Claim Submission Instruction Post-PHE - Continued Use of Modifier CR and COVID Narrative - Revised - JA DME

Joint DME MAC Publication
Posted May 18, 2023

After the end of the Public Health Emergency on May 11, 2023, suppliers will require a method for indicating that claims for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items were specifically excluded from enforcement of the clinical indications of coverage referenced in Interim Final Rules CMS-1744-IFC and CMS-5531-IFC. The National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) impacted by these interim rules are:

• Home Oxygen (NCD 240.2)
• Infusion Pumps (NCD 280.14)
• Continuous Positive Airway Pressure for Obstructive Sleep Apnea (NCD 240.4)
• Intrapulmonary Percussive Ventilator (NCD 240.5)
• Durable Medical Equipment Reference List (NCD 280.1) - Only clinical indications for ventilators are not enforced
• Oxygen and Oxygen Equipment (L33797)
• Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea (L33718)
• Oral Appliances for the Treatment of Obstructive Sleep Apnea (L33611)
• Respiratory Assist Devices (L33800)
• Mechanical In-exsufflation Devices (L33795)
• High Frequency Chest Wall Oscillation (L33785)
• Nebulizers (L33370)
• Suction Pumps (L33612) - Only clinical indications for respiratory suction pumps (E0600) are not enforced
• Glucose Monitors (L33822) - Only clinical indications for Continuous Glucose Monitors (CGM) are not enforced
• External Infusion Pumps (L33794)

To address concerns for continued claims payment of DMEPOS items provided during the PHE and to identify claims for supplies and accessories associated with DMEPOS items initially dispensed, rendered or otherwise impacted by the PHE, the DME MACs are instructing suppliers to continue the use of the CR modifier (Catastrophe/disaster related) and COVID-19 narrative.  The CR Modifier and COVID-19 narrative can continue to be used for any DMEPOS item (ongoing rentals) and related supplies/accessories where the base item was initially dispensed, rendered or otherwise impacted by the PHE (dates of service on March 1, 2020 through May 11, 2023) or specifically excluded from enforcement of the clinical indications of coverage referenced in Interim Final Rules CMS-1744-IFC and CMS-5531-IFC. The use of the CR modifier and COVID-19 narrative is intended to allow the DME MACs to implement new system editing for PHE-dispensed DMEPOS items and provide the ability to identify these claims for future review, if indicated. The CR modifier and narrative of "COVID-19" should be entered into the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format, field 390-BM of the National Council for Prescription Drug Program (NCPDP) format, or Item 19 of paper claims. Additionally, suppliers should continue to bill the KX, and/or CG modifiers, as applicable, for any DMEPOS item or related supply/accessory dispensed on dates of service between March 1, 2020 through May 11, 2023 that were specifically excluded from enforcement of the clinical indications of coverage referenced in Interim Final Rules CMS-1744-IFC and CMS-5531-IFC.

As a reminder, for oxygen claims covered by Medicare prior to April 1, 2023, suppliers may continue to use the KX modifier or may use the N-modifiers for claims with dates of service on or after April 1, 2023. This is in addition to the CR modifier and "COVID-19" narrative as described above.

For initial claims for oxygen or new 36-month oxygen rental periods with dates of service on or after April 1, 2023, suppliers must use the N1, N2 or N3 modifier as described below:

• N1 modifier only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met for Group I beneficiaries.
• N2 modifier only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met for Group II beneficiaries.
• N3 modifier only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met for Group III beneficiaries.

In addition to the N-modifiers, suppliers may use the CR modifier and "COVID-19" narrative as described above for dates of service on or after April 1, 2023 through May 11, 2023. If none of the N modifiers are applicable, suppliers may continue to use the CR modifier and "COVID-19" narrative without appending an N modifier.

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