Clinical Template and CDE Downloads

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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:
12/01/2021 05:40 PM
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