Monday, May 31, 2010

When to use CR and DR modifier

Use of the CR Modifier and DR Condition Code for Disaster/Emergency-Related Claims

Modifier CR Catastrophe/Disaster

Correct Use

This modifier must be submitted only when an item or service is impacted by an emergency or disaster.

    Use for both institutional and non-institutional billing
    Effective August 31, 2009: use of CR modifier is mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned directly or indirectly on the presence of a "formal waiver"
    Formal Waiver: waiver of a program requirement that otherwise would apply by statute or regulation
        Two types of formal waivers
            Waiver of a requirement specified in Section 1135(b) of the Social Security Act. This may permit Medicare payment in a circumstance where payment would otherwise be barred.
            Waiver based on a provision of the Title XVIII of the Act or its implementing regulations.

In the event of a disaster or emergency, CMS will issue specific guidance to Medicare contractors.

Incorrect Use

    When there are no instructions from CMS to use the modifier

    Item/service/claim was not affected by an emergency/disaster

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 authority 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 effective 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 requirements, if any, may be waived or modified under the Secretary’s authorization and whether specific conditions within the geographic area(s) specified by the Secretary’s declaration warrant waiver or modification of one or more requirements of Title XVIII of 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 specified. 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 Administrator 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 relaxed 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 contractor, 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 contractors via one or more Joint Signature Memorandum/Technical Direction Letter (JSM/TDL) that will contain a summary of the Secretary’s 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: Contractors must compile reports of utilization of the use of the condition code and/or modifier as specified in this Transmittal and/or via any JSM/TDL as may be issued in the event of a specific disaster or emergency.

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