Form Cms-484 Certificate Of Medical Necessity Cms-484 - Oxygen 2005
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0534
CERTIFICATE OF MEDICAL NECESSITY
DME MAC 484.03
CMS-484 — OXYGEN
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)
__________
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 1-9. (Circle Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.)
a)_________mm Hg
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.
b)_____________%
c)____/____/____
2. Was the test in Question 1 performed (1) with the patient in a chronic stable state as an outpatient, (2) within two
1
2
3
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
1
2
3
4. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering portable
Y
N
D
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”.
______________LPM
a)_________mm Hg
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).
b)_____________%
c)____/____/____
ANSWER QUESTIONS 7-9 ONLY IF PO2 = 56–59 OR OXYGEN SATURATION = 89 IN QUESTION 1
Y
N
7. Does the patient have dependent edema due to congestive heart failure?
Y
N
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?
Y
N
9. Does the patient have a hematocrit greater than 56%?
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)
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