Hurricane Relief: Waivers of Medicare Regulatory Requirements in Emergency Situations

In the aftermath of the devastation caused by both Hurricanes Harvey and Irma, the Centers for Medicare & Medicaid Services (CMS) has issued blanket waivers of some the regulatory requirements for hospitals and post-acute care settings to support access to services and allow healthcare facilities to provide timely care to those impacted by the storms.

As in past situations in which CMS has provided this type of relief, individual facilities do not need to apply for blanket waivers; however, they must comply with documentation and coding requirements for the waivers.

Medicare Waivers Currently in Effect (Sept. 18, 2017)

Waivers are currently in effect for providers in the affected areas. We strongly urge providers to review the information available in the reference section of this document and to look for updates to this information over the coming weeks to ensure that they are working within the parameters outlined in the waivers.

Blanket waivers – those issued by CMS that do not require individuals to apply – are outlined below, along with a summary of the instructions provided by CMS for documentation by providers. 

Skilled Nursing Facilities (SNFs)  

• The waiver of the requirement for a three-day prior hospitalization for coverage of a SNF stay provides temporary emergency coverage of SNF services without a qualifying hospital stay for those people who are evacuated, transferred, or otherwise dislocated because of the effects of Hurricanes Harvey and Irma.
• For certain beneficiaries who recently exhausted their SNF benefits, CMS authorizes renewed SNF coverage without first having to start a new benefit period.
• The waiver provides relief to SNFs on the time frame requirements for Minimum Data Set assessments and transmission.

 Medicare’s Instructions for Documentation

• Providers that receive beneficiaries without a three-day qualifying stay (and for whom the requirement was waived under section 1812(f)) should report condition code “DR” (disaster related) on their claim. Based on the presence of this code, Medicare systems will bypass the three-day stay requirement, and occurrence span code “70” (qualifying stay dates) need not be reported.
• In addition, providers should include remarks indicating “declared emergency/disaster” on their “remarks” page for tracking/verification purposes.

Home Health Agencies (HHAs)

• This waiver provides relief to HHAs on the timeframes related to Outcome and Assessment Information Set (OASIS) transmission.

Critical Access Hospitals (CAHs)

• Waiver of the requirements that CAHs limit their number of beds to 25
• Waiver of the requirement that the length of stay be limited to 96 hours (blanket waiver for all impacted hospitals)

Medicare’s Instructions for Documentation

• CAHs must clearly indicate in the medical record where an admission is made or length of stay extended to meet the demands of the emergency.
• They must also annotate all Medicare fee-for-service claims for such admissions or length-of-stay extensions with the “DR” condition code or the “CR” modifier, as applicable, for the period that they remain affected by the emergency.

Housing Acute Care Patients in Excluded Distinct Part Units (DPUs)

This waiver primarily impacts Inpatient Rehabilitation Facilities (IRFs) that are units of hospitals as well as psychiatric units within hospitals. Also:

• This provides a blanket waiver to Inpatient Prospective Payment System (IPPS) hospitals that, because of Hurricanes Harvey and Irma, need to house acute-care inpatients in excluded distinct part units, wherein the distinct part unit’s beds are appropriate for acute-care inpatients. 
• CMS indicates that each IPPS hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute-care inpatient being housed in the excluded unit because of capacity issues related to Hurricanes Harvey or Irma. 

Medicare’s Instructions for Documentation

• The hospital must clearly indicate in the medical record where the patient is located when he or she is in a non-IPPS bed to meet the demands of the emergency.
• The hospital also must annotate all Medicare fee-for-service claims related to such admissions with the “DR” condition code or the “CR” modifier, as applicable, for the period the hospital remains affected by the emergency.
• The IPPS hospital should submit the claim rather than the distinct part.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

• Under this waiver, the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required for replacement.

Medicare’s Instructions for Documentation

• Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced, and they are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged, or otherwise rendered unusable as a result of the hurricane. 
• Medicare’s emergency-related policies also indicate that:

“The “RA” modifier is always required on the claim for a replacement item. If the beneficiary is displaced from the federally declared disaster/emergency area, the beneficiary may obtain the replacement item from a Medicare-enrolled supplier located outside the area. If the supplier is aware that the item is a replacement, the supplier should annotate the claim with the “RA” modifier.

If the beneficiary is displaced from a federally declared disaster/emergency area that is, or that encompasses, a competitive bidding area (CBA), and the replacement item is a competitive bid (CB) item, in addition to billing with the “RA” modifier, the out-of-CBA, Medicare-enrolled supplier must also annotate the claim with the “KT” modifier. “

Final Reminders

These waivers are intended to address immediate access issues for patients, and they are time-limited. Providers should frequently check the emergency-related sections of the CMS and Medicare Administrative Contractor (MAC) websites to be certain that waivers have not been terminated. Additionally, keeping good documentation of why a patient qualifies for a waiver and logs of how the waivers are used are recommended.

Key Resources

More Information

• For summary information related to the blanket waivers:   https://www.cms.gov/About-CMS/Agency-Information/Emergency/downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf
• For summary information related to 1135 waivers (includes additional instructions on coding and documentation for blanket waivers:
  • https://www.cms.gov/About-CMS/Agency-Information/Emergency/downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf
• For summary information related to Hurricane Harvey and Medicare-related Texas claims:
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17020.pdf
• For summary information related to Hurricane Irma and Medicare-related U.S. Virgin Islands, Puerto Rico, and Florida claims:
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17022.pdf
• For more information refer to the DMEPOS for Medicare beneficiaries impacted by an emergency or disaster fact sheet at: https://www.cms.gov/AboutCMS/AgencyInformation/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf