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Certificate of Medical Necessity Seat Lift Mechanisms Attachment (CMNSLM)

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 severe arthritis of the hip or knee?  

1
Question 2: Does the patient have a severe neuromuscular disease?   1
Question 3: Is the patient completely incapable of standing up from a regular armchair or any chair in his/her home?   1
Question 4: Once standing, does the patient have the ability to ambulate?   1
Question 5: Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position (e.g. medication, physical therapy) been tried and failed? If yes please document in the patient's medical records   1