CO-96+M114+M115+N211

Step-by-Step Resolution

Steps tailored specifically to this CO-96+M114+M115+N211 combination — not generic advice.

1. 1

   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

2. 2

   Ensure correct modifiers were included with claim and appeal when applicable

3. 3

   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

4. 4

   Appeal claim with documentation to support need post-surgery

5. 5

   If brace provided post-surgery, claim should adhere to the following guidelines:

6. 6

   Claim must have same date of service (DOS) as surgery

7. 7

   If brace provided as part of an unbillable follow-up visit during post-operative period and related to recovery

8. 8

   Bill with surgery DOS, or

9. 9

   Bill with follow-up visit DOS and include narrative indicating brace applies to same date as surgery

10. 10

    Narrative example: Brace associated with surgery DOS 05/01/2023

11. 11

    Enter narrative in Item 19 of 1500 claim form or 2400/NTE segment of electronic claim

12. 12

    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.

13. 13

    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:

14. 14

    Brace provided at unbillable office visit with KV modifier on claim

15. 15

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

16. 16

    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.

Specialty Context

How CO-96+M114+M115+N211 typically presents across different practice types.

Individual Code References

View the standalone definition for each code in this combination.

How to Prevent CARC 96 Denials

• ✓

  Review the service billed to ensure the correct code was submitted.

• ✓

  If the claim is being submitted for statutorily excluded services, you can append a GY modifier to the line item. The GY modifier indicates that the item or service is statutorily excluded or does not meet the definition of a Medicare benefit.