835 Denial Combination
PR-96+M15
Patient Responsibility · Claim + Service Level Adjustment
Contractual ObligationWhat This Combination Means
The payer has determined that multiple separately billed services should have been submitted as a single bundled procedure and therefore denied the redundant line item(s) as non-covered. Because this is marked PR, the patient is responsible for the non-covered bundled charge amounts per their benefit plan terms, though this typically reflects a billing error rather than a patient liability that should be collected.
Financial Responsibility
patient responsibility
The patient is technically responsible per the PR designation, but this usually represents charges that should not have been billed separately in the first place due to bundling rules.
N/A
Appeal Success
Immediate (write-off)
Avg. Resolution
Easy
Difficulty
No
Appealable
Step-by-Step Resolution
Steps tailored specifically to this PR-96+M15 combination — not generic advice.
- 1
Identify the bundled service components on the claim
Locate all line items on this claim to determine which services the payer bundled together and which line item(s) received the PR-96-M15 denial versus which received payment.
- 2
Write off the denied bundled charge(s) as contractual adjustment
The separately billed component is non-covered per bundling rules; adjust off the balance rather than billing the patient, as this represents a billing error not a patient obligation.
- 3
Update charge entry protocols to prevent recurrence
Document this bundling rule in your coding guidelines and configure practice management system edits to prevent future separate billing of these component services together.
Specialty Context
How PR-96+M15 typically presents across different practice types.
Dental
Common when separately billing procedures that are inclusive of comprehensive treatments, such as billing prophylaxis components separately from periodontal maintenance, or individual restorative steps that are part of a single restoration procedure.
Medical
Frequently occurs with surgical procedures when incidental services (closure, irrigation, anesthesia access) are billed separately, or when labs/diagnostics are billed independently though inclusive of an E/M or procedure code per NCCI edits.
Behavioral Health
May appear when crisis intervention components, assessment elements, or brief interventions are billed separately from comprehensive behavioral health service codes that already include these elements per CPT bundling rules.
Individual Code References
View the standalone definition for each code in this combination.
Medicare Contractor Guidance for CARC 96
FCSO + NoridianThis denial is received when the service billed is statutorily excluded from coverage under the Medicare program. Payment cannot be made for the service under Part A or Part B.
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.
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