Section A: certification and patient
Initial, revised or recertification date, and the patient's name, address, phone, Medicare ID, date of birth, sex, height and weight.
CMS-849
Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A
- Agency
- CMS
- Revision
- 06/19
- Fillable fields
- 32
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-849: Certificate of Medical Necessity for Seat Lift Mechanisms (DME 07.03A)
Form CMS-849 is the Certificate of Medical Necessity (CMN) for Seat Lift Mechanisms, numbered DME 07.03A, from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. It is completed by a supplier and the treating physician: the instructions say the supplier may complete Section A and completes Section C, Section B may not be completed by the supplier, and the physician completes Section D.
Section A covers the certification type and dates, the patient, the supplier, place of service, procedure codes, facility and physician. Section B gives the estimated length of need, diagnosis codes and five questions about the seat lift mechanism, each answered Y, N or D. Section C describes the equipment with the supplier's charge and the Medicare fee schedule allowance. Section D is the physician attestation and signature.
The second page holds the instructions for each section. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-849
Section A: supplier, place and physician
Supplier name, address, phone and NSC or NPI number, place of service, procedure codes, facility name and address if applicable, 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 up to 4 diagnosis codes, the first for the primary reason for ordering the item.
Section B: questions 1 to 5
Y, N or D answers on severe arthritis of the hip or knee, severe neuromuscular disease, standing up from a chair, ability to ambulate once standing, and whether other therapeutic modalities were tried and failed.
Section C: equipment and cost
A narrative description of all items, accessories and options ordered, the supplier's charge, and the Medicare fee schedule allowance for each.
Section D: physician attestation
The attestation, the physician's signature and the date. The form says signature and date stamps are not acceptable.
How Form CMS-849 is completed
- 1
Complete Section A
Enter the certification type with dates, and the patient, supplier, place of service, procedure codes, facility and physician details. The instructions say a revised or recertification CMN always gives the INITIAL date too.
- 2
Format the ID numbers
The instructions say an NPI uses the qualifier XX before the 10-digit number, an NSC number uses 1C before 10 digits, and a UPIN uses 1G before 6 digits.
- 3
Complete Section B
Section B may not be completed by the supplier. It takes the length of need, diagnosis codes, Y, N or D answers to questions 1 to 5, and the name of the person answering if not the physician.
- 4
Complete Section C
The supplier describes each item, option and accessory ordered, with the supplier's charge and the Medicare fee schedule allowance.
- 5
Physician signs Section D
After completing or reviewing Sections A, B and C, the physician signs and dates Section D. Signature and date stamps are not acceptable.
Why fill Form CMS-849 on indox
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Codes, claims and OMB notice
Where it goes
The form does not print a submission address. Its Paperwork Reduction Act notice says not to submit claims to the CMS address and to see medicare.gov for information on claim filing.
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.
Procedure codes
The instructions say to list all procedure codes for items ordered, and that procedure codes that do not require certification should not be listed on the CMN.
Revised certifications
The instructions say a revised certification is completed when the physician changes the order, based on the patient's changing clinical needs.
OMB number and time
OMB No. 0938-0679. The PDF prints Expires 02/2024, and the CMS page lists an OMB expiration date of 2020-02-01. The form estimates an average of 12 minutes per response.
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Who uses Form CMS-849?
The instructions say who completes each section.
Official sources and the blank
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Questions about Form CMS-849
Who fills out Form CMS-849?
The instructions say the supplier may complete Section A and completes Section C. Section B may not be completed by the supplier. The treating physician completes and signs Section D.
Can the supplier complete Section B?
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 a physician employee may complete it, and the treating practitioner reviews it and signs the CMN.
What does 99 mean for length of need?
The form says to enter 99 if the patient will require the item for the duration of their life. Otherwise it is the number of months, from 1 to 99.
Are signature stamps accepted?
No. Section D says signature and date stamps are not acceptable.
What do Y, N and D mean in Section B?
The instructions say to answer each question that applies to the items ordered, checking Y for yes, N for no, or D for does not apply.
Is the OMB approval on Form CMS-849 current?
The PDF prints Expires 02/2024 under OMB No. 0938-0679, and the CMS page lists an OMB expiration date of 2020-02-01. Both dates are in the past.