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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 Draft R1.0a 9/5/2017
Template Draft R1.0b 10/31/2017

Order

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

Lab Test Results

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

Home Oxygen Therapy

F2F Encounter

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

Order

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

Lab Test Results

Home Oxygen Therapy Lab Test Results CDEs Draft R4.0 9/5/2017
Template 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 Draft R1.0c 4/12/2018
Template Draft R1.0c 4/12/2018

Order

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

Ventilators

Progress Note

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

Order

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

Respiratory Assist Devices

F2F Encounter

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

Order

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

Lab Test Results

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

Appendices

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

External Infusion Pumps

F2F Encounter

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

Order

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

Lab Test Results

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

Appendices

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

Nebulizers

F2F Encounter

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

Order

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

Appendices

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

Immunosuppressive Drugs

Progress Note

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

Order

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

Order and Dispense

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

Enteral Nutritional Therapy

Progress Note

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

Order

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

Appendices

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

Parenteral Nutritional Therapy

Progress Note

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

Order

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

Lab Test Results

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

Appendices

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

Therapeutic Shoes for Persons with Diabetes

Progress Note

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

Order

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

Certification Statement

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

Appendices

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

Lower Limb Prosthesis (LLP)

F2F Encounter

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

Power Mobility Device (PMD)

F2F Encounter

Power Mobility Device F2F Encounter CDEs 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 Draft R2.0 7/9/2018
Template Draft R2.0 7/9/2018
Version 1 - Home Health Plan of Care / Certification CDEs Draft R1.0b 9/5/2017
Template Draft R1.0b 9/5/2017

F2F Encounter

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

Vitamin and Metabolic Assays

Progress Note

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

Order

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

Appendices

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

Non-Emergency Ambulance Transportation (NEAT)

Order / Physician Certification Statement (PCS)

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

Progress Note

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

Prior Authorization (PA) Request

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


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