Home Health & Hospice Week

Have you been using DR codes incorrectly?

If your billing staff have been adding the DR code to claims associated with the COVID-19 public health emergency, you’ve got to change your ways.

Reminder: The DR condition code (disaster related) is required after a PHE is declared and formal waivers ensue. This is mandated by Section 1135 of the Social Security Act and outlined in the Medicare Claims Processing Manual, Chapter 38, Section 10.

In 2020, the Centers for Medicare & Medicaid Services added insight on the code usage for Medicare claims in its COVID-19 Frequently Asked Questions set on fee-for-service (FFS) billing. The DR condition code applies to institutional providers only “when all of the services/items billed on the claim are related to a COVID-19 waiver,” according to the guidance.

As the COVID PHE is expected to end on May 11, providers may want to review the policies, CMS advises. “Since the … DR condition code should only be reported during a PHE when a formal waiver is in place, plan to discontinue using them for claims with dates of service on or after May 12, 2023,” the agency reminds in a March 16 MLN Connects brief.

Hold on: However, home health agencies may have been using these codes incorrectly all along under the PHE, CMS indicates in a recent MLN Matters article. “HH&H MACs report that HHAs submitted claims with condition code DR (indicating disaster related) during the COVID-19 PHE,” CMS says in MM13020.

The problem is that agencies should “only use condition code DR on disaster-related claims when Outcome and Assessment Information Set (OASIS) is waived,” HHH Medicare Administrative Contractor Palmetto GBA explains in a message about the article.

“No waiver of OASIS reporting has occurred during the current PHE, so condition code DR isn’t needed on these claims,” CMS clarifies in the article.

Why is it a problem? If claims with DR codes “aren’t matched to a corresponding OASIS assessment in the Internet Quality Improvement Evaluation System (iQIES), the claims aren’t returned to the provider,” CMS explains. “This is because the condition code DR causes the claims-assessment matching edit to be bypassed, assuming the condition code represents a waiver of assessment reporting requirements is in effect. Currently, such claims are then suspended by other edits and require manual workarounds to process.”

The CR related to the article takes effect July 1, it notes.

How it will work: Going forward, “upon emergency declaration and waiver implementation, when a provider is unable to submit a SOC OASIS, for an admission period of care, they should submit the HIPPS code weighted closest to 1,” the transmittal directs. “For a period of continuing care, when a provider is unable to submit a follow-up OASIS, they should carry forward the last HIPPS code generated from the previous OASIS.”

Don’t forget: As you update your post-PHE policies, remember to review CMS guidance on the COVID waivers and flexibilities across the various parts of Medicare as some are set to expire while others have been extended (see HHHW by AAPC, Vol. XXXII, No. 5 for more details).

Note: Check out the Medicare Claims Processing Manual specifics at www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/clm104c38.pdf, the COVID-19 FAQs at www.cms.gov/files/document/03092020-covid-19-faqs-508. pdf, and CMS’ oft-updated COVID waiver links at www. cms.gov/coronavirus-waivers. The MLN Matters article is at www.cms.gov/files/document/mm13020-home-health-changes-disaster-claims-and-certain-adjustments.pdf.