CMS-10269

CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea

Agency
CMS
Revision
12/09
Fillable fields
89
Pages
2
Official source
CMS form page
Checked
October 20, 2026
Fill CMS-10269 online
Page 1 of form CMS-10269

Form CMS-10269: Certificate of Medical Necessity, PAP Devices for Obstructive Sleep Apnea

Form CMS-10269 is the Certificate of Medical Necessity (CMN) for Positive Airway Pressure (PAP) Devices for Obstructive Sleep Apnea from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. It is marked DME 03.03. The form is completed by the supplier of the device and the ordering physician for a Medicare patient, and its instructions say the questions in Section B gather clinical information to determine medical necessity.

The form has four sections. Section A identifies the patient, supplier, place of service, HCPCS codes and physician, and may be completed by the supplier. Section B asks for the estimated length of need, diagnosis codes and 10 questions, and may not be completed by the supplier. Section C describes the equipment and its cost, and Section D is the physician's attestation and signature.

The form says signature and date stamps are not acceptable. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Form CMS-10269: Certificate of Medical Necessity, PAP Devices for Obstructive Sleep Apnea, as printed by CMS

What's on Form CMS-10269

Section A: certification type and date

The initial date, plus a revised or recertification date where one applies. The instructions say a revised or recertified CMN always gives the initial date as well.

Section A: patient, supplier and physician

Patient and supplier details, place of service, facility name and address if applicable, HCPCS codes, the patient's date of birth, sex, height and weight, and the physician's name, address, NSC or NPI number and phone.

Section B: length of need and diagnosis

Estimated length of need in months from 1 to 99, where 99 means lifetime, and ICD-9 diagnosis codes. The instructions ask for the primary code first and up to 3 more.

Section B: questions 1 to 7, initial evaluation

Whether the device is ordered for obstructive sleep apnea (ICD-9 code 327.23), the dates of the initial face-to-face evaluation and sleep test, whether the test was in a facility-based lab, the AHI or RDI, documented symptoms, and for a bilevel device whether CPAP was tried.

Section B: questions 8 to 10, recertification

The date of the follow-up face-to-face evaluation, whether a report documents PAP use of 4 hours or more per night on at least 70% of nights in a 30 consecutive day period, and whether symptoms improved with PAP.

Sections C and D

Section C: a narrative description of all items, accessories and options ordered, the supplier's charge and the Medicare fee schedule allowance for each. Section D: the physician attestation, signature and date.

How to complete Form CMS-10269

  1. 1

    Supplier fills in Section A

    Enter the certification type and date, patient and supplier details, place of service, HCPCS codes and physician information. The instructions say procedure codes that do not require certification are not listed on the CMN.

  2. 2

    Supplier fills in Section C

    Describe every item, option, accessory, supply and drug ordered, with the supplier's charge and the Medicare fee schedule allowance for each, where applicable.

  3. 3

    Clinician answers Section B

    Enter the length of need and diagnosis codes, then answer questions 1 to 7 for an initial evaluation or 8 to 10 for a recertification. The form says that if the answer to question 1 is no, proceed to Section D.

  4. 4

    Physician reviews and signs

    The physician reviews Sections A, B and C, then signs and dates Section D. The form says signature and date stamps are not acceptable.

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Signing, recertification and what the form says

Where it goes

The form does not print a submission address. The CMS address on page 2 is for comments on the time estimate or suggestions for improving the form.

Revised and recertified CMNs

The instructions say a revised certification is completed when the physician changes the order based on the patient's changing clinical needs, and that the initial date is always given along with the revised or recertification date.

Signatures

Only the physician signs, in Section D. The form says signature and date stamps are not acceptable.

Accuracy statement

Section D says any falsification, omission or concealment of material fact in Section B may subject the physician to civil or criminal liability.

Place of service codes

The instructions give examples: patient's home is 12, skilled nursing facility is 31 and ESRD facility is 65, and point to the DME MAC supplier manual for the full list.

Time to complete

The form estimates an average of 15 minutes per response, including reviewing the instructions and gathering the data. It shows OMB No. 0938-0679.

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Who uses Form CMS-10269?

  • Suppliers

    The instructions say Section A may be completed by the supplier and Section C is to be completed by the supplier. The supplier gives its name, address, phone number and NSC or NPI number.

  • Ordering physicians

    Section D is completed by the physician. The instructions say the physician reviews Sections A, B and C and signs and dates the CMN, and that the signature also certifies the items ordered are medically necessary for this patient.

  • Other clinicians

    Section B may be completed by a non-physician clinician or a physician employee. The instructions say it is then reviewed, and the CMN signed, by the ordering physician, and that person prints their name, title and employer.

  • Medicare patients

    The patient is the person the device is ordered for. Section A records the patient's name, address, phone, HICN as it appears on the Medicare card, date of birth, sex, height and weight. The form has no patient signature line.

The form splits the work between the supplier and the physician, section by section.

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Questions about Form CMS-10269

Who fills out Form CMS-10269?

The form splits it: the supplier may complete Section A and completes Section C, Section B may not be completed by the supplier, and the physician completes and signs Section D.

Can the supplier answer the Section B questions?

No. The form says information in Section B may not be completed by the supplier. A non-physician clinician or physician employee may complete it, but the ordering physician reviews it and signs the CMN.

Which questions apply to a recertification?

The form says to answer questions 1 to 7 for an initial evaluation and questions 8 to 10 for a follow-up evaluation (recertification).

What does 99 mean for the length of need?

The form says 99 means lifetime. The instructions say to enter 99 if the physician expects the patient to need the item for the rest of their life.

Can the physician use a signature stamp?

No. The form says signature and date stamps are not acceptable.

What diagnosis codes does the form use?

It asks for ICD-9 diagnosis codes, and question 1 names ICD-9 code 327.23 for obstructive sleep apnea.

How long does Form CMS-10269 take?

The form estimates an average of 15 minutes per response, including reviewing the instructions, gathering the data and reviewing the information.