Get Dme Mac Form 04.04c Cms Form 847 Osteogenesis ... - Cortex Edi

Filling out the DME MAC Form 04.04C CMS Form 847 is essential for documenting medical necessity for osteogenesis stimulators. This guide provides clear, step-by-step instructions to ensure that you complete the form accurately and efficiently in an online format.

Follow the steps to complete your form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in an online editor.
2. In Section A, select the certification type and date. Indicate whether it is an initial certification, revised, or recertification by checking the appropriate box and filling in the corresponding dates.
3. Complete the patient information section with the patient's full name, address, phone number, and health insurance claim number as stated on their Medicare card.
4. Fill in the supplier information with your company name, address, phone number, and either your National Supplier Clearinghouse number or National Provider Identifier.
5. Specify the place of service where the osteogenesis stimulator will be used. Also, provide the name and address of the facility if applicable.
6. List all relevant HCPCS codes for the items ordered in the designated area. Ensure not to include codes that do not require certification.
7. Provide the patient's date of birth, height, weight, and sex in the corresponding fields.
8. Complete the physician's information with their name, address, and applicable identification numbers, ensuring accuracy for potential follow-up.
9. In Section B, which may not be completed by the supplier, estimate the length of need for the equipment in months. Use '99' if it is for a lifetime.
10. Enter relevant diagnosis codes, ensuring the primary ICD-9 code is listed first followed by any additional codes up to four total.
11. Answer the questions in Section B related to medical necessity by circling 'Y' for yes, 'N' for no, or 'D' for does not apply.
12. If another professional completes Section B, they must fill in their name, title, and employer information.
13. In Section C, provide a narrative description of the ordered equipment and associated costs, including both your charge and the Medicare fee schedule allowance.
14. Section D must be completed and signed by the physician. This certifies the necessity and provides an attestation of the information provided.
15. Review the completed form for accuracy. Once all sections are filled out, save your changes, then download, print, or share the form as needed.

Complete your DME MAC Form 04.04C CMS Form 847 online today!