Fern Medical Supplies

Pneumatic Compression Device Order Form/SWO

Clinical documentation recommendations must match order form

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Phone # *

Patient Email *

Date of Order *

ICD 10 Diagnosis *

Q82.0 Primary Lymphedema (including Praecox, Milroy's Disease, Tarda)

I89.0 Lymphedema, not otherwise classified

I97.2 Secondary Lymphedema - Post Mastectomy

I97.89 Other post-procedural complications and disorders of the circulatory system

L59.8 Radiation Therapy

I87.2 Chronic Venous Insufficiency

Duration of Need *

Lifetime

If other duration of need, please specify:

Does the patient currently have a pump?

Yes

Unsure

If YES, reason for new order:

Needs Advanced Pump

Current Is >5 Years Old

Current Is Borrowed/Bought Outside of Insurancce

Other...

Involved Extremity *

Arm

Leg

Involved Side *

Left

Right

Bilateral

Qualifying Information (check at least one) *

Skin breakdown with persisting lymphorrhea

Marked hyperkeratosis with hyperplasia and hyperpigmentation

Papillomatosis cutis lymphostatica

Deformity of elephantiasis

Detailed measurements confirming the persistence of the lymphedema (IF SELECTED, MEASUREMENTS WILL BE NEEDED)

Product Order

BASIC Pneumatic Compression Device

E0651 Gradient Sequential Compression Device - QTY 1

BASIC Leg Sleeves

Full Leg Left (E0667) QTY 1

Full Leg Right (E0667) QTY 1

Full Leg Bilateral (E0667) QTY 2

BASIC Arm Sleeves

Arm (E0668) QTY 1

Arm Bilateral (E0668) QTY 2

Arm Plus (E0668) QTY 1

ADVANCED Pneumatic Compression Device E0652

E0652 Gradient Sequential Compression Device with Calibrated Gradient Pressure - QTY 1

ADVANCED Leg Sleeves

Single Leg (E0667) QTY 1

Bilateral Legs (E0667) QTY 2

Pants (E0670)

Other...

Submitter Name *

Submitter Email Address *

Referring Provider *

Referring Provider NPI # *

Referring Provider Fax # *

Fern Med will send out for Physician/APP Signture

Upload Clinical Documentation/Notes (include Initial Evaluation and 4-Week Note) *

As per the NCD: The two notes must be at least 28 days apart, documentation must show "failed" 4-week trial of conservative therapy (ie use of bandages/medical grade compression garments, exercise & elevation), patient diagnosis and prognosis, symptoms & objective findings.

Upload Patient Insurance Card Front/Back *

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