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Certificate Of Medical Necessity CMS-484 - Official Federal Forms

Certificate Of Medical Necessity Form. This is a national form and can be used in Centers For Medicare And Medicaid Services .
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0534 CERTIFICATE OF MEDICAL NECESSITY CMS-484-- OXYGEN SECTION A: Certification Type/Date: INITIAL PATIENT NAME, ADDRESS, TELEPHONE and HICN DME 484.3 / / REVISED / / RECERTIFICATION / / SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI # ( ) ­ HICN ( ) / / ­ Sex NSC or NPI # (M/F) Ht. _(in) Wt PLACE OF SERVICE NAME and ADDRESS of FACILITY if applicable (see reverse) Supply Item/Service Procedure Code(s): PT DOB PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI # ( ) ­ UPIN or NPI # SECTION B: Information in this Section May Not Be Completed by the Supplier of the Items/Supplies. EST. LENGTH OF NEED (# OF MONTHS): 1­99 (99=LIFETIME) DIAGNOSIS CODES: ANSWERS a) b) c) o1 ANSWER QUESTIONS 1­9. (Check Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.) / o2 mm Hg 1. Enter the result of most recent test taken on or before the certification date listed in % Section A. Enter (a) arterial blood gas PO2 and/or (b) oxygen saturation test; / (c) date of test. o3 2. Was the test in Question 1 performed (1) with the patient in a chronic stable state as an outpatient, (2) within two days prior to discharge from an inpatient facility to home, or (3) under other circumstances? o1 o2 o3 3. Check the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise; (3) During Sleep oY oN oD 4. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering portable oxygen, check D. LPM 5. Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter an "X". a) mm Hg 6. If greater than 4 LPM is prescribed, enter results of most recent test taken on 4 LPM. This may be an b) % (a) arterial blood gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state. Enter date of test (c). c) / / ANSWER QUESTIONS 79 ONLY IF PO2 = 56­59 OR OXYGEN SATURATION = 89 IN QUESTION 1 oY oY oY oN oN oN 7. Does the patient have dependent edema due to congestive heart failure? 8. Does the patient have cor pulmonale or pulmonary hypertension documented by P pulmonale on an EKG or by an echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement. 9. Does the patient have a hematocrit greater than 56%? NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print): NAME TITLE EMPLOYER SECTION C: Narrative Description of Equipment and Cost (1) Narrative description of Iall items, accessories and option ordered; (2) Suppliers charge; and (3) Medicare Fee Schedule Allowance for each item, accessory, and option (see instructions on back) SECTION D: PHYSICIAN Attestation and Signature/Date I certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of Medical Necessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in Section B is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability. PHYSICIAN'S SIGNATURE Signature and Date Stamps Are Not Acceptable. Form CMS­484 (11/11) DATE / / American LegalNet, Inc. INSTRuCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR OXYGEN SECTION A: CERTIFICATION DATE: (May be completed by the supplier) If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the space TYPE/ marked "INITIAL." If this is a revised certification (to be completed when the physician changes the order, based on the patient's changing clinical needs), indicate the initial date needed in the space marked "INITIAL," and indicate the recertification date in the space marked "REVISED." If this is a recertification, indicate the initial date needed in the space marked "INITIAL," and indicate the recertification date in the space marked "RECERTIFICATION." Whether submitting a REVISED or a RECERTIFIED CMN, be sure to always furnish the INITIAL date as well as the REVISED or RECERTIFICATION date. Indicate the patient's name, permanent legal address, telephone number and his/her health insurance claim number (HICN) as it appears on his/her Medicare card and on the claim form. Indicate the name of your company (supplier name), address and telephone number along with the Medicare Supplier Number assigned to you by the National Supplier Clearinghouse (NSC) or applicable National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. If using a legacy number, e.g. NSC number, use the qualifier 1C followed by the 10-digit number. (For example. 1Cxxxxxxxxxx) Indicate the place in which the item is being used, i.e., patient's home is 12, skilled nursing facility (SNF) is 31, End Stage Renal Disease (ESRD) facility is 65, etc. Refer to the DMERC supplier manual for a complete list. If the place of service is a facility, indicate the name and complete address of the facility. List all procedure codes for items ordered. Procedure codes that do not require certification should not be listed on the CMN. Indicate patient's date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in pounds, if requested. Indicate the PHYSICIAN'S name and complete mailing address. Accurately indicate the treating physician's Unique Physician Identification Number (UPIN) or applicable National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. If using UPIN number, use the qualifier 1G followed by the 6-digit number. (For example. 1Gxxxxxx) Indicate the telephone number where the physician can be contacted (preferably where records would be accessible pertaining to this patient) if more information is needed. (May not be completed by the supplier. While this section may be completed by a non-physician clinician, or a Physician employee, it must be reviewed, and the CMN signed (in Section D) by the treating practitioner.) Indicate the estimated length of need (the length of time the physician expects the patient to require use of the ordered item) by filling in the approp
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