DME 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]