Fill out CMS-484 (Certificate of Medical Necessity - Oxygen) online
Form CMS-484 is the Certificate of Medical Necessity (CMN) specifically for oxygen equipment and supplies. It documents the medical justification for Medicare to cover home oxygen therapy, including the type of oxygen delivery system, flow rate, and clinical findings that demonstrate the medical necessity of supplemental oxygen.
How to fill out CMS-484 (Certificate of Medical Necessity - Oxygen)
Complete patient and supplier information
Enter the patient's name, address, date of birth, Medicare Beneficiary Identifier (MBI) number, and the supplier's name, address, and NSC/NPI number.
Document the oxygen prescription
Specify the type of oxygen delivery system (concentrator, liquid, compressed gas), the flow rate in liters per minute, and the frequency and duration of use (at rest, during exercise, during sleep).
Record the qualifying test results
Enter the arterial blood gas (ABG) or pulse oximetry test results that demonstrate the need for supplemental oxygen. Include the test date, the patient's condition during testing, and whether the patient was on room air or supplemental oxygen.
Physician certification and signature
The prescribing physician reviews the information, certifies the medical necessity of the oxygen therapy, and signs and dates the form. The physician must be the treating physician who ordered the oxygen.
About CMS-484 (Certificate of Medical Necessity - Oxygen)
Who needs this form
Durable medical equipment (DME) suppliers who need to obtain Medicare coverage approval for oxygen equipment and supplies. The prescribing physician provides the medical justification, and the supplier completes the administrative sections.
Where to submit
The DME supplier retains the completed form and submits it as supporting documentation with the Medicare claim to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC).
Source and content freshness
- Filing deadlines may shift for weekends and holidays. Verify due dates with official instructions.
Common mistakes to avoid
- Not including qualifying arterial blood gas or pulse oximetry test results
- Missing the prescribing physician signature and date
- Providing test results that do not meet the Medicare coverage threshold
- Not updating the CMN when the oxygen prescription changes
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