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documentation needed in the patients chart is fairly minimal the prescription needs to be filled out by a mddo or dpm this starts the initial documentation in your chart the diagnosis code is the descriptor that best defines the patients clinical picture by way of example a posterior tibial tendon dysfunction is coded out as 727.68 which the verbiage in the icd-9 as of today is non-traumatic rupture of the tendon a posterior tibial tendon dysfunction actually is a functional tear this is where the linear arrangement of the collagen fibers elongate and lead to a symptom complex 355.5 is tarsal tunnel this adequately describes distal tarsal tunnel which is non-resolving heel pain of at least three months where the nerves have become entrapped therefore the diagnosis code may not be exactly descriptive of what youre seeing clinically but you are to pick the best descriptor that defines the patients clinical presentation you must have this signed in the chart prior to dispensing an afo