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DMEPOS Templates and Suggested Clinical Data Elements (CDEs)

Home Blood Glucose Monitors

F2F Encounter

 
Basic Home Blood Glucose Monitor F2F Encounter CDEs (PDF) Draft R1.0a 9/5/2017
  Template (PDF) Draft R1.0b 10/31/2017

Order

 
Basic Home Blood Glucose Monitor & Supplies Order CDEs (PDF) Draft R1.0a 9/5/2017
  Template (PDF) Draft R1.0a 9/5/2017
Specialty Home Blood Glucose Monitor & Supplies Order CDEs (PDF) Draft R1.0a 9/5/2017
  Template (PDF) Draft R1.0a 9/5/2017

Lab Test Results

 
Basic & Specialty Home Blood Glucose Monitor Lab Test Results CDEs (PDF) Draft R1.0a 9/5/2017
  Template (PDF) Draft R1.0a 9/5/2017

 

Home Oxygen Therapy

F2F Encounter

 
Home Oxygen Therapy F2F Encounter CDEs (PDF) Draft R4.0 9/5/2017
  Template (PDF) Draft R4.0 9/5/2017

Order

 
Home Oxygen Therapy Order CDEs (PDF) Draft R4.2 6/19/2018
  Template (PDF) Draft R4.2 6/19/2018

Lab Test Results

 
Home Oxygen Therapy Lab Test Results CDEs (PDF) Draft R4.0 9/5/2017
  Template (PDF) Draft R4.0 9/5/2017

 

Positive Airway Pressure Devices for Obstructive Sleep Apnea (OSA)

F2F Encounter

 
Positive Airway Pressure Device for OSA F2F Encounter CDEs (PDF) Draft R1.0c 4/12/2018
  Template (PDF) Draft R1.0c 4/12/2018

Order

 
Positive Airway Pressure Device for OSA Order CDEs (PDF) Draft R1.0c 4/12/2018
  Template (PDF) Draft R1.0c 4/12/2018

 

Ventilators

Progress Note

 
Ventilator Progress Note CDEs (PDF) Draft R1.0a 4/12/2018
  Template (PDF) Draft R1.0a 4/12/2018

Order

 
Ventilator Order CDEs (PDF) Draft R1.0a 4/12/2018
  Template (PDF) Draft R1.0a 4/12/2018

 

Respiratory Assist Devices

F2F Encounter

 
Respiratory Assist Device F2F Encounter CDEs (PDF) Draft R1.0b 4/12/2018
  Template (PDF) Draft R1.0b 4/12/2018

Order

 
Respiratory Assist Device Order CDEs (PDF) Draft R1.0a 4/12/2018
  Template (PDF) Draft R1.0b 4/12/2018

Lab Test Results

 
Respiratory Assist Device Lab Test Results CDEs (PDF) Draft R1.0b 4/12/2018
  Template (PDF) Draft R1.0b 4/12/2018

Appendices

 
Respiratory Assist Device Appendices A and B Appendices (PDF) Draft R1.0b 4/12/2018

 

External Infusion Pumps

F2F Encounter

 
External Infusion Pumps F2F Encounter CDEs (PDF) Draft R1.0a 4/30/2018
  Template (PDF) Draft R1.0a 4/30/2018

Order

 
External Infusion Pumps Order CDEs (PDF) Draft R1.0a 4/30/2018
  Template (PDF) Draft R1.0a 4/30/2018

Lab Test Results

 
External Infusion Pumps Lab Test Results CDEs (PDF) Draft R1.0a 4/30/2018
  Template (PDF) Draft R1.0a 4/30/2018

Appendices

 
External Infusion Pumps Appendices Appendices (PDF) Draft R1.0a 4/30/2018

 

Nebulizers

F2F Encounter

 
Nebulizers F2F Encounter CDEs (PDF) Draft R1.0a 4/30/2018
  Template (PDF) Draft R1.0a 4/30/2018

Order

 
Nebulizers Drugs Order CDEs (PDF) Draft R1.0a 4/30/2018
  Template (PDF) Draft R1.0a 4/30/2018

Appendices

 
Nebulizer Appendix A Appendices (PDF) Draft R1.0a 4/30/2018

 

Immunosuppressive Drugs

Progress Note

 
Immunosuppressive Drugs Progress Note CDEs (PDF) Draft R1.0a 4/30/2018
  Template (PDF) Draft R1.0a 4/30/2018

Order

 
Immunosuppressive Drugs Order CDEs (PDF) Draft R1.0a 4/30/2018
  Template (PDF) Draft R1.0a 4/30/2018

Order and Dispense

 
Immunosuppressive Drugs Order and Dispense Template (PDF) Draft R1.0a 4/30/2018

 

Enteral Nutritional Therapy

Progress Note

 
Enteral Nutritional Therapy Progress Note CDEs (PDF) Draft R1.0b 5/20/2018
  Template (PDF) Draft R1.0b 5/20/2018

Order

 
Enteral Nutritional Therapy Order CDEs (PDF) Draft R1.0b 5/20/2018
  Template (PDF) Draft R1.0b 5/20/2018

Appendices

 
Enteral Nutritional Therapy Appendix A Appendices (PDF) Draft R1.0b 5/20/2018

 

Parenteral Nutritional Therapy

Progress Note

 
Parenteral Nutritional Therapy Progress Note CDEs (PDF) Draft R1.0d 5/20/2018
  Template (PDF) Draft R1.0d 5/20/2018

Order

 
Parenteral Nutritional Therapy Order CDEs (PDF) Draft R1.0d 5/20/2018
  Template (PDF) Draft R1.0d 5/20/2018

Lab Test Results

 
Parenteral Nutritional Therapy Lab Test Results CDEs (PDF) Draft R1.0d 5/20/2018
  Template (PDF) Draft R1.0d 5/20/2018

Appendices

 
Parenteral Nutritional Therapy Appendices Appendices (PDF) Draft R1.0d 5/20/2018

 

Therapeutic Shoes for Persons with Diabetes

Progress Note

 
Therapeutic Shoes for Persons with Diabetes Progress Note CDEs (PDF) Draft R1.0a 6/08/2018
  Template (PDF) Draft R1.0a 6/08/2018

Order

 
Therapeutic Shoes for Persons with Diabetes Order CDEs (PDF) Draft R1.0a 6/08/2018
  Template (PDF) Draft R1.0a 6/08/2018

Certification Statement

 
Therapeutic Shoes for Persons with Diabetes Certification Statement CDEs (PDF) Draft R1.0a 6/08/2018
  Template (PDF) Draft R1.0a 6/08/2018

Appendices

 
Therapeutic Shoes for Persons with Diabetes Appendices Appendices (PDF) Draft R1.0a 6/08/2018

 

Lower Limb Prosthesis (LLP)

F2F Encounter

 
Lower Limb Prosthesis F2F Encounter CDEs (PDF) Draft v5 (11/06/13)

 

Power Mobility Device (PMD)

F2F Encounter

 
Power Mobility Device F2F Encounter CDEs (PDF) Draft v9.8 (11/02/12)

 


Other Benefit Templates and Suggested Clinical Data Elements (CDEs)

Home Health

Plan of Care / Certification

 
Version 2 - Home Health Plan of Care / Certification CDEs (PDF) Draft R2.0 7/9/2018
  Template (PDF) Draft R2.0 7/9/2018
Version 1 - Home Health Plan of Care / Certification CDEs (PDF) Draft R1.0b 9/5/2017
  Template (PDF) Draft R1.0b 9/5/2017

F2F Encounter

 
Version 2 - Home Health F2F Encounter CDEs (PDF) Draft R2.0 7/9/2018
  Template (PDF) Draft R2.0 7/9/2018
Version 1 - Home Health F2F Encounter CDEs (PDF) Draft R1.0c 2/14/2018
  Template (PDF) Draft R1.0d 2/14/2018

 

Vitamin and Metabolic Assays

Progress Note

 
Vitamin and Metabolic Assays Progress Note CDEs (PDF) Draft R1.0b 6/19/2018
  Template (PDF) Draft R1.0b 6/19/2018

Order

 
Vitamin and Metabolic Assays Order CDEs (PDF) Draft R1.0b 6/19/2018
  Template (PDF) Draft R1.0b 6/19/2018

Appendices

 
Vitamin and Metabolic Assays Appendix Appendices (PDF) Draft R1.0b 6/19/2018

 

Non-Emergency Ambulance Transportation (NEAT)

Order / Physician Certification Statement (PCS)

 
NEAT Order-PCS CDEs (PDF) Draft R1.0e 7/20/2018
  Template (PDF) Draft R1.0e 7/20/2018

Progress Note

 
NEAT Progress Note CDEs (PDF) Draft R1.0e 7/20/2018
  Template (PDF) Draft R1.0e 7/20/2018

Prior Authorization (PA) Request

 
NEAT PA Request CDEs (PDF) Draft R1.0e 7/20/2018
  Template (PDF) Draft R1.0e 7/20/2018

 

Page Last Modified:
11/13/2019 05:05 PM