Unraveling the CMS COVID-19 PHE Modifiers

Written by Joanne Byron, BS, LPN, CCA, CHA, CHBS, CHCO, CIFHA, CMDP, OHCC, ICDCT-CM/PCS

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Healthcare providers, coders and billers are striving to keep up with changes evolving as we proceed deeper into the SARS-CoV-2 (Coronavirus Disease 2019) pandemic. Until an effective vaccine is created, distributed world-wide and administered to enough people globally, we will continue to suffer from this Public Health Emergency (PHE). After the vaccine? We are likely to see COVID-19 reappear each flu season.

This article is to help your organization gain access to the COVID-19 PHE modifier chart and explain a few pertinent facts related to Modifier “CS” which waives cost-sharing during the PHE, the Catastrophe/Disaster-Related modifier “CR”, Disaster-Related Claim Covered by the Blanket Waivers” modifier “DR”, Telemedicine modifier “95” and Modifier “CG” which identifies policy criteria has been applied to the claim. Confused? Let’s try to unravel the modifiers.

These modifiers are not just for COVID-19, but are used during any Public Health Emergency or “PHE”. The U.S. Department of Health & Human Services has a dedicated COVID-19 PHE webpage for “Public Health & Medical Emergency Support for a Nation Prepared” – this is the URL:

https://www.phe.gov/emergency/events/COVID19/Pages/default.aspx

First, remember that there is a difference in how these modifiers are used on a Part A UB04 claim versus the Part B Professional 1500 claim. Therefore, each modifier will be addressed for each type of claim.

Modifier CS (waives cost-sharing)

These guidelines apply to Part B claims - When this modifier is used, it demonstrates that cost-sharing during the PHE has been waived. It is used only for a medical visit that results in an order for, or administration of, a COVID-19 lab test. Append it to each line item on the claim that would result in patient responsibility. In addition to the visit, apply for all COVID-19 testing-related services to get 100% of the Medicare-approved amount; it does not need to be applied to Lab Codes.

Part A claim exceptions – there are special usage guidelines for institutional (Part A) providers which allows CS to be used on claims for HCPCS C9803 which reports “Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sarscov-2) (coronavirus disease [COVID-19]), any specimen source”. Cost-sharing does not apply to an inpatient visit.

Modifier CR (Catastrophe/Disaster-Related)

Never use modifier CR on a telehealth claim. The CR modifier is used in relation to Part B items and services for both institutional and non-institutional billing. The CR modifier is used for Part B items and services only but may be used in either institutional or non-institutional billing. Use of the CR modifier is required when an item or service is impacted by an emergency or disaster and Medicare payment for such item or service is conditioned on the presence of a “formal waiver*”.

In previous emergencies, use of the CR modifier has been discretionary with the billing provider or supplier. It no longer may be used at the provider or supplier’s discretion.

Use of the CR modifier will be mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned on the presence of a “formal waiver*.” The CR modifier also may be required for any HCPCS code for which, at the A/B MAC (A)’s, (B)’s, or (HHH)’s or DME MAC’s discretion or as directed by CMS in a particular disaster or emergency, the use of the CR modifier is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee-for-service program.

* 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 temporary waiver or modification of a requirement under the authority described in §1135 of the Social Security Act (the Act). This waiver authority under §1135 may permit Medicare payment in a circumstance where such payment would otherwise be barred because of noncompliance with the requirement being waived or modified.
The second type of formal waiver is a waiver based on a provision of Title XVIII of the Act or its implementing regulations. This is the most commonly employed waiver.

Part A claim exceptions – there are special usage guidelines for institutional (Part A) providers which allows the in-center dialysis center to also apply condition code DR to claims if all of the treatments billed on the claim meet this condition, or modifier CR, on the line level to identify individual treatments meeting this condition.

DR Condition Code (not a modifier) for Disaster/Emergency-Related Claims

The definition requires Condition Code DR be “used to identify claims that are or may be impacted by specific payer/health plan policies related to a national or regional disaster.” Condition Code DR should be used for institutional billing (UB04 or Form CMS-1450), at the claim level, when all of the services/items billed on the claim are related to a COVID-19 waiver.

In previous emergencies, use of the DR condition code has been discretionary with the billing provider or supplier. It no longer may be used at the provider or supplier’s discretion. Use of the DR condition code will be mandatory for any claim for which Medicare payment is conditioned on the presence of a “formal waiver.”

Condition Code DR is not used on Part B claims

Modifier 95 Used for Telehealth Part B Claims

Modifier 95 is defined as "Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System" and is also used on audio-only E&M services. It should only be appended to approved telehealth codes.

Part A Exceptions –

Rural Health Clinics (RHCs): optional (not required);
Federally Qualified Health Centers (FQHCs): required with 99214 (or other FQHC PPS Qualifying Payment Code) and G2025 from January 27, 2020 through June 30, 2020; optional starting July 1, 2020.
Hospitals do not use Modifier 95 when billing for the originating site fee only

Modifier CG Required on RHC Claims

This modifier identified that policy criteria were applied to the claim and is required on Rural Health Clinic (RHC) claims from January 27, 2020 through June 30, 2020. This modifier is not applied to Part B claims.

Additional Resources on this topic:

Download the CMS COVID-19 Modifier Chart PDF published by Medicare Part A and B Provider Outreach & Education Group