Reason Code B15 | Remark Codes M114 - JA DME

Common Reasons for Denial

• There was not a Part B practitioner claim on file with the same date of service as this claim for DME item. This item was furnished by a Non-Contract Physician or Other Treating Practitioner, Physical Therapist, or Occupational Therapist for a competitive bid item and must meet certain requirements

Next Step

• 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.
  • 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.
    • Brace must be medically necessary to be worn at home prior to surgery
    • Claims must have the same date of service as the office visit or surgery date
    • Or if furnished as part of an unbillable follow-up visit during a surgical post-operative period related to recovery, the claim should be billed with the same date of service or noted as applying to the same date as the surgery
  • Claim must include narrative of surgery date. Narrative example DOS 05/01/23
    • Item 19 of the 1500 claim form or the 2400/NTE segment of an electronic claim
• 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 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

How to Avoid Future Denials

• 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 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