Form Cms-853 - Certificate Of Medical Necessity printable pdf download

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0679

CERTIFICATE OF MEDICAL NECESSITY

DMERC 10.02B

ENTERAL NUTRITION

SECTION A

Certification Type/Date:

INITIAL ___/___/___

REVISED ___/___/___

___/___/___

RECERTIFICATION

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.)

PLACE OF SERVICE ________

HCPCS CODES:

NAME and ADDRESS of FACILITY if applicable (See

PHYSICIAN NAME, ADDRESS (Printed or Typed)

Reverse)

PHYSICIAN'S UPIN:

PHYSICIAN'S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __

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 7, 8, AND 10 - 15 FOR ENTERAL NUTRITION

(Circle

for Yes,

for No, or

for Does Not Apply, Unless Otherwise Noted)

Questions 1 - 6, and 9, reserved for other or future use.

Does the patient have permanent non-function or disease of the structures that normally permit food to reach

or be absorbed from the small bowel?

Does the patient require tube feedings to provide sufficient nutrients to maintain weight and strength

commensurate with the patient's overall health status?

10.

Print product name(s).

11.

Calories per day for each product?

12.

Days per week administered? (Enter 1 - 7)

13.

Circle the number for method of administration?

1 - Syringe 2 - Gravity 3 - Pump 4 - Does not apply

14.

Does the patient have a documented allergy or intolerance to semi-synthetic nutrients?

15.

Additional information when required by policy:

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 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-853 (04/96)