Prescription for TENS Unit

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Prescription for TENS Unit

Date of Order:________________ Patient Demographics: Name: _________________________________________________Sex:_________DOB:_____________________ Address: ________________________________________City:__________________ State:________ Zip:______ Home phone:___________________________________Work phone:___________________________________

Referring Physician Demographics:

Physician Name: _____________________________________________ UPIN:___________________ NPI:________________________

Items Prescribed:

EQUIPMENT ____ E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED

STIMULATION ____ E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR \

MULTIPLE NERVE STIMULATION ____ E0731 FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE

FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC) SUPPLIES ____ A4557 LEAD WIRES, (E.G., APNEA MONITOR), PER PAIR ____ A4595 ELECTRICAL STIMULATOR SUPPLIES, 2 LEAD, PER MONTH, (E.G. TENS, NMES)

Qualifying Diagnoses:

_____ 353.4 Lumbosacral root lesions, not elsewhere classified _____ 720.2 Sacroilitis, not elsewhere classified _____ 721.3 Lumbosacral spondylosis without myelopathy _____ 721.42 Thoracic or lumbar spondylosis with myelopathy ? lumbar region ____ 722.10 Lumbar intervertebral disc without myelopathy _____ 722.52 Lumbosacral intervertebral disc _____ 722.73 Intervertebral disc disorder myelopathy ? lumbar region _____ 722.83 Post laminectomy syndrome ? lumbar region _____ 722.93 Other and unspecified disc disorders, lumbar region _____ 724.02 Spinal stenosis, lumbar region without neurogenic claudication _____ 724.03 Spinal stenosis, lumbar region with neurogenic claudication _____ 724.2 Lumbago _____ 724.3 Sciatica _____ 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified, radicular syndrome of lower

extremities _____ 738.4 Acquired spondylolysthesis _____ 739.3 Non-allopathetic lesions NEC (not elsewhere classified) ? lumbar region _____ 756.11 Spondylosysis, lumbosacral region _____ 756.12 Spondylolisthesis _____ 805.4 Fracture of vertebral column without mention of spinal cord injury, lumbar, closed _____ 806.4 Fracture of vertebral column with mention of spinal cord injury, lumbar, closed _____ 846.0 Sprains and strains of sacroiliac region ? lumbosacral (joint) (ligament) _____ 846.1 Sprains and strains of sacroiliac ligament _____ 847.2 Sprains and strains of other and unspecified parts of back, lumbar _____ 953.2 Injury to nerve roots and spinal plexus, lumbar root ____ Other uses of TENS: acute post-operative pain, chronic pain other than low back pain

Physician Signature:_____________________________________________ Date:_______________

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