CMS Issues Billing Guidance Related to COVID-19 Blanket Waivers

Client Alert

Gibbons Special Alert

June 4, 2020

The Centers for Medicare & Medicaid Services (“CMS”) clarified billing requirements for providers and suppliers that submit fee-for-service claims relating to the wide array of blanket waivers issued by CMS in connection with the Public Health Emergency (PHE) caused by the coronavirus pandemic.

As a result of the PHE, various types of claims for which payment is based on a Section 1135 or Section 1812(f) waiver must be identified with either a disaster related (“DR”) condition code (for institutional billing) and/or a catastrophic/disaster (“CR”) modifier for Part B billing. According to CMS, due to the extensive volume and scope of the waivers, clarification was warranted regarding how these codes and modifiers should be used.

The DR and CR codes and modifiers apply to the following types of claims:

  •  Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital (DR)
  • Housing Acute Care Patients in the IRF or Inpatient Psychiatric Facility (IPF) Excluded Distinct Part Units (DR)
  • Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital (DR)
  • Supporting Care for Patients in Long Term Care Acute Hospitals (DR)
  • Care for Patients in Extended Neoplastic Disease Care Hospital (DR)
  • Skilled Nursing Facilities (DR)
  • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (CR)
  • Modification of 60-Day Limit for Substitute Billing Arrangements (Locum Tenens) (CR)
  • Critical Access Hospitals (DR)
  • Replacement Prescription Fills (CR)
  • Hospitals Classified as Sole Community Hospitals (DR)
  • Hospitals Classified as Medicare-Dependent, Small Rural Hospitals (DR)
  • IRF 60 Percent Rule (DR)
  • Waivers of certain hospital and Community Mental Health Center Conditions of Participation and provider-based rules (CR & DR)
  • Billing Procedures for ESRD services when the patient is in a SNF/NF (CR & DR)
  • Clinical Indications for Certain Respiratory, Home Anticoagulation Management, Infusion Pump, and Therapeutic Continuous Glucose Monitor national and local coverage determinations (CR)
  • Face-to-face and In-person Requirements for national and local coverage determinations (CR)
  • Requirement for DMEPOS Prior Authorization (CR)
  • Signature requirements for proof of delivery (CR)
  • Part B Prescription Drug Refills (CR)

CMS notes that it could deny claims that are missing the required modifier or condition code. On the other hand, CMS indicates that it will not deny claims due to the presence of a DR or CR modifier for services or items that are not on the list, or for services or items that are not related to a COVID-19 waiver.

In light of the foregoing announcement, we therefore urge Medicare providers and suppliers to immediately incorporate this guidance into their current billing practices.