AFO documentation requirements

Do a thorough H/P and document all clinical findings and radiology findings. Be thorough about discussions of dx and tx options. Note any changes of the patient's condition if they have had an AFO in past five years and why current device is no longer functional and or beneficial. Document the medical necessity for the parent and each add on code of the device.

Simply stating that the patient has an arthritic foot and atrophic skin does not justify an AFO. Stating that the patient has signficant djd w/pain on ambulation w/atrophic skin and requires motion control in more than one plane to reduce pain and edema and requires soft tissue interface to protect the atrophic skin goes much further (you will need to state more).

Note success or failure of previous tx.

Patient will need custom device to correct and maintain multiplane deformity (simply stating presence of mutiplane deformity is insuficient)

Patient will require device for >6 months.

Thoroughly discuss casting technique

Reference your lab order as your detailed written order. Put you NPI on the DWO.

When you dispense be sure you metion any adjustments you had to make during fitting, note that the patient was examined while wearing the device and that there was no rubbing and the lenght and width is fine and no signs of irritation.

Note the patient demonstrated their abilities to don (apply) and doff (remove) the device.

Provided patient w/written use instructions, warranty information, copy of current supplier standards, made aware of practice's complaint protocol.

Patient instructed to discontinue use if any pain, irritation or swelling w/use occurs and to contact the office immediately.

Patient signed authorization of benefits and provided with a follow up appointment in ... weeks.