Form CMS-853 "Certificate of Medical Necessity"

What Is Form CMS-853?

Form CMS-853, Certificate of Medical Necessity, is the form used to document the necessity of medical equipment used for enteral nutrition. The form - also known as the "Сertificate of Medical Necessity (CMN) Form" - was issued by the Centers for Medicare and Medicaid Services (CMS), a component of the U.S. Department of Health and Human Services.

The last revision of the document was on April 1, 1996. The form is not available for download from RegInfo, but is active and still in use. Download printable Form CMS-853 through the link below.

The CMN-853 Form is used to document the medical necessity of the selected durable medical equipment, orthotics, prosthetics, and supplies items. The document may be used in support of a medical need and as a substitute for a written order. For the form to be recognized as a physician's detailed written order, the narrative description in Section C must be sufficiently explained, including quantities needed, frequency of replacement, nutrients, supplies, and drugs. To be valid, the form must display the current OMB number.

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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:

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.

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Download Form CMS-853 "Certificate of Medical Necessity"

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U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
DMERC 10.02B
ENTERAL NUTRITION
SECTION A
Certification Type/Date:
INITIAL ___/___/___
REVISED ___/___/___
___/___/___
RECERTIFICATION
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER
(__ __ __) __ __ __ - __ __ __ __ HICN
(__ __ __) __ __ __ - __ __ __ __ NSC #
PT DOB ____/____/____; Sex ____ (M/F) ;
HT.______(in.) ;
WT._______(lbs.)
PLACE OF SERVICE ________
HCPCS CODES:
NAME and ADDRESS of FACILITY if applicable (See
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 7, 8, AND 10 - 15 FOR ENTERAL NUTRITION
Y
N
D
(Circle
for Yes,
for No, or
for Does Not Apply, Unless Otherwise Noted)
Questions 1 - 6, and 9, reserved for other or future use.
Y
N
7.
Does the patient have permanent non-function or disease of the structures that normally permit food to reach
or be absorbed from the small bowel?
Y
N
8.
Does the patient require tube feedings to provide sufficient nutrients to maintain weight and strength
commensurate with the patient's overall health status?
A)
10.
Print product name(s).
B)
A)
11.
Calories per day for each product?
B)
12.
Days per week administered? (Enter 1 - 7)
13.
Circle the number for method of administration?
1
2
3
4
1 - Syringe 2 - Gravity 3 - Pump 4 - Does not apply
Y
N
D
14.
Does the patient have a documented allergy or intolerance to semi-synthetic nutrients?
15.
Additional information when required by policy:
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-853 (04/96)
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
DMERC 10.02B
ENTERAL NUTRITION
SECTION A
Certification Type/Date:
INITIAL ___/___/___
REVISED ___/___/___
___/___/___
RECERTIFICATION
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER
(__ __ __) __ __ __ - __ __ __ __ HICN
(__ __ __) __ __ __ - __ __ __ __ NSC #
PT DOB ____/____/____; Sex ____ (M/F) ;
HT.______(in.) ;
WT._______(lbs.)
PLACE OF SERVICE ________
HCPCS CODES:
NAME and ADDRESS of FACILITY if applicable (See
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 7, 8, AND 10 - 15 FOR ENTERAL NUTRITION
Y
N
D
(Circle
for Yes,
for No, or
for Does Not Apply, Unless Otherwise Noted)
Questions 1 - 6, and 9, reserved for other or future use.
Y
N
7.
Does the patient have permanent non-function or disease of the structures that normally permit food to reach
or be absorbed from the small bowel?
Y
N
8.
Does the patient require tube feedings to provide sufficient nutrients to maintain weight and strength
commensurate with the patient's overall health status?
A)
10.
Print product name(s).
B)
A)
11.
Calories per day for each product?
B)
12.
Days per week administered? (Enter 1 - 7)
13.
Circle the number for method of administration?
1
2
3
4
1 - Syringe 2 - Gravity 3 - Pump 4 - Does not apply
Y
N
D
14.
Does the patient have a documented allergy or intolerance to semi-synthetic nutrients?
15.
Additional information when required by policy:
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-853 (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
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 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
INFORMATION:
(HICN) 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), 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, option, accessory, supply and drug; and (3) the Medicare fee schedule allowance
EQUIPMENT & COST:
for 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
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 must sign and date the
CMN in 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, write to: CMS, 7500 Security Blvd., N2-14-26, Baltimore, Maryland 21244-1850.
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