DME documentation is the record behind a Medicare equipment order: the face-to-face encounter, the qualifying test, the standard written order, and the follow-up that shows the item still helps. Copy the free template, see a home oxygen order for COPD and a CPAP order with its 3-month adherence check, and check the CMS and DME MAC requirements for oxygen and CPAP.
For clinicians in the United States.
Blank DME documentation template
FreeDME DOCUMENTATION Patient: [Name, date of birth, Medicare Beneficiary Identifier] Date of encounter: [Date] Encounter type: [In person, or telehealth that meets Medicare's rules] Treating practitioner: [Name, credentials, NPI] Item: [Home oxygen, CPAP, or other equipment, with its HCPCS code] Supplier: [Name, phone, fax] FACE-TO-FACE ENCOUNTER Reason for the item: [The condition the equipment treats, and why it is needed now] History: [Symptoms, how long, course, recent hospital stays or exacerbations] Examination: [Findings tied to the item: vital signs, BMI, neck circumference, heart and lung exam, airway, edema, gait] Function at home: [What the condition stops the patient doing; how they move around the home] Treatments tried: [Medicines, therapy, or devices used before, and the result] Diagnosis: [Diagnosis and ICD-10-CM code] QUALIFYING TEST Test and date: [Spot oximetry, arterial blood gas, overnight oximetry, or sleep study, and the date] Conditions: [Awake at rest, with exercise, or during sleep; room air, or on oxygen at a stated flow] Performed by: [Practitioner's office, hospital, laboratory, IDTF, or sleep laboratory, never the supplier] Result: [SpO2 or PaO2; or AHI or RDI, the number of events, and the hypopnea rule] Measurement concerns: [Anything that could skew the reading: age, skin pigmentation, altitude, anemia, poor perfusion; or none] Practitioner review: [Who reviewed the result, the date, and the coverage criterion it meets] STANDARD WRITTEN ORDER Beneficiary: [Name or MBI] Order date: [Date] Item: [General description, HCPCS code, or brand and model] Settings and use: [Oxygen flow in L/min and when it is used; or the PAP pressure or pressure range] Accessories and supplies: [Each listed separately, with its quantity] Quantity to dispense: [Amount, if applicable] Treating practitioner: [Name or NPI] Signature: [Handwritten or electronic signature; no stamps] Sent to supplier: [Date sent, and what went with it] FOLLOW-UP AND CONTINUED NEED Re-evaluation: [Date, in person or telehealth, and days since the item started] Benefit: [Change in symptoms and function since the item started] Use: [Device download or reported use: hours a night, share of nights, residual AHI, leak] Repeat test: [Repeat qualifying test where the policy asks for one, with the date and result] Plan: [Continue, change settings with a new order, or stop] Signed: [Practitioner name, credentials, date]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family physician’s office, face-to-face visit and order, November 2026
In person, November 4, 2026. 72-year-old man with COPD, seen for 6 weeks of worsening breathlessness, 5 weeks after a hospital stay for an exacerbation. Items: stationary and portable home oxygen. Supplier: a local DME supplier he chose.
Breathless walking from the bedroom to the kitchen, about 40 feet; stops twice on the way to the mailbox. Sleeps propped on 3 pillows. No chest pain, ankle swelling, or fever; sputum unchanged. Former smoker, 50 pack-years, quit in 2019. Spirometry in March 2026: post-bronchodilator FEV1/FVC 0.46, FEV1 38% predicted. Daily LAMA-LABA inhaler, technique good on check today; albuterol as needed; finished pulmonary rehabilitation in 2025. Exam: RR 22, HR 94, BP 136/78, temperature 36.8 °C. Speaks in full sentences. Quiet breath sounds throughout with prolonged expiration; no wheeze or crackles. No ankle edema; JVP not raised. Walks inside the house with a cane, and goes out twice a week with his wife. Diagnosis: COPD, J44.9; chronic respiratory failure with hypoxia, J96.11.
Spot pulse oximetry in the office by the practice nurse, awake, seated at rest for 10 minutes, on room air: SpO2 86%, and 86% again 5 minutes later. Warm hands, steady waveform, no nail polish. No concern about the reading: office near sea level, hemoglobin 14.6 g/dL on September 24. On 2 L/min by nasal cannula at rest: 93%. Walking the hallway for 6 minutes on 2 L/min: lowest 90%. Reviewed by the treating physician the same day: meets Group I, an SpO2 at or below 88% awake at rest on room air.
Beneficiary: name and MBI. Order date: November 4, 2026. Stationary oxygen concentrator, E1390: 2 L/min by nasal cannula, continuous, including during sleep. Portable gaseous oxygen system, E0431: 2 L/min for walking and trips out of the home. Treating practitioner: name and NPI, signed electronically. Sent to the supplier on November 4, before delivery, with this note and the oximetry results.
Use oxygen continuously, including during sleep and walking. No one smokes in the home; fire safety reviewed: keep the concentrator and tubing away from the gas stove, candles, and heaters. Inhalers unchanged; COPD action plan reviewed. Group I, so Medicare sets no retest date, but the need is reviewed at each visit. Next visit December 16, 2026: SpO2 on oxygen, hours of use, and breathlessness.
Primary care office: evaluation in July, order in August, re-evaluation in October 2026
In person, July 14, 2026. 54-year-old woman, an office manager. Loud snoring for about 6 years; her husband sees pauses in her breathing and hears her gasp several nights a week. Morning headaches 3 or 4 days a week; dozes at her desk after lunch. Epworth Sleepiness Scale 14. Hypertension on lisinopril 20 mg daily. Exam: BP 144/90, BMI 34.6, neck circumference 40 cm. Mallampati class IV, small tonsils, clear nasal passages. Heart regular, lungs clear, no edema. Suspected obstructive sleep apnea; in-lab polysomnogram ordered.
Diagnostic polysomnogram in a sleep laboratory, July 29, 2026, read by a sleep physician. Total sleep time 370 minutes. 148 apneas and hypopneas, with hypopneas scored at a 4% desaturation: AHI 24.0 an hour. Lowest SpO2 84%. Moderate obstructive sleep apnea, G47.33. Meets Medicare’s rule: an AHI of 15 or more with at least 30 events. Results reviewed with her by video on August 12, 2026.
Order date: August 12, 2026. CPAP, E0601, auto-adjusting, 5 to 15 cm H2O. Heated humidifier, E0562. Nasal mask, A7034, 1 per 3 months. Nasal cushions, A7032, 2 per month. Headgear, A7035, 1 per 6 months. Heated tubing, A4604, 1 per 3 months. Disposable filters, A7038, 2 per month. Treating practitioner name and NPI; signed electronically. Sent to the supplier with the July 14 note and the sleep study report. Set up and taught by the supplier on August 24, 2026.
In person, October 26, 2026, 63 days after starting CPAP. Sleeps through the night; her husband hears no snoring or pauses. Morning headaches gone. No longer dozes at work. Epworth 5, down from 14. Dry nose in the first 2 weeks, better with the humidifier turned up. BP 132/82.
Supplier’s download for September 24 to October 23, 2026, 30 consecutive nights, reviewed and signed today: 4 hours or more on 26 of 30 nights, 87%. Average use 6 hours 10 minutes a night. Residual AHI 2.6 an hour. Leak within the device’s normal range. 95th percentile pressure 11 cm H2O. Report scanned into the chart.
Symptoms better and adherence met within days 31 to 91: meets Medicare’s rule for coverage after 3 months. Continue auto-CPAP at 5 to 15 cm H2O; no new order needed. This note and the download sent to the supplier. Blood pressure recheck in 3 months; CPAP use reviewed at her annual visit, or sooner if snoring or sleepiness returns.
Medicare’s equipment rules come from federal regulation, a standard documentation article shared by the DME MACs, and an LCD and policy article for each item. CGS and Noridian publish the same oxygen and PAP policies for all four DME jurisdictions.
Who the patient is, who is ordering, how you saw them, and which item, so the supplier and a reviewer can match your record to the claim.
Avoid: An item named only as “oxygen” or “CPAP supplies”. Name the equipment and the code the claim will use.
The visit note that shows why the patient needs the item now. Oxygen equipment needs this encounter in the 6 months before the order.
Avoid: “Needs oxygen” with no findings. Your record, not the order, has to show the need.
The result that meets the item’s coverage rule, how it was done, and your review of it.
Avoid: An oximetry reading from the supplier. Medicare doesn’t accept a test the supplier did or paid for.
The order the supplier needs before it bills, or before it delivers oxygen equipment and other items on Medicare’s required face-to-face list.
Avoid: A signature stamp. Sign by hand or electronically, even when staff fill in the rest.
The visit that shows the item still helps and is used. CPAP has a fixed re-evaluation window, and Group II oxygen a retest window.
Avoid: Filing the supplier’s usage report without comment. Record what it shows and what you’ll do about it.
A form the supplier drafts doesn’t replace your medical record, even when you sign it. Write the findings, the test, and your reasoning in the encounter note, and send the note with the order.
Since April 13, 2026, oxygen concentrators and home oxygen systems need a face-to-face encounter in the 6 months before the order. The order must reach the supplier before delivery, or the claim is denied.
For oxygen based on exercise, record three readings in one session: at rest without oxygen, walking without oxygen, and walking with oxygen. A reading taken while resting after the walk doesn’t qualify.
Medicare’s PAP policy counts a hypopnea only with a fall in saturation of at least 4%. A study scored at 3%, or with arousals, can give a higher number. Check which rule the report used before you quote it.
A visit before day 31 can’t show benefit for Medicare, and after day 91 coverage restarts only from the visit date. Book the re-evaluation when the device is set up, for week 6 to 10.
Vero Scribe writes the DME documentation in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your EHR or export it to Word or PDF. Vero works in 60+ languages.
A standard written order with six elements: the beneficiary’s name or MBI, the order date, a description of the item, the quantity if applicable, your name or NPI, and your signature. Behind it, your medical record must show the need for the type and quantity ordered: the diagnosis, findings, treatments tried, and any qualifying test the item’s LCD asks for, such as oximetry for oxygen or a sleep test for CPAP. Certificates of medical necessity aren’t used for claims with dates of service from January 1, 2023.
Only for items on CMS’s required face-to-face and written order prior to delivery list. Stationary and portable oxygen equipment joined it on April 13, 2026, and K0738, a home system that fills oxygen cylinders, on October 28, 2026. For these, the encounter must fall in the 6 months before the order, and telehealth counts when it meets Medicare’s rules. CPAP isn’t on the list, but its LCD asks for an in-person evaluation before the sleep test and again between days 31 and 91.
Under Group I, an SpO2 at or below 88%, or a PaO2 at or below 55 mm Hg, awake at rest on room air. The same values reached only during sleep or exercise cover oxygen for those times only. Group II covers an SpO2 of 89% or a PaO2 of 56 to 59 mm Hg with dependent edema suggesting heart failure, pulmonary hypertension or cor pulmonale, or a hematocrit above 56%. You or a qualified provider must do the test, not the supplier.
Use of 4 or more hours a night on 70% of nights, in any 30 consecutive days within the first 3 months. Between day 31 and day 91, see the patient in person, record that their sleep apnea symptoms are better, and review a download of the usage data; keep the report in the chart. If the trial fails, requalifying takes a new in-person evaluation and a repeat sleep test in a sleep laboratory.
Yes. Copy it, or download it as a Word or text file. No account needed.
The preventive visit: interval history, screening and vaccines due, full exam, and counseling.
The Medicare AWV, G0438 and G0439: health risk assessment, cognition, screening schedule, risk factors, and the prevention plan.
The one-time IPPE, G0402: history, depression and safety review, exam with visual acuity, end-of-life planning, and the written plan.
The standing summary at the front of the chart: problems, history, medications, allergies, immunizations, risks, and reminders, kept current.
Screening, vaccines, and counselling due at an adult periodic health review, by age and sex, with a next due date on every line.
Notes, forms, and follow-up for visits with several concerns, equipment orders included.
Respiratory visits documented with the testing behind them, from spirometry to oximetry.
Sleep visits, study results, and device follow-up in one note.
Certifications, notices, and DME prior authorization requests from CMS and its contractors.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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