Form Hcfa 484 – Fill Out and Use This PDF

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION

OMB NO. 0938-0534

CERTIFICATE OF MEDICAL NECESSITY

DMERC 484.2

OXYGEN

SECTION A

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

RECERTIFICATION __/___/__

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER

(__ __ __) __ __ __ - __ __ __ __ HICN ____________________________

(__ __ __) __ __ __ - __ __ __ __ NSC # __________________________________

PLACE OF SERVICE ________

HCPCS CODE

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

HT.______(in.) ; WT._____(lbs.)

NAME and ADDRESS of FACILITY if applicable (See

PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN NUMBER

Reverse)

(__ __ __) __ __ __ - __ __ __ __ UPIN # __________________________________

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 (ICD-9): _________ _________ _________ _________

ANSWERS

ANSWER QUESTIONS 1-10. (Circle Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.)

a)

mm Hg

1.

Enter the result of most recent test taken on or before the certification date listed in Section A. Enter (a) arterial blood

b)

%

gas PO2 and/or (b) oxygen saturation test. Enter date of test (c).

c)

/

/

Y

N

2.

Was the test in Question 1 performed EITHER with the patient in a chronic stable state as an outpatient OR within two

days prior to discharge from an inpatient facility to home?

1

2

3

3.

Circle the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise; (3) During Sleep

XXXXXXXXXXXXXXX 4. Physician/provider performing test in Question 1 (and, if applicable, Question 7). Print/type name and address below:

XXXXXXXXXXXXXXX

NAME:

ADDRESS:

XXXXXXXXXXXXXXX

Y

N

D

5. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering portable oxygen,

circle D.

LPM

6. Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter a “X”.

a)

mm Hg

7. If greater than 4 LPM is prescribed, enter results of most recent test taken on 4 LPM. This may be an (a) arterial blood

b)

%

gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state. Enter date of test (c).

Y

N

D

8.

Does the patient have dependent edema due to congestive heart failure?

Y

N

D

9.

Does the patient have cor pulmonale or pulmonary hypertension documented by P pulmonale on an EKG or by an

echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement?

Y

N

D

10.

Does the patient have a hematocrit greater than 56%?

SECTION C

Narrative Description of Equipment and Cost

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 marked

TYPE/DATE:

"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 recertification

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 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 health insurance claim number (HICN)

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 the Medicare Supplier

INFORMATION:

Number assigned to you by the National Supplier Clearinghouse (NSC).

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.

HCPCS CODES:

List all HCPCS procedure codes for items ordered that require a CMN. Procedure codes that do not require certification

should not be listed 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:

UPIN:

Accurately indicate the treating physician's Unique Physician Identification Number (UPIN).

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 physician.)

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 physician expects that the patient will require the item for the duration of

his/her life, then enter 99.

DIAGNOSIS CODES:

In the first space, list the ICD9 code that represents the primary reason for ordering this item. List any additional ICD9 codes

that would further describe the medical need for the item (up to 3 codes).

QUESTION SECTION:

This section is used to gather clinical information to determine medical necessity. Answer each question which applies to

the items ordered, circling "Y" for yes, "N" for no, "D" for does not apply, a number if this is offered as an answer option, or

fill in the blank if other information is requested.

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, option, accessory, supply and drug; and (3) the Medicare fee schedule allowance for

EQUIPMENT & COST:

each item/option/accessory/supply/drug, 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 answers

ATTESTATION:

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 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. Signature and date stamps are not acceptable.