1.0/1.1 Clinical & Subjective Patient Assessment

1.0    Clinical Assessment

Definition: The assessment of the patient and/or the patient-prosthesis/orthosis interaction in order to provide treatment plan to the patient.

1.1       Subjective Patient Assessment

May involve any or all of the following codes:

Code Procedure Description
1 Patient interview May include:

Height, weight, gender, age, occupation (or specific tasks), allergies, medical history, social history (family dynamics), previous prosthetic/orthotic history (including compliance), independence level (ADL’s-Activities of Daily Living), cognitive abilities, language, pain, symptoms onset, frequency, surgeries, medication, patient well-being/distress/anxiety, weight fluctuations, degree of caregiver involvement, history of skin tolerance, pressure sores, hyperhidrosis, visual impairments, patient’s mobility status (use of walking aids and ambulatory status) and any current treatment(s).

Prosthetics: reason for amputation or prosthetic treatment, date of amputation, revisions, sequelae leading to amputation, affected level and side, and prosthetic history.

Orthotics: primary diagnosis and pathology,
co-morbidities, identified problems.

2 Patient goals Discuss with patient/caregiver expectations and goals of prosthetic/orthotic treatment, range of prosthetic/orthotic options, and alternatives to prosthetic/orthotic use. This should include a discussion of vocational and hobby goals of prosthetic/orthotic treatment, specific time frames for treatment, anatomical restoration expectations, and improvements or concerns with current prosthetic/orthotic treatment (if applicable).
3 Explain prosthetic/orthotic funding Discuss possible funding/reimbursement sources. Ensure patient/caregiver is informed of his/her financial responsibility and expectations.

 

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