Competitive Bidding: Appealing Denials
Effective January 1, 2021, Competitive Bidding Round 2021 is in effect and this round includes off the shelf back braces and knee braces. In previous posts, we discuss physician billing, traveling beneficiaries, and the fee schedules involved. There are new requirements regarding modifiers physicians use when billing for a Competitive Bid product. (See R&R post on March 11 2021.)
In the case where the modifier was used incorrectly or omitted, which results in claim denial, the supplier you may receive a claim denial with error message MA130 “your claim contains incomplete and/or invalid information.” In this situation, you may follow the redetermination process as the first level of appeals.
The DME MAC reviews redetermination requests. You simply complete the Redetermination Request Form and indicate the modifier that was used incorrectly or inadvertently omitted. The DME MAC has 60 days to review the redetermination request.
You may download the redetermination forms here:
What Does This Mean for You?
Be familiar with the modifiers required for use when billing an off the shelf back brace or knee brace included in Round 2021.
KV - DMEPOS item subject to Competitive Bidding Program that is furnished as part of a professional service (non-contract supplier, physicians and other treating practitioners.)
J5 - Physical therapists and occupational therapists furnishing DMEPOS item subject to Competitive Bidding Program as a non-contract supplier.
KT - Beneficiary resides in a competitive bidding area and travels to a non -competitive bidding area and receives items from a non-contract supplier.
KX - Requirements specified in the medical policy have been met. NOTE: this modifier is required for knee orthoses
LT - Left side (Used to identify item provided for the left side of the body.)
RT - Right side (Used to identify item provided for the right side of the body.)