Cms 849 Form Details

Medical form lift chairs are a great way to improve your quality of life if you have trouble getting around. These chairs can help you get up from a sitting or lying down position with ease, making it much easier for you to move around. In this post, we'll take a look at the different types of medical form lift chairs available and what each one is best suited for. We'll also discuss some of the features you should look for when shopping for a lift chair.

You might find it beneficial to understand the amount of time you'll need to fill in this medical form lift chair and just how long the document is.

QuestionAnswer
Form NameMedical Form Lift Chair
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslift chair medicare form, cms 849 form, medicare form for lift chair, certificate of medical necessity for lift chair

Form Preview Example

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

 

 

 

 

 

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

CERTIFICATE OF MEDICAL NECESSITY

OMB NO. 0938-0679

 

 

DMERC 07.02A

 

 

 

SEAT LIFT MECHANISM

 

 

 

SECTION A

Certification Type/Date:

INITIAL ___/___/___

REVISED ___/___/___

 

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

 

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER

 

 

 

 

 

ActiveForever

 

 

 

 

 

 

 

 

10799฀N.฀90th฀St.

 

 

 

 

 

 

 

Scottsdale,฀AZ฀85260

 

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

 

 

 

480฀฀767-6800฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀N/A

 

 

 

 

(__

)

-

NSC #

 

PLACE OF SERVICE

 

 

HCPCS CODE:

 

PT DOB ____/____/____;

Sex ____ (M/F) ; HT.______(in.) ;

WT._____(lbs.)

NAME and ADDRESS of FACILITY if applicable (See

 

E062__nu

 

PHYSICIAN NAME, ADDRESS (Printed or Typed)

 

Reverse)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN'S UPIN:

 

 

 

 

 

 

 

PHYSICIAN'S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __

 

 

 

 

 

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 -5 FOR SEAT LIFT MECHANISM

 

 

 

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

Y

N

D

1.

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

 

 

 

 

 

 

 

Y

N

D

2.

Does the patient have a severe neuromuscular disease?

 

 

 

 

 

 

Y

N

D

3.

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

 

 

 

 

 

 

Y

N

D

4.

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

 

 

 

 

 

 

Y

N

D

5.

Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position

 

 

 

 

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

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) Supplier's 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 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)

CMS 849 (04/96)

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 ordering 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 ordering 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.

NAME OF PERSON

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

ANSWERING SECTION B or a 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, 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.

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 15 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(s) or suggestions for improving this form, please write to: CMS, 7500 Security Blvd., N2-14-26, Baltimore, Maryland 21244-1850.