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Certificate Of Medical Necessity Seat Lift Mechanisms CMS-849 - Official Federal Forms

Certificate Of Medical Necessity Seat Lift Mechanisms 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-849 -- SEAT LIFT MECHANISMS PATIENT NAME, ADDRESS, TELEPHONE and HICN DME 07.03A SECTION A: Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___ SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI # (__ __ __) __ __ __ - __ __ __ __ HICN _______________________ (__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________ PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI # PLACE OF SERVICE ______________ Supply Item/Service Procedure Code(s): PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____ NAME and ADDRESS of FACILITY if applicable (see reverse) __________ __________ __________ __________ (__ __ __) __ __ __ - __ __ __ __ 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): ______ 1-99 (99=LIFETIME) ANSWERS oY oY oY oY oY oN oN oN oN oN oD oD oD oD oD DIAGNOSIS CODES: ______ ______ ______ ______ ANSWER QUESTIONS 1-5 FOR SEAT LIFT MECHANISM (Check Y for Yes, N for No, or D for Does Not Apply) 1. 2. 3. 4. 5. Does the patient have severe arthritis of the hip or knee? Does the patient have a severe neuromuscular disease? Is the patient completely incapable of standing up from a regular armchair or any chair in his/her home? Once standing, does the patient have the ability to ambulate? Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position (e.g., medication, physical therapy) been tried and failed? If YES, this is documented in the patient's medical records. 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 _____/_____/_____ Signature and Date Stamps Are Not Acceptable. Form CMS-849 (11/11) American LegalNet, Inc. INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR SEAT LIFT MECHANISMS (CMS-849) 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 appropriate number of months. If the patient will require the item for the duration of his/her life, then enter "99". In the first space, list the diagnosis code that represents the primary reason for ordering this item. List any additional diagnosis codes that would further describe the medical need for the item (up to 4 codes). This section is used to gather clinical information to help Medicare determine
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