(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 38 - Emergency Preparedness Fee- For-Service Guidance   Table of Contents  (Rev. 10135, 05- 15-20)  Transmittals for Chapter 38   01  Foreward  10  Use of the CR Modifier and DR Condition Code for Disaster/Emergency -Related Claims   01  Foreward  (Rev. 1784, Issued: 07- 31-09, Effective: 08- 31-09, Implementation: 08 -31-09)  Generally, this chapter describes the guidance that may be implemented for the Medicare fee-for-service program in the event of a disaster/emergency. As part of its preparedness efforts for a disaster/emergency, the Centers for M edicare and Medicaid Services (CMS) has developed certain disaster/emergency guidance that may  be implemented for the Medicare fee- for-service program in the event of a disaster/emergency.  CMS has also developed certain additional disaster/emergency guida nce that may  be implemented if: 1. the President declares an emergency or disaster under the National Emergencies Act or the Stafford Act; and  2. the Secretary of the Department of Health and Human Services declares -  under  319 of the Public Health Servi ce Act -  that a public health emergency exists, and  3. the Secretary elects to waive one or more requirements of Title XVIII of the Social Security Act (Act) pursuant to  1135 of such Act.  Until CMS declares these guidances to be in effect, the guidances  are considered to be pending.   10  Use of the CR Modifier and DR Condition Code for Disaster/Emergency -Related Claims  (Rev.  2999, Issued; 07- 25-14, Effective: 01- 01-12, Implementation: 08- 25-14)  In order to facilitate claims processing and track services and items provided to beneficiaries during disaster/emergency situations, a modifier and condition code have been established for providers to use on disaster/emergency related claims.  The modifier and condition code have been in effect since August 21, 2005.  The codes are effective for dates of service on and after August 21, 2005.  The modifier and/or condition code can be used by providers submitting claims for beneficiaries who are emergency patients in any part of the country.  The DR Condition Code :  The title of the DR condition code is disaster related and its definition requires it to be used to identify claims that are or may be impacted by specific payer/health plan policies related to a national or regional disaster.   The DR condition code is used only for institutional billing, i.e., claims submitted by providers using the ASC X12 837 institutional claim format or on an institutional paper claim Form CMS -1450.  In previous emergencies, use of the DR condition code ha s been discretionary with the billing provider or supplier. It no longer may be used at the provider or suppliers discretion. Use of the DR condition code will be mandatory for any claim for which Medicare payment is conditioned on the presence of a form al waiver, as defined below. The DR condition code also may be required for any type of claim for which, at the A/B MAC (A)s or (HHH) s discretion or as directed by CMS in a particular disaster or emergency, the use of the DR condition code is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee- for-service program.   The CR Modifier :  Both the short and long descriptors of the CR modifier are catastrophe/disaster related .  The CR modifier is used in relation t o Part B items and services for both institutional and non- institutional billing.  Non -institutional billing, i.e., claims submitted by physicians and other suppliers, are submitted either using the ASC X12 837 professional claim format or on a professional paper claim Form CMS -1500 or, for pharmacies, in the NCPDP format.  In previous emergencies, use of the CR modifier has been discretionary with the billing provider or supplier.  It no longer may be used at the provider or suppliers discretion.  Use of the CR modifier will be mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned on the presence of a formal waiver, as defined below.  The CR modifier also may be required for any HCPCS code for which, at the A/B MAC (A)s, (B) s, or (HHH)s or DME MACs discretion or as directed by CMS in a particular disaster or emergency, the use of the CR modifier is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee- for-service program.   Formal Waivers :  A formal waiver is a waiver of a program requirement that otherwise would apply by statute or regulation.  There are two types of formal waivers.  One type is a temporary waiver or modification of a requirement under the autho rity described in 1135 of the Social Security Act (the Act).  Although Medicare payment rules themselves are not waivable under this statutory provision, the waiver authority under 1135 may permit Medicare payment in a circumstance where such payment would otherwise be barred because of noncompliance with the requirement being waived or modified.  The second type of formal waiver is a waiver based on a provision of Title XVIII of the Act or its implementing regulations.  The most commonly employed waiver in this latter category is the waiver of the 3 -day qualifying hospital stay requirement that is a precondition for Medicare payment for skilled nursing facility services.  This requirement may be waived under 1812(f) of the Act .  Several conditions must  be met for a 1135 waiver to be implemented.  First, the President must declare an emergency or disaster under the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act.  Such a declaration will specify both an ef fective date and the geographic area(s) covered by the declaration.  Second, the Secretary of the Department of Health and Human Services must declare - under 319 of the Public Health Service Act -  that a public health emergency exists within some or all of the areas covered by the Presidential declaration.  Third, the Secretary must authorize the waiver of one or more requirements specified in 1135 of the Act.  Fourth, the Secretary or the Administrator of CMS must determine which Medicare program requir ements, if any, may be waived or modified under the Secretarys authorization and whether specific conditions within the geographic area(s) specified by the Secretarys declaration warrant waiver or modification of one or more requirements of Title XVIII o f the Act.  If all of the foregoing conditions are met, the Secretary or CMS Administrator may specify the extent to which a waiver or modification of a specific Medicare requirement is to be applied within the geographic area(s) with respect to which the waiver authority has been invoked.   The waiver of a Medicare requirement based on authority included in the provision of Title XVIII of the Act or its implementing regulations may be made at the discretion of the Administrator of CMS unless otherwise speci fied.  Such a waiver does not require either a Presidential or a Secretarial declaration nor, if such declarations are made, would such a waiver be necessarily limited by the geographic boundaries specified in such declarations.  Nevertheless, the Administ rator may elect to limit the effect of Title XVIII waivers to such geographic areas and to such time frames as are specified by such declarations.   A Medicare requirement established in statute or regulation that is not subject to waiver under either of these types of formal waiver generally may not be waived as a matter of administrative discretion.  Because most Medicare requirements are not waivable, nearly all Medicare entitlement, coverage, and payment rules will remain in effect during a disaster or emergency.   Informal Waivers :  An informal waiver is a discretionary waiver or relaxation of a procedural norm, when such norm is not required by statute or regulation, but rather is reflected in CMS guidance or policy.  Such norm may be waived or r elaxed administratively if circumstances warrant.  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 Administrative Contractor (MAC), alternative claims filing jurisdictions could be established.  Informal waivers are made by the CMS Administrator or his/her delegates.   Further Instructions in the Event of a Disaster or Emergency :  In the event of a disaster or emergency, CMS will issue specific guidance to MACs via one or more Technical Direction Letter (TDL) that will contain a summary of the Secretarys declaration (if any); specify the geographic areas affected by any declarations of a disaster or emergency; specify what formal waivers and/or informal waivers, if any, have been authorized; specify the beginning and end dates that apply to the use of the DR condition code and/or the CR modifier; and specify what other uses of the condition code and/or modifier, if any, will be mandatory for the particular disaster/emergency.   Reporting Utilization of the Condition Code and Modifier :  MACs must compile reports of utilization of the use of the condition code and/or modifier as specified via any TDL as may be issued in the event of a specific disast er or emergency.   B. Policy:   The DR Condition Code :   The DR condition code is used for institutional billing only.    Use of the DR condition code is required when a service is affected by an emergency or disaster and Medicare payment for such service is conditioned on the presence of a formal waiver (as that term is described in Background, above)    Use of the DR condition code also may be required when either the A/B MAC (A) or (HHH)  or CMS determine that such use is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee -for-service program.    The DR condition code is used at t he claim level when all of the services/items billed on the claim are related to the emergency/disaster.   The CR Modifier :   The CR modifier is used for Part B items and services only but may be used in either institutional or non -institutional billing.    Use of the CR modifier is required when an item or service is impacted by an emergency or disaster and Medicare payment for such item or service is conditioned on the presence of a formal waiver (as that term is described in Background, above)   Use of th e CR modifier also may be required when either the A/B MAC (A), (B), or (HHH), or DME MAC or CMS determine that such use is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee -for-service program.   Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R10135CP  05/15/2020  Manual Update to Pub. 100 -04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section  06/16/2020  11778  R2999CP  07/25/2014  Update to Pub. 100 -04, Chapter 38 to Provide Language -Only Changes for Updating ASC X12 08/25/2014  8772  R2021CP  08/06/2010  National Modifier and Condition Code to Identify Items or Services Related to the 2010 Oil Spill in  the Gulf of Mexico  01/03/2011  7087  R1784CP  07/31/2009  The Use of the CR Modifier and DR Condition Code on Disaster/Emergency Related Claims -Initial re lease of chapter  08/31/2009  6451  Back to top of chapter