Certificate of Medical Necessity Transcutaneous Electrical Nerve Stimulator Attachment (CMNTENS)

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 intractable pain?   1
Question 2: Number of months (1-99) that the patient has had the intractable pain?   50
Question 3: Condition the TENS unit is being prescribed for?   1
Question 4: Is there documentation of multiple medications and/or other therapies that have been tried and failed?   1
Question 5: Has the patient received a TENS trial of at least 30 days?   1
Question 6: Enter the date the patient was reevaluated at the end of the trial period     10