Cms-10126 -- Enteral And Parenteral Nutrition

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0679

DME INFORMATION FORM
CMS-10126 — ENTERAL AND PARENTERAL NUTRITION

DME 10.03

All INFORMATION ON THIS FORM MAY BE COMPLETED BY THE SUPPLIER
Certification Type/Date: INITIAL ___/___/___

REVISED ___/___/___

RECERTIFICATION___/___/___

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable
NPI NUMBER/LEGACY NUMBER

(__ __ __) __ __ __ - __ __ __ __ HICN _______________________

(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________

PLACE OF SERVICE______________
NAME and ADDRESS of FACILITY
if applicable (see reverse)

HCPCS CODE

PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs.)

__________
__________
__________
__________

PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable
NPI NUMBER or UPIN

EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME)
ANSWERS

(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________
DIAGNOSIS CODES (ICD-9): ______ ______ ______ ______

ANSWER QUESTIONS 1–6 FOR ENTERAL NUTRITION, AND 6 - 9 FOR PARENTERAL NUTRITION
(Circle Y for Yes, N for No, Unless Otherwise Noted)

Y

N

1. Is there documentation in the medical record that supports the patient having a permanent non-function or disease of
the structures that normally permit food to reach or be absorbed from the small bowel?

Y

N

2. Is the enteral nutrition being provided for administration via tube? (i.e., gastrostomy tube, jejunostomy tube,
nasogastric tube)

A)________________
B)________________

3. Print HCPCS code(s) of product.

A)________________
B)________________

4. Calories per day for each corresponding HCPCS code(s).

1

2

3

4

_______
Y

N

5. Circle the number for method of administration?
1 – Syringe
2 – Gravity
3 – Pump
4 – Oral (i.e. drinking)
6. Days per week administered or infused (Enter 1 – 7)
7. Is there documentation in the medical record that supports the patient having permanent disease of the gastrointestinal
tract causing malabsorption severe enough to prevent maintenance of weight and strength commensurate with the
patient's overall health status?
8. Formula components:
Amino Acid ___________(ml/day) _____________concentration % _______gms protein/day
Dextrose _____________(ml/day) _____________concentration %
Lipids _______________(ml/day) _____________days/week ___________concentration %

1

2

3

9. Circle the number for the route of administration.
1 – Central Line (Including PICC)
2 – Hemodialysis Access Line

3 – Peritoneal Catheter

Supplier Attestation and Signature/Date
I certify that I am the supplier identified on this DME Information Form and that the information provided is true, accurate and complete, to the best
of my knowledge. I understand that any falsification, omission, or concealment of material fact associated with billing this service may subject me to
civil or criminal liability.

SUPPLIER SIGNATURE___________________________________________________________________________ DATE _____/_____/_____

Form CMS-10126 (09/05) EF 08/2006

INSTRUCTIONS FOR COMPLETING DME INFORMATION FORM
FOR ENTERAL AND PARENTERAL NUTRITION (CMS-10126)
CERTIFICATION
TYPE/DATE:

If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in
the space marked “INITIAL.” If this is a revised certification (to be completed when the physician changes
the order, based on the patient's changing clinical needs), indicate the initial date needed in the space
marked “INITIAL,” and also indicate the revision date in the space marked “REVISED.” If this is a
recertification, indicate the initial date needed in the space marked “INITIAL,” and also indicate the
recertification date in the space marked “RECERTIFICATION.” Whether submitting a REVISED or a
RECERTIFICATION DIF, be sure to always furnish the INITIAL date as well as the REVISED or
RECERTIFICATION date.

PATIENT
INFORMATION:

Indicate the patient's name, permanent legal address, telephone number and his/her health insurance
claim number (HICN) as it appears on his/her Medicare card and on the claim form.

SUPPLIER
INFORMATION:

Indicate the name of your company (supplier name), address and telephone number along with the
Medicare Supplier Number assigned to you by the National Supplier Clearinghouse (NSC) or applicable
National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed
by the 10-digit number. If using a legacy number, e.g. NSC number, use the qualifier 1C followed by the
10-digit number. (For example. 1Cxxxxxxxxxx)

PLACE OF SERVICE:

Indicate the place in which the item is being used, i.e., patient’s home is 12, skilled nursing facility (SNF)
is 31, End Stage Renal Disease (ESRD) facility is 65, etc. Refer to the DMERC supplier manual for a
complete list.

FACILITY NAME:

If the place of service is a facility, indicate the name and complete address of the facility.

HCPCS CODES:

List all HCPCS procedure codes for items ordered that require a DIF. Procedure codes that do not require
certification should not be listed in this section of the DIF.

PATIENT DOB, HEIGHT, Indicate patient’s date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in
WEIGHT AND SEX:
pounds, if required.
PHYSICIAN NAME,
ADDRESS:

Indicate the physician’s name and complete mailing address.

PHYSICIAN
INFORMATION:

Accurately indicate the treating physician’s Unique Physician Identification Number (UPIN) or applicable
National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed
by the 10-digit number. If using UPIN number, use the qualifier 1G followed by the 6-digit number.
(For example. 1Gxxxxxx)

PHYSICIAN’S
TELEPHONE NO.:

Indicate the telephone number where the physician can be contacted (preferably where records would be
accessible pertaining to this patient) if more information is needed.

QUESTION SECTION:

This section is used to gather clinical information about the item or service billed. Answer each question
which applies to the items ordered, circling “Y” for yes, “N” for no, a number if this is offered as an answer
option, or fill in the blank if other information is requested.

SUPPLIER
ATTESTATION:

The supplier’s signature certifies that the information on the form is an accurate representation of the
situation(s) under which the item or service is billed.

SUPPLIER SIGNATURE After completion, supplier must sign and date the DME Information Form, verifying the Attestation.
AND DATE:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for
this information collection is 0938-0679. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing
resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form,
please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.

DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/ for information on claim filing.
Form CMS-10126 (09/05) INSTRUCTIONS EF 08/2006