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 1: Is there documentation in the medical record that supports the patient having a permanent non-function or disease of the structures that normally permit food to reach or be absorbed from the small bowel? |
|
1 |
|
| Question 2: Is the enteral nutrition being provided for administration via tube? | |
1 |
|
| Question 3A: Select the HCPCS product code | |
1 |
|
| Question 3B: Calories per day for the HCPCS product code | |
50 |
|
| Question 4A: Select an additional HPCPS product code if applicable | 1 |
||
| Question 4B: Calories per day for the additional HCPCS product code | 50 |
||
| Question 5: Indicate method of administration | |
1 |
|
| Question 6: Days per week administered or infused | |
50 |
|
| Question 7: Is there documentation in the medical record that supports the patient having permanent disease of the gastrointestinal tract causing malabsorption severe enough to prevent maintenance of weight and strength commensurate with the patient's overall health status? | |
1 |
|
| Question 8A: Amino Acid (ml/day) | |
50 |
|
| Question 8A: Amino Acid concentration % | |
50 |
|
| Question 8A: Amino Acid gms protein/day | |
50 |
|
| Question 8B: Dextrose ml/day | |
50 |
|
| Question 8B: Dextrose concentration % | |
50 |
|
| Question 8C: Lipids ml/day | |
50 |
|
| Question 8C: Lipids days/week | |
50 |
|
| Question 8C: Lipids concentration % | |
50 |
|
| Question 9: Route of Administration | |
1 |
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