Certificate of Medical Necessity Pneumatic Compression Devices Attachment (CMNPCD)

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: Does the patient have chronic venous insufficiently with venous stasis ulcers?  

1
Question 2: If the patient has venous stasis ulcers, have you seen the patient regularly over the past 6 months and treated the ulcers with a compression bandage system or compression garment?   1
Question 3: Has the patient had radical cancer surgery or radiation for cancer that interrupted normal lymphatic drainage of the extremity?   1
Question 4: Does the patient have a malignant tumor with obstruction of the lymphatic drainage of an extremity?   1
Question 5: Has the patient had lymphedema since childhood or adolescence?   1