Form Cms-484 - Certificate Of Medical Necessity - Oxygen
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1
2DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0534
CERTIFICATE OF MEDICAL NECESSITY
DME 484.3
CMS-484 — OXYGEN
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.
NAME and ADDRESS of FACILITY if
PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #
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:
ANSWERS
ANSWER QUESTIONS 1–9.
(Check Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.)
1. Enter the result of most recent test taken on or before the certification date listed in Section A.
a)
mm Hg
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,
1
2
3
(2) within two days prior to discharge from an inpatient facility to home, or (3) under other circumstances?
3. Check the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise;
1
2
3
(3) During Sleep
4. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering
Y
N
D
portable oxygen, check D.
5. Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter
LPM
an “X”.
6. If greater than 4 LPM is prescribed, enter results of most recent test taken on 4 LPM. This may be an (a)
a)
mm Hg
arterial blood gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state. Enter date
b)
%
of test (c).
/
/
c)
ANSWER QUESTIONS 7–9 ONLY IF PO2 = 56–59 OR OXYGEN SATURATION = 89 IN QUESTION 1
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
Y
N
or by an echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement?
9. Does the patient have a hematocrit greater than 56%?
Y
N
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) Suppliers 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-484 (11/11)
1
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