Patient Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.123456PATIENT INFORMATION Patient Name:Date of Birth:Address:Phone:Insurance Name:Member ID:NextPRESCRIBING PHYSICIAN INFORMATIONPhysician Name:NPI:EmailPhone: PreviousNextDEVICE OR SUPPLY INFORMATIONTypes of Device or Supply *Continuous Glucose Monitor (CGM)Orthotic BracesCathetersWound Care SuppliesPreviousNextMEDICAL NECESSITY DETAILSFor Continuous Glucose MonitorCGM SuppliesE2103: CGM transmitterA4239: CGM supplies (sensors, accessories)DiagnosisE10.9E10.65E10.649E11.9E11.8E11.65E11.649OtherHistory of hypoglycemiaPatient has recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persists despite multiple (more than one) attempts to adjust medications(s) and/or modify the diabetes treatment plan;Diagnosis – Other:Insulin UsageYesNoTraining Confirmation:Select Confirmation (Yes/No)YesNoRecent Evaluation:Select Recent Evaluation (Yes/No)YesNoFor Orthotic BracesOrthotic SuppliesSelect Orthotic SupplyL0450: TLSO, flexible, trunk supportL0455: TLSO, flexible, sacrum to T-9, strapsL0457: TLSO, rigid back, soft frontL0467: TLSO, rigid anterior/posterior panelsL0469: TLSO, sagittal/coronal control, rigid panelsL0648: LSO, rigid panels, sacrum to T-9L0649: LSO, sagittal/coronal, sacrum to T-9, pubis to xiphoidL0650: LSO, rigid panels, with lateral strengthenersL0651: LSO, sagittal/coronal, rigid panels, lateral strengthenersL1832: Knee orthosis, adjustable knee joint, prefabricated, includes fitting and adjustment.L1833: Knee orthosis, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1843: Knee orthosis, single upright, adjustable knee joint, prefabricated, includes fitting and adjustment.L1844: Knee orthosis, single upright, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1845: Knee orthosis, double upright, adjustable knee joint, prefabricated, includes fitting and adjustment.L1846: Knee orthosis, double upright, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1851: Knee orthosis, single upright, with adjustable flexion and extension joint, prefabricated, includes fitting and adjustment.L1852: Knee orthosis, single upright, with adjustable flexion and extension joint, custom-fabricated, includes fitting and adjustment.L1902: Ankle orthosis, gauntlet style, OTSL1906: Ankle-foot orthosis, multiligamentous support, OTSL3809: Wrist-hand-finger orthosis, no joints, OTSL3916: Wrist-hand orthosis (WHO), includes wrist extension, flexion, or bothSelect Orthotic SupplyL0450: TLSO, flexible, trunk supportL0455: TLSO, flexible, sacrum to T-9, strapsL0457: TLSO, rigid back, soft frontL0467: TLSO, rigid anterior/posterior panelsL0469: TLSO, sagittal/coronal control, rigid panelsL0648: LSO, rigid panels, sacrum to T-9L0649: LSO, sagittal/coronal, sacrum to T-9, pubis to xiphoidL0650: LSO, rigid panels, with lateral strengthenersL0651: LSO, sagittal/coronal, rigid panels, lateral strengthenersL1832: Knee orthosis, adjustable knee joint, prefabricated, includes fitting and adjustment.L1833: Knee orthosis, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1843: Knee orthosis, single upright, adjustable knee joint, prefabricated, includes fitting and adjustment.L1844: Knee orthosis, single upright, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1845: Knee orthosis, double upright, adjustable knee joint, prefabricated, includes fitting and adjustment.L1846: Knee orthosis, double upright, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1851: Knee orthosis, single upright, with adjustable flexion and extension joint, prefabricated, includes fitting and adjustment.L1852: Knee orthosis, single upright, with adjustable flexion and extension joint, custom-fabricated, includes fitting and adjustment.L1902: Ankle orthosis, gauntlet style, OTSL1906: Ankle-foot orthosis, multiligamentous support, OTSL3809: Wrist-hand-finger orthosis, no joints, OTSL3916: Wrist-hand orthosis (WHO), includes wrist extension, flexion, or bothSelect Orthotic SupplyL0450: TLSO, flexible, trunk supportL0455: TLSO, flexible, sacrum to T-9, strapsL0457: TLSO, rigid back, soft frontL0467: TLSO, rigid anterior/posterior panelsL0469: TLSO, sagittal/coronal control, rigid panelsL0648: LSO, rigid panels, sacrum to T-9L0649: LSO, sagittal/coronal, sacrum to T-9, pubis to xiphoidL0650: LSO, rigid panels, with lateral strengthenersL0651: LSO, sagittal/coronal, rigid panels, lateral strengthenersL1832: Knee orthosis, adjustable knee joint, prefabricated, includes fitting and adjustment.L1833: Knee orthosis, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1843: Knee orthosis, single upright, adjustable knee joint, prefabricated, includes fitting and adjustment.L1844: Knee orthosis, single upright, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1845: Knee orthosis, double upright, adjustable knee joint, prefabricated, includes fitting and adjustment.L1846: Knee orthosis, double upright, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1851: Knee orthosis, single upright, with adjustable flexion and extension joint, prefabricated, includes fitting and adjustment.L1852: Knee orthosis, single upright, with adjustable flexion and extension joint, custom-fabricated, includes fitting and adjustment.L1902: Ankle orthosis, gauntlet style, OTSL1906: Ankle-foot orthosis, multiligamentous support, OTSL3809: Wrist-hand-finger orthosis, no joints, OTSL3916: Wrist-hand orthosis (WHO), includes wrist extension, flexion, or bothSelect Orthotic SupplyL0450: TLSO, flexible, trunk supportL0455: TLSO, flexible, sacrum to T-9, strapsL0457: TLSO, rigid back, soft frontL0467: TLSO, rigid anterior/posterior panelsL0469: TLSO, sagittal/coronal control, rigid panelsL0648: LSO, rigid panels, sacrum to T-9L0649: LSO, sagittal/coronal, sacrum to T-9, pubis to xiphoidL0650: LSO, rigid panels, with lateral strengthenersL0651: LSO, sagittal/coronal, rigid panels, lateral strengthenersL1832: Knee orthosis, adjustable knee joint, prefabricated, includes fitting and adjustment.L1833: Knee orthosis, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1843: Knee orthosis, single upright, adjustable knee joint, prefabricated, includes fitting and adjustment.L1844: Knee orthosis, single upright, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1845: Knee orthosis, double upright, adjustable knee joint, prefabricated, includes fitting and adjustment.L1846: Knee orthosis, double upright, adjustable knee joint, custom-fabricated, includes fitting and adjustment.L1851: Knee orthosis, single upright, with adjustable flexion and extension joint, prefabricated, includes fitting and adjustment.L1852: Knee orthosis, single upright, with adjustable flexion and extension joint, custom-fabricated, includes fitting and adjustment.L1902: Ankle orthosis, gauntlet style, OTSL1906: Ankle-foot orthosis, multiligamentous support, OTSL3809: Wrist-hand-finger orthosis, no joints, OTSL3916: Wrist-hand orthosis (WHO), includes wrist extension, flexion, or bothBrace TypeSelect Brace TypeBack BraceKnee BraceAnkle BraceWrist BraceSelect Brace TypeBack BraceKnee BraceAnkle BraceWrist BraceSelect Brace TypeBack BraceKnee BraceAnkle BraceWrist BraceSelect Brace TypeBack BraceKnee BraceAnkle BraceWrist BraceDiagnosisSelect DiagnosisM50.10 – Cervical disc disorder with radiculopathy, unspecified cervical regionM50.20 – Other cervical disc displacement, unspecified cervical regionM53.82 – Other specified dorsopathies, cervical regionM54.2 – CervicalgiaM54.6 – Pain in thoracic spineS22.0XXA – Fracture of thoracic vertebra, initial encounterM51.26 – Other intervertebral disc displacement, lumbar regionM51.27 – Other intervertebral disc displacement, lumbosacral regionM51.36 – Other intervertebral disc degeneration, lumbar regionM51.37 – Other intervertebral disc degeneration, lumbosacral regionM54.5 – Low back painM54.89 – Other dorsalgiaS32.0XXA – Fracture of lumbar vertebra, initial encounterS32.2XXA – Fracture of sacrum, initial encounterM40.20 – Unspecified kyphosis, site unspecifiedM40.25 – Unspecified kyphosis, thoracolumbar regionM41.00 – Unspecified scoliosis, site unspecifiedM41.05 – Unspecified scoliosis, thoracolumbar regionM41.20 – Other idiopathic scoliosis, site unspecifiedM41.25 – Other idiopathic scoliosis, thoracolumbar regionM41.30 – Thoracogenic scoliosis, site unspecifiedM41.35 – Thoracogenic scoliosis, thoracolumbar regionM41.40 – Neuromuscular scoliosis, site unspecifiedM41.45 – Neuromuscular scoliosis, thoracolumbar regionM41.50 – Other secondary scoliosis, site unspecifiedM41.55 – Other secondary scoliosis, thoracolumbar regionM41.80 – Other forms of scoliosis, site unspecifiedM41.85 – Other forms of scoliosis, thoracolumbar regionM41.9 – Scoliosis, unspecifiedM43.00 – Spondylolysis, site unspecifiedM43.05 – Spondylolysis, thoracolumbar regionM43.10 – Spondylolisthesis, site unspecifiedM43.15 – Spondylolisthesis, thoracolumbar regionM43.20 – Fusion of spine, site unspecifiedM43.25 – Fusion of spine, thoracolumbar regionM43.6 – TorticollisM43.8X9 – Other specified deformities of spine, site unspecifiedM48.00 – Spinal stenosis, site unspecifiedM48.05 – Spinal stenosis, thoracolumbar regionM51.9 – Intervertebral disc disorder, unspecifiedQ76.2 – Congenital spondylolisthesisQ76.4 – Other congenital malformations of spine, not associated with scoliosisM96.1 – Postlaminectomy syndrome, not elsewhere classifiedM96.6 – Fracture of vertebrae following insertion of orthopedic implant, joint prosthesis, or bone plateS12.0XXA – Fracture of first cervical vertebra, initial encounterS22.0XXA – Fracture of thoracic vertebra, initial encounterS32.0XXA – Fracture of lumbar vertebra, initial encounterS32.2XXA – Fracture of sacrum, initial encounterG04.1 – Tropical spastic paraplegiaG35 – Multiple sclerosisG57.01 – Lesion of sciatic nerve, right lower limbG57.02 – Lesion of sciatic nerve, left lower limbG57.03 – Lesion of sciatic nerve, bilateral lower limbsG57.21 – Lesion of femoral nerve, right lower limbG57.22 – Lesion of femoral nerve, left lower limbG57.23 – Lesion of femoral nerve, bilateral lower limbsG80.9 – Cerebral palsy, unspecifiedG81.91 – G81.94 – Hemiplegia, unspecified (right dominant side to left nondominant side)G82.20 – G82.22 – Paraplegia, unspecified (to incomplete paraplegia)M05.061 – Felty's syndrome, right kneeM05.062 – Felty's syndrome, left kneeM05.261 – Rheumatoid vasculitis with rheumatoid arthritis of right kneeM05.262 – Rheumatoid vasculitis with rheumatoid arthritis of left kneeM05.361 – Rheumatoid heart disease with rheumatoid arthritis of right kneeM05.362 – Rheumatoid heart disease with rheumatoid arthritis of left kneeM05.561 – Rheumatoid polyneuropathy with rheumatoid arthritis of right kneeM05.562 – Rheumatoid polyneuropathy with rheumatoid arthritis of left kneeM17.0 – Bilateral primary osteoarthritis of kneeM17.11 – Unilateral primary osteoarthritis, right kneeM17.12 – Unilateral primary osteoarthritis, left kneeS72.001A – S72.002S – Fracture of unspecified part of neck of femur (right initial to left sequela)S72.101A – S72.102S – Unspecified trochanteric fracture of femur (right initial to left sequela)S82.011A – S82.012S – Displaced osteochondral fracture of patella (right initial to left sequela)S82.014A – S82.015S – Nondisplaced osteochondral fracture of patella (right initial to left sequela)S83.011A – S83.012S – Lateral subluxation of patella (right initial to left sequela)S83.014A – S83.015S – Lateral dislocation of patella (right initial to left sequela)M80.051A – M80.052S – Age-related osteoporosis with pathological fracture (right femur initial to left sequela)M80.861A – M80.862S – Other osteoporosis with pathological fracture (right lower leg initial to left sequela)M84.351A – M84.352S – Stress fracture (right femur initial to left sequela)Q68.2 – Congenital deformity of kneeQ68.6 – Discoid meniscusQ74.1 – Congenital malformation of kneeT84.012A – T84.013S – Broken internal knee prosthesis (right initial to left sequela)T84.022A – T84.023S – Instability of internal knee prosthesis (right initial to left sequela)T84.062A – T84.063S – Wear of articular bearing surface of prosthetic knee joint (right initial to left sequela)Z96.651 – Z96.653 – Presence of artificial knee joint (right, left, or bilateral)M25.571 – Pain in right ankle and joints of right footM25.572 – Pain in left ankle and joints of left footM19.071 – Primary osteoarthritis, right ankle and footM19.072 – Primary osteoarthritis, left ankle and footS93.401A – Sprain of unspecified ligament of right ankle, initial encounterS93.402A – Sprain of unspecified ligament of left ankle, initial encounterM24.871 – Ligamentous laxity, right ankleM24.872 – Ligamentous laxity, left ankleM25.371 – Instability, right ankleM25.372 – Instability, left ankleS93.411A – Sprain of calcaneofibular ligament of right ankle, initial encounterS93.412A – Sprain of calcaneofibular ligament of left ankle, initial encounterM25.531 – Pain in right wristM25.532 – Pain in left wristM19.031 – Primary osteoarthritis, right wristM19.032 – Primary osteoarthritis, left wristS63.501A – Unspecified sprain of right wrist, initial encounterS63.502A – Unspecified sprain of left wrist, initial encounterM24.531: Ankylosis of right wristM24.532: Ankylosis of left wristM65.4: Radial styloid tenosynovitis [de Quervain]M70.831: Other soft tissue disorders related to use, overuse, and pressure, right wristM70.832: Other soft tissue disorders related to use, overuse, and pressure, left wristM77.41: Radial styloid tenosynovitis, right wristM77.42: Radial styloid tenosynovitis, left wristM24.831: Other specific joint derangements of right wrist, not elsewhere classifiedM24.832: Other specific joint derangements of left wrist, not elsewhere classifiedM67.431: Ganglion, right wristM67.432: Ganglion, left wristM18.11: Osteoarthritis of first carpometacarpal joint, right handM18.12: Osteoarthritis of first carpometacarpal joint, left handM25.831: Other instability, right wristM25.832: Other instability, left wristM24.431: Recurrent dislocation, right wristM24.432: Recurrent dislocation, left wristOtherSelect DiagnosisM50.10 – Cervical disc disorder with radiculopathy, unspecified cervical regionM50.20 – Other cervical disc displacement, unspecified cervical regionM53.82 – Other specified dorsopathies, cervical regionM54.2 – CervicalgiaM54.6 – Pain in thoracic spineS22.0XXA – Fracture of thoracic vertebra, initial encounterM51.26 – Other intervertebral disc displacement, lumbar regionM51.27 – Other intervertebral disc displacement, lumbosacral regionM51.36 – Other intervertebral disc degeneration, lumbar regionM51.37 – Other intervertebral disc degeneration, lumbosacral regionM54.5 – Low back painM54.89 – Other dorsalgiaS32.0XXA – Fracture of lumbar vertebra, initial encounterS32.2XXA – Fracture of sacrum, initial encounterM40.20 – Unspecified kyphosis, site unspecifiedM40.25 – Unspecified kyphosis, thoracolumbar regionM41.00 – Unspecified scoliosis, site unspecifiedM41.05 – Unspecified scoliosis, thoracolumbar regionM41.20 – Other idiopathic scoliosis, site unspecifiedM41.25 – Other idiopathic scoliosis, thoracolumbar regionM41.30 – Thoracogenic scoliosis, site unspecifiedM41.35 – Thoracogenic scoliosis, thoracolumbar regionM41.40 – Neuromuscular scoliosis, site unspecifiedM41.45 – Neuromuscular scoliosis, thoracolumbar regionM41.50 – Other secondary scoliosis, site unspecifiedM41.55 – Other secondary scoliosis, thoracolumbar regionM41.80 – Other forms of scoliosis, site unspecifiedM41.85 – Other forms of scoliosis, thoracolumbar regionM41.9 – Scoliosis, unspecifiedM43.00 – Spondylolysis, site unspecifiedM43.05 – Spondylolysis, thoracolumbar regionM43.10 – Spondylolisthesis, site unspecifiedM43.15 – Spondylolisthesis, thoracolumbar regionM43.20 – Fusion of spine, site unspecifiedM43.25 – Fusion of spine, thoracolumbar regionM43.6 – TorticollisM43.8X9 – Other specified deformities of spine, site unspecifiedM48.00 – Spinal stenosis, site unspecifiedM48.05 – Spinal stenosis, thoracolumbar regionM51.9 – Intervertebral disc disorder, unspecifiedQ76.2 – Congenital spondylolisthesisQ76.4 – Other congenital malformations of spine, not associated with scoliosisM96.1 – Postlaminectomy syndrome, not elsewhere classifiedM96.6 – Fracture of vertebrae following insertion of orthopedic implant, joint prosthesis, or bone plateS12.0XXA – Fracture of first cervical vertebra, initial encounterS22.0XXA – Fracture of thoracic vertebra, initial encounterS32.0XXA – Fracture of lumbar vertebra, initial encounterS32.2XXA – Fracture of sacrum, initial encounterG04.1 – Tropical spastic paraplegiaG35 – Multiple sclerosisG57.01 – Lesion of sciatic nerve, right lower limbG57.02 – Lesion of sciatic nerve, left lower limbG57.03 – Lesion of sciatic nerve, bilateral lower limbsG57.21 – Lesion of femoral nerve, right lower limbG57.22 – Lesion of femoral nerve, left lower limbG57.23 – Lesion of femoral nerve, bilateral lower limbsG80.9 – Cerebral palsy, unspecifiedG81.91 – G81.94 – Hemiplegia, unspecified (right dominant side to left nondominant side)G82.20 – G82.22 – Paraplegia, unspecified (to incomplete paraplegia)M05.061 – Felty's syndrome, right kneeM05.062 – Felty's syndrome, left kneeM05.261 – Rheumatoid vasculitis with rheumatoid arthritis of right kneeM05.262 – Rheumatoid vasculitis with rheumatoid arthritis of left kneeM05.361 – Rheumatoid heart disease with rheumatoid arthritis of right kneeM05.362 – Rheumatoid heart disease with rheumatoid arthritis of left kneeM05.561 – Rheumatoid polyneuropathy with rheumatoid arthritis of right kneeM05.562 – Rheumatoid polyneuropathy with rheumatoid arthritis of left kneeM17.0 – Bilateral primary osteoarthritis of kneeM17.11 – Unilateral primary osteoarthritis, right kneeM17.12 – Unilateral primary osteoarthritis, left kneeS72.001A – S72.002S – Fracture of unspecified part of neck of femur (right initial to left sequela)S72.101A – S72.102S – Unspecified trochanteric fracture of femur (right initial to left sequela)S82.011A – S82.012S – Displaced osteochondral fracture of patella (right initial to left sequela)S82.014A – S82.015S – Nondisplaced osteochondral fracture of patella (right initial to left sequela)S83.011A – S83.012S – Lateral subluxation of patella (right initial to left sequela)S83.014A – S83.015S – Lateral dislocation of patella (right initial to left sequela)M80.051A – M80.052S – Age-related osteoporosis with pathological fracture (right femur initial to left sequela)M80.861A – M80.862S – Other osteoporosis with pathological fracture (right lower leg initial to left sequela)M84.351A – M84.352S – Stress fracture (right femur initial to left sequela)Q68.2 – Congenital deformity of kneeQ68.6 – Discoid meniscusQ74.1 – Congenital malformation of kneeT84.012A – T84.013S – Broken internal knee prosthesis (right initial to left sequela)T84.022A – T84.023S – Instability of internal knee prosthesis (right initial to left sequela)T84.062A – T84.063S – Wear of articular bearing surface of prosthetic knee joint (right initial to left sequela)Z96.651 – Z96.653 – Presence of artificial knee joint (right, left, or bilateral)M25.571 – Pain in right ankle and joints of right footM25.572 – Pain in left ankle and joints of left footM19.071 – Primary osteoarthritis, right ankle and footM19.072 – Primary osteoarthritis, left ankle and footS93.401A – Sprain of unspecified ligament of right ankle, initial encounterS93.402A – Sprain of unspecified ligament of left ankle, initial encounterM24.871 – Ligamentous laxity, right ankleM24.872 – Ligamentous laxity, left ankleM25.371 – Instability, right ankleM25.372 – Instability, left ankleS93.411A – Sprain of calcaneofibular ligament of right ankle, initial encounterS93.412A – Sprain of calcaneofibular ligament of left ankle, initial encounterM25.531 – Pain in right wristM25.532 – Pain in left wristM19.031 – Primary osteoarthritis, right wristM19.032 – Primary osteoarthritis, left wristS63.501A – Unspecified sprain of right wrist, initial encounterS63.502A – Unspecified sprain of left wrist, initial encounterM24.531: Ankylosis of right wristM24.532: Ankylosis of left wristM65.4: Radial styloid tenosynovitis [de Quervain]M70.831: Other soft tissue disorders related to use, overuse, and pressure, right wristM70.832: Other soft tissue disorders related to use, overuse, and pressure, left wristM77.41: Radial styloid tenosynovitis, right wristM77.42: Radial styloid tenosynovitis, left wristM24.831: Other specific joint derangements of right wrist, not elsewhere classifiedM24.832: Other specific joint derangements of left wrist, not elsewhere classifiedM67.431: Ganglion, right wristM67.432: Ganglion, left wristM18.11: Osteoarthritis of first carpometacarpal joint, right handM18.12: Osteoarthritis of first carpometacarpal joint, left handM25.831: Other instability, right wristM25.832: Other instability, left wristM24.431: Recurrent dislocation, right wristM24.432: Recurrent dislocation, left wristOtherSelect DiagnosisM50.10 – Cervical disc disorder with radiculopathy, unspecified cervical regionM50.20 – Other cervical disc displacement, unspecified cervical regionM53.82 – Other specified dorsopathies, cervical regionM54.2 – CervicalgiaM54.6 – Pain in thoracic spineS22.0XXA – Fracture of thoracic vertebra, initial encounterM51.26 – Other intervertebral disc displacement, lumbar regionM51.27 – Other intervertebral disc displacement, lumbosacral regionM51.36 – Other intervertebral disc degeneration, lumbar regionM51.37 – Other intervertebral disc degeneration, lumbosacral regionM54.5 – Low back painM54.89 – Other dorsalgiaS32.0XXA – Fracture of lumbar vertebra, initial encounterS32.2XXA – Fracture of sacrum, initial encounterM40.20 – Unspecified kyphosis, site unspecifiedM40.25 – Unspecified kyphosis, thoracolumbar regionM41.00 – Unspecified scoliosis, site unspecifiedM41.05 – Unspecified scoliosis, thoracolumbar regionM41.20 – Other idiopathic scoliosis, site unspecifiedM41.25 – Other idiopathic scoliosis, thoracolumbar regionM41.30 – Thoracogenic scoliosis, site unspecifiedM41.35 – Thoracogenic scoliosis, thoracolumbar regionM41.40 – Neuromuscular scoliosis, site unspecifiedM41.45 – Neuromuscular scoliosis, thoracolumbar regionM41.50 – Other secondary scoliosis, site unspecifiedM41.55 – Other secondary scoliosis, thoracolumbar regionM41.80 – Other forms of scoliosis, site unspecifiedM41.85 – Other forms of scoliosis, thoracolumbar regionM41.9 – Scoliosis, unspecifiedM43.00 – Spondylolysis, site unspecifiedM43.05 – Spondylolysis, thoracolumbar regionM43.10 – Spondylolisthesis, site unspecifiedM43.15 – Spondylolisthesis, thoracolumbar regionM43.20 – Fusion of spine, site unspecifiedM43.25 – Fusion of spine, thoracolumbar regionM43.6 – TorticollisM43.8X9 – Other specified deformities of spine, site unspecifiedM48.00 – Spinal stenosis, site unspecifiedM48.05 – Spinal stenosis, thoracolumbar regionM51.9 – Intervertebral disc disorder, unspecifiedQ76.2 – Congenital spondylolisthesisQ76.4 – Other congenital malformations of spine, not associated with scoliosisM96.1 – Postlaminectomy syndrome, not elsewhere classifiedM96.6 – Fracture of vertebrae following insertion of orthopedic implant, joint prosthesis, or bone plateS12.0XXA – Fracture of first cervical vertebra, initial encounterS22.0XXA – Fracture of thoracic vertebra, initial encounterS32.0XXA – Fracture of lumbar vertebra, initial encounterS32.2XXA – Fracture of sacrum, initial encounterG04.1 – Tropical spastic paraplegiaG35 – Multiple sclerosisG57.01 – Lesion of sciatic nerve, right lower limbG57.02 – Lesion of sciatic nerve, left lower limbG57.03 – Lesion of sciatic nerve, bilateral lower limbsG57.21 – Lesion of femoral nerve, right lower limbG57.22 – Lesion of femoral nerve, left lower limbG57.23 – Lesion of femoral nerve, bilateral lower limbsG80.9 – Cerebral palsy, unspecifiedG81.91 – G81.94 – Hemiplegia, unspecified (right dominant side to left nondominant side)G82.20 – G82.22 – Paraplegia, unspecified (to incomplete paraplegia)M05.061 – Felty's syndrome, right kneeM05.062 – Felty's syndrome, left kneeM05.261 – Rheumatoid vasculitis with rheumatoid arthritis of right kneeM05.262 – Rheumatoid vasculitis with rheumatoid arthritis of left kneeM05.361 – Rheumatoid heart disease with rheumatoid arthritis of right kneeM05.362 – Rheumatoid heart disease with rheumatoid arthritis of left kneeM05.561 – Rheumatoid polyneuropathy with rheumatoid arthritis of right kneeM05.562 – Rheumatoid polyneuropathy with rheumatoid arthritis of left kneeM17.0 – Bilateral primary osteoarthritis of kneeM17.11 – Unilateral primary osteoarthritis, right kneeM17.12 – Unilateral primary osteoarthritis, left kneeS72.001A – S72.002S – Fracture of unspecified part of neck of femur (right initial to left sequela)S72.101A – S72.102S – Unspecified trochanteric fracture of femur (right initial to left sequela)S82.011A – S82.012S – Displaced osteochondral fracture of patella (right initial to left sequela)S82.014A – S82.015S – Nondisplaced osteochondral fracture of patella (right initial to left sequela)S83.011A – S83.012S – Lateral subluxation of patella (right initial to left sequela)S83.014A – S83.015S – Lateral dislocation of patella (right initial to left sequela)M80.051A – M80.052S – Age-related osteoporosis with pathological fracture (right femur initial to left sequela)M80.861A – M80.862S – Other osteoporosis with pathological fracture (right lower leg initial to left sequela)M84.351A – M84.352S – Stress fracture (right femur initial to left sequela)Q68.2 – Congenital deformity of kneeQ68.6 – Discoid meniscusQ74.1 – Congenital malformation of kneeT84.012A – T84.013S – Broken internal knee prosthesis (right initial to left sequela)T84.022A – T84.023S – Instability of internal knee prosthesis (right initial to left sequela)T84.062A – T84.063S – Wear of articular bearing surface of prosthetic knee joint (right initial to left sequela)Z96.651 – Z96.653 – Presence of artificial knee joint (right, left, or bilateral)M25.571 – Pain in right ankle and joints of right footM25.572 – Pain in left ankle and joints of left footM19.071 – Primary osteoarthritis, right ankle and footM19.072 – Primary osteoarthritis, left ankle and footS93.401A – Sprain of unspecified ligament of right ankle, initial encounterS93.402A – Sprain of unspecified ligament of left ankle, initial encounterM24.871 – Ligamentous laxity, right ankleM24.872 – Ligamentous laxity, left ankleM25.371 – Instability, right ankleM25.372 – Instability, left ankleS93.411A – Sprain of calcaneofibular ligament of right ankle, initial encounterS93.412A – Sprain of calcaneofibular ligament of left ankle, initial encounterM25.531 – Pain in right wristM25.532 – Pain in left wristM19.031 – Primary osteoarthritis, right wristM19.032 – Primary osteoarthritis, left wristS63.501A – Unspecified sprain of right wrist, initial encounterS63.502A – Unspecified sprain of left wrist, initial encounterM24.531: Ankylosis of right wristM24.532: Ankylosis of left wristM65.4: Radial styloid tenosynovitis [de Quervain]M70.831: Other soft tissue disorders related to use, overuse, and pressure, right wristM70.832: Other soft tissue disorders related to use, overuse, and pressure, left wristM77.41: Radial styloid tenosynovitis, right wristM77.42: Radial styloid tenosynovitis, left wristM24.831: Other specific joint derangements of right wrist, not elsewhere classifiedM24.832: Other specific joint derangements of left wrist, not elsewhere classifiedM67.431: Ganglion, right wristM67.432: Ganglion, left wristM18.11: Osteoarthritis of first carpometacarpal joint, right handM18.12: Osteoarthritis of first carpometacarpal joint, left handM25.831: Other instability, right wristM25.832: Other instability, left wristM24.431: Recurrent dislocation, right wristM24.432: Recurrent dislocation, left wristOtherSelect DiagnosisM50.10 – Cervical disc disorder with radiculopathy, unspecified cervical regionM50.20 – Other cervical disc displacement, unspecified cervical regionM53.82 – Other specified dorsopathies, cervical regionM54.2 – CervicalgiaM54.6 – Pain in thoracic spineS22.0XXA – Fracture of thoracic vertebra, initial encounterM51.26 – Other intervertebral disc displacement, lumbar regionM51.27 – Other intervertebral disc displacement, lumbosacral regionM51.36 – Other intervertebral disc degeneration, lumbar regionM51.37 – Other intervertebral disc degeneration, lumbosacral regionM54.5 – Low back painM54.89 – Other dorsalgiaS32.0XXA – Fracture of lumbar vertebra, initial encounterS32.2XXA – Fracture of sacrum, initial encounterM40.20 – Unspecified kyphosis, site unspecifiedM40.25 – Unspecified kyphosis, thoracolumbar regionM41.00 – Unspecified scoliosis, site unspecifiedM41.05 – Unspecified scoliosis, thoracolumbar regionM41.20 – Other idiopathic scoliosis, site unspecifiedM41.25 – Other idiopathic scoliosis, thoracolumbar regionM41.30 – Thoracogenic scoliosis, site unspecifiedM41.35 – Thoracogenic scoliosis, thoracolumbar regionM41.40 – Neuromuscular scoliosis, site unspecifiedM41.45 – Neuromuscular scoliosis, thoracolumbar regionM41.50 – Other secondary scoliosis, site unspecifiedM41.55 – Other secondary scoliosis, thoracolumbar regionM41.80 – Other forms of scoliosis, site unspecifiedM41.85 – Other forms of scoliosis, thoracolumbar regionM41.9 – Scoliosis, unspecifiedM43.00 – Spondylolysis, site unspecifiedM43.05 – Spondylolysis, thoracolumbar regionM43.10 – Spondylolisthesis, site unspecifiedM43.15 – Spondylolisthesis, thoracolumbar regionM43.20 – Fusion of spine, site unspecifiedM43.25 – Fusion of spine, thoracolumbar regionM43.6 – TorticollisM43.8X9 – Other specified deformities of spine, site unspecifiedM48.00 – Spinal stenosis, site unspecifiedM48.05 – Spinal stenosis, thoracolumbar regionM51.9 – Intervertebral disc disorder, unspecifiedQ76.2 – Congenital spondylolisthesisQ76.4 – Other congenital malformations of spine, not associated with scoliosisM96.1 – Postlaminectomy syndrome, not elsewhere classifiedM96.6 – Fracture of vertebrae following insertion of orthopedic implant, joint prosthesis, or bone plateS12.0XXA – Fracture of first cervical vertebra, initial encounterS22.0XXA – Fracture of thoracic vertebra, initial encounterS32.0XXA – Fracture of lumbar vertebra, initial encounterS32.2XXA – Fracture of sacrum, initial encounterG04.1 – Tropical spastic paraplegiaG35 – Multiple sclerosisG57.01 – Lesion of sciatic nerve, right lower limbG57.02 – Lesion of sciatic nerve, left lower limbG57.03 – Lesion of sciatic nerve, bilateral lower limbsG57.21 – Lesion of femoral nerve, right lower limbG57.22 – Lesion of femoral nerve, left lower limbG57.23 – Lesion of femoral nerve, bilateral lower limbsG80.9 – Cerebral palsy, unspecifiedG81.91 – G81.94 – Hemiplegia, unspecified (right dominant side to left nondominant side)G82.20 – G82.22 – Paraplegia, unspecified (to incomplete paraplegia)M05.061 – Felty's syndrome, right kneeM05.062 – Felty's syndrome, left kneeM05.261 – Rheumatoid vasculitis with rheumatoid arthritis of right kneeM05.262 – Rheumatoid vasculitis with rheumatoid arthritis of left kneeM05.361 – Rheumatoid heart disease with rheumatoid arthritis of right kneeM05.362 – Rheumatoid heart disease with rheumatoid arthritis of left kneeM05.561 – Rheumatoid polyneuropathy with rheumatoid arthritis of right kneeM05.562 – Rheumatoid polyneuropathy with rheumatoid arthritis of left kneeM17.0 – Bilateral primary osteoarthritis of kneeM17.11 – Unilateral primary osteoarthritis, right kneeM17.12 – Unilateral primary osteoarthritis, left kneeS72.001A – S72.002S – Fracture of unspecified part of neck of femur (right initial to left sequela)S72.101A – S72.102S – Unspecified trochanteric fracture of femur (right initial to left sequela)S82.011A – S82.012S – Displaced osteochondral fracture of patella (right initial to left sequela)S82.014A – S82.015S – Nondisplaced osteochondral fracture of patella (right initial to left sequela)S83.011A – S83.012S – Lateral subluxation of patella (right initial to left sequela)S83.014A – S83.015S – Lateral dislocation of patella (right initial to left sequela)M80.051A – M80.052S – Age-related osteoporosis with pathological fracture (right femur initial to left sequela)M80.861A – M80.862S – Other osteoporosis with pathological fracture (right lower leg initial to left sequela)M84.351A – M84.352S – Stress fracture (right femur initial to left sequela)Q68.2 – Congenital deformity of kneeQ68.6 – Discoid meniscusQ74.1 – Congenital malformation of kneeT84.012A – T84.013S – Broken internal knee prosthesis (right initial to left sequela)T84.022A – T84.023S – Instability of internal knee prosthesis (right initial to left sequela)T84.062A – T84.063S – Wear of articular bearing surface of prosthetic knee joint (right initial to left sequela)Z96.651 – Z96.653 – Presence of artificial knee joint (right, left, or bilateral)M25.571 – Pain in right ankle and joints of right footM25.572 – Pain in left ankle and joints of left footM19.071 – Primary osteoarthritis, right ankle and footM19.072 – Primary osteoarthritis, left ankle and footS93.401A – Sprain of unspecified ligament of right ankle, initial encounterS93.402A – Sprain of unspecified ligament of left ankle, initial encounterM24.871 – Ligamentous laxity, right ankleM24.872 – Ligamentous laxity, left ankleM25.371 – Instability, right ankleM25.372 – Instability, left ankleS93.411A – Sprain of calcaneofibular ligament of right ankle, initial encounterS93.412A – Sprain of calcaneofibular ligament of left ankle, initial encounterM25.531 – Pain in right wristM25.532 – Pain in left wristM19.031 – Primary osteoarthritis, right wristM19.032 – Primary osteoarthritis, left wristS63.501A – Unspecified sprain of right wrist, initial encounterS63.502A – Unspecified sprain of left wrist, initial encounterChoice 110M24.531: Ankylosis of right wristM24.532: Ankylosis of left wristM65.4: Radial styloid tenosynovitis [de Quervain]M70.831: Other soft tissue disorders related to use, overuse, and pressure, right wristM70.832: Other soft tissue disorders related to use, overuse, and pressure, left wristM77.41: Radial styloid tenosynovitis, right wristM77.42: Radial styloid tenosynovitis, left wristM24.831: Other specific joint derangements of right wrist, not elsewhere classifiedM24.832: Other specific joint derangements of left wrist, not elsewhere classifiedM67.431: Ganglion, right wristM67.432: Ganglion, left wristM18.11: Osteoarthritis of first carpometacarpal joint, right handM18.12: Osteoarthritis of first carpometacarpal joint, left handM25.831: Other instability, right wristM25.832: Other instability, left wristM24.431: Recurrent dislocation, right wristM24.432: Recurrent dislocation, left wristOtherQtyNoteDiagnosis 1- Other:Diagnosis 2 – Other:Diagnosis 3 – Other:Diagnosis 4 – Other:Brace TypeSelect Brace TypeBack BraceKnee BraceSelect Brace TypeBack BraceKnee BraceSelect Brace TypeBack BraceKnee BraceQualificationsSelect QualificationBB – Reduced Mobility – Difficulty bending, twisting, or lifting due to spinal instability or pain.BB – Poor Posture – Inability to maintain an upright posture due to muscular weakness or spinal misalignment.BB – Chronic Pain – Limited movement caused by lower back pain, sciatica, or herniated discs.BB – Weak Core Muscles – Decreased ability to support the spine during physical activity.BB – Spinal Instability – Functional issues caused by scoliosis, spondylolisthesis, or vertebral fractures.BB – Post-Surgical Recovery – Restricted mobility following spine-related surgeries.BB – Muscle Strain or Injury – Reduced activity due to strained or weak back muscles.KB – Joint Instability – Difficulty walking or standing due to ligament injuries (e.g., ACL, MCL tears).KB – Limited Range of Motion – Inability to fully bend or extend the knee following injury or surgery.KB – Pain While Weight-Bearing – Discomfort or pain when putting weight on the knee during activities like walking, running, or climbing stairs.KB – Weakness or Atrophy – Muscle weakness around the knee causing reduced stability or mobility.KB – Swelling and Inflammation – Restricted movement caused by arthritis, bursitis, or other inflammatory conditions.KB – Post-Surgical Recovery – Limited ability to perform daily activities during recovery from knee surgeries (e.g., meniscus repair, ligament reconstruction).KB – Alignment Issues – Difficulty maintaining proper knee alignment due to patellar instability or bowlegs.Select QualificationBB – Reduced Mobility – Difficulty bending, twisting, or lifting due to spinal instability or pain.BB – Poor Posture – Inability to maintain an upright posture due to muscular weakness or spinal misalignment.BB – Chronic Pain – Limited movement caused by lower back pain, sciatica, or herniated discs.BB – Weak Core Muscles – Decreased ability to support the spine during physical activity.BB – Spinal Instability – Functional issues caused by scoliosis, spondylolisthesis, or vertebral fractures.BB – Post-Surgical Recovery – Restricted mobility following spine-related surgeries.BB – Muscle Strain or Injury – Reduced activity due to strained or weak back muscles.KB – Joint Instability – Difficulty walking or standing due to ligament injuries (e.g., ACL, MCL tears).KB – Limited Range of Motion – Inability to fully bend or extend the knee following injury or surgery.KB – Pain While Weight-Bearing – Discomfort or pain when putting weight on the knee during activities like walking, running, or climbing stairs.KB – Weakness or Atrophy – Muscle weakness around the knee causing reduced stability or mobility.KB – Swelling and Inflammation – Restricted movement caused by arthritis, bursitis, or other inflammatory conditions.KB – Post-Surgical Recovery – Limited ability to perform daily activities during recovery from knee surgeries (e.g., meniscus repair, ligament reconstruction).KB – Alignment Issues – Difficulty maintaining proper knee alignment due to patellar instability or bowlegs.Select QualificationBB – Reduced Mobility – Difficulty bending, twisting, or lifting due to spinal instability or pain.BB – Poor Posture – Inability to maintain an upright posture due to muscular weakness or spinal misalignment.BB – Chronic Pain – Limited movement caused by lower back pain, sciatica, or herniated discs.BB – Weak Core Muscles – Decreased ability to support the spine during physical activity.BB – Spinal Instability – Functional issues caused by scoliosis, spondylolisthesis, or vertebral fractures.BB – Post-Surgical Recovery – Restricted mobility following spine-related surgeries.BB – Muscle Strain or Injury – Reduced activity due to strained or weak back muscles.KB – Joint Instability – Difficulty walking or standing due to ligament injuries (e.g., ACL, MCL tears).KB – Limited Range of Motion – Inability to fully bend or extend the knee following injury or surgery.KB – Pain While Weight-Bearing – Discomfort or pain when putting weight on the knee during activities like walking, running, or climbing stairs.KB – Weakness or Atrophy – Muscle weakness around the knee causing reduced stability or mobility.KB – Swelling and Inflammation – Restricted movement caused by arthritis, bursitis, or other inflammatory conditions.KB – Post-Surgical Recovery – Limited ability to perform daily activities during recovery from knee surgeries (e.g., meniscus repair, ligament reconstruction).KB – Alignment Issues – Difficulty maintaining proper knee alignment due to patellar instability or bowlegs.Face-to-Face EncounterYesNoYesNoYesNoFor CathetersDiagnosisSelect DiagnosisN39.0 Urinary tract infection, site unspecifiedN31.9 Neuromuscular dysfunction of bladder, unspecifiedR33.9 Retention of urine, unspecifiedN13.9 Obstructive and reflux uropathy, unspecifiedOtherDiagnosis- OtherSelect DiagnosisN39.0 Urinary tract infection, site unspecifiedN31.9 Neuromuscular dysfunction of bladder, unspecifiedR33.9 Retention of urine, unspecifiedN13.9 Obstructive and reflux uropathy, unspecifiedOtherDiagnosis- OtherSelect DiagnosisN39.0 Urinary tract infection, site unspecifiedN31.9 Neuromuscular dysfunction of bladder, unspecifiedR33.9 Retention of urine, unspecifiedN13.9 Obstructive and reflux uropathy, unspecifiedOtherDiagnosis- OtherDoes Patient Have Permanent Urinary Incontinence or Retention?Yes or NoYesNoDo any of the following conditions apply?Select ConditionTwo UTIs/12 monthsImmunosuppressedBPHStrictureSpina BifidaParaplegiaQuadriplegiaCatheter SuppliesSelect Catheter SupplyA4314 : Foley catheter tray, 2-way latex, 10 cc balloonA4316 : Foley catheter tray, 2-way siliconeA4351 : Intermittent urinary catheter, straight tipA4352 : Intermittent urinary catheter, coude tipA4353 : Intermittent urinary catheter, closed systemA4349 : Male external catheter, adhesive or non-adhesiveA4354 : Urinary leg bag, vinyl, with/without tubeA4357 : Bedside drainage bag, with/without anti-refluxA5200 : Catheter anchoring device or leg strapSelect Catheter SupplyA4314 : Foley catheter tray, 2-way latex, 10 cc balloonA4316 : Foley catheter tray, 2-way siliconeA4351 : Intermittent urinary catheter, straight tipA4352 : Intermittent urinary catheter, coude tipA4353 : Intermittent urinary catheter, closed systemA4349 : Male external catheter, adhesive or non-adhesiveA4354 : Urinary leg bag, vinyl, with/without tubeA4357 : Bedside drainage bag, with/without anti-refluxA5200 : Catheter anchoring device or leg strapSelect Catheter SupplyA4314 : Foley catheter tray, 2-way latex, 10 cc balloonA4316 : Foley catheter tray, 2-way siliconeA4351 : Intermittent urinary catheter, straight tipA4352 : Intermittent urinary catheter, coude tipA4353 : Intermittent urinary catheter, closed systemA4349 : Male external catheter, adhesive or non-adhesiveA4354 : Urinary leg bag, vinyl, with/without tubeA4357 : Bedside drainage bag, with/without anti-refluxA5200 : Catheter anchoring device or leg strapQTYFrequencyFor Wound Care SuppliesDIAGNOSISSelect DiagnosisL89.309: Pressure ulcer, unspecified buttock, stage unspecifiedL89.899: Pressure ulcer, other site, stage unspecifiedL97.909: Non-pressure chronic ulcer, unspecified lower legL98.499: Non-pressure chronic ulcer, other skin siteE11.621: Type 2 diabetes mellitus with foot ulcerE11.622: Type 2 diabetes mellitus with other skin ulcerI83.009: Varicose veins with ulcer, unspecified lower extremityI70.235: Atherosclerosis, right leg with ulcer, footT81.30XA: Disruption of wound, unspecified, initial encounterT87.40XA: Infection of amputation stump, unspecified extremityOtherSelect DiagnosisL89.309: Pressure ulcer, unspecified buttock, stage unspecifiedL89.899: Pressure ulcer, other site, stage unspecifiedL97.909: Non-pressure chronic ulcer, unspecified lower legL98.499: Non-pressure chronic ulcer, other skin siteE11.621: Type 2 diabetes mellitus with foot ulcerE11.622: Type 2 diabetes mellitus with other skin ulcerI83.009: Varicose veins with ulcer, unspecified lower extremityI70.235: Atherosclerosis, right leg with ulcer, footT81.30XA: Disruption of wound, unspecified, initial encounterT87.40XA: Infection of amputation stump, unspecified extremityOtherSelect DiagnosisL89.309: Pressure ulcer, unspecified buttock, stage unspecifiedL89.899: Pressure ulcer, other site, stage unspecifiedL97.909: Non-pressure chronic ulcer, unspecified lower legL98.499: Non-pressure chronic ulcer, other skin siteE11.621: Type 2 diabetes mellitus with foot ulcerE11.622: Type 2 diabetes mellitus with other skin ulcerI83.009: Varicose veins with ulcer, unspecified lower extremityI70.235: Atherosclerosis, right leg with ulcer, footT81.30XA: Disruption of wound, unspecified, initial encounterT87.40XA: Infection of amputation stump, unspecified extremityOtherSelect DiagnosisL89.309: Pressure ulcer, unspecified buttock, stage unspecifiedL89.899: Pressure ulcer, other site, stage unspecifiedL97.909: Non-pressure chronic ulcer, unspecified lower legL98.499: Non-pressure chronic ulcer, other skin siteE11.621: Type 2 diabetes mellitus with foot ulcerE11.622: Type 2 diabetes mellitus with other skin ulcerI83.009: Varicose veins with ulcer, unspecified lower extremityI70.235: Atherosclerosis, right leg with ulcer, footT81.30XA: Disruption of wound, unspecified, initial encounterT87.40XA: Infection of amputation stump, unspecified extremityOtherSTAGESelect Wound StageSores have not yet broken skinSores break in top 2 layers of skinSores affect top 2 layers of skinSores deep into muscle and boneSelect Wound StageSores have not yet broken skinSores break in top 2 layers of skinSores affect top 2 layers of skinSores deep into muscle and boneSelect Wound StageSores have not yet broken skinSores break in top 2 layers of skinSores affect top 2 layers of skinSores deep into muscle and boneSelect Wound StageSores have not yet broken skinSores break in top 2 layers of skinSores affect top 2 layers of skinSores deep into muscle and boneWOUND EXUDATESelect Wound ExudateNoneLowModHVYSelect Wound ExudateNoneLowModHVYSelect Wound ExudateNoneLowModHVYSelect Wound ExudateNoneLowModHVYWOUND LOCATIONDIAGNOSIS – OtherDIAGNOSIS – OtherDIAGNOSIS – OtherDIAGNOSIS – OtherWound Care SuppliesSelect Wound SupplyA4450 : Tape, non-waterproof, per 18 square inchesA4452 : Tape, waterproof, per 18 square inchesA6209 : Foam dressing, sterile, ≤16 sq. in., without adhesiveA6212 : Foam dressing, sterile, ≤16 sq. in., with adhesiveA6213 : Foam dressing, sterile, >16 and ≤48 sq. in., with adhesiveA6214 : Foam dressing, sterile, >48 sq. in., with adhesiveA6216 : Contact layer dressing, sterile, ≤16 sq. inA6220 : Gauze dressing, impregnated, sterile, ≤16 sq. in.A6235 : Hydrocolloid dressing, sterile, >48 sq. in., with adhesiveA6250 : Specialty absorptive dressing, sterile, per ounceSelect Wound SupplyA4450 : Tape, non-waterproof, per 18 square inchesA4452 : Tape, waterproof, per 18 square inchesA6209 : Foam dressing, sterile, ≤16 sq. in., without adhesiveA6212 : Foam dressing, sterile, ≤16 sq. in., with adhesiveA6213 : Foam dressing, sterile, >16 and ≤48 sq. in., with adhesiveA6214 : Foam dressing, sterile, >48 sq. in., with adhesiveA6216 : Contact layer dressing, sterile, ≤16 sq. inA6220 : Gauze dressing, impregnated, sterile, ≤16 sq. in.A6235 : Hydrocolloid dressing, sterile, >48 sq. in., with adhesiveA6250 : Specialty absorptive dressing, sterile, per ounceSelect Wound SupplyA4450 : Tape, non-waterproof, per 18 square inchesA4452 : Tape, waterproof, per 18 square inchesA6209 : Foam dressing, sterile, ≤16 sq. in., without adhesiveA6212 : Foam dressing, sterile, ≤16 sq. in., with adhesiveA6213 : Foam dressing, sterile, >16 and ≤48 sq. in., with adhesiveA6214 : Foam dressing, sterile, >48 sq. in., with adhesiveA6216 : Contact layer dressing, sterile, ≤16 sq. inA6220 : Gauze dressing, impregnated, sterile, ≤16 sq. in.A6235 : Hydrocolloid dressing, sterile, >48 sq. in., with adhesiveA6250 : Specialty absorptive dressing, sterile, per ounceQTYNotesOrder ID: Order Date: I certify that the medical necessity information provided is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in the form may subject me to civil or criminal liability.Signature: Clear Signature NPI: Date:PreviousNextADDITIONAL DOCUMENTATION Phone: EXUDATE Relevant Medical Records:PreviousNextUpdating preview…This is a preview of your 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It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.Agreement *I confirm that the information provided is accurate to the best of my knowledge.PreviousSubmit
