Medicare Compliance & Reimbursement

Question: Are Medicare providers supposed to be using the CR modifier or DR condition code on COVID-19-related claims?

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Answer: Yes, according to Centers for Medicare & Medicaid Services (CMS) guidance in the agency’s “COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing” brief.

“With the exception of telehealth services, use of the ‘DR’ condition code and ‘CR’ modifier are mandatory for institutional and non-institutional providers in billing situations related to COVID-19 for any claim for which Medicare payment is conditioned on the presence of a ‘formal waiver,’” CMS says in the FAQs set.

Reminder: The CR modifier (Catastrophe/disaster related) and DR condition code (disaster related) are required after a public health emergency (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.

The 1135 blanket waivers authorize HHS Secretary Alex Azar to waive or modify specific Medicare requirements to ensure that sufficient healthcare items and services are available to meet the needs of beneficiaries.

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,” CMS instructs.

Both institutional and non-institutional providers should append the CR modifier for Part B line items/services in connection with COVID-19 waivers, suggests the guidance.

Some examples that might impact your practice include the following:

• Claims for testing services at newly set up swab sites.
• Telephone calls (98966‒98968; 99441‒99443). Note that these are not telehealth services.
• Providers rendering services in states in which they are not licensed.
• Services by a teaching physician supervised virtually under the waiver for an in-person supervision.

Best bet: Though CMS insists it will not deny Medicare claims that are missing the modifier or condition code, every effort should be made to use the CR modifier and DR condition code when applicable on claims covered by COVID-19 blanket waivers.

Resources: See a complete list of the 1135 blanket waivers at www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf and review the COVID-19 FAQs on Medicare FFS billing at www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf.