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
  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 Dec 09 , 2023