Cms 849 – Fill Out and Use This PDF

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

No. 0938-0679

CENTERS FOR MEDICARE & MEDICAID SERVICES

Expires 02/2024

PATIENT NAME, ADDRESS, TELEPHONE and MEDICARE ID

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #

(__ __ __) __ __ __ - __ __ __ __ Medicare ID _______________________

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

__________

PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #

if applicable (see reverse)

__________

__________

__________

(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________

ANSWERS

ANSWER QUESTIONS 1-5 FOR SEAT LIFT MECHANISM

(Check Y for Yes, N for No, or D for Does Not Apply)

o Y

o N

o D

1.

Does the patient have severe arthritis of the hip or knee?

o Y

o N

o D

2.

Does the patient have a severe neuromuscular disease?

o Y

o N

o D

3.

Is the patient completely incapable of standing up from a regular armchair or any chair in his/her home?

o Y

o N

o D

4.

Once standing, does the patient have the ability to ambulate?

o Y o N o D

(e.g., medication, physical therapy) been tried and failed? If YES, this is documented in the patient’s medical

records.

SECTION A:

(May be completed by the supplier)

CERTIFICATION

If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the space TYPE/

DATE:

marked “INITIAL.” If this is a revised certification (to be completed when the physician changes the order, based on the

patient’s changing clinical needs), indicate the initial date needed in the space marked “INITIAL,” and indicate the

recertification date in the space marked “REVISED.” If this is a recertification, indicate the initial date needed in the

space marked “INITIAL,” and indicate the recertification date in the space marked “RECERTIFICATION.” Whether

submitting a REVISED or a RECERTIFIED CMN, be sure to always furnish the INITIAL date as well as the REVISED or

RECERTIFICATION date.

PATIENT

Indicate the patient’s name, permanent legal address, telephone number and his/her Medicare ID as it appears on his/her

INFORMATION:

Medicare card and on the claim form.

SUPPLIER

Indicate the name of your company (supplier name), address and telephone number along with the Medicare Supplier

INFORMATION:

Number assigned to you by the National Supplier Clearinghouse (NSC) or applicable National Provider Identifier (NPI). If

using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. If using a legacy number,

e.g. NSC number, use the qualifier 1C followed by the 10-digit number. (For example. 1Cxxxxxxxxxx)

PLACE OF SERVICE:

Indicate the place in which the item is being used, i.e., patient’s home is 12, skilled nursing facility (SNF) is 31, End

Stage Renal Disease (ESRD) facility is 65, etc. Refer to the DMERC supplier manual for a complete list.

FACILITY NAME:

If the place of service is a facility, indicate the name and complete address of the facility.

SUPPLY ITEM/SERVICE

List all procedure codes for items ordered. Procedure codes that do not require certification should not be listed

PROCEDURE CODE(S):

on the CMN.

PATIENT DOB, HEIGHT,

Indicate patient’s date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in pounds, if requested.

WEIGHT AND SEX:

PHYSICIAN NAME,

Indicate the PHYSICIAN’S name and complete mailing address.

ADDRESS:

PHYSICIAN

Accurately indicate the treating physician’s Unique Physician Identification Number (UPIN) or applicable National

INFORMATION:

Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number.

If using UPIN number, use the qualifier 1G followed by the 6-digit number. (For example. 1Gxxxxxx)

PHYSICIAN’S

Indicate the telephone number where the physician can be contacted (preferably where records would be accessible

TELEPHONE NO:

pertaining to this patient) if more information is needed.

SECTION B:

(May not be completed by the supplier. While this section may be completed by a non-physician clinician, or a

Physician employee, it must be reviewed, and the CMN signed (in Section D) by the treating practitioner.)

EST. LENGTH OF NEED:

Indicate the estimated length of need (the length of time the physician expects the patient to require use of the ordered

item) by filling in the appropriate number of months. If the patient will require the item for the duration of his/her life,

then enter “99”.

DIAGNOSIS CODES:

In the first space, list the diagnosis code that represents the primary reason for ordering this item. List any additional

diagnosis codes that would further describe the medical need for the item (up to 4 codes).

QUESTION SECTION:

This section is used to gather clinical information to help Medicare determine the medical necessity for the item(s)

being ordered. Answer each question which applies to the items ordered, checking “Y” for yes, “N” for no, or “D” for

does not apply.

NAME OF PERSON

If a clinical professional other than the treating physician (e.g., home health nurse, physical therapist, dietician) or a

ANSWERING SECTION B

physician employee answers the questions of Section B, he/she must print his/her name, give his/her professional title

QUESTIONS:

and the name of his/her employer where indicated. If the physician is answering the questions, this space may be

left blank.

SECTION C:

(To be completed by the supplier)

NARRATIVE

Supplier gives (1) a narrative description of the item(s) ordered, as well as all options, accessories, supplies and drugs;

DESCRIPTION OF

(2) the supplier’s charge for each item(s), options, accessories, supplies and drugs; and (3) the Medicare fee schedule

EQUIPMENT & COST:

allowance for each item(s), options, accessories, supplies and drugs, if applicable.

SECTION D:

(To be completed by the physician)

PHYSICIAN

The physician’s signature certifies (1) the CMN which he/she is reviewing includes Sections A, B, C and D; (2) the

ATTESTATION:

answers in Section B are correct; and (3) the self-identifying information in Section A is correct.

PHYSICIAN SIGNATURE

After completion and/or review by the physician of Sections A, B and C, the physician’s must sign and date the CMN in

AND DATE:

Section D, verifying the Attestation appearing in this Section. The physician’s signature also certifies the items ordered

are medically necessary for this patient.