We designed these printable clinical templates and suggested clinical data elements (CDEs) to assist providers and 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.
Providers and IT vendors can choose whether or not to use the printable clinical templates and/or the suggested CDEs.
- The suggested CDEs aren't a form, but a tool that IT vendors can integrate into electronic health record (EHR) systems to create prompts to assist providers with their medical record documentation for Medicare purposes.
- The templates and CDEs are intended to be a helpful guide but every section may not apply to all patients’ services and/or Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). Providers can choose the information or CDEs that do apply.
- Once completed by the physician or other practitioner, the resulting documentation would become part of the medical record.