This attachment does not have any specific triggers, but is required for DMERC carriers when this Certificate of Medical Necessity is needed.
Data Field Information
| Prompt | Response | Req | Len |
|---|---|---|---|
| Patient Weight in Pounds | Enter the patient's weight in pounds. Populates Loop 2000B, Segment PAT. | 
|
7 |
| Patient Height in Inches | Enter the patient's height in inches. Populates Loop 2400, Segment MEA. | |
4 |
| Certification Type | Select the certification type from the list. Populates Loop 2400, Segment CR3. | |
1 |
| Recertification/Revision Date | Enter the date you want or click the calendar icon to select a date. Populates Loop 2400, Segment DTP*607. | 10 | |
| Replacement Item | If this is a replacement item, select this check box. Populates Loop 2400, Segment CRC. | 10 | |
| CMN Attestation and Signature Date | Enter the date you want or click the calendar icon to select a date. Populates Loop 2400, Segment DTP*461. | |
10 |
| Initial Certification/Therapy Date | Enter the date you want or click the calendar icon to select a date. Populates Loop 2400, Segment DTP*463. | |
10 |
| Specify the number of months the DME Equipment is needed | Enter the number of months. Populates Loop 2400, Segment CR3 | |
50 |
| Question 1A: Select the HCPCS code for the drug(s) that requires the use of the pump. | 1 |
||
| Question 1B: Select an additional HCPCS code for the drug(s) that requires the use of the pump. | 1 |
||
| Question 1C: Select an additional HCPCS code for the drug(s) that requires the use of the pump. | 1 |
||
| Question 2A: If a NOC (not otherwise classified) HCPCS code is listed in question 1, print the name of the drug. | 50 |
||
| Question 2B: If an additional NOC (not otherwise classified) HCPCS code is listed in question 1, print the name of the drug | 50 |
||
| Question 2C: If an additional NOC (not otherwise classified) HCPCS codes is listed in question 1, print the name of the drug | 50 |
||
| Question 3: Select number for route of administration | |
1 |
|
| Question 4: Select number for method administration | |
1 |
Copyright and Trademark Notice. Copyright © 2019 CompuGroup Medical, Inc. CGM®, CompuGroup Medical® and the CGM logo are registered trademarks and CGM webPRACTICE™ and CGM webTOOLS™ are trademarks of CompuGroup Medical AG in the United States and/or other countries. Any rights not expressly granted herein are reserved.
