Form Cms 847 PDF Details

Form CMS 847 is a tax form used to report certain information about the use of timber in a trade or business. This form is generally used by businesses that deal in lumber and other forestry products. Knowing how and when to use Form CMS 847 can help you avoid penalties from the IRS. Let's take a closer look at this form and what it entails. Forms are an important part of any business, especially those dealing with inventory or products that have a specific tax code attached to them. In our previous blog post, we took a look at Form 720, which is used to report excise taxes on goods and services. Today, we'll be focusing on Form CMS 847: the Timber Tax Form.

If you wish to first find out how much time you need to fill in the form cms 847 and what number of pages it's got, here is some general information that may be helpful.

QuestionAnswer
Form NameForm Cms 847
Form Length2 pages
Fillable?Yes
Fillable fields52
Avg. time to fill out10 min 58 sec
Other names

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Form Approved OMB

DEPARTMENT OF HEALTH AND HUMAN SERVICES

No. 0938-0679

CENTERS FOR MEDICARE & MEDICAID SERVICES

Expires 02/2024

 

 

 

CERTIFICATE OF MEDICAL NECESSITY

CMS-847 — OSTEOGENESIS STIMULATORS

DME 04.04C

SECTION A: 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/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 #____________

 

 

 

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

QUESTIONS 1–5 ARE BLANK.

 

ANSWER QUESTIONS 6–8 FOR NONSPINAL ELECTRICAL OSTEOGENESIS STIMULATOR.

 

ANSWER QUESTIONS 9–11 FOR SPINAL ELECTRICAL OSTEOGENESIS STIMULATOR.

 

ANSWER QUESTIONS 6 AND 12 FOR ULTRASONIC OSTEOGENSIS STIMULATOR.

 

(Check Y for Yes, N for No, or D for Does Not Apply. For questions about months, enter 1–99 or D. If less than one month, enter 1.)

a) oY o N oD 6. In a fracture, has there been no clinically significant radiographic evidence of healing for a minimum of 90 days?

a)oY o N oD 7. (a) Does the patient have a failed fusion of a joint other than the spine?

(b)How many months prior to ordering the device did the patient have the fusion?

b )_____________

o Y o N o D

8. Does the patient have a congenital pseudoarthrosis?

a)oY o N oD 9. (a) Is the device being ordered as a treatment of a failed single level spinal fusion surgery in a patient who has not had a recent repeat fusion?

b)

(b) How many months prior to ordering the device did the patient have the fusion?

a)o Y o N o D 10. (a) Is the device being ordered as an adjunct to repeat single level spinal fusion surgery in a patient with a previously failed spinal fusion at the same level(s)?

b)_____________

(b) How many months prior to ordering the device did the patient have the repeat fusion?

 

c)______________

(c) How many months prior to ordering the device did the patient have the previously failed fusion?

 

 

 

 

 

 

o Y

o

N o D

11. Is the device being ordered following multi¬level spinal fusion surgery?

 

 

 

 

 

 

o Y o N o D

12. Has there been at least one open surgical intervention for treatment of the fracture?

 

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 Iall items, accessories and option 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–847 (06/19)

INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY

FOR OSTEOGENESIS STIMULATORS

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.

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-847 (06/19) INSTRUCTIONS

How to Edit Form Cms 847 Online for Free

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Please type in the following details to create the dmerc PDF:

portion of fields in omb

Include the asked details in the a) oY o N oD, b ), ) How many months prior to, o Y o N o, a) oY o N oD, (b) How many months prior to, a) o Y o N o, D 10, b) c), (b) How many months prior to, previously failed spinal fusion at, o Y o N o D o Y o N o D, NAME OF PERSON ANSWERING SECTION B, SECTION C: Narrative Description, and (1) Narrative description of Iall segment.

omb a) oY o N oD, b ), ) How many months prior to, o Y o N o, a) oY o N oD, (b) How many months prior to, a) o Y o N o, D 10, b) c), (b) How many months prior to, previously failed spinal fusion at, o Y o N o D o Y o N o D, NAME OF PERSON ANSWERING SECTION B, SECTION C: Narrative Description, and (1) Narrative description of Iall fields to insert

The application will require information to instantly submit the field I certify that I am the treating, PHYSICIAN’S SIGNATUREDATE //, and Form CMS–847 (06/19).

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