Sleep Medicine - Polysomnography Documentation Requirements - JE Part B
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:
|Check box if submitted
|Requested Records (as applicable)
|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
|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.
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.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Sleep Medicine webpage for additional information and resources.
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.