Emergencies and Disasters - JA DME
Emergencies and Disasters
The COVID-19 PHE has expired.
All COVID-19 All COVID - 19 flexibilities and waivers, except for certain telehealth flexibilities, are expired. Visit the Post COVID-19 Public Health Emergency (PHE) page for more information.
Clarification for Using the "CR" Modifier and "DR" Condition Code
| Waiver/Flexibility | Summary | CR | DR |
|---|---|---|---|
| Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital | Allows acute care 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 a disaster or emergency. | X | |
| Housing Acute Care Patients in the IRF or Inpatient Psychiatric Facility (IPF) Excluded Distinct Part Units | Allows acute care hospitals to house acute care inpatients in excluded distinct part units, such as excluded distinct part unit IRFs or IPFs, where the distinct part unit’s beds are appropriate for acute care inpatients. | X | |
| Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital | Allows acute care 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 this PHE. | X | |
| Supporting Care for Patients in Long Term Care Acute Hospitals (LTCHs) | CMS has determined it is appropriate to issue a blanket waiver to long-term care hospitals (LTCHs) to exclude patient stays where an LTCH admits or discharges patients in order to meet the demands of the emergency from the 25-day average length of stay requirement, which allows these facilities to be paid as LTCHs. In addition, during the applicable waiver time period, we would also apply this waiver to facilities not yet classified as LTCHs, but seeking classification as an LTCH. | X | |
| Care for Patients in Extended Neoplastic Disease Care Hospital | Allows extended neoplastic disease care hospitals to exclude inpatient stays where the hospital admits or discharges patients in order to meet the demands of the emergency from the greater than 20-day average length of stay requirement, which allows these facilities to be excluded from the hospital inpatient prospective payment system and paid an adjusted payment for Medicare inpatient operating and capital-related costs under the reasonable cost-based reimbursement rules | X | |
| Skilled Nursing Facilities (SNFs) | Using the authority under Section 1812(f) of the Act, CMS is waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances). | X | |
| Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) | When DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable, allow the DME Medicare Administrative Contractors (MACs) to have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable as a result of the emergency. | X | |
| Modification of 60-Day Limit for Substitute Billing Arrangements (Locum Tenens) | Modifies the 60-day limit to allow a physician or physical therapist to use the same substitute for the entire time he or she is unavailable to provide services during the COVID-19 emergency, plus an additional period of no more than 60 continuous days after the public health emergency expires. On the 61st day after the public health emergency ends (or earlier if desired), the regular physician or physical therapist must use a different substitute or return to work in his or her practice for at least one day in order to reset the 60-day clock. Physicians and eligible physical therapists must continue to use the Q5 or Q6 modifier (as applicable) and do not need to begin including the CR modifier until the 61st continuous day. | X | |
| Critical Access Hospitals | Waives the requirements that Critical Access Hospitals limit the number of inpatient beds to 25, and that the length of stay, on an average annual basis, be limited to 96 hours | X | |
| 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 by damage due to the disaster or emergency. | X | |
| Hospitals Classified as Sole Community Hospitals (SCHs) | Waives certain eligibility requirements for hospitals classified as SCHs prior to the PHE, specifically the distance requirements and the "market share" and bed requirements (as applicable) | X | |
| Hospitals Classified as Medicare-Dependent, Small Rural Hospitals (MDHs) | For hospitals classified as MDHs prior to the PHE, waives the eligibility requirements that the hospital has 100 or fewer beds during the cost reporting period and that at least 60 percent of the hospital's inpatient days or discharges were attributable to individuals entitled to Medicare Part A benefits during the specified hospital cost reporting periods. | X | |
| IRF 60 Percent Rule | Allows an IRF to exclude patients from its 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") if an IRF admits a patient solely to respond to the emergency. In addition, during the applicable waiver time period, we would also apply the exception to facilities not yet classified as IRFs, but that are attempting to obtain classification as an IRF. | X | |
| Waivers of certain hospital and Community Mental Health Center (CMHC) Conditions of Participation and provider-based rules | Allows a hospital or Community Mental Health Center (CMHC) to consider temporary expansion locations, including the patient’s home, to be a provider-based department of the hospital or extension of the CMHC, which allows institutional billing for certain outpatient services furnished in such temporary expansion locations. If the entire claim falls under the waiver, the provider would only use the DR condition code. If some claim lines fall under this waiver and others do not, then the provider would only append the CR modifier to the particular line(s) that falls under the waiver. | X | X |
| Billing Procedures for ESRD services when the patient is in a SNF/NF | In an effort to keep patients in their SNF/NF and decrease their risk of being exposed to COVID-19, ESRD facilities may temporarily furnish renal dialysis services to ESRD beneficiaries in the SNF/NF instead of the offsite ESRD facility. The in-center dialysis center should bill Medicare using Condition Code 71 (Full care unit. Billing for a patient who received staff-assisted dialysis services in a hospital or renal dialysis facility). The in-center dialysis center should also apply condition code DR to claims if all the treatments billed on the claim meet this condition or modifier CR on the line level to identify individual treatments meeting this condition. | X | X |
| Clinical Indications for Certain Respiratory, Home Anticoagulation Management, Infusion Pump and Therapeutic Continuous Glucose Monitor national and local coverage determinations | In the interim final rule with comment period (CMS-1744-IFC and CMS-5531-IFC) CMS states that clinical indications of certain national and local coverage determinations will not be enforced during the COVID-19 public health emergency. CMS will not enforce clinical indications for respiratory, oxygen, infusion pump and continuous glucose monitor national coverage determinations and local coverage determinations. | X | |
| Face-to-face and In-person Requirements for national and local coverage determinations | In the interim final rule with comment period (CMS-1744-IFC) CMS states that to the extent a national or local coverage determination would otherwise require a face-to-face or in-person encounter for evaluations, assessments, certifications or other implied face-to-face services, those requirements would not apply during the COVID-19 public health emergency. | X | |
| Requirement for DMEPOS Prior Authorization | The requirement to submit a prior authorization request for certain DMEPOS items and services was paused. Suppliers were given the option to voluntary continue submitting prior authorization requests or to skip prior authorization and have the claim reviewed through post payment review at a later date. Claims that would normally require prior authorization, but were submitted without going through the process should be submitted with a CR modifier. | X | |
| Signature requirements for proof of delivery | The signature requirement for Part B drugs and certain Durable Medical Equipment (DME) that require a proof of delivery and/or a beneficiary signature was waived. Providers should use a CR modifier on the claim and document in the medical record the appropriate delivery date and that a signature could not be obtained because of COVID-19. | X | |
| Part B Prescription Drug Refills | MACs may exercise flexibilities regarding the payment of Medicare Part B claims for drug quantities that exceed usual supply limits, and to permit payment for larger quantities of drugs, if necessary. MACs may require the use of the CR modifier in these cases. | X |
COVID-19: Advance Payment
CMS Announces New Repayment Terms for Medicare Loans made to Providers during COVID-19
CMS announced amended terms for payments issued under the Accelerated and Advance Payment Program. Providers were required to make payments starting August of 2020, but with this action, repayment will be delayed until one year after payment was issued.
See CMS Announces New Repayment Terms for Medicare Loans made to Providers during COVID-19 for complete information.
View the CMS COVID-19 Accelerated and Advance Payment (CAAP) Repayment & Recovery Frequently Asked Questions resource for additional information.
CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program
On April 26, the Centers for Medicare & Medicaid Services (CMS) announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. The agency made this announcement following the successful payment of over $100 billion to health care providers and suppliers through these programs and in light of the $175 billion recently appropriated for health care provider relief payments.
See CMS MLN Connects, Special Edition – Monday, April 27, 2020 for complete information.
CMS has expanded the current Advance Payment Program during the COVID-19 public health emergency to extend financial hardship relief to impacted Medicare suppliers. Special considerations will be given for COVID-19 circumstances. See the FACT SHEET: EXPANSION OF THE ACCELERATED AND ADVANCE PAYMENTS PROGRAM FOR PROVIDERS AND SUPPLIERS DURING COVID-19 EMERGENCY for more information.
An Accelerated and Advance Payment Form [PDF] must be completed to begin the process. One form must be completed for JA and one form for JD. Please indicate the jurisdiction on the form.
The request may be submitted to Noridian via email, fax or mail, using the below information.
Email: dmemsprecoupment@noridian.com
Fax: 701-277-7892
US Postal Mail
Noridian Healthcare Solutions
Attn: DME-Recoupment
PO Box 6055
Fargo, ND 58108-6055
Mail sent through FedEx or Other Courier
Noridian Healthcare Solutions
Attn: DME-Recoupment
4510 13th Ave S
PO Box 6055
Fargo, ND 58103
We encourage fax and email submissions for faster action on your request.
Resources
In the event of a national or regional catastrophe or disaster, the Emergency Response and Recovery webpage contains information about the most recent emergencies and disasters.
Access the below topic related information from this page.
Access additional resources that may assist providers when handling claims related inquiries from the below.
