Completion of Certificate of Medical Necessity Forms (Rev. 2993, Upon Implementation of ICD- 10)

by  Jared Staheli
June 18th, 2015

1. SECTION A: (This may be completed by supplier.)

a. Certification Type/Date - If this is an initial certification for this patient, the date (MM/DD/YY) is indicated in the space 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), the initial date is indicated in the space marked "INITIAL", and the revision date is indicated in the space marked "REVISED". If this is a recertification, the initial date is indicated in the space marked "INITIAL", and the recertification date is indicated in the space marked "RECERTIFICATION". Whether a REVISED or RECERTIFIED CMN is submitted, the INITIAL date as well as the REVISED or RECERTIFICATION date is always furnished.

b. Patient Information - This indicates the patient's name, permanent legal address, telephone number, and his/her health insurance claim number (HICN) as it appears on his/her Medicare card and on the claim form.

c. Supplier Information - This indicates the name of the company (supplier name), address, telephone number, and the Medicare supplier number assigned by the National Supplier Clearinghouse (NSC).

d. Place of Service - This indicates the place in which the item is being used, i.e., patient's home is 12, skilled nursing facility (SNF) is 31, or end stage renal disease (ESRD) facility is 65. See chapter 23 for place of service codes.

e. Facility Name - This indicates the name and complete address of the facility, if the place of service is a facility.

f. HCPCS Codes - This is a list of all HCPCS procedure codes for items ordered that require a CMN. Procedure codes that do not require certification are not listed on the CMN.

g. Patient Date of Birth (DOB), Height, Weight, and Sex - This indicates patient's DOB (MM/DD/YY), height in inches, weight in pounds, and sex (male or female).

h. Physician Name and Address - This indicates the treating physician's name and complete mailing address.

i. UPIN - This indicates the treating physician's unique physician identification number (UPIN).

j. Physician's Telephone Number - This indicates the telephone number where the treating physician can be contacted (preferably where records would be accessible pertaining to this patient) if additional information is needed.

2. SECTION B: (This 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 by the treating physician. Contractors publish this requirement about section B in their bulletins at least annually.)

a. Estimated Length of Need - This indicates the estimated length of need (the length of time (in months) the physician expects the patient to require use of the ordered item). If the treating physician expects that the patient will require the item for the duration of his/her life, 99 is entered. For recertification and revision CMNs, the cumulative length of need (the total length of time in months from the initial date of need) is entered.

k. Diagnosis Codes - Listed in the first space is the diagnosis code that represents the primary reason for ordering this item. Additional diagnosis codes that would further describe the medical need for the item (up to 3 codes) are also listed. A given CMN may have more than one item billed, and for each item, the primary reason for ordering may be different. For example, a CMN is submitted for a manual wheelchair (K0001) and elevating leg rests (K0195). The primary reason for K0001 is stroke, and the primary reason for K0195 is edema.

l. Question Section - This section is used to gather clinical information regarding the patient's condition, the need for the DME, and supplies.

m. Name of Person Answering Section B Questions - If a clinical professional other than the treating physician (e.g., home health nurse, physical therapist, dietician, or a physician employee) answers the questions in section B, he/she must print his/her name, give his/her professional title, and the name of his/her employer, where indicated. If the treating physician answered the questions, this space may be left blank.

3. SECTION C: (This is completed by the supplier.)

a. Narrative Description of Equipment and Cost - The supplier indicates (1) a narrative description of the item(s) ordered, as well as all options, accessories, supplies, and drugs; (2) the supplier's charge for each item, option, accessory, supply, and drug; and (3) the Medicare fee schedule allowance for each item, option, accessory, supply, or drug, if applicable.

4. SECTION D: (This is completed by the treating physician.)

a. Physician Attestation - The treating physician's signature certifies the CMN that he/she is reviewing includes sections A, B, C, and D, the answers in section B are correct, and the self-identifying information in section A is correct.

b. Physician Signature and Date - After completion and/or review by the treating physician of sections A, B, and C, the treating physician must sign and date the CMN in section D, verifying the attestation appearing in this section. The treating physician's signature also certifies the items ordered are medically necessary for this patient. Signature and date stamps are not acceptable.

Certifications and recertifications may not be altered by "whiting out" or "pasting over" and entering new data. Such claims are denied and suppliers that show a pattern of altering CMNs are identified for educational contact and/or audit.

Also suppliers who have questionable utilization or billing practices or who are under sanction are considered for audit.


Completion of Certificate of Medical Necessity Forms (Rev. 2993, Upon Implementation of ICD- 10). (2015, June 18). Find-A-Code Articles. Retrieved from

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