DME MAC JURISDICTION C - CGS

CMNs Chapter 4Certificates of Medical Necessity (CMNs) and DME MAC InformationForms (DIFs)A Certificate of Medical Necessity (CMN) or DME Information Form (DIF) is required to helpdocument the medical necessity and other coverage criteria for selected durable medical equipment,prosthetics, orthotics and supplies (DMEPOS) items. The Documentation section of the medicalpolicy shows which items require one of these forms. CMNs contain four sections, A through D.Sections A and C are completed by the supplier and Sections B and D are completed by thephysician. A DIF is completed and signed by the supplier. It does not require a narrative descriptionof equipment and cost or a physician signature.For certain items or services billed to a DME MAC, the supplier must receive a signed CMN from thetreating physician. A supplier must have a faxed, photocopied, original signed order or an electronicCMN in their records before they can submit a claim for payment to Medicare. CMNs and DIFs arereferred to by their CMS form numbers. The CMS form number is located in the bottom left corner ofthe form. DME MAC form numbers identify the CMN on electronic claims submitted to the DMEMAC.A faxed, photocopied, original signed order, or an electronic signed CMN/DIF must be maintained bythe supplier and be available to the DME MAC or DME PSC on request. When hardcopy CMNs/DIFsare submitted to the DME MAC or DME PSC, the supplier must include a copy of the front side.When CMNs are submitted electronically to the DME MAC or DME PSC, information from sections Aand B are required.In 2006, the Centers for Medicare and Medicaid Services (CMS) developed new and improvedCertificates of Medical Necessity (CMNs) and DME MAC Information Forms (DIFs). These changesare indicated below.The new CMN/DIF forms must be used for CMN/DIFs received on or after July 1, 2007. The oldCMN forms are no longer valid.Newly Revised FormsThe following table indicates the newly revised DME MAC CMN forms.Note: The title of the CMS form 484 for Home Oxygen Therapy changed to Oxygen. In addition, thetitle of CMS form 846 was changed from Lymphedma Pumps to Pneumatic Compression Devices.DME MAC FORM CMS FORM ITEMS ADDRESSED484.03 484 Oxygen04.04B 846 Pneumatic CompressionDevices04.04C 847 Osteogenesis Stimulators06.03B 848 Transcutaneous ElectricalNerve Stimulators (TENS)07.03A 849 Seat Lift Mechanisms11.02 854 Section C Continuation FormDME MAC Jurisdiction C Supplier Manual Page 1