Ocular Prosthetics, Inc
Prosthetic Eye Order
From To
Doctor: ___________________________________ Stephen E. Haddad, B.C.O.
Ocular Prosthetics, Inc.
NPI: __________________________ 321 N. Larchmont Blvd., Suite 711
Los Angeles, CA 90004
Address: ___________________________________ T: 323.462.6004 F: 323.462.4939
___________________________________ Date: ____________________
For
Patient: ___________________________________ DOB: ____________________
Procedure Order Diagnosis ICD10 Codes
HCPCS Codes: ____LT/OS ____RT/OD ____OU ____Z44. Encounter for fitting and adjustment
of prosthetic eye. ____.21 right / ____.22 left
____V2623 Custom Ocular Prosthesis
____Z90.01 Acquired absence of eye
____V2624 Polishing Ocular Prosthesis
____Z97.0 Presence of prosthetic eye
____V2625 Enlargement of Ocular Prosthesis
____Q11.1 Anopthalmos
____V2626 Reduction of Ocular Prosthesis
____Q11.2 Microphthalmos
____V2627 Scleral Cover Shell Prosthesis
____ ___.__ Primary DX for loss of eye
____V2628 Fabrication Ocular Conformer
____________________________________
Length of Need: Prosthesis _X_ Lifetime
Polishing ____ Every six months ____ Yearly
Date of Surgery: ____________________ Type of Implant: _______________________
Notes/Comments: _____________________________________________________________________
_______________________________________________________________________________________
Physician Signature: _______________________________ Date: ____________________
PLEASE RETURN THE SIGNED AND DATED ORDER TO OUR BUSINESS OFFICE AND MAINTAIN A COPY IN THE PATIENTS MEDICAL FILE. CMS requires that a copy of this order appear in the records of both the referring provider and the Ocularist and should be available upon request by Medicare.
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