Certificate Of Medical Necessity Possitive Airway Pressure (PAP) Devices {CMS-10269}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. OMB 0938-0679 CERTIFICATE OF MEDICAL NECESSITY CMS-10269: POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR OBSTRUCTIVE SLEEP APNEA SECTION A: Certification Type/Date: INITIAL ____/____/____ RECERTIFICATION ____/____/____ SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI # PATIENT NAME, ADDRESS, TELEPHONE and HICN DME 03.03 (__ __ __) __ __ __ - __ __ __ __ HICN _________________________ HCPCS CODE ________________ ________________ ________________ ________________ (__ __ __) __ __ __ - __ __ __ __ NSC or NPI # ____________________________ PLACE OF SERVICE __________________________ NAME and ADDRESS of FACILITY if applicable (See Reverse) PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.) PHYSICIAN NAME, ADDRESS (Printed or Typed) PHYSICIAN'S NSC or NPI #: ____________________________________________ 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): _________ 1­99 (99=LIFETIME) DIAGNOSIS CODES (ICD-9): ___________ ___________ ___________ ___________ ANSWERS ANSWER QUESTIONS 1­7 FOR INITIAL EVALUATION ANSWER QUESTIONS 8­10 FOR FOLLOW-UP EVALUATION (RECERTIFICATION) (Check Y for Yes, N for No, D for Does Not Apply) Y N 1. 2. 3. 4. 5. 6. D 7. 8. 9. Is the device being ordered for the treatment of obstructive sleep apnea (ICD-9 diagnosis code 327.23)? If YES, continue to Questions 2­5; If NO, Proceed to Section D Enter date of initial face-to-face evaluation Enter date of sleep test (If test spans multiple days, enter date of first day of test) Was the patient's sleep test conducted in a facility-based lab? What is the patient's Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI)? Does the patient have documented evidence of at least one of the following? Excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or history of stroke. If a bilevel device is ordered, has a CPAP device been tried and found ineffective? Enter date of follow-up face-to-face evaluation. Is there a report documenting that the patient used PAP 4 hours per night on at least 70% of nights in a 30 consecutive day period? ____/____/____ ____/____/____ Y N ______________ Y Y N N ____/____/____ Y Y N N 10. Did the patient demonstrate improvement in symptoms of obstructive sleep apnea with the use of PAP? 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) Form CMS-10269 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com 1 INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR OBSTRUCTIVE SLEEP APNEA (CMS-10269) SECTION A: (May be completed by the supplier) CERTIFICATION TYPE/DATE: If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially 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), 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 INFORMATION: Indicate 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. SUPPLIER INFORMATION: Indicate the name of your company (supplier name), address and telephone number along with the National Provider Identification (NPI) 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 DME MAC 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, WEIGHT AND SEX: Indicate patient's date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in pounds, if requested. PHYSICIAN NAME, ADDRESS: Indicate the physician's name and complete mailing address. NPI: Accurately indicate the ordering physician's National Provider Identification number (NPI). PHYSICIAN'S TELEPHONE NO: Indicate the telephone number where the physician can be contacted (preferably where records would be accessible 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: Indica