What kind of documentation does Medicare require when physicians write requisitions or orders for respiratory-assistive devices (RADs)?


This is a good question since the Centers for Medicare & Medicaid Services (CMS) recently published information about insufficient documentation for RADs. CMS gave the following guidelines to physicians and other non-physician practitioners:

  • Document and communicate to the durable medical equipment (DME) supplier that you had a face-to-face encounter with the beneficiary on or before the date of the written order. The encounter must be no more than six months prior to the written order, and be on or before the date of delivery for the item(s) prescribed.
  • Perform a needs assessment at the face-to-face encounter, and evaluate and/or treat the beneficiary for the medical condition that supports the need for each item ordered.
  • Document the face-to-face encounter in the pertinent portion of the medical record, and sign or co-sign the pertinent portion of the medical record indicating the date it occurred.



CPT® copyright 2021 American Medical Association (AMA). All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.