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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