Ankle Pain/Sprain/Injury/Deformity New or Recurrent Issue

Ankle problems are often overlooked (as many patients will ignore symptoms or not mention them to their physician). Many of these conditions can easily be improved or resolved by wearing a low profile brace, orthotics or by strengthening/improving range of motion with the incorporation of physical therapy.

Patient intake forms should include questions regarding possible ankle conditions (no matter what the patient presents for initially): Example: “Do you have (or have you had in the past) frequent ankle strains or sprains or experience ankle pain or weakness when walking for extended periods?” Yes/No Please explain _______________________________________________

*If patient states injury as part of reason for visit, always ask, “Is this a work related injury or problem” to determine worker’s compensation status. Authorization to evaluate and treat must be in place prior to visit.

Initial Visit:

Staff Evaluation Questions

□ Please point to the area that is painful□ Is the pain only in that area, or does it radiate up the leg, into the foot, etc.?□ How long have you been experiencing the pain? □ Was this caused by an injury or trauma that you can recall? □ Has the area been swollen? (If currently swollen; “Is this less or more swelling

than usual?”)□ Have you tried anything at home to alleviate the discomfort? Icing, rest,

compression, brace, insert in shoes?

Possible Diagnosis Codes: □ S93.411/S93.412 (Ankle Sprain Grade 1 right/left)) □ M25.571/M25.572 (Ankle Pain Grade 2 right/left)□ M24.871/M24.872 (Other specific joint derangements of ankle, right/left)□ M62.81 (Muscle weakness, generalized)□ R26.2 (Difficulty walking) □ M76.821/M76.822 (Posterior tibial tendonitis, right/left)□ M65.871/M65.872 (Other synovitis, ankle, foot, right/left)□ M79.671/M79.672 (Pain in joint, ankle, foot, right/left)□ M19.071/M19.072 (Primary osteoarthritis, ankle and foot, right/left

Possible Actions following Evaluation:

• DPM evaluates injury/condition and area of focus (determining x-ray views)• X-ray performed by MA (ankle 3 views or foot 3 views)

• MA to prepare and DPM to perform Diagnostic Ultrasound • MA to ready patient handout on sprains/injuries • DPM to discuss benefits of controlling discomfort with topical analgesic

• Dispense SubZero (or similar product available in gel or spray for bony areas such as the ankle) and give instructions for use 3-4 times daily (remembering to wash hands thoroughly after applying and never apply to broken skin) (Self-pay for patient)

• DPM to determine appropriate device (brace) according to severity of condition, diagnosis(es) and therapeutic objectives

• MA to prepare device in appropriate size and dispense to patient (assuring all questions are answered, patient is able to wear and adjust device to maximum comfort level while at home• Acknowledgement form is signed by patient along with

witness/MA signature• This form is copied and handed to patient upon check out

Device options:

For mild pain dispense: L4350 brace example – Ankle Stirrup (easy to use for pediatric ankle sprains and strains)

For mild to moderate pain dispense: L1902 Figure 8 lace-up/multi-ligamentous brace

Or A60 (DJO PTTD Brace) for moderate conditions or patients with difficulty lacing

For moderate to severe conditions:

Apply Unna’s Boot to control swelling and discomfort Dispense L4361: Tall pneumatic device shown on left (able to be inflated);

Achilles/ankle involvement (for pain that radiates higher on the ankle and needs compression)

Or Dispense Reparel Ankle Sleeve in place of Unna’s boot shown on the left (self

pay) or Reparel lower leg sleeve on right (cash pay or billable as per carrier determination) to be worn under boot or as stand alone for additional support and compression

For chronic conditions which may require custom bracing in the future: Dispense L1971:

Comfortland Accord III (left)OR

DJO Exos Free Motion Ankle Brace (right)

Ensure substantial customization is provided when fitting patient with device and documentation is adequate to substantiate dispensing of the L1971 device

Rx for NSAID or Medrol Dose Pak

L4387: short non-pneumatic device (does not inflate) can be dispensed for foot involvement/pain only without swelling

Patient instructed to Rest, Ice, Compress, Elevate (RICE) and Limit Weight Bearing

**If right foot injury and patient is placed in walking boot, they should always be instructed to remove the boot before driving**

If Unna’s Boot is applied, patient to return to office in one week

For mild to moderate conditions, patient is to return to the office in 2 weeks

Compliance and documentation notes:

• All DME items (billable) should be accompanied by a Prescription stating Diagnosis and prescribed device. Documentation stating therapeutic objectives and medical necessity shall also be included in the patient’s chart.

• Patient should receive and sign an acknowledgement form (patient receipt) also stating warranty and break-in instructions. This should include the patient’s name, D.O.B., address, date of dispensing, patient signature, as well as physician (supplier name), address, NPI, and witness signature.

• 30 DME Supplier Standards should also be offered/handed to the patient (along with a signed copy of the receipt- keeping the original along with other required compliance documentation in the patient’s chart – scanned into a DME folder if possible).

• In the case that a “Letter of Medical Necessity” is requested by the carrier, a pre-printed form stating the most common diagnosis codes and dispensed DME items (appropriate to treat said diagnoses) shall be made available and readily accessible to the billing staff.

Follow-up visit:

Evaluation by MA:

o Ask patient how they are feeling and if they have developed any new problemso Ask patient if they have consistently worn the brace or walker dispensed and have

been using/taking the topical or oral medication as prescribed

Actions:  DPM Examines and evaluates progress

If no improvement and patient is following instructions: Consider MRI to rule out any tears

Patient will be called to schedule an appointment when MRI report is received.

If more than 50% improvement (for mild to moderate conditions):• Continue with AFO, pneumatic/non-pneumatic walker

RTO in 2-3 weeks to be re-evaluated or fit with lower grade AFO or to be casted for medical grade or custom orthotics

If condition is severe and improvement is noted: Apply second Unna’s boot (at DPM discretion) or switch to ankle sleeve and

continue with Cam walker and RICE. 

Patient to finish NSAIDs. 

Physical therapy to be considered. 

Patient instructed to return again in 1 week

If less than 50% improvement: Apply second Unna’s boot (at DPM discretion) or switch to ankle sleeve

for compression

Continue with pneumatic/non-pneumatic walker

If in L4350 or L1902 brace, switch to pneumatic walker: L4361 (if swelling is evident) or L4387 (if no edema)

Patient to return to office in 2 weeks

**If condition is longstanding or chronic, always utilize the “least expensive method of treatment first” documenting improvement or lack there of before discussing/casting for custom brace or considering surgical correction.