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.
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:
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.