Does CMS provide any guidelines for the documentation required for respiratory devices and other common respiratory procedures?
The Centers for Medicare & Medicaid Services (CMS) recently announced that it has designed printable clinical templates and suggested clinical data elements (CDEs) to assist providers and information technology (IT) professionals with data collection and medical record documentation to support coverage of selected items and services. These templates and CDEs are intended to help reduce the risk of claim denials and ensure that medical record documentation is more complete.
On its website, CMS has posted data elements that it believes would be useful in supporting the documentation requirements for coverage of respiratory assist devices (RADs), positive airway pressure (PAP) device for obstructive sleep apnea (OSA), and ventilators. For all items, CMS lists order and face-to-face encounter. It also lists lab test results for RADs.