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Certificate Of Medical Necessity Transcutaneous Electrical Nerve Stimulator (TENS) CMS-848 - Official Federal Forms
| Certificate Of Medical Necessity Transcutaneous Electrical Nerve Stimulator (TENS) 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 DME 06.03B CERTIFICATE OF MEDICAL NECESSITY CMS-848 -- TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS) SECTION A Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___ SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable NPI NUMBER/LEGACY NUMBER PATIENT NAME, ADDRESS, TELEPHONE and HIC 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 ANSWERS Y N Information in this Section May Not Be Completed by the Supplier of the Items/Supplies. DIAGNOSIS CODES (ICD-9): ______ ______ ______ ______ ANSWER QUESTIONS 1-6 for purchase of TENS (Circle Y for Yes, N for No,) 1. Does the patient have chronic, intractable pain? 2. How long has the patient had intractable pain? (Enter number of months, 1 - 99.) 3. Is the TENS unit being prescribed for any of the following conditions? (Circle appropriate number) 1 - Headache 2 - Visceral abdominal pain 3 - Pelvic pain 4 - Temporomandibular joint (TMJ) pain 5 - None of the above 4. Is there documentation in the medical record of multiple medications and/or other therapies that have been tried and failed? 5. Has the patient received a TENS trial of at least 30 days? 6. What is the date that you reevaluated the patient at the end of the trial period? EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME) _________ Months 12345 Y N 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-848 (09/05) EF 08/2006 American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS) (CMS-848) 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 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 ICD9 code that represents the primary reason for ordering this item. List any additional ICD9 codes that would further describe the medical need
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