Form Cms-848 Certificate Of Medical Necessity Cms-848 - Transcutaneous Electrical Nerve Stimulator (Tens)
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
DME MAC 06.03B
CMS-848 — TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)
SECTION A
Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable
NPI NUMBER/LEGACY NUMBER
Borbas Pharmacy
2046 Bath Avenue
Brooklyn, NY 11214
7186779066
1801926019
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
PLACE OF SERVICE______________
HCPCS CODE
PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs.)
__________
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable
if applicable (see reverse)
NPI NUMBER or UPIN
__________
__________
__________
(__ __ __) __ __ __ - __ __ __ __ 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)
DIAGNOSIS CODES (ICD-9): ______ ______ ______ ______
ANSWERS
ANSWER QUESTIONS 1-6 for purchase of TENS
(Circle Y for Yes, N for No,)
Y
N
1. Does the patient have chronic, intractable pain?
_________ Months
2. How long has the patient had intractable pain? (Enter number of months, 1 - 99.)
1 2 3 4 5
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
Y
N
4. Is there documentation in the medical record of multiple medications and/or other therapies that have been
tried and failed?
Y
N
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?
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)
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