Patient Information Device Information

Name: Serial Number:

Street 1: Prescription Pressure Setting(s):
Street 2: Humidification:
City, State, Zip Code: Interface:
Phone: Device Type:
Date of Birth: Date on Which Therapy Was Started:
Payor: Date Code Was Collected:
ID: # Calendar Days in Report Period:
Patient Record #: Titration Mode: AutoAdjust
Minimum Use Threshold: 4 hours

Provider Information Referring Physician Information

Company Name: Name:

Street 1: Group/Practice:
Street 2: Street 1:
City, State, Zip Code: Street 2:
Contact Person: City, State, Zip Code:
Phone:
Fax
E-mail:

Last 90 Days Last 30 Days Last 7 Days Last Day

95th Percentile Pressure 14.0 14.0 14.5 15.0

90th Percentile Pressure 13.0 13.0 14.0 14.5

Pressure Plateau Time 4% 5% 10% 8%

% Days at least 4 hours (not 99% 97% 100% 100%

continuous) in a 24 hour
period

Day Count 81 30 7 1

Days at least 4 hours 80 29 7 1

Apnea/Hypopnea Index 5.5 6.0 6.5 4.0

Central Apnea Index 1.0 1.0 1.0 0.5

% Time In Exhale Puff 0% 0% 0% 0%

% Time In Flow Limitation 2% 2% 1% 2%

% Poor Mask Fit 0% 0% 0% 3%

SmartCode 2DG4-XBD5-BJF5-F5EBN 2KY6-9DE3-FD6G-FL3G 2B3W-TGAG-4B22-F6QL 2NDB-FFA6-GBBY-FX49

While Breathing Hours Last 9.0

Day

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SmartCode Report Definitions

Minimum Use Threshold:

Determines the minimum amount of time that the patient must use the device to be logged as a compliant day. Device settings allow for 3-9 hours for DV6x series
CPAP devices and 4-5 hours for DV5x series CPAP devices, with 4 hours being the default setting. This setting can be changed in the device clinical set-up menu.
Many insurance carriers, including Medicare, state that they pay for the therapy if the patient is compliant. A compliant patient is considered to be one that uses their
CPAP 70% of the days for 4 hours minimum for 30 consecutive days within the first 90 days of therapy.

SmartCode Adherence Score™:

Shows the maximum adherence achieved for any period of thirty consecutive days of use within a ninety-day time frame. The score represents the percentage of
days, within thirty consecutive days, where usage met or exceeded the ‘Usage Threshold.’ This reports the ‘best’ consecutive thirty days of usage. For example, if the
‘best’ 30 out of the last 90 days show 22 days used above the usage threshold and 8 days below the threshold, then the SmartCode Adherence Score™ would show
73% (22/30). For this calculation in DV5x series CPAP devices, the usage must be 4 continuous hours in a 24 hour period and longer than the Usage Threshold. For
this calculation in DV6x series CPAP devices, the usage must be 4 non-continuous hours in a 24 hour period and longer than the Usage Threshold.

Days at Least X Hours

Shows the number of days in the timeframe where the total usage within each day is at least X hours. “X” represents the ‘Usage Threshold’ setting in the patient’s
device. For this calculation, all usage within a 24-hour period is recorded.

% Days at Least X Hours

Shows the percentage of days in the timeframe where the total usage within each day is at least X hours. “X” represents the ‘Usage Threshold’ setting in the patient’s
device. For this calculation, all usage within a 24-hour period is recorded.

Day Count

Shows a count of days for each timeframe. If, for example, the 90-day SmartCode is collected at day 45 of therapy. The “Day Count” for this code will be 45 days. In
most cases, however, the day count is equal to the days in the code’s timeframe(s).

While Breathing Hours

While breathing hours are only available within the last-day timeframe and with the cumulative code. This measurement shows the total hours of CPAP device use.

95th Percentile Pressure

The AutoAdjust pressure or AutoBilevel IPAP (Inspiratory Positive Airway Pressure) was at or below this pressure 95-percent of the time it is in use. This
measurement is often used to determine an optimal pressure for a fixed-pressure CPAP device.

90th Percentile Pressure

AutoAdjust pressure or AutoBilevel IPAP pressure was at or below this pressure 90-percent of the time it is in use. If these pressures are close to the maximum
pressure at which the machine is set, it can be an indication that the patient requires a higher maximum pressure.

Apnea/Hypopnea Index

Apnea/Hypopnea Index (AHI) represents the average number of apneas and hypopneas per hour for the timeframe. While on the AutoAdjust or AutoBilevel, an AHI
equal to or below 10/hour is acceptable but an AHI equal to or below 5/hour is best.

Pressure Plateau Time

Represents the percentage of time the AutoAdjust or AutoBilevel spent at the upper pressure setting. A value of 10% or more indicates a possible need to raise the
upper pressure setting to allow higher pressures.

High Leak Flow Time

Shows the percentage of time where leak was above 95 liters per minute. A value of 10% or more indicates that the mask fit should be checked. NOTE: This only
applies to DV5x series data.

Non-Obstructive Index

Non-Obstructive Event Index (NOI) represents the average number of non-obstructive events per hour. A non-obstructive event is a respiratory event that is detected
but by design does not result in a pressure change during AutoAdjust or AutoBilevel therapy. The Non-Responding Index reflects a possible central apnea and may
indicate a primary central apnea problem or when PAP pressures are increased, the centrals may be CAUSED by the PAP pressure. NOTE: This only applies to
DV5x series data.

Exhale Puff Index

The Exhale Puff Index (EPI) is the number of exhale puff events detected per hour. Exhale puffing is caused by inhaling through the nose and exhaling through the
mouth. If the SmartCode reported EPI is higher than 30 this puffing should be addressed, perhaps through the use of a full face mask or chin strap. NOTE: This only
applies to DV5x series data.

% Time In Exhale Puff

The % Time in Exhale Puff is the percentage of time a patient spent experiencing Exhale Puffing events. Exhale puffing is caused by inhaling through the nose and
exhaling through the mouth. NOTE: This only applies to DV6x series data.

% Machine Inspiration

% Machine Inspiration indicates the percentage of breaths in which the timed backup feature of the Bilevel ST has initiated an inspiration trigger. NOTE: This only
applies to DV56 data

% Machine Expiration

% Machine Expiration indicates the percentage of breaths in which the timed backup feature of the Bilevel ST has initiated an expiration cycle. NOTE: This only
applies to DV56 data.

Central Apnea Index

Central Apnea Index (CAI) represents the average number of central apnea events per hour. NOTE: This only applies to DV6x series data.

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% Poor Mask Fit

Percent of time where leak exceeded a threshold above average intentional leak of the patient’s interface. NOTE: This only applies to DV6x series data.

Days Elapsed

The number of days elapsed in the study period. This value will never go above 90. NOTE: This only applies to DV6x series data.

Therapy Start Date

The date when the unit detects that therapy has started. Start Monitoring is automatically triggered when the device is used continuously for 0.5 hours.

SmartCode Adherence Score™ Met Date

The first date that the SmartCode Adherence Score™ reached 70% (21 days out of 30 days).

Code Collected Date

The date that this SmartCode data was created in the CPAP, either by viewing on the CPAP display or downloading to an external device.

Days >= {0} hours

Shows the number of days in the timeframe where the total usage within each day is at least X hours. "X" represents the ‘Usage Threshold’ setting in the patient’s
device. For this calculation, all usage within a 24-hour period is recorded and only includes days greater than or equal to X hours. NOTE: This only applies to DV6x
series data.

% Days >= {0} hours

Shows the percentage of days in the timeframe where the total usage within each day is at least X hours. "X" represents the ‘Usage Threshold’ setting in the patient’s
device. For this calculation, all usage within a 24-hour period is recorded and only includes days greater than or equal to X hours. (Days at Least X Hours / Day
Count) NOTE: This only applies to DV6x series data.

% Time In Flow Limitation

Percent of time where flow limitation was detected. NOTE: This only applies to DV6x series data.

Days used < {0} hours

Shows the number of days in the timeframe where the total usage within each day is less than X hours. "X" represents the ‘Usage Threshold’ setting in the patient’s
device. This indicates a patient who is using the CPAP but not making the Usage Threshold instead of assuming that all use less than the threshold is zero. For this
calculation, all usage within a 24-hour period is recorded and only includes days less than X hours. NOTE: This only applies to DV6x series data.

% Spontaneous Breath

Percentage of breaths that are spontaneously triggered or cycled. NOTE: This only applies to DV66 data.

1 Day

Hours used for last day. NOTE: This only applies to DV6x data.

7 Days

Average hours used for last 7 days. NOTE: This only applies to DV6x data.

28 Days

Average hours used for last 28 days. NOTE: This only applies to DV6x data.

91 Days

Average hours used for last 91 days. NOTE: This only applies to DV6x data.

Second 28 Day Period

Average hours used for 28 days prior to last 28 Days. NOTE: This only applies to DV6x data.

Third 28 Day Period

Average hours used for 28 days prior to Second 28 Day Period. NOTE: This only applies to DV6x data.

Fourth 28 Day Period

Average hours used for 28 days prior to Third 28 Day Period. NOTE: This only applies to DV6x data.

Fifth 28 Day Period

Average hours used for 28 days prior to Fourth 28 Day Period. NOTE: This only applies to DV6x data.

Sixth 28 Day Period

Average hours used for 28 days prior to Fifth 28 Day Period. NOTE: This only applies to DV6x data.

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