Form CMS-853 Certificate of Medical Necessity

CMS Certificate of Medical Necessity Forms

Aside from the CMS-853, the department provides several CMN forms, each of them covering its own type of the required medical equipment:

• Form CMS-484, Certificate of Medical Necessity - Oxygen. Fill out this form to document the necessity of oxygen and oxygen equipment;
• Form CMS-846, Certificate of Medical Necessity - Pneumatic Compression Devices. Complete the form to record the necessity of pneumatic compression devices;
• Form CMS-847, Certificate of Medical Necessity - Osteogenesis Stimulators. Use this document to support the necessity of osteogenesis stimulators;
• Form CMS-848, Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS). Complete this form when you need to document the medical necessity of transcutaneous electrical nerve stimulator;
• Form CMS-849, Certificate of Medical Necessity - Seat Lift Mechanisms. Fill out this document to record a seat lift mechanism medical necessity;
• Form CMS-854, Certificate of Medical Necessity. This is a supplementary form used with the CMS-853. Use it when the space provided in Section C on any of the previous forms is not enough for a sufficient description of the required equipment and costs.

Each of the aforementioned CMN Form can fall under one out of three types:

1. Initial. Documents the initial medical necessity of a specific item.
2. Revised. Contains changes made to the order, e.g., change in the quantity of the units prescribed, change in the physician, or other related changes.
3. Recertification. Used to confirm that the medical need for the indicated equipment is still present.

Form CMS-853 Instructions

Form CMS-853 consists of four sections named with letters A through D. Section A is completed by the supplier. The initial date requested in Section A of the form is the date when the physician provides as the start of the medical necessity for the equipment. If the beneficiary's physician does not provide a start date, indicate the date of the order in this field.

Section C must be completed by the supplier. Sections B and D must be filled out by the beneficiary's physician. A supplier who deliberately fills out Section B of the form is subject to a civil penalty. The amount of penalty may reach up to $1,000 per form. The date required in Section D is the date the physician has signed the form.

According to the regulation requirements, the information you provide to the physician on this form is limited to the description of the ordered equipment and supplies, information required for proper identification of the beneficiary and the supplier, procedure codes for the equipment and supplies, and other related administrative information. If you need to communicate with the physician regarding the changes in the patient regimen, brief description of the items provided, or issues related to any CMS or Contractor policy changes, you may do it via CMN cover letters. Cover letters are not required by the CMS.