Use of the CR HCPCS Modifier and the DR Condition Code on Disaster/Emergency-Related Claims
MLN Matters® Number: MM6451
Related Change Request (CR) #: 6451
Related CR Release Date: July 31, 2009
Effective Date: August 31, 2009
Related CR Transmittal #: R1784CP
Implementation Date: August 31, 2009
Provider Types Affected
Physicians, providers, and suppliers submitting claims to Palmetto GBA for disaster/emergency-related services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on CR 6451, which updates and amends claims processing requirements for the use of condition codes and modifiers on Medicare fee-for-service claims when the furnishing of an item or service to a Medicare beneficiary was affected by a disaster or other general public emergency. CR 6451 also establishes a new chapter in the Medicare Claims Processing Manual dedicated to standing policies and procedures applicable to disasters and other public emergencies. Please make sure your billing staff is familiar with these changes, especially if they submit claims affected by emergencies to Medicare.
Background
As part of its response to the 2005 Katrina hurricane emergency, the Centers for Medicare & Medicaid Services (CMS) developed the DR condition code and the CR HCPCS modifier to facilitate the processing of claims affected by that emergency. The DR condition code and CR HCPCS modifier were also authorized for use on claims for items and services affected by subsequent emergencies. Based on that experience, the Medicare fee-for-service program is refining the uses of both the code and the modifier to ensure that program operations are sufficiently flexible to accommodate the emergency health care needs of beneficiaries and the delivery of health care items and services by health care providers/suppliers in emergency situations without adding undue administrative burden associated with claim submission. The use of the CR HCPCS modifier and DR condition code indicates not only that the item/service/claim was affected by the emergency/disaster, but also that the provider has met all of the requirements CMS has issued to Medicare contractors regarding the emergency/disaster.
Key Points of CR 6451
The DR Condition Code:
The title of the DR condition code is 'disaster related' and its definition requires it to be “used to identify claims that are or may be impacted by specific payer/health plan policies related to a national or regional disaster.” The DR condition code is used only for institutional billing, i.e., claims submitted by providers on an institutional paper claim form CMS-1450/UB-04 or in the electronic format ANSI ASC X12 837I. In previous emergencies, use of the DR condition code was entirely discretionary with the billing provider or supplier. It no longer may be used at the provider or supplier’s discretion. Effective August 31, 2009, use of the DR condition code will be mandatory for any claim for which Medicare payment is conditioned directly or indirectly on the presence of a formal waiver.
The CR HCPCS modifier: Both the short and long descriptors of the CR HCPCS modifier are 'catastrophe/disaster related.' The CR HCPCS modifier is used in relation to Part B items and services for both institutional and non-institutional billing. Non-institutional billing, i.e., claims submitted by physicians and other suppliers, are submitted either on a professional paper claim form CMS-1500 or in the electronic format ANSI ASC X12 837P or – for pharmacies – in the NCPDP format. In previous emergencies, use of the CR HCPCS modifier was entirely discretionary with the billing provider or supplier. It no longer may be used at the provider or supplier’s discretion. Effective August 31, 2009, use of the CR HCPCS modifier will be mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned directly or indirectly on the presence of a 'formal waiver.'
Formal Waivers:
A formal waiver is a waiver of a program requirement that otherwise would apply by statute or regulation. There are two types of formal waivers. One type is a waiver of a requirement specified in Section 1135(b) of the Social Security Act (Act). Although Medicare payment rules themselves are not 'waivable' under this statutory provision, the waiver of a Section 1135(b) requirement may permit Medicare payment in a circumstance where such payment would otherwise be barred. The second type of formal waiver is a waiver based on a provision of Title XVIII of the Act or its implementing regulations. The most commonly employed waiver in this latter category is the waiver of the '3-day qualifying hospital stay' requirement that is a precondition for Medicare payment for skilled nursing facility services. This requirement may be waived under Section 1812(f) of the Social Security Act.
Further Instructions in the Event of a Disaster or Emergency: In the event of a disaster or emergency, CMS will issue specific guidance to Medicare contractors that will contain a summary of the Secretary’s declaration (if any); specify the geographic areas affected by any declarations of a disaster or emergency; specify what formal waivers and/or informal waivers, if any, have been authorized; specify the beginning and end dates that apply to the use of the DR condition code and/or the CR HCPCS modifier; and specify what other uses of the condition code and/or modifier, if any, will be mandatory for the particular disaster/emergency.
Additional Information
The official instruction, CR 6451, issued to Palmetto GBA regarding this change may be viewed at www.cms.hhs.gov/Transmittals/downloads/R1784CP.pdf (PDF, 270 KB).
If you have any questions, please contact our Provider Contact Center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.