Lower Limb Biomechanical Examination Click here for completion instructions.

Patient Name: Chief Complaint: History of problem: Nature of discomfort/pain Location (anatomic) Duration Onset Course Aggravating and/or alleviating factors Treatments and response Left

Stance Evaluation: Angle of gait:→ Base of gait:→ Foot appearance Tibial influence Relaxed calcaneal stance position (RCSP) Neutral calcaneal stance position (NCSP) Non-Weight Bearing Evaluation: Limb length:→ Hip sagittal planeKnee extended Knee flexed Hip transverse planeKnee extended Knee flexed Hip frontal plane Knee sagittal plane Knee recurvatum Ankle sagittal planeKnee extended Knee flexed Subtalar jointInversion Eversion

Right

Normative values:

0⁰-2⁰ varus or valgus 0⁰ 0⁰ Equal Flexion 120⁰/extension 20-30⁰ Flexion 45-60⁰/extension 20-30⁰ 45⁰ each direction 45⁰ each direction 45⁰ each direction Flexion 120⁰/extension 0-10⁰ Absent Dorsiflexion 10⁰/plantarflexion 40-70⁰ Dorsiflexion 10⁰/plantarflexion 40-70⁰ 20⁰ 10⁰

Subtalar joint axis location Midtarsal joint 1st ray range of motion 1st MTPJ range of motion Lesser MTPJ's Other comments: Muscle testing (extrinsics): Invertors Evertors Dorsiflexors Plantarflexors Neurological testing: Romberg→ Patellar reflex Achilles reflex Babinski Clonus Protective sensation Gait Evaluation Gait pattern

0⁰ Dorsal & plantar excursion 5mm Dorsal 65⁰ or >unloaded/20-40⁰ loaded

5/5: normal strength 5/5: normal strength 5/5: normal strength 5/5: normal strength Balance intact 2+ normal 2+ normal No hallux extension Absent Present

Comment on head/shoulders, spine, pelvis, sagittal/transverse/frontal plane, postural, etc.

Footgear (size/width, wear pattern(s))→ Existing orthoses/type→ Weight→ Height→ Biomechanical assessment: Treatment plan: Enter resident name

Enter date of exam

Signature of resident

Signature of program director

RXTAFO15929

Document of Medical Necessity: Cane, Crutches, Walker Patient Name: _________________________________ Prognosis: Good

HICN: _________________

DOB: _____/______/_____

Duration of usage: 12 Months

Appliance c

Cane (EO100)

c

Walker, Folding (EO135)

c

Quad Cane (EO105)

c

Folded Wheeled Walker (EO143)

c

Crutches (EO114)

Product Name _____________________________________ I hereby certify that Mr. / Ms. ________________________________________ qualifies for and will benefit from the product designated above based on the following criteria (check all that apply):

c

Partial or complete paralysis of one or more leg muscles.



c

Significant weakness, ataxia or gait abnormality



c

Significant impairment of gait due to pain or ankle / foot deformity.



c

Instability in gait with recurrent sprains or falls.

The goal of this therapy (check all that apply):

c

Improve mobility



c

Improve lower extremity stability



c

Decrease pain



c

Decrease risk for fall

Medical Necessity (check all that apply):

c

The patient’s mobility deficit can be resolved by the use of this cane or walker.

c

The patient is able to safely use the cane or walker.

c

The patient’s mobility related deficit does NOT allow the patient to complete activities of daily living within a reasonable time frame.

c

The patient is prohibited from accomplishing their mobility related activities of daily living completely.

The patient has a mobility limitation that impairs his/her ability to participate in one or more mobility-related activities of daily living in the home. c

This patient is at high risk of morbidity or mortality secondary to attempts to perform their mobilty-related activities of living in the home. c

I certify that the appliance described above is, in my opinion, both reasonable and necessary in reference to accepted standards of medical practice in the treatment of the patient condition and rehabilitation. Dr. ___________________________________________

Phone: _____________________________________________

Signature: ______________________________________

Type I NPI: _____________

Date: ______/______/______

The codes contained herein are not the official position or endorsement of any organization or company. They are offered as a suggestion based upon input from previous customers. Each prescribing practitioner should contact his or her local carrier or Medicare office to verify billing codes, regulations and guidelines relevant to their geographic location.

TM

CCWRX15929

Rx: Cane (EO100), Quad Cane (EO105) Crutches (EO114), Walker, Folding (EO135) Folded Wheeled Walker (EO143) Doctor Name: _________________________________________

Patient Name: _______________________________________

Phone: ______________________________________________

HICN: _______________________ DOB: _________________

Appliance

c c

Cane (EO100) Walker, Folding (EO135)

c c

Quad Cane (EO105) Folded Wheeled Walker (EO143)

c

Crutches (EO114)

Product Name _____________________________________ DX: CHECK ALL THAT APPLY - Corresponds to Biomechanical Examination Form DJD of Ankle and Rearfoot

Fall Risk/Imbalance

Lateral Ankle Instability

Muscle weakness, generalized (M62.81)

Primary osteoarthritis, ankle and foot

c

Ataxic gait (R26.0)

Pain in ankle and joints of foot

c right (M24.871)

c right (M25.571)

c left (M25.572)

c

Difficulty in walking (R26.2)

Pain in lower leg

Other specific joint derangements of foot, not elsewhere classified

c

Unsteadiness on feet (R26.81)

c right (M79.661)

c left (M79.662)

c right (M24.874)

c

c right (M19.071)

c left (M19.072)

Pain in foot

Other abnormalities of gait and mobility (R26.89) c

c right (M79.671)

c left (M79.672)

Other specific joint derangements of ankle, not elsewhere classified

Condition is bilateral

c

Other: _________________________

c left (M24.875)

Foot Drop Foot Drop, acquired c right (M21.371)

c

c left (M24.872)

c left (M21.372)

Hemiplegia c affecting dominant side (438.21) c affecting nondominant side (438.22)

Medical Necessity: (check all that apply) c

The patient’s mobility deficit can be resolved by the use of this cane or walker.

c

The patient is able to safely use the can or walker.

c



The patient’s mobility related deficit does NOT allow the patient to complete activities of daily living within a reasonable time frame.

c

The patient is prohibited from accomplishing their mobility related activities of daily living completely.

c

Patient has a mobility limitation that impairs his/her ability to participate in one or more mobility-related activities of daily living in the home.

c



This patient is at high risk of morbidity or mortality secondary to attempts to perform their mobilty-related activities of living in the home.

Signature of Prescribing Physician: __________________________________ Type I NPI: _______________ Date: ______/_______/_______

TM

RXTAFO15929

Patient Receipt: Cane, Crutches, Walker Doctor Name:__________________________________________________ Phone: ________________________________ PATIENT INFORMATION: Mr./Ms. ______________________________________________HICN: __________________ DOB: ______/_______/_______

Appliance c

Cane (EO100)

c

Quad Cane (EO105)

c

Crutches (EO114)

c

Walker, Folding (EO135)

c

Folded Wheeled Walker (EO143)

Product Name _____________________________________

Material failure warrantee coverage: • Hardware, plastic and metal components are covered at no-charge for six months. • All soft materials: material covers, Velcro straps and limb support pads, are covered at no-charge up to ninety days. You have been dispensed this appliance in order to prevent falls and imbalance. Should the appliance crack or break, do not use it again until you contact our office. I am aware of the office’s Complaint Resolution Policy and have been provided with a copy of the Medicare Supplier Standards. I certify that I have received the item(s) indicated. The supplier has reviewed the instructions for proper use and care and provided me with written instructions. I understand that failure to properly care for this item(s) will result in the warranty being voided. This could result in my responsibility for future repair or replacement costs if my insurance policy will not cover such costs. The supplier has instructed me to call the office if I have any difficulties or problems with the appliance.

Patient Signature: ________________________________________

Date: ______/_______/_______

Print Patient Name: ________________________________________ Patient Address:

________________________________________

________________________________________ ________________________________________ Original in patient’s chart, copy to patient The codes contained herein are not the official position or endorsement of any organization or company. They are offered as a suggestion based upon input from previous customers. Each prescribing practitioner should contact his or her local carrier or Medicare office to verify billing codes, regulations and guidelines relevant to their geographic location. Page 8 of 9 TM

DCNCCWAFO15929

Dispensing Chart Notes: Cane, Crutches, Walker Patient:___________________________________________ HICN: _________________________ DOB: _____/______/______ DX: CHECK ALL THAT APPLY - Corresponds to Biomechanical Examination Form DJD of Ankle and Rearfoot

Fall Risk/Imbalance

Lateral Ankle Instability

Muscle weakness, generalized (M62.81)

Primary osteoarthritis, ankle and foot

c

Ataxic gait (R26.0)

Pain in ankle and joints of foot

c right (M24.871)

c right (M25.571)

c left (M25.572)

c

Difficulty in walking (R26.2)

Pain in lower leg

Other specific joint derangements of foot, not elsewhere classified

c

Unsteadiness on feet (R26.81)

c right (M79.661)

c left (M79.662)

c right (M24.874)

c

c right (M19.071)

c left (M19.072)

Pain in foot

Other abnormalities of gait and mobility (R26.89) c

c right (M79.671)

Other specific joint derangements of ankle, not elsewhere classified

Condition is bilateral

c

Other: _________________________

c left (M24.875)

Foot Drop

c left (M79.672)

Foot Drop, acquired c right (M21.371)

c

c left (M24.872)

c left (M21.372)

Hemiplegia c affecting dominant side (438.21) c affecting nondominant side (438.22)

Appliance

c c

Cane (EO100) Walker, Folding (EO135)

c c

Quad Cane (EO105) Folded Wheeled Walker (EO143)

c

Crutches (EO114)

S) (Product name) _______________________________________ was dispensed and fit at this visit. Patient is ambulatory. There is pain with range of motion that requires stabilization. Due to the indicated diagnosis(s) and related symptoms this device is medically necessary as part of the overall treatment. It is anticipated that the patient will benefit functionally with the use of this device. The custom device is utilized in an attempt to avoid the need for surgery. O) Upon gait analysis, the device appeared to be fitting well and the patient states that the device is comfortable. A) Good fit. The patient was able to apply properly and ambulate without distress. The function of this device is to restrict and limit motion and provide stabilization in the ankle joint. P) The goals and function of this device were explained in detail to the patient. The patient was shown how to properly apply, wear, and care for the device. It was explained that the device will fit and function best in a lace-­up shoe with a stiff heel counter and a wide base of support. When the device was dispensed, it was suitable for the patient’s condition and not substandard. No guarantees were given. Precautions were reviewed. Written instructions, warranty information and a copy of DMEPOS Supplier Standards were provided. All questions were answered. Supplier Signature: ____________________________________________________ Print Supplier Name: ___________________________________________________

TM

Date: ______________________