CMS Pub. 100-08, ch. 5, § 5.5

Forms (DIFs)

(Rev. 11431; Issued: 05-26-22; Effective: 06-28-22; Implementation: 06-28-22)

The CMS seeks to reduce burden and modernize processes to ensure a reduction in

improper payments and an increase in customer satisfaction. The CMN form and DIF

were originally required to help document the medical necessity and other coverage

criteria for selected Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

(DMEPOS) items. In the past, a supplier received a signed CMN from the treating

physician or created and signed a DIF to submit with the claim. Due to improvements in

claims processing and medical records management, the information found on CMNs or

DIFs is available either on the claim or in the medical record and is

redundant. Therefore, to reduce burden and increase customer satisfaction, providers and

suppliers no longer need to submit these forms for services rendered after January 1,

2023.

• For claims with dates of service on or after January 1, 2023 – providers and

suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic

filing requirements, claims received with these forms attached will be rejected and

returned to the provider or supplier.

• For claims with dates of service prior to January 1, 2023 – processes will not

change and if the CMN or DIF is required, it will still need to be submitted with

the claim, or be on file with a previous claim.

This statement applies throughout the Program Integrity Manual wherever CMNs and

DIFs are mentioned.

A CMN or a DIF is a form required to help document the medical necessity and other

coverage criteria for selected DMEPOS items. CMNs contain Sections A through D.

Sections A and C are completed by the supplier and Sections B and D are completed by

the physician. A DIF is completed and signed by the supplier. It does not require a narrative

description of equipment and cost or a physician signature.

The following forms below have been approved by the Office of Management and Budget

(OMB). For the CMS. For the CMS forms 484, 846, 847, 848, 849, 854, 10125 and 10126,

the OMB# is 0938-0679.

• CMN CMS-484 – Oxygen

• CMN CMS-846 – Pneumatic Compression Devices

• CMN CMS-847 -- Osteogenesis Stimulators

• CMN CMS-848 – Transcutaneous Electrical Nerve Stimulators

• CMN CMS-849 – Seat Lift Mechanisms

• CMN CMS-854 – Section C Continuation Form

• DME Information Form CMS-10125 – External Infusion Pumps

• DME Information Form CMS-10126 – Enteral & Parenteral Nutrition

The TENS CMN is for purchases only. A TENS CMN will no longer be necessary for

rentals.

For certain items or services billed to a DME MAC, the supplier must receive a signed

CMN from the treating physician or a signed DIF from the supplier. For these items, a

supplier must have a signed original, faxed, photocopied, or electronic CMN or DIF i n

their records when submitting a claim for payment to Medicare.

A signed original, faxed, photocopied, or electronic CMN or DIF must be maintained by

the supplier and be available to the DME MACs, UPICs, SMRC, and DME RACs on

request. When hardcopy CMNs or DIFs are submitted to the DME MACs, UPICs, SMRC

and DME RACs, the supplier must include a copy of only the front side. When CMNs are

submitted electronically to the DME MAC, information from sections A and B are

required.

It is in the supplier’s interest to maintain a copy of what they faxed to the physician.

Suppliers must maintain a copy of the completed CMN or DIF in their records. However,

if the physician only faxes the front of the completed CMN then the supplier is only

required to maintain the front portion of the CMN.

However, when the CMN or DIF is submitted electronically and the supplier chooses to

maintain a hard copy CMN or DIF, the font may be modified as follows:

o Pitch may vary from 10 characters per inch (cpi) to 17.7 cpi;

o Line spacing must be 6 lines per inch

o Each form must have a minimum 1/4 inch margin on all four sides.

Without exception, these modified hard copy forms must contain identical

questions/wording to the CMS forms, in the same sequence, with the same pagination, and

identical instructions/definitions printed on the back; and CMN question sets may not be

combined.

The CMN can serve as the physician's detailed written order if the narrative description in

section C is sufficiently detailed. This would include quantities needed and frequency of

replacement for accessories and supplies. For items requiring both a CMN a nd a written

order prior to delivery (e.g., seat lift mechanisms) suppliers may utilize a completed and

physician-signed CMN for this purpose. Otherwise, a separate order in addition to a

subsequently completed and signed CMN is necessary.

The supplier may not complete the information in section B of the CMN. A supplier who

knowingly and willfully completes section B of the form is subject to a civil monetary

penalty up to $1,000 for each form or document so distributed. Any supplier who remains

in non- compliance after repeated attempts by the contractor to get the supplier into

compliance, refer to your RO (for UPICs refer the supplier to the primary GTL or associate

GTL and SME) as a potential civil monetary penalty case.

The fee schedule amount, narrative description of the items furnished and the supplier's

charge for the medical equipment or supplies being furnished must be completed on a

CMN by the supplier prior to it being furnished to the physician. A supplier who

knowingly and willfully fails to include this information may be subject to a civil monetary

penalty up to $1,000 for each form or document so distributed. Any supplier who remains

in non- compliance, after repeated attempts by the contractor to get the suppl ier into

compliance, refer to your RO (for UPICs, refer the supplier to the primary GTL or

associate GTL and SME) as a potential civil monetary penalty case.

The CMS will not accept any other certifications of medical necessity by other insurers or

government agencies.

Suppliers and physician may choose to utilize electronic CMNs (e -CMNs) or electronic

DIFs (e-DIFs). E-CMNs or e -DIFS must adhere to all privacy, security, and electronic

signature rules and regulations promulgated by CMS and DHHS. Additionally, e -CMNs

or e -DIFs must contain identical questions/wording to the CMS forms, in the same

sequence, with the same pagination, and identical instructions/definitions as printed on the

back of the hardcopy form.

If an item requires a CMN or a DIF and the supplier does not have a faxed, photocopied,

original hardcopy, or an electronic signed CMN or DIF in their records when they submit

a claim to Medicare, the claim will be denied.

In cases where two or more suppliers merge, the resultant supplier should make all

reasonable attempts to secure copies of all active CMNs or DIFs from the supplier(s)

purchased. This document should be kept on file by the resultant supplier for future

presentation to the DME MACs, and UPICs.

When reviewing claims where the medical record contains a copied, faxed or electronically

maintained CMN or DIF (any CMN or DIF created, modified, and stored via electronic

means such as commercially available software packages and servers), the DME MACs,

or UPICs must accept the copied, faxed or electronic document as fulfilling the

requirements for these documents.

When a UPIC is investigating potentially fraudulent behavior by a supplier, it will be the

supplier's responsibility to prove the authenticity/validity of the claim(s) under

investigation. UPICs may require the supplier to prove the authenticity/validity of the

signature on the CMN, DIF, order, or any other questionable portion of the claim(s) under

investigation.

Upon request by the DME MACs, UPICs, SMRC or DME RACs, suppliers must provide

the CMN or DIF, in a format that the DME MACs, UPICs, SMRC, and DME RACs can

accept, in a timely manner. Upon medical review, the DME MACs, UPICs, SMRC, and

DME RACs should not deny claims solely because the CMN or DIF is faxed, copied, or

electronic. The DME MACs, UPICs, SMRC, and DME RACs may request the supplier to

download and print a hard copy of an electronic order, CMN or DIF if the DME MACs,

UPICs, SMRC, and DME RACs cannot access it electronically.

For items that require a CMN, and for accessories, supplies, and drugs related to an item

requiring a CMN, the CMN may serve as the written order if the narrative description in

Section C is sufficiently detailed (as described above). This applies to both hard copy and

electronic orders or CMNs. A DIF does not contain a section for a narrative description

and is not applicable.

A supplier must have a hard copied, faxed or electronic order, CMN or DIF in their records

when they can submit a claim for payment to Medicare. Suppliers must ensure the security

and integrity of electronically maintained CMNs or DIFs are in accordance wi th any

regulations published by CMS.

The DME MACs or UPICs need not make any shared system changes to electronically

accept e-CMNs or e-DIFS as CMS views e-CMNs or e-DIFs as a transaction between the

physician and suppliers. Suppliers must continue to use current systems for transmitting

claim information to the DME MAC or UPICs.