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Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)

Craneware® Insights Regulatory Updates – CWI1211 (19 March 2020)

Topic

Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)

On March 16, 2020, CMS released MLN Matters® Special Edition Article, number SE20011, in which information is provided regarding blanket waivers issued under a declared public health emergency (PHE) that affect Medicare Fee-for-Service (FFS providers.

Types Affected

Critical Access Hospitals
OPPS Hospitals
Physicians

Departments/Areas Affected

Business Office
Compliance / Revenue Integrity
Durable Medical Equipment (DME)
Finance
HIM/Medical Records
Pharmacy

What You Need to Know

The Secretary of the Department of Health & Human Services declared a public health emergency (PHE) in the entire United States on January 31, 2020. On March 13, 2020 the Secretary authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to March 1, 2020.

Consistent with the Secretary’s authorization, the Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers to prevent gaps in access to care for beneficiaries impacted by the PHE. Hospitals and/or providers do not need to apply for an individual waiver when a blanket waiver has been issued.

Billing Medicare FFS

CMS instructs providers to apply the following condition code and modifier to all Medicare fee-for-service claims that will receive Medicare payment based on a “formal waiver” issued under Section 1135 or Section 1812(f) of the Act:

  • Condition Code = “DR” (disaster related): For use with institutional (hospital) billing for claims using the ASC X12 837 institutional claims format or paper Form CMS-1450 (UB-04).
  • Modifier = “CR” (catastrophe/disaster related): For use with Part B billing, both institutional and non-institutional, (i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format).

Critical Access Hospitals (CAHs)

CMS waives the requirements for CAHs to limit the number of beds to 25 and the length of stay to 96 hours.

Inpatient Prospective Payment System (IPPS) Hospitals Relocating Acute Care Patients to Excluded Distinct Part Units

CMS has issued a blanket waiver to allow IPPS hospitals to house acute care inpatients in excluded distinct part units that are appropriate for acute care inpatients. CMS states that the IPPS hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to the PHE.

Inpatient Psychiatric Unit Patients Relocated to an Acute Care Unit

CMS has issued a blanket waiver to permit IPPS and other acute hospitals with excluded distinct part inpatient psychiatric units to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit as a result of the emergency. CMS states that the hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the emergency. The waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the environment is conducive to safe care.

Inpatient Rehabilitation Unit Patients Relocated to an Acute Care Unit

CMS has issued a blanket waiver to permit IPPS and other acute hospitals with excluded distinct part inpatient rehabilitation units to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit as a result of the emergency. CMS states that the hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility (IRF) prospective payment system for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the emergency. The waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients.

If an IRF admits a patient solely to respond to the emergency and the patient’s medical record properly identifies the patient as such, the IRF may exclude patients from the hospital’s or unit’s inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the “60 percent rule”). During the applicable waiver time period CMS will also apply the exception to facilities attempting to obtain classification as an IRF.

Emergency Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by the Emergency

CMS has issued a waiver for contractors to waive replacement requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable. Suppliers must still provide a narrative description on the claim explaining why equipment must be replaced. The supplier must also maintain documentation indicating that the DMEPOS was lost destroyed, irreparably damaged or otherwise rendered unusable or unavailable as a result of the emergency.

Replacement Prescription Fills

Medicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable or unavailable due to the emergency.

The MLN Matters article provides the following  links to webpages containing information pertaining to waivers:

  • Waivers and Flexibilities Medicare FFS Questions & Answers (Q&As):

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities

  • Questions and Answers on Emergency-Related Policies and Procedures That May be Implemented Without § 1135 Waivers:

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf

  • Questions and Answers on Emergency and Disaster-Related Policies and Procedures That May Be Implemented Only With a § 1135 Waiver:

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf

Action Needed

Facilities and providers need to read the MLN Matters article and the associated Question and Answer documents in their entirety. Educate billing staff on the appropriate use of the “DR” condition code on claims where the hospital has implemented any of the above-mentioned actions due to the current PHE. Non-institutional providers need to add the “CR” modifier to HCPCS codes, via the patient financial system and/or order entry system, for use in signifying the service furnished is provided under the condition of the “formal waiver”.

Effective Date

01 March 2020

Background

Section 1135 of the Social Security Act:

https://www.ssa.gov/OP_Home/ssact/title11/1135.htm

Section 1812(f) of the Social Security Act:

https://www.ssa.gov/OP_Home/ssact/title18/1812.htm

CMS Emergency Webpage:

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page

Reference

https://www.cms.gov/files/document/se20011.pdf

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