Reason Code 96 | Remark Codes M114 M115 N211 - JA DME

Common Reasons for Denial

• Medicare does not pay for this item or supply when provided by a non-contract supplier
• Only contract suppliers may provide brace with the exception of Non-Contract Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists with special modifiers and non-contract suppliers providing items to a traveling beneficiary

Next Step

• Non-Contracted Suppliers submitting claims for beneficiaries that reside in a CBA and do not meet the definition of a traveling beneficiary, will need to obtain a properly executed ABN, prior to providing item, for off-the-shelf (OTS) back and knee braces, with the exception of Non-Contract Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists. Suppliers that provide off-the-shelf (OTS) back and knees braces without a properly executed ABN cannot collect payment from the beneficiary
• Ensure correct modifiers were included with claim and appeal when applicable
• If supplier is a non-contract Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists ensure proper billing was performed, including correct modifers, and appeal claim
  • Appeal claim with documentation to support need post-surgery
    • If brace provided post-surgery, claim should adhere to the following guidelines:
      • Claim must have same date of service (DOS) as surgery
    • If brace provided as part of an unbillable follow-up visit during post-operative period and related to recovery
      • Bill with surgery DOS, or
      • Bill with follow-up visit DOS and include narrative indicating brace applies to same date as surgery
    • Narrative example: Brace associated with surgery DOS 05/01/2023
      • Enter narrative in Item 19 of 1500 claim form or 2400/NTE segment of electronic claim

A redetermination request may be submitted with all relevant supporting documentation and all information required for billing above. Noridian encourages Redeterminations/Appeals be submitted using the Noridian Medicare Portal. Review applicable Competitive Bidding requirements prior to submitting request.

CMS Update: Appeal rights have been offered for off-the-shelf orthotics furnished by non contract physicians and other treating practitioners in a CBA on DOS January 1, 2021 - December 31, 2023. Braces must have been furnished under the non contract physician exception for these circumstances to allow an appeal:

• Brace provided at unbillable office visit with KV modifier on claim
• Brace provided (as necessary part of recovery) at unbillable office visit as part of global services following post-op procedure with KV modifier

The OTS back brace or OTS knee brace must be billed to a Durable Medical Equipment Medicare Administrative Contractor (DME MAC) using the DMEPOS billing number that is assigned to the physician, the treating practitioner (if possible), or the group practice to which the physician or other treating practitioner has reassigned the right to receive Medicare payment.

How to Avoid Future Denials

• Check eligibility on the Noridian Medicare Portal to verify the beneficiary's permanent address on file with the Social Security Administration prior to providing service.
• Utilize the Round 2021 CBA Zip Code Lookup Tool to verify if beneficiary's permanent address resides in a CBA
  • Only contract suppliers may provide brace with the exception of Non-Contract Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists and non-contract suppliers providing items to a traveling beneficiary
• Utilize the Competitive Bid HCPCS Lookup Tool to verify if item is a competitive bid item and if item requires prior authorization, face-to-face and written order prior to delivery
• Please refer to the Competitive Bidding page on the Noridian Medicare website for more information.
• If this supplier is a non-contract Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists, the following must be met:
  • The OTS back brace or OTS knee brace must be furnished by the physician or other treating practitioner to his or her own patient as part of his or her professional service
  • If brace provided prior to surgery or no surgery planned, brace must be medically necessary to be worn at home prior to surgery
  • Practitioners and physicians must append KV modifier to claim line in these circumstances
• If brace provided post-surgery, claim should adhere to the following guidelines:
  • If brace provided post-surgery, claim should adhere to the following guidelines:
    • Claim must have same date of service (DOS) as surgery
  • If brace provided as part of an unbillable follow-up visit during post-operative period and related to recovery
    • Bill with surgery DOS, or
    • Bill with follow-up visit DOS and include narrative indicating brace applies to same date as surgery
  • Narrative example: Brace associated with surgery DOS 05/01/2023
    • Enter narrative in Item 19 of 1500 claim form or 2400/NTE segment of electronic claim