General Surgery Coding Alert

Watch for Medicare waivers and modifiers.

If you’re a general surgery practice operating in the middle of a disaster area or otherwise treating disaster victims, you need to know some special rules to make sure you get the pay you deserve.

Status: On Oct. 9, HHS Secretary Alex M. Azar issued a Public Health Emergency (PHE) for Florida and Georgia in the wake of Hurricane Michael. This PHE follows a similar announcement on Sept. 12 for North Carolina, South Carolina, and Virginia following Hurricane Florence.

“Hurricane Michael poses a significant threat to the health and safety of those in its path,” Secretary Azar said in an HHA release on the PHE. “These actions help ensure that our fellow Americans who rely on Medicare and Medicaid have continuous access to the care they need.”

Issuing the PHE allowed the HHS Secretary to invoke Section 1135 of the Social Security Act (SSA), permitting waiver or modification of certain Medicare, Medicaid, CHIP, and HIPAA requirements. Read on for the essentials you’ll need to know to submit claims after disaster strikes — now or in the future.

See What Determines ‘Public Health Emergency’ — and What Follows

People may lightly throw around the term “disaster,” but the feds have very strict guidelines when declaring an emergency. Read on to see the timeline and protocol that ends with the 1135 waiver and certain Medicare allowances.

Who: After the President of the United States establishes an emergency under the Stafford Act, the HHS Secretary declares a PHE.

What: The HHS Secretary determines there’s a PHE under Section 319 of the Public Health Service Act (PHSA).

When: A Section 319 PHE is good for a duration of 90 days, but it may be shortened by the HHS Secretary if it’s determined an emergency no longer exists. The HHS Secretary can also extend a PHE.

Where: The PHE covers only the state and/or local areas referenced in the HHS Secretary’s declaration under Section 319 of the PHSA.

Why: The Secretary determines there’s a high risk of disease and disorder due to the emergency or disaster.

The hazards must be significant enough to declare the PHE in the first place. And that’s why under Section 319 of the PHSA, the HHS Secretary then can offer grants, do investigations, support state and local healthcare efforts, and waive certain federal requirements that may be compromised due to the disaster.

Medicare requirements that may be waived could include, but are not limited to:

• Conditions of Participation
• Certain preapproval and state licensing rules and restrictions
• Emergency Medical Treatment and Labor Act (EMTALA) sanctions
• Stark Law punishments
• Medicare reporting exceptions and extensions.

Pocket These Coding Tips for Clean Claims

Remember, HHS allows these waivers to better monitor how payers process claims in these uncertain circumstances, explains Dawn Rogers, coding specialist at Caduceus Inc. in Jersey City, New Jersey.

There’s more: Your coding and modifier usage could also change when reporting services for patients affected by the disaster. CMS created modifier CR (Catastrophe/disaster related) “in order to track and facilitate claims processing for disaster victims,” indicates Rogers.

“In accordance with CR 6451, use of the ‘DR’ condition code and the ‘CR’ modifier are mandatory on claims for items and services for which Medicare payment is conditioned on the presence of a ‘formal waiver’ including, but not necessarily limited to, waivers granted under either Section 1135 or Section 1812(f) of the Act,” states MLN Matters release SE18014.

Fundamentals: When a Section 1135 waiver is official, CMS will notify payers of the event and provide them with the following information, says Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania:

• A summary of the Secretary’s declaration (if any)
• Specific geographic areas affected by catastrophe/disaster declarations
• Specific instructions on which formal/informal waivers are permitted for use
• The beginning and end dates for use of the CR modifier
• Other uses of the modifier that will be mandatory for the particular catastrophe/disaster.

While you might think any service related to a disaster would qualify for modifier CR, there are some very specific parameters that you must meet before using the modifier. You can only use the modifier in clearly-defined catastrophe/disaster situations, confirms Falbo.

Of interest: The type of disaster doesn’t really matter. While the preceding information involves Hurricane Michael, you might also use the CR modifier “for mass shootings, bombings, explosions; anything that would meet the criteria for a Section 1135 waiver,” explains Rogers.

Tip: Once the President and Secretary make the Section 1135 waiver official, you should report modifier CR along with any services for patients affected by these catastrophes, she reminds.

Check with your specific MAC to determine any other changes on how, when, and where to report your disaster claims.

Resources: You can find more information about the 1135 Waiver policies at: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/1135-Waivers-At-A-Glance.pdf. More details on agency efforts and waivers for Hurricane Michael at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18021.pdf and PHE notices at www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx.