reading the response by Dr. Poggio to this query, I must disagree. For the appropriate way to bill a hospital visit on a Medicare patient, it would not be appropriate to use the initial hospital care coding, E/M services. One need look no further than the CPT Manual. Under Initial Hospital Care, New or Established Patient: "The following codes are used to report the first hospital inpatient encounter with the patient by the admitting physician. For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231-99233) as appropriate."


 


There was no indication in the query that the physician in question was the admitting physician and based upon the fact that the initial inpatient consultation codes do not apply, it is clear that the most appropriate E/M codes to use for the scenario described in the query are the subsequent hospital care codes.


 


Michael G. Warshaw, DPM, CPC, Lady Lake, FL

10/18/2016    

CODINGLINE CORNER


Query: Billing An Established Patient Hospital Visit


 


When a patient has already been established with care by the physician in the last 3 years, and then has to be seen in the hospital for another diagnosis, do we code CPT 99232 (subsequent care hospital) or CPT 99222 for initial hospital care since the diagnosis is new? 


 


Vanessa Sloan, Effingham, IL


 


Response: When billing a hospital visit on a Medicare patient, you would use the initial hospital care coding. The description is new or established patient. The key is that you are seeing a patient for the first time for that admission. If you need to see that patient again during the same admission, then you would bill the subsequent care code series based upon medical acuity of the services you rendered. 


 


If that same patient were seen X weeks later during a different admission, then you would still bill the initial care code series. 


 


Tony Poggio, DPM, Alameda, CA 


 


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10/15/2016    

CODINGLINE CORNER


Query: Correct Location for DME Dispense


 


We do not dispense many items to be billed to DMERC (Noridian is our MAC), but we do dispense fabricated Richie and Moore Balance braces. My billing department has been billing out the location of "12" for home because they were told to do so (not sure by whom) a long time ago. They think we were denied when we listed the office as the dispense site a long time ago and were told to use 'home' as the location. Is this correct? 


 


Cheryl Christensen, Ankle & Foot Clinic, Everett, WA


 


Response: DME covers services when they are used not in a medical facilty, but rather in the patient's home. Therefore, the use of POS =12 is correct. 


 


Paul Kesselman, DPM, Woodside, NY


 


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10/11/2016    

CODINGLINE CORNER


Query: ICD-10 Metatarsal Coding


 


With the new ICD-10 code for metatarsal varus (Q66.22 [congenital metatarsus adductus; Inclusion Term: congenital metatarsus varus]), which of the metatarsal codes would be most appropriate for a prominent metatarsal head? M77.41 (Metatarsalgia, right foot), or M21.6x1 (Other acquired deformities of right foot), or Q66.22? 


 


Edward Stein, DPM, Peters, MO


 


Response: The answer to your question starts with, is this "acquired" vs "congenital"? A prominent metatarsal head is a deformity which is usually acquired. The most specific codes for an acquired deformity are: 


 


1) Other acquired deformities of right foot M21.6X1 


2) Other acquired deformities of left foot M21.6X2 


 


Q66.22 is "congenital metatarsus adductus or metatarsus varus". This is defined as a foot deformity noted at birth that causes the front half of the foot, or forefoot, to turn inward. 


 


David J. Freedman, DPM, CPC, Silver Spring, MD 


 


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10/08/2016    

CODINGLINE CORNER


Query: Cheilectomy and Amniotic Interposition


 


If a doctor does a cheilectomy and interposes an amniotic membrane into the joint prior to closure, is that a billable fee separately? I thought that the surgical center would bill for the supply and the surgeon really doesn't bill anything except the CPT 28289. Is that correct? 


 


Mike King, DPM, Alpharetta, GA


 


Response: Correct, you would bill for the cheilectomy procedure. The insertion of the amniotic graft would be incidental to your procedure and would not be separately billable by you. 


 


You or the ASC should pre-certify the graft to see if the insurance company will pay the ASC for that item. Most insurance companies in my area consider that graft material experimental and investigational, and therefore a non-pay item. 


 


Paul Kinberg, DPM, Dallas, TX 


 


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10/04/2016    

CODINGLINE CORNER


Query: Heel Fissures?


 


We commonly see complaints of heel fissures. Isn't a "heel fissure" by definition an ulcer, whether it be partial or full thickness, and therefore eligible for a debridement code? 


 


Jennifer, Office of Charles Perry, DPM, Cambridge, OH 


 


Response: If you are treating an open wound (e.g., full thickness) beneath cracked and bleeding heel fissures, then CPT 97597 would likely be your code. The more common scenario, however, is a presentation of hyperkeratotic tissue (cracked skin around the heels) without an open wound. There is no debriding of dermis; there is debridement or paring of hyperkeratotic tissue. If that is the case, CPT 11055 is your likely code. And, yes, that is a routine foot care code...and, yes, most payers will not reimburse that code without "at risk" findings present. 


 


Harry Goldsmith, DPM, Cerritos, CA


 


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09/30/2016    

CODINGLINE CORNER


Query: Health Net Demanding Refunds


 


Recently, we have had Health Net take back portions of payments from years 2008 and 2007. The explanation code is BD - Bad Debt adjustment & OA-216 - Based on the findings of a review organization. When I called Health Net, they refused to give any information, as I could not verify the patient's date of birth. Since it has been over 7 years since these patients have been in our office, we no longer have any records on them and cannot provide that information. So, in essence Health Net is taking money away from us far after the allowed time and refusing to give any details as to why. Does anyone have any advice on how to proceed? 


 


Rob Kelso, Office of Michael DiGiacomo, DPM, Oakland, CA


 


Response: Ask to speak to a supervisor about the process they are taking, not so much the individual patient aspect. I think, in all reasonableness, 7 years is a very long time period to go back and ask for money (who has those records at their fingertips, especially in an "inactive" patient). If you run into a brick wall, I would tell them that you will be calling the state insurance commissioner to file a formal complaint and request an inquiry into the payer's practices. Health Net might recognize that the effort to recover a 7-year overpayment is not worth the scrutiny. 


 


I believe there are provisions in California law that if you acted in good faith and delivered medically necessary and reasonable care, and the insurance company paid on it, they cannot come after you later to get the money back. You might also wish to contact your malpractice carrier to see if they have an administrative defense provision/benefit, or the California Podiatric Medical Association for assistance and possibly assist/join you in filing a complaint. If Health Net is demanding refunds like this from you, it is possible others are in the same boat. 


 


You did not mention how much money they are asking back. Obviously, that can be a very relevant issue in terms of time and effort on both you and whether the payer is willing to defend or pursue this. That said, sometimes it's the principle of the thing not to get walked over by an insurance company. Making a stand might stop this process for the next doc in line to get such a letter. 


 


Tony Poggio, DPM, Alameda, CA 


 


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09/28/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Paul Kesselman, DPM


 


There are two "orders" which are required by Medicare regarding DMEPOS items. The first is a dispensing order, the second is the detailed written order. A dispensing order is akin to a prescription, which can be verbal or written. It is quite simple and may be oral and without specific name brand, model numbers, and with very brief information about the patient. A dispensing order is required prior to the item being provided to the patient.


 


As for the detailed written order, this requires much more information about the item being provided (e.g. name brand, size, width, model number, etc.) as well as very detailed information about the patient. In addition, a detailed written order must be provided prior to the claim being sent to Medicare. However, as physicians who supply our own patients, these separate documents are not required. Rather, the elements of the dispensing order (prescription) and Detailed Written Order (DWO) are required within the patient's medical record. 


 


Paul Kesselman, DPM, Woodside, NY 

09/27/2016    

CODINGLINE CORNER


Query: Medicare DME Orders


 


Medicare DME dispensing rules require an "order" by the physician, but what does that entail? Is that part of the physician's note or a separate note such as a written prescription? Please advise. 


 


Amy Meehan, Billing Manager, Potomac, MD


 


Response: The physician order is the prescription. In the case of DME, there would be no difference. The order would need to include patient identifying information, item name/description, diagnosis, and the expected length this device will be needed (e.g., lifetime for an AFO vs. 3 months for crutches). 


 


The physician-supplier does not need to produce a unique prescription for their own patient for DME or supplies. That order can be included within the physician's medical record. You should check with your DMAC to see about any other requirements. Make sure that your records include what you are prescribing, the medical necessity, why a custom device is required vs. an OTC device, the level of disability/impairment, symptoms, etc. 


 


Tony Poggio, DPM, Alameda, CA 


 


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