Form Cms-848 - Certificate Of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (Tens) - Dme 06.03b
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1
2DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
DME 06.03B
CMS-848 — TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)
SECTION A: Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HICN
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
PLACE OF SERVICE ______________ Supply Item/Service Procedure Code(s): PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs
__________
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #
if applicable (see reverse)
__________
__________
__________
(__ __ __) __ __ __ - __ __ __ __ 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: ______ ______ ______ ______
ANSWER QUESTIONS 1–6 for purchase of TENS
ANSWERS
(Check Y for Yes, N for No,)
o Y
o 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.)
3.
Is the TENS unit being prescribed for any of the following conditions? (Check appropriate number)
o 1 o 2 o 3
1 - Headache
2 - Visceral abdominal pain
3 - Pelvic pain
o 4 o 5
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
o Y
o N
tried and failed?
o Y
o 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 _____/_____/_____
Signature and Date Stamps Are Not Acceptable.
Form CMS-848 (09/05)
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