Form Cms 10125 PDF Details

The CMS-10125 form, fundamentally designed by the Department of Health and Human Services and approved by the Office of Management and Budget (OMB No. 0938-0679), serves the crucial purpose of facilitating the provision of External Infusion Pumps under the Centers for Medicare & Medicaid Services. With an expiration date set for February 2024, this Durable Medical Equipment (DME) Information Form is integral for certifying initial, revised, or recertified claims for service. The form encapsulates various segments requiring detailed patient information, supplier data, and specific guidelines to accurately code the supply item/service procedure. Furthermore, it delineates a section dedicated to the physician's details, including their name, address, telephone number, and UPIN or NPI number if applicable. Questions aimed at unearthing clinical specifics about the item or service billed are a part of this comprehensive form, which also insists on a supplier attestation to validate the authenticity and accuracy of the information provided. Ultimately, the CMS-10125 form is pivotal in ensuring that the administration and billing of external infusion pumps are handled in a structured and standardized manner, safeguarding the alignment with regulatory compliance and aiding in the streamlined processing of Medicare claims.

QuestionAnswer
Form NameForm Cms 10125
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdif form sample, form recertification cms, cms dme forms print, form recertification cms online

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved OMB

No. 0938-0679

CENTERS FOR MEDICARE & MEDICAID SERVICES

Expires 02/2024

DME INFORMATION FORM

CMS-10125 — EXTERNAL INFUSION PUMPS

DME 09.03

Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___

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

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

Ht. ____(in) Wt ____(lbs.)

 

 

PROCEDURE CODE(S):

 

 

 

 

 

 

 

__________________________________________

 

 

 

 

 

 

 

 

 

NAME and ADDRESS of FACILITY

 

__________

PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #

if applicable (see reverse)

 

 

__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________

 

 

 

 

 

 

 

__________

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

 

 

 

 

 

 

 

 

 

 

ANSWERS

 

 

ANSWER QUESTIONS 1–4 FOR EXTERNAL INFUSION PUMP.

 

 

 

SUPPLY ITEM/SERVICE PROCEDURE CODE(S):

1. Provide the Supply Item/Service Procedure code(s) for the

 

 

 

 

 

drug(s) that requires the use of the pump.

a) _____________________________________________________________

 

 

 

 

b)_____________________________________________________________

 

 

 

 

c) _____________________________________________________________

 

 

 

 

 

 

 

 

 

 

a) _____________________________________________________________

2.

If a NOC (not otherwise classified) Supply Item/Service

 

Procedure code is listed in question 1, print name of drug.

 

 

 

 

 

b)_____________________________________________________________

 

 

 

 

c) _____________________________________________________________

 

 

 

 

 

 

 

 

 

o 1

o 2

o 3

o 4

3. Check number for route of administration?

 

 

 

 

 

1 – Intravenous

2 – Subcutaneous

3 – Epidural 4 – Other

 

 

 

 

 

 

 

o 1

o 2

 

4.

Check number for method of administration?

 

 

 

1 – Continuous

2 – Intermittent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplier Attestation and Signature/Date

I certify that I am the supplier identified on this DME Information Form and that the information provided is true, accurate, and complete, to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact associated with billing this service may subject me to civil or criminal liability.

SUPPLIER SIGNATURE_________________________________________________________________________ DATE _____/_____/_____

Signature and Date Stamps Are Not Acceptable.

Form CMS-10125 (06/19)

INSTRUCTIONS FOR COMPLETING DME INFORMATION FORM

FOR EXTERNAL INFUSION PUMPS (CMS-10125)

CERTIFICATION

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

TYPE/DATE:

initially in the space 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 also indicate the revision date in the

 

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

 

space marked “INITIAL,” and also indicate the recertification date in the space marked

 

“RECERTIFICATION.” Whether submitting a REVISED or a RECERTIFICATION DIF, 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

INFORMATION:

as it appears on his/her Medicare card and on the claim form.

SUPPLIER

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

INFORMATION:

the Medicare Supplier 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 HCPCS procedure codes for items ordered that require a DIF. Procedure codes that do PROCEDURE CODES: not require certification should not be listed in this section of the DIF.

PATIENT DOB,

Indicate patient’s date of birth (MM/DD/YY) and sex (male or female); height in inches

HEIGHT, WEIGHT

and weight in pounds, if required.

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

INFORMATION:

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 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

TELEPHONE NO:

would be accessible pertaining to this patient) if more information is needed.

QUESTION SECTION:

This section is used to gather clinical information about the item or service billed. Answer each

 

question which applies to the items ordered, checking “Y” for yes, “N” for no, a number if this is

 

offered as an answer option, or fill in the blank if other information is requested.

SUPPLIER

The supplier’s signature certifies that the information on the form is an accurate representation

ATTESTATION:

of the situation(s) under which the item or service is billed.

SUPPLIER

After completion, supplier must sign and date the DME Information Form,

SIGNATURE

verifying the Attestation.

AND DATE:

 

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0679. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.

DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/ for information on claim filing.

Form CMS-10125 (06/19) INSTRUCTIONS