M54.50 Low Back Pain

M54.16 Radiculopathy, lumbar regionM54.17 Radiculopthy, lumbosacral region

routine healingS38.1XXA Crushing injury of abdomen, lower back, and pelvis, initial encounterM51.36 Other intervertebral disc degeneration, lumbar regionM51.37 Other intervertebral disc degeneration, lumbosacral regionM99.83 Other biomechanical lesions of lumbar regionM99.84 Other biomechanical lesions of sacral regionQ06.2 Diastematomyelia (spinal cord anomaly)M51.26 Other intervertebral disc displacement, lumbar regionM51.27 Other intervertebral disc displacement, lumbosacral regionM51.06 Intervertabral disc disorders with myelopathy, lumbar regionM51.07 Intervertabral disc disorders with myelopahty, lumbosacral region

for fracture

Q67.5 Congenital deformity of spine

M96.4 Postsurgical lordosis

M62.838 Other muscle spasm

Z87.311 Personal history of (healed) other pathological fracture

M96.5 Postradiation scoliosis

S34.3XXA Injury of cauda equina, initial encounterM48.06 Spinal Stenosis, lumbar region

Q76.2 Congenital spondylolisthesisM47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.16 Other spondylosis with myelopathy, lumbar region

reaction of the patient, or of later complication, without mention of misadventure at the time of the procedureOther _____________________________________________________________________Other _____________________________________________________________________

M54.6 Pain in the thoracic spineM54.14 Radiculopathy, thoracic regionM54.15 Radiculopathy, thoracolumbar regionM54.16 Radiculopathy, lumbar regionM54.17 Radiculopathy, lumbosacral region

M51.34 Other intervertebral disc degeneration, thoracic regionM51.35 Other intervertebral disc degeneration, thoracolumbar regionM51.24 Other intervertebral disc displacement, thoracic regionM51.25 Other intervertebral disc displacement, thoracolumbar regionM51.04 Intervertebral disc disorders with myelopahty, thoracic regionM51.05 Interverebral disc disorders with myelopahty, thoracolumbar region

M96.2 Postradiation kyphosisM96.3 Postlaminectomy kyphosis

Z87.311 Personal history of (healed) other pathological fractureM81.0 Age-related osteoporosis without current pathological fracture

Q67.5 Congenital deformity of spine Q76.425 Congenital lordosis, thoracolumbar regionQ76.426 Congenital lordosis, lumbar regionQ76.427 Congenital lordosis, lumbosacral regionQ76.428 Congenital lordosis, sacral and sacrococcygeal region

initial encounterM48.04 Spinal Stenosis, thoracicM47.814 Spondylosis without myelopathy or radiculopathy, thoracic regionM47.14 Other spondylosis with myelopathy, thoracic region

Other _______________________________________________________Other _______________________________________________________

Physician Signature: _______________________________________________________________ Date:_________________________

Physician Name Printed: ___________________________________________________________ NPI __________________________

Address: __________________________________________________ Phone: ___________________ Fax:______________________

Patient Name: ____________________________________ DOB ____/_____/_______

Address: ____________________________________Phone: ____________________

City: ________________________________ State:_______ Zip : _________________

Length of NeedDDS 500 - HCPCS L0631/L0648 DDS Double - HCPCS L0637/L0650 Substitutions NO YES X

Torso Measurement (at the naval): ______ inches

DDS 500 DDS DOUBLE

To reduce pain by restricting mobility of the trunkTo facilitate healing following surgery on spine/related soft tissueTo otherwise support weak spinal muscles and / or a deformed spineTo facilitate healing following injury to spine/related soft tissue

One of the following criteria has to be met. Please check the appropriate box.

(Criteria must also be transcribed onto patient’s chart notes)

8” Extension Piece: YES No

Detailed Written Order: DDS 500 / DDS Double Lumbar LSO

Order Date: ____/_____/_______