Sleep Medicine / Polysomnography Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

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Brief Description
Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
Practitioner, nurse, and ancillary progress notes
Physician, Technician, Sleep Center and/or Laboratory Accreditation Certification in Sleep Medicine
Vital sign records, weight sheets, care plans, treatment records
Epworth Sleepiness Scale
A complete facility-based, attended polysomnogram
Polysomnography Results
Interpretive statement, which specifically explains the test results and how it will be used in the beneficiary's care
Documentation that supports the clinical significance of the test performed
Sleep Oximetry Study Results
Download of Usage Data from PAP Device
Diagnostic other/tests and results
Documentation supporting the diagnosis code(s) required for the item(s) billed
Documentation to support the code(s) and modifier(s) billed
List of all non-standard abbreviations or acronyms used, including definitions
Any other supporting/pertinent documentation
Signature and credentials of all personnel providing services. Include a signature log or signature attestation for any missing or illegible signatures within the medical record.
If an electronic health record is utilized, include your facility's process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)

Multiple CMS contractors are charged with completing reviews of medical records. See the Who Reviewed My Claim webpage for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Sleep Medicine webpage for additional information and resources.

Last Updated Aug 23 , 2024

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.