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Cetificate Of Medical Necessity Osteogenesis Stimulators CMS-847 - Official Federal Forms
| Cetificate Of Medical Necessity Osteogenesis Stimulators 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. 0938-0679 CERTIFICATE OF MEDICAL NECESSITY CMS-847 -- OSTEOGENESIS STIMULATORS SECTION A Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER DME 04.04C 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) Ht. ____(in) Wt ____(lbs.) PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable NPI NUMBER or UPIN __________ __________ __________ __________ (__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________ SECTION B Information in this Section May Not Be Completed by the Supplier of the Items/Supplies. DIAGNOSIS CODES (ICD-9): ______ ______ ______ ______ EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME) ANSWERS QUESTIONS 1-5 ARE BLANK. ANSWER QUESTIONS 6-8 FOR NONSPINAL ELECTRICAL OSTEOGENESIS STIMULATOR. ANSWER QUESTIONS 9-11 FOR SPINAL ELECTRICAL OSTEOGENESIS STIMULATOR. ANSWER QUESTIONS 6 AND 12 FOR ULTRASONIC OSTEOGENSIS STIMULATOR (Circle Y for Yes, N for No, or D for Does Not Apply. For questions about months, enter 199 or D. If less than one month, enter 1.) D 6. In a fracture, has there been no clinically significant radiographic evidence of healing for a minimum of 90 days? 7. (a) Does the patient have a failed fusion of a joint other than the spine? (b) How many months prior to ordering the device did the patient have the fusion? 8. Does the patient have a congenital pseudoarthrosis? 9. (a) Is the device being ordered as a treatment of a failed single level spinal fusion surgery in a patient who has not had a recent repeat fusion? (b) How many months prior to ordering the device did the patient have the fusion? 10. (a) Is the device being ordered as an adjunct to repeat single level spinal fusion surgery in a patient with a previously failed spinal fusion at the same level(s)? (b) How many months prior to ordering the device did the patient have the repeat fusion? (c) How many months prior to ordering the device did the patient have the previously failed fusion? 11. Is the device being ordered following multi-level spinal fusion surgery? 12. Has there been at least one open surgical intervention for treatment of the fracture? a) Y N a) Y N D b)________________ Y N D a) Y N D b)________________ a) Y N D b)________________ c)________________ Y Y N N D D 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-847 (09/05) EF 08/2006 American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR OSTEOGENESIS STIMULATORS (CMS-847) 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 number where th
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