Thermoplastic AFOs Compliance Documentation Packet | Page 9

TADCN170913
Dispensing Chart Notes : Thermoplastic AFO
Patient Name : _______________________________________
HICN : __________________________
Product Information ( Check brand and model , circle base code and addition ( s )):
� Arizona Optima Brace , Standard , Restricted
� AZ CROW Walker ™
R
L
L1970 An articulated molded plastic orthosis with
ankle joints that allow for free motion of the ankle ,
( dorsi-plantar fl exion ), custom molded from a model
of the patient , custom fabricated , includes casting and
cast preparation .
R
L
L2820 Addition to lower extremity orthosis , soft interface
for molded plastic below knee section .
� Arizona Thermoplastic AFO - Articulated , Dorsi-Assist
R
L
L1970 Articulated molded plastic orthosis with ankle joints , custom molded from a model of the patient , includes casting and cast preparation .
R
L
L2210 Addition to lower extremity , dorsi-fl exion assist ( plantarfl exion resist ), each joint .
� Arizona Thermoplastic AFO - Articulated
R
L
L1970 An articulated molded plastic orthosis with ankle joints that allow for free motion of the ankle , ( dorsi-plantar fl exion ), custom molded from a model of the patient , custom fabricated , includes casting and cast preparation .
� Arizona Thermoplastic AFO
R
L
L1960 A molded plastic ankle foot orthosis , posterior solid ankle trim lines , custom molded from a model of the patient , custom fabricated , includes casting and cast preparation
R
L
L4631 A bivalved custom molded plastic orthosis , with
a removable custom arch support , soft interface , and
a rocker bottom walking sole . For patients with Charcot .
� Split Upright AFO
R
L
L1970 An articulated molded plastic orthosis with ankle joints that allow for free motion of the ankle , ( dorsi-plantar fl exion ), custom molded from a model of the patient , custom fabricated , includes casting and cast preparation .
R
L
L2820 Addition to lower extremity orthosis , soft interface for molded plastic below knee section
� Split Upright AFO , Dorsi-Assist
R
L
L1970 An articulated molded plastic orthosis with ankle joints that allow for free motion of the ankle , ( dorsi-plantar fl exion ), custom molded from a model of the patient , custom fabricated , includes casting and cast preparation .
R
L
L2210 Addition to lower extremity , dorsi-flexion assist ( plantarflexion resist ), each joint .
R
L
L2820 Addition to lower extremity orthosis , soft interface for molded plastic below knee section
� Supramallleolar Orthosis
R
L
L1907 Ankle orthosis , supramalleolar , with straps , with or without pads , custom fabricated
S ) A thermoplastic AFO was dispensed and fi t at this visit . Patient is ambulatory . There is pain with range of motion that requires stabilization . Due to the indicated diagnosis ( s ) and related symptoms this device is medically necessary as part of the overall treatment . It is anticipated that the patient will benefi t functionally with the use of this device . The custom device is utilized in an attempt to avoid the need for surgery . O ) Upon gait analysis , the device appeared to be fi tting well and the patient states that the device is comfortable . A ) Good fi t . The patient was able to apply properly and ambulate without distress . The function of this device is to restrict and limit motion and provide stabilization in the ankle joint .
P ) The goals and function of this device were explained in detail to the patient . The patient was shown how to properly apply , wear , and care for the device . It was explained that the device will fi t and function best in a lace- up shoe with a fi rm heel counter and a wide base of support . When the device was dispensed , it was suitable for the patient ’ s condition and not substandard . No guarantees were given . Precautions were reviewed . Written instructions , warranty information and a copy of DMEPOS Supplier Standards were provided . All questions were answered .
Additional Notes : __________________________________________________________________________________________________ Supplier Signature : _______________________________________________________
Dispensing Date : ________________________
Print Supplier Name : ___________________________________________________
The codes contained herein are not the offi cial position or endorsement of any organization or company . They are offered as a suggestion based upon input from previous customers . Each prescribing practitioner should contact his or her local carrier or Medicare offi ce to verify billing codes , regulations and guidelines relevant to their geographic location .
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