Article Detail - JA DME

Exception: Medicare physicians or other treating practitioners IN a CBA, who are enrolled as Medicare DMEPOS suppliers (without being a competitive bid contract supplier) must append the KV or J5 modifier to the claim only when the following requirements are met:

• The OTS back or knee brace must be furnished by the physician or other treating practitioner to their own patient as part of their 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

CMS Update: If a brace is provided post-surgery, the claim should adhere to the following guidelines:

• If brace provided after surgery, 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

If the claim denies, appeal with documentation to support need for the brace post-surgery.

CMS Appeal Update: Appeal rights have been offered for off-the-shelf orthotics furnished by physicians and other treating practitioners in a CBA on DOS January 1, 2021 - December 31, 2023. Braces must have been furnished under the physician exception (above) 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

Find additional information on the Noridian Competitive Bidding webpage.