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Advanced COPD:

Gather data from: CRD (Coverage Requirements of Discovery) use cases, DTR (Documentation Templates and Payer Rules)


, Prior Auth

Advanced COPD:

Persona: 65 yo with end stage COPD and OSA (Obstructive Sleep Apnea)

Coverage Transition: Commercial to MA

*Diagnosis Codes: TBDICD-10-CM at a minimum, ok to use a SNOMED-CT translation code if available *note what is allowed in HIPPA 837 Claims requirements

Active Treatments: relevant metadata – schedule, supplier, duration of therapy, ordering provider

  • Home O2 – 2L daytime, 4L nighttime – 
  • DME: Class (from order), Make, Model, Date Provided, Date Expiring/Replacement?, GUDID?, Instructions on how to use?(probably not) * likely to have prior auth 
    • CPAP
    • Oxygen supplies (Canisters, concentrators, cannulas)
    • Nebulizer
    • Oxymeter
  • Medications: 
    • Spiriva inhaler
    • Advair inhaler
    • Duonebs inhaled via nebulizer
  • Routine PFTs
  • Home monitoring?
  • Specialty care: 
    • Pulmonary Consult

Prior authorizations: specific to insurer, patient and plan-- there is not a category-- would be an optional component for which the payer would want the information about what was provided and the determination


Gather data from: Wound care implementation guide/data set, ADA?