Physician Documentation Page

The insurance landscape to provide patients with prosthetic care is constantly changing. We hope these resources can help providers provide the complete documentation required to obtain insurance authorization for a prosthesis. Our team of billing specialists will help walk patients through this process, and our local clinical teams will be happy to set up a system within your clinic structures for these documentation requirements.

Prior to coming to our clinic, the patient will need to see their referring physician to receive clearance for prosthesis use, especially shortly after any surgeries.

To ensure an efficient and expedient process, the patient should come to their first OPSB Clinic visit with updated documentation, including an order for the prosthesis. This should include:

• Initial Prescription:
  • Patient information (Name, DOB, address)
  • Diagnosis – level of limb loss, laterality, etiology. ICD-10 code(s)
  • Device prescribed – type of prosthesis and laterality (or “evaluate and treat for right lower limb prosthesis prosthesis”, eg.)
• Clinical note from the most recent clinic visit, which must be within the last 6 months. This clinic note should include the following information:
  • Medical and amputation history, including:
    • Date and cause of limb loss
    • Amputation level
    • Any wound healing status, clearance for prosthesis use
  • Activity Level (K-level, as defined by Medicare standards.
  • Documentation of compliant, daily prosthesis use and activities (if applicable–hours of wear per day and activities requiring prosthesis use), or that they have never had a prosthesis before and require one for daily ambulation and activities
  • Details of poorly fitting prosthesis or current functional deficits requiring change to patient’s current prosthesis
  • Plan
    • Goals for patient, specific to desired activity level
    • Recommendation for Physical Therapy (if new prosthesis user or medical status change)
    • Any restrictions
• After we receive all of the above documentation, our team will be sending you additional documentation, such as an SWO/DWO (Signed/Detailed Written Order) with the specific details of the device design. This needs to be signed and returned to our office for use in the authorization process. If you have any questions with the paperwork or device design, please reach out directly to the clinician working with your patient.
• Insurance Eligibility: It is important the patient verify we are in network with their insurance and their provider has DME (durable medical equipment) coverage.
  • The patient can contact their insurance company or our office to verify this information
  • We are in network with most major state and private insurance companies, however there may be plan differences to the patient’s individual insurance plan. Please be sure patients call our office to confirm their specific plan details with our team.
• Once the patient has received the appropriate documentation, they can contact the office to schedule their initial evaluation appointment.