With fluctuating volumes of COVID-19 cases and the unknown elements of infection and reinfection, condition codes and modifiers are being appended to every claim associated with COVID-19, whether it is a confirmed or suspected case. Appropriate processing of claims is important not only for reimbursement purposes, but also for data collection, and having an understanding of these codes will allow for greater visibility and ease of reimbursement. Developed by Oxford’s experts in the health information management field, this summary of the condition codes and modifiers will help explain best practices for approaching billing and claims during this turbulent time.
On January 31, 2020, in response to the global COVID-19 pandemic, the US Secretary of Health and Human Services declared a public health emergency (PHE) for the entire United States. Additionally, Secretary Azar authorized modifications and waivers under Section 1135 of the Social Security Act (the Act) on March 13, 2020, retroactive to March 1, 2020. The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. These modifications and waivers prevent gaps in access to care for beneficiaries.1
On January 27, 2020, the US Department of Health and Human Services (DHHS) declared the COVID-19 pandemic as a federal PHE. As a result, any claims with a date of service on or after January 27, 2020, until the end of the PHE need to have the correct ICD-10-CM codes related to COVID-19, and the appropriate condition code and modifier (outpatient Part-B) to provide payers a trigger for special handling of claims for COVID-19 related services.2
As outlined in Section 1135 and Section 1812(f) Waivers of the Act, the following condition codes and modifiers should be utilized:
- The DR (disaster-related) condition code for institutional billing. For example, claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450.
- The title of the DR condition code indicates “disaster-related,” and its definition requires it to be used “to identify claims that are or may be impacted by specific payer/health plan policies related to a national or regional disaster.”
- The CR (catastrophe/disaster-related) is the modifier that should be used for Part B billing, both institutional and non-institutional. For example, claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or for pharmacies (in the NCPDP format) should incorporate the CR modifier.
- Both the short and long descriptors of the CR modifier are “catastrophe/disaster-related.”1
The National Uniform Billing Committee (NUBC) recommends applying the following codes to COVID-19 claims to ensure appropriate flagging of patient care provided relating to COVID-19:
- DR condition code identifying claims that are or may be affected by specific policies related to the PHE.
- One of the following ICD-10-CM codes either interim or final:
- B97.29: Other coronavirus as the cause of diseases classified elsewhere for services provided before April 1, 2020
- U07.1: COVID-19 for services provided on or after April 1, 2020
- Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out
- Z11.59: Encounter for screening other viral diseases
- Z20.828: Contact with and suspected exposure to other viral communicable diseases
- An appropriate date of service of January 27, 2020, to the end of the PHE.2
It is of vital importance to utilize the correct condition code on inpatient claims and the appropriate modifier on outpatient claims to ensure that they are handled correctly, and accurate data collection can occur. These condition codes and modifiers are designed to create a more streamlined, accurate billing experience. If your organization needs additional support with coding, data collection, reimbursement, or other claims processing needs, connect with a member of our team and learn how Oxford’s experts can help.