Critical Care Pharmacy - A Specialty Compounding Pharmacy



1143001968500Check list for Proper identification and ordering of LSO BracesThe patient needs an approved medical necessity. The letter of medical necessity lists three approved conditions, one of these three should be selected. The diagnosis code selected should support the medical necessity.The brace must be ordered pre-op and not related to any inpatient care or rehabilitation. Any braces ordered post op or while the patient is hospitalized or in a skilled facility will be covered by the global DRG and NOT paid for by insurance.With each referral a copy of the patient’s medical record supporting the diagnosis and medical necessity is required. We do not need the whole record just the supporting documentation for the brace.The letter of necessity can be filled out by office staff but must be signed and dated by physician. If the patient has had a brace within the previous 5 years it will not be covered. We will check insurance prior to filling order but asking the patient upfront would be helpful.The brace can be delivered to the office or patient’s home. Please indicate your preference. The local representative for the brace company will provide staff training and support but actual fitting of the brace will be done by office staff. Under these circumstances it may be easier to deliver the brace directly to the office but we will deliver to whatever location the MD’s office directs. A delivery ticket signed and dated by the patient will be required to bill.The letter of necessity includes a place for patient name, demographics and insurance but if it is easier a face sheet can be sent with the signed order. It is important to include insurance information so we do not have to bother the office for follow up details.2019300-1612900024928844527550025146006858002247900554990Chart Checklist for Brace/Bone StimPatient Name_________________________ Date of Referral_______________________Dr._______________________________________ Patient Demographic, insurance and office visit notes justifying brace______ Insurance verified Medicare yes___ no___ At this time confirm patient qualifies for Brace based on Medicare guidelines Private Insurance yes____ no____ _____ Approval or denial sent to Dr’s office _____CMN prepared by Critical Care justifying brace medical necessity based on office notes_____CMN faxed to Dr’s office for signature and date_____Doctor’s office schedules brace fitting and brace is delivered to Dr’s office or home set up scheduled by rep._____Delivery ticket signed and dated by patient upon fitting. Ticket forwarded to Critical Care._____Insurance billedPlease include status and notes next to each checklist item as needed.__PHYSICIAN’S ORDER/LETTER OF MEDICAL NECESSITY FOR BRACES__Patient Name:________________________________DOB:______________________Patient Address:_______________________________________________________________Phone:_____________________________Alternate Phone:______________________Height:_______________________Weight:_____________________Waist:_________Length of need:________99 mths _______otherInsurance:____________________________ID#______________________________Secondary Insurance:_____________________________ID#_____________________Physician Name:_________________________________________NPI_____________________Physician Signature:________________________________________Date:__________I certify that the item prescribed is medically necessary for the treatment of this patient for the below diagnosis.HORIZON 637 LSOVISTA 464 TLSOHORIZON 456 TLSOPEAK ADULT SCOLIOSIS L1005VISTA MULTIPOST COLLAR L0180VISTA CTO L0200VISTA 637 LSOOther treatment Methods used: ___Physical Therapy __Injections __Prescribed Medication ___Hot/Cold Pack ___OtherDiagnosis:KYPHOSIS M40.209SPINAL STENOSIS M48.06LUMBAGO M54.5SCOLIOSIS M41.20CERVICAL DISK DISORDER M50.00OSTEOPOROSIS M81.0SCOLIOSIS CERVICAL M41.22CERVICAL DISK DISPLACEMENT M50.20DEGENERATIVE DISK DISEASE___ M51.36 LUMBAR REGION___ M51.37 LUMBOSACRAL REGIONADULT SCOLIOSIS THORACIC M41.24CERVICAL DISK DEGENERATION M50.30ARTHRITIS OF SPINE M47.819DISK HERNIATION M51.9OTHER DX/ICD 10:CONDITIONS THAT APPLY-MUST BE INDICATEDTo reduce pain by restricting mobility of the trunkTo facilitate healing following an injury to the spine or related soft tissuesTo facilitate healing following a surgical procedure on the spine or related soft tissueTo otherwise support weak spinal muscles and/or a deformed spinePLEASE FAX TO 630-530-029522885408318500 Delivery Verification Acknowledgement Customer Name: ______________________________________________________________ Address: _____________________________________________________________________ City________________________________ State ___________________Zip: ______________ Telephone:________________________ I, the undersigned, have been fully instructed in the use and operation of the following equipment: Description: Make Serial #: (If Provided): ____________________ ____________________ _____________________ ____________________ ____________________ ____________________I acknowledge acceptance of this equipment in good working order, operating properly and adjusted appropriately for my use. I also acknowledge receipt of product instructions, and warranty information. Signature: _______________________________________ Date: _____________________Relationship to Patient: ____________________________________________________________ ................
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