CMS-847

Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C

Agency
CMS
Revision
06/19
Fillable fields
53
Pages
2
Official source
CMS form page
Checked
October 20, 2026
Fill CMS-847 online
Page 1 of form CMS-847

Form CMS-847: Certificate of Medical Necessity, Osteogenesis Stimulators

Form CMS-847 is the Certificate of Medical Necessity (CMN) for osteogenesis stimulators from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. The form is printed as DME 04.04C. Its instructions say the question section gathers clinical information to help Medicare determine the medical necessity for the items being ordered, and the CMS page notes the form is to be used starting January 1, 2007.

The form has four sections. Section A identifies the patient, supplier, place of service, procedure codes, facility and physician, and may be completed by the supplier. Section B covers the estimated length of need, diagnosis codes and questions on nonspinal electrical, spinal electrical and ultrasonic osteogenesis stimulators, 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-847: Certificate of Medical Necessity, Osteogenesis Stimulators, as printed by CMS

What's on Form CMS-847

Section A: certification type and date

Initial, revised or recertification dates. 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 with NSC or NPI number, place of service, facility, procedure codes, date of birth, sex, height and weight, and the physician's name, address, phone and UPIN or NPI.

Section B: length of need and diagnosis

Estimated length of need in months, 1 to 99, where 99 means lifetime, and diagnosis codes, up to 4.

Section B: questions 6 to 8 and 12

Questions 1 to 5 are blank. Questions 6 to 8 are for a nonspinal electrical stimulator and ask about fracture healing, failed fusion of a joint other than the spine and congenital pseudoarthrosis. Questions 6 and 12 are for an ultrasonic stimulator.

Section B: questions 9 to 11

For a spinal electrical stimulator: a failed single level spinal fusion, an adjunct to repeat single level fusion, and multi-level spinal fusion, with months since each fusion where asked.

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's attestation, signature and date.

How Form CMS-847 is filled out

  1. 1

    Supplier completes Section A

    Enter the certification type and date, patient, supplier, place of service, procedure codes and physician details. The instructions say procedure codes that do not require certification should not be listed.

  2. 2

    Use the identifier qualifiers

    The instructions say to use XX before a 10-digit NPI, 1C before a legacy NSC number and 1G before a 6-digit UPIN.

  3. 3

    Answer Section B

    Enter the length of need and diagnosis codes, then answer the questions for the stimulator type ordered with Y, N or D. For month questions the form says to enter 1 to 99 or D, and 1 if less than one month.

  4. 4

    Name who answered Section B

    If someone other than the treating physician answered Section B, they print their name, professional title and employer. If the physician answered, the instructions say the space may be left blank.

  5. 5

    Supplier completes Section C

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

  6. 6

    Physician signs Section D

    After completing or reviewing Sections A, B and C, the physician signs and dates Section D. The form says signature and date stamps are not acceptable.

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Signing, claims and what the form says

Where it goes

The form does not print a submission address. The CMS address in the Paperwork Reduction Act notice is for comments on the form, and the form says not to submit claims to it. It points to medicare.gov for information on claim filing.

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.

Place of service codes

The instructions give examples: patient's home is 12, skilled nursing facility (SNF) is 31 and End Stage Renal Disease (ESRD) facility is 65. They refer to the DMERC supplier manual for a complete list.

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.

Time to complete

The form estimates an average of 12 minutes per response, including reviewing the instructions and gathering the data. It shows OMB No. 0938-0679.

Related forms

Who fills out Form CMS-847?

  • Suppliers

    The instructions say Section A may be completed by the supplier, and Section C, the narrative description of equipment and cost, is completed by the supplier.

  • Treating physicians

    Section D is completed by the physician, whose signature certifies the CMN, the answers in Section B and the information in Section A.

  • Clinicians answering Section B

    The instructions say a non-physician clinician or a physician employee may complete Section B and print their name, title and employer. The treating practitioner still reviews it and signs the CMN.

  • Patients named on the form

    Section A records the patient's name, permanent legal address, telephone number and Medicare ID as it appears on the Medicare card and on the claim form.

The form splits its sections between the supplier and the physician.

Official sources and the blank

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Questions about Form CMS-847

Who fills out Form CMS-847?

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

Can the supplier answer the Section B questions?

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

Which Section B questions apply to which stimulator?

The form says questions 1 to 5 are blank. Questions 6 to 8 are for a nonspinal electrical osteogenesis stimulator, questions 9 to 11 for a spinal electrical stimulator, and questions 6 and 12 for an ultrasonic stimulator.

What does 99 mean for the length of need?

The form uses 99 for lifetime. The instructions say to enter 99 if the patient will require the item for the duration of their life, and otherwise the number of months.

Can the physician use a signature stamp?

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

Can claims be sent to the address on the form?

No. The form says do not submit claims to the CMS address in its Paperwork Reduction Act notice, and points to medicare.gov for information on claim filing.