Medicare Compliance & Reimbursement

Tip: Some Medicare Conditions of Participation are waived with an 1135 waiver.

When a natural disaster strikes, the last thing you’re thinking about is whether your Medicare claims are on target. But, if you are in the middle of the mess and assisting patients, it is vital to know the rules that cover coding and billing for disaster — to ensure you get the pay you deserve.

Background: On Sept. 12, HHS Secretary Alex M. Azar issued a Public Health Emergency (PHE) in the wake of Hurricane Florence for North Carolina, South Carolina, and Virginia. Once a PHE is declared then the HHS Secretary may invoke Section 1135 of the Social Security Act (SSA), which will allow Azar to waive or modify certain Medicare, Medicaid, CHIP, and HIPAA requirements. These updates cover the essentials you’ll need to submit claims after disaster strikes.

“Hurricane Florence is an intense storm and is predicted to be highly destructive, which poses a significant threat to the health and safety of those in its path,” said Secretary Azar in an HHS release on the PHE. “These actions help ensure that Americans who rely on Medicare and Medicaid have continuous access to the care they need when the storm makes landfall.”

You can find the PHE notices at www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx.

Review How a Public Health Emergency Is Determined — and What Follows

Though the term “disaster” is sometimes thrown around lightly, 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.

However, your coding, and modifier usage, could 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.

See more details on agency efforts and waivers for Hurricane Florence at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18014.pdf.

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 and;
• 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 must be met 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 above involves Hurricane Florence, 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.

Medicare Compliance & Reimbursement will continue to keep you abreast of federal updates from HHS and CMS.  Check with your specific MAC to determine any other changes on how, when, and where to report your disaster claims.

Resource: 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.