- Mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned directly or indirectly on presence of a "formal waiver"
- For Part B items and services related to both institutional and non institutional billing
- Non-institutional billing, i.e., claims submitted by "physicians and other suppliers", are submitted either on a professional paper claim form CMS-1500 or in electronic format ANSI ASC X12 837P or - for pharmacies - in the NCPDP format
Note: Per Change Request (CR) 6451 - The Use of the CR Modifier and DR Condition Code on Disaster/Emergency-Related Claims
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 waiver of a requirement specified in Section 1135(b) of the Social Security Act (Act). Although Medicare payment rules themselves are not "waivable" under this statutory provision, the waiver of a Section 1135(b) requirement may permit Medicare payment in a circumstance where such payment would otherwise be barred. 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 Section 1812(f) of the Social Security Act.
Further Instructions in the Event of a Disaster or Emergency
Additional Information: In the event of a disaster or emergency, CMS will issue specific guidance to Medicare contractors 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.
- Using it at supplier discretion
- CMS Medicare Learning Network (MLN) Matters (MM) 6451 - The Use of the CR Modifier and the DR Condition Code on Disaster/Emergency-Related Claims
Last Updated May 02, 2018