M105Remark Code (RARC)Active
M105 Remark Code - Break in Therapy Not Supported
The M105 remark code indicates that the information provided does not justify a break in therapy for the billed item. The payer has determined that the medical information does not support the necessity of the item as billed, leading to a reduced payment without initiating a new capped rental period.
How It Relates to the Denial
The M105 remark code typically accompanies a Claim Adjustment Reason Code that indicates a payment reduction. This combination signals that while the item is covered, the justification for the full billed amount is lacking based on the medical documentation provided.
Common Scenarios
1A provider submits a claim for a durable medical equipment rental, indicating a break in therapy. The remittance shows a reduction in payment with the M105 remark code.
→ In this case, the M105 remark is pointing out that the documentation does not support the need for a break in therapy, resulting in a lower payment without starting a new rental period.
2A claim for a physical therapy service is submitted with a request for a higher frequency of visits due to a change in the patient's condition. The payer responds with a payment adjustment and includes the M105 remark code.
→ The M105 remark suggests that the medical records provided do not substantiate the increased frequency of visits, leading to a reduced payment.
3A claim for a home oxygen therapy rental is billed with a request for a break in therapy due to the patient's improved condition. The remittance returns with a payment reduction and the M105 remark code.
→ The M105 remark indicates that the payer does not find evidence supporting the break in therapy, thus not approving a new rental period and reducing the payment.
What to Do
- Review the medical documentation to ensure it clearly supports the need for the item as billed.
- Consider resubmitting the claim with additional information if necessary, but only if it substantiates the break in therapy.
- Ensure that the claim reflects the correct rental period if applicable.
What to Check
- The patient's medical records to confirm the necessity of the item billed.
- Any prior authorization documents that may have been submitted with the claim.
- The original claim details to verify the billed amount and the associated services.