Detailed Written Order Form: Dds Oa Kneetrac Brace Hcpcs L1852
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1Detailed Written Order: DDS OA KneeTrac Brace HCPCS L1852
Patient Name:
______________________________DOB ____/_____/__________
Address:____________________________________ Phone: ___________________
City: _______________________________________ State:___________Zip:_______
DDS OA KNEETRAC BRACE L1852 (KX Modifier)
x
Left Knee(LT Modifier)
Size ________ Length of Need ________ Substitutions No
Yes
Right Knee (RT Modifier) Size________ Order Date___________ Start Date____________
DIAGNOSIS
ASSESSMENT
The patient is responding to treatment:
M17.0: Bilateral Primary Osteoarthritis Knee
M 17.11: Unilateral Primary Osteoarthritis RT
As Expected
M 17.12: Unilateral Primary Osteoarthritis LT
M 23.51: Chronic Instability RT
Slower than Expected
M 23.52: Chronis Instability LT
Faster than Expected
Q 68.2: Congenital Deformity of Knee
M 23.203: Derangement of Medical Meniscus RT
PLAN
M23.204: Derangement of Medical Mensicus LT
Patient is being fitted today for a DDS OA
SUBJECTIVE
Kneetrac Brace L1852
Patient has significant knee pain which interferes with
To facilitate healing following post surgery
daily activities. The patient reports trouble with:
To otherwise support weak knee muscles
and or deformed knee
To improve an unstable knee & joint laxity
Lifting
Stairs
Total Time Spent fitting Brace_____________
Walking
Total Time Spent with Patient_____________
Daily Activities
Other
Knee Brace Sizing Chart
Thigh
Calf
Left
Right
Center of Knee
Size
6” Above
6” Below
OBJECTIVE
Center of Knee
Center of Knee
Knee Range of Motion
7”-15.5”
12”-13”
10”-12”
XS
Flexion___________________
S
13”-14”
15.5”-18.5”
12”-14”
Extension__________________
M
18.5”-21”
14”-15”
14”-16”
Left Lateral Flex______________
Right Lateral Flex____________
L
21”-23.5” 15”-17”
16”-18”
XL
17”-19”
23.5”-26.5”
18”-20”
Tenderness
19”-21”
2XL
26.5”-29.5”
20”-22”
Medial
Positive Anterior/ Posterior Draw test
Patella
Varus Instability
3XL
29.5”-32” 21”-23”
22”-24”
Lateral
Valgus Instability
*If the Kneetrac
is for the left leg then the measurements
TM
Anterior
Posterior
must be taken from the left leg. If the Kneetrac
is for the right
TM
then the measurements must be taken from the right leg.
Physician Signature______________________________
Easy Wrap Accessory(One Size Fits All)
Right Leg (RT Modifier)
HCPCS L2397 (KX Modifier
Left Leg (LT Modifier)
Physician Name Printed___________________________
M17.0
Date:_________NPI:______________
Bilateral Primary Osteoarthritis of Knee
M17.10
Address:_______________________________
Unilateral Primary Osteoarthritis, unspecified knee
Phone:_________________Fax:_____________________
M17.9
Osteoarthritis of knee, unspecified
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