Medicare Compliance & Reimbursement

Reminder: CR modifier isn’t just for natural disasters.

The earthquakes in Puerto Rico are a reminder that natural disasters are not just seasonal events but can hit at any time, anywhere. And with weather-related catastrophes on the rise, you must prepare in advance for any possible outcome.

Context: On Jan. 8, Department of Health and Human Services (HHS) Secretary Alex Azar issued a public health emergency (PHE) for the Commonwealth of Puerto Rico after a series of earthquakes rocked the island. “These actions and flexibilities are retroactive to Dec. 28, 2019,” mentions HHS in a release on the PHE.

“We are concerned about potential impacts of this week’s earthquakes on the lives of our fellow citizens in Puerto Rico,” said Azar in the release. “Across HHS, we have worked closely with the territory’s health and human services authorities on disaster recovery and will continue to do everything we can to help ensure the health and well-being of people across the island.”

See the PHE announcement at  www.hhs.gov/about/news/2020/01/08/hhs-secretary-azar-declares-public-health-emergency-for-puerto-rico-following-earthquakes.html.

Reminder: Once the government declares a PHE, the HHS Secretary can invoke Section 1135 of the Social Security Act (SSA), which now allows Azar to waive or modify certain Medicare, Medicaid, CHIP, and HIPAA requirements.

“The Trump Administration is gravely concerned about public health conditions in Puerto Rico, and we are doing everything within our authority to provide relief to those affected by these devastating earthquakes,” said Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma in a release. “During this trying time for the island, CMS is coordinating with our federal, state, and local partners in doing everything possible to facilitate our beneficiaries’ access to care — care that very well may be life-saving.”

In addition to certain waived requirements, CMS plans to do the following, according to a brief on the earthquakes:

• Open enrollment to those most impacted and in need of services in Puerto Rico.
• Maintain dialysis for critical care patients.
• Suspend some Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) requirements to ensure beneficiaries get their supplies.
• Delay facility survey and enforcement activity temporarily.
• Protect and assist Medicare Advantage providers and Part D plan sponsors.

Register These Medicare Requirements Before a Disaster Strikes

There are certain things that happen after the HHS Secretary declares the PHE and announces a formal waiver. First, the feds will alert the impacted Medicare Administrative Contractor (MACs) with a concise outline of the geographic areas affected by the disaster or catastrophe.

Plus, HHS and CMS will break down the specifics on what the MACs should know for both the formal and informal waivers.

Reminder: Informal waivers relax certain Medicare procedures — usually related to administration and “not required by statute or regulation” — and are “discretionary,” explains Change Request (CR) 7156. “One example of such a norm would be claims filing jurisdiction. In the event of a disaster/emergency that impaired or limited operations at a particular Medicare contractor, alternative claims filing jurisdictions could be established,” CMS instructs.

Lastly, HHS and CMS set a time frame for the waivers with start (retroactive in this instance) and end dates, alerting the MACs of the specifics and the usage of required codes. Depending on the nature of the disaster, the feds may issue a waiver extension.

In July 2009, CMS issued CR 6451, which mandated the use of the DR condition code (disaster related) and the CR modifier (Catastrophe/disaster related) on Medicare claims with a “formal waiver” like the 1135 waiver in this case.

Why? HHS allows these waivers to better monitor how payers process claims in these uncertain circumstances, says Dawn Rogers, coding specialist at Caduceus Inc. in Jersey City, New Jersey. Plus, your coding and modifier usage could also change when reporting services for patients affected by the disaster. CMS created modifier CR “in order to track and facilitate claims processing for disaster victims,” indicates Rogers.

Understand the Specifics of the DR Condition Code

When a formal waiver is in place, institutional providers need to use a DR condition code. For submissions, providers should use the ASC X12 837 institutional claims format or paper form CMS-1450, MLN Matters SE 20003 reminds.

Review these DR condition code basics before you write up your disaster coding protocols:

• Scan updates and revisions after each disaster and emergency to CR 6451 and the Medicare Claims Processing Manual, Chapter 38 for claims and billing changes.
• Know that the DR condition code is “used to identify claims that are or may be impacted by specific payer/health plan policies related to a national or regional disaster,” according to Chapter 38, Section 10 of the Medicare Claims Processing Manual.
• Remember the DR condition code is for institutional providers only when a formal waiver like the 1135 is issued.

See the Medicare Claims Processing Manual guidance at  www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c38.pdf.

Review These CR Modifier Basics

Once a 1135 waiver is issued, providers must append the CR modifier for Part B claims for both institutional and non-institutional providers. You should submit Part B claims “using the ASC X12 837 professional claim format or paper form CMS-1500 or, for pharmacies, in the NCPDP format,” advises MLN Matters SE 20003. 

Pocket this CR modifier advice for your catastrophe checklist:

• Note that CMS created modifier CR with the descriptor to track and facilitate claims processing for disaster victims.
• Use the CR modifier for Medicare Part B items and services for both institutional and non-institutional providers and suppliers.
• Attach the mandatory CR modifier to your HCPCS codes when a formal waiver like the section 1135 waiver is instituted.
• Know that the CR modifier is not weather-specific and can be used for any catastrophe under section 1135 after both the President and HHS Secretary declare emergencies. For example, you can use the CR modifier “for mass shootings, bombings, explosions; anything that would meet the criteria for a section 1135 waiver,” explains Rogers.

Bottom line: Check in with your MAC to see how its dealing with both formal and informal waivers, including the use of the CR modifier and DR condition code.

Resource: For specifics on the Puerto Rico earthquakes and the Medicare fee-for-service response, visit MLN Matters SE20003 at  www.cms.gov/files/document/se20003.pdf.