Certificate Of Medical Necessity Form

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U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICARE SERVICES

OMB NO. 0938-0875

CERTIFICATE OF MEDICAL NECESSITY

DMERC 02.03A

MOTORIZED WHEELCHAIRS

SECTION A

Certification Type/Date:

INITIAL ___/___/___

REVISED ___/___/___

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER

(__ __ __) __ __ __ - __ __ __ __ HICN

(__ __ __) __ __ __ - __ __ __ __ NSC #

PT DOB ____/____/____; Sex ____ (M/F) ;

HT.______(in.) ;

WT._____(lbs.)

HCPCS CODES:

PLACE OF SERVICE ________

NAME and ADDRESS of FACILITY if applicable (See

PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN NUMBER

Reverse)

(__ __ __)__ __ __-__ __ __ __

UPIN #

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): _________ _________ _________ _________

ANSWER QUESTIONS 1, 6 AND 7 FOR MOTORIZED WHEELCHAIR BASE, 1-5 FOR

ITEM ADDRESSED

ANSWERS

WHEELCHAIR OPTIONS/ACCESSORIES.

(Circle

for Yes,

for No, or

for Does Not Apply, unless otherwise noted.)

Motorized Whlchr Base

1. Does the patient require and use a wheelchair to move around in their residence?

and All Accessories

Reclining Back

2. Does the patient have quadriplegia, a fixed hip angle, a trunk cast or brace, excessive extensor

tone of the trunk muscles or a need to rest in a recumbent position two or more times during the

day?

Elevating Legrest

3. Does the patient have a cast, brace or musculoskeletal condition, which prevents 90 degree flexion

of the knee, or does the patient have significant edema of the lower extremities that requires an

elevating legrest, or is a reclining back ordered?

Adjustable Height Armrest

4. Does the patient have a need for arm height different than that available using non-adjustable

arms?

Reclining Back;

5. How many hours per day does the patient usually spend in the wheelchair? (1–24) (Round up to

________

Adjustable Height Armrest

the next hour)

Motorized Whlchr Base

6. Does the patient have severe weakness of the upper extremities due to a neurologic, muscular, or

cardiopulmonary disease/condition?

Motorized Whlchr Base

7. Is the patient unable to operate any type of manual wheelchair?

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.) If additional space is needed, list wheelchair base

and most costly options/accessories on this page and continue on Form CMS-854.

Manufact

Model

Part Number

Description

Code

Modifier

Billed

Allowable

r r

CHECK HERE IF ADDITIONAL OPTIONS/ACCESSORIES ARE LISTED ON Form CMS-854

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)

CMS-843 (05/97)