|
Recommended Procedure
• • •
|
Recommended Procedure Comments
|
|
Multiple Select Education
• • •
|
Multiple Select Education Comments
|
|
Education
|
Education Comments
|
|
No Fault Cases
|
|
|
Causally related to (check box)
• • •
|
Causally related Comments
|
|
Using Chief Complaint to create causation statement
|
Causally related Comments
|
|
Using typed values to create causation statement
|
Causally related Comments
|
|
Eligible for Spine MRI Switch After Conservative Mgmt
|
|
|
Urgent MRI
|
|
|
Patient requires urgent MRI imaging due to the following symptoms:
• • •
|
Additional comments for urgent MRI:
|
|
MEDICAL NECESSITY SWITCH
|
|
|
Lumbar MBB Medical Necessity
|
Lumbar MBB MN
|
|
Cervical MBB Medical Necessity
|
Cervical MBB MN
|
|
RFA Medical Necessity
|
RFA MN
|
|
Epidural Medical Necessity
|
Epidural MN
|
|
Gen Block Medical Necessity
|
Gen Block MN
|
|
Patient has tried and failed
• • •
|
|
|
Gen RFA Medical Necessity
|
Gen RFA MN
|
|
Patient has tried and failed
• • •
|
|
|
SI Joint Injection (Diagnostic)
|
SI Joint Injection (Diagnostic)
|
|
ADL DEFICITS
|
ADL Comments
|
|
Length of duration that ADLs have been affected:
• • •
|
Length of time ADLs have been affected comments
|
|
TPI with Steroid Medical Necessity
|
TPI with Steroid Medical Necessity
|
|
TPI Medical Necessity (No Steroid)
|
TPI Medical Necessity (No Steroid)
|
|
EMG/NCS Medical Necessity
|
EMG/NCS Medical Necessity
|
|
Visco Med Necessity
|
Visco Med Necessity
|
|
SCS Medical Necessity
|
|
|
SCS Trial Specifics
• • •
|
Medications attempted and failed:
|
|
Lumbar Endoscopic Discectomy
|
Lumbar endoscopic discectomy
|
|
Lumbar Percutaneous Discectomy
|
Lumbar Percutaneous Discectomy
|
|
MILD Procedure
|
MILD Procedure
|
|
ADL DEFICITS
|
|
|
ADL deficits
• • •
|
ADL Comments
|
|
Length of duration that ADLs have been affected:
• • •
|
Length of time ADLs have been affected comments
|
|
Post Procedure Switch
|
|
|
Follow up
• • •
|
|
|
COVID TESTING
|
Post Testing Instructions
• • •
|
|
General Instructions
• • •
|
General Instruction Comments
|
|
Labs
• • •
|
Lab Comments
|
|
Radiology
• • •
|
Radiology Comments
|
|
PT Recommendations
|
PT Recommendation Comments
|
|
Home Health
• • •
|
Home health comments
|
|
Other Referrals
• • •
|
Referral Comments
|
|
Diet
|
Diet Comments
|
|
Referrals
|
|
