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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 .
 Fillable pdf Last Modified 8/7/2006
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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 PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER DME 484.03 Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___ SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable NPI NUMBER/LEGACY NUMBER (__ __ __) __ __ __ - __ __ __ __ HICN _______________________ PLACE OF SERVICE______________ NAME and ADDRESS of FACILITY if applicable (see reverse) HCPCS CODE (__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________ PT DOB ____/____/____ Sex ____ (M/F) __________ __________ __________ __________ PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable NPI NUMBER or UPIN (__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________ SECTION B ANSWERS a)_________mm Hg b)_____________% c)____/____/____ 1 2 3 Information in This Section May Not Be Completed by the Supplier of the Items/Supplies. DIAGNOSIS CODES (ICD-9): ______ ______ ______ ______ ANSWER QUESTIONS 1-9. (Circle Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.) 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. EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME) 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? 3. Circle the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise; (3) During Sleep 4. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering portable oxygen, circle D. 5. Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter a "X". 6. If greater than 4 LPM is prescribed, enter results of most recent test taken on 4 LPM. This may be an (a) arterial blood gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state. Enter date of test (c). 1 Y 2 N 3 D ______________LPM a)_________mm Hg b)_____________% c)____/____/____ ANSWER QUESTIONS 7-9 ONLY IF PO2 = 56­59 OR OXYGEN SATURATION = 89 IN QUESTION 1 Y Y N N 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%? Y N 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 all items, accessories and options ordered; (2) Supplier's 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 ______________________________________________________________________ DATE _____/_____/_____ Form CMS-484 (09/05) EF 08/2006 American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR OXYGEN (CMS-484) SECTION A: CERTIFICATION TYPE/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 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 HCPCS 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 nu
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