Modifier & Condition Code Assignment During COVID-19 Public Health Emergency

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Summary

We’ve collected all the most asked COVID-19 billing questions from those that use our chargemaster and knowledge solutions, and from attendees of past webinars. We then categorized them to make answers easier to find. In this article, we’ll cover FAQs around modifier usage during COVID-19 public health emergency.

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As coding and billing regulations continuously change, the content of this article may not be the most up-to-date information and is not intended to take the place of either the written policies or regulations. We encourage participants to review the specific regulations and other interpretive materials as necessary.

Is modifier CR required when billing for COVID-19 lab tests?

CMS has requested that modifier CR, Catastrophe/disaster related, be assigned to identify Part B line item services/items that are related to a COVID-19 waiver for both institutional and non-institutional providers. Note that Medicare also stated that they will not deny claims due to the presence of this modifier for items or services that are not related to a COVID-19 waiver.¹ (05/05/2020)

¹COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, page 41 (May 1, 2020)

Are modifiers GT and 95 required in addition to modifiers PO and PN?

There are no circumstances in which modifiers GT and 95 would be used with modifiers PO or PN. Modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, is appended to CPT® and HCPCS codes for professional services provided via telehealth, and reported on the CMS-1500 professional claim form. Modifier GT, Via interactive audio and video telecommunication systems, is only allowed on institutional claims billed under Critical Access Hospital Method II, as of October 1, 2018. The current public health emergency has not changed the use of modifier GT.¹ Modifier PO, Services, procedure and/or surgeries provided at off-campus provider-based outpatient departments, and modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, may only be reported by OPPS hospitals. (05/05/2020)

¹Transmittal R2095OTN, “Revisions to the Telehealth Billing Requirements for Distant Site Services” (June 20, 2018)

Is modifier CR strictly for billing on the CMS-1500 for professional claims, or can it be used on both the facility claim (UB-04) and the professional claim (CMS-1500)?

Modifier CR, Catastrophe/Disaster Related, is for use on both the CMS-1500 claim form for professional services and on the UB-04 facility claim form (CMS-1450). The modifier should be applied to all line items that are related to a COVID-19 waiver.¹ (05/06/2020)

¹Pub. 100-04 Medicare Claims Processing Manual, “Chapter 38 Emergency Preparedness Fee-for-Service Guidance, Section 10 Use of the CR Modifier and DR Condition Code for Disaster/Emergency-Related Claims”, page 2 (July 25, 2014)

Can you clarify when to use Condition Code DR? Is that used only if you have an extended facility site?

Condition code DR, Disaster related, is used when all items and services submitted on a claim are related to a COVID-19 waiver. If the patient’s visit is impacted by COVID-19, then the condition code is appropriate. Examples provided by CMS include instances where a non-COVID-19 patient is housed in a separate unit to keep the patient from the COVID-19 positive population. Medical record documentation that explains how the patient’s care was impacted by COVID-19 should be available.¹ (05/06/2020)

We’re looking for some clarification on modifier CS. CMS states modifier CS is appropriate for use with E/M levels and labs. Can we add it to chest x-rays if done as part of the workup for COVID-19? How about any other services during the Emergency Department visit, such as infusions and injections?

The Families First Coronavirus Response Act (FFCRA) states that cost-sharing is waived for “items and services furnished to an individual…that result in an order for or administration of…”¹ This verbiage is causing some confusion regarding which specific items and services should be provided without cost-sharing. In the absence of further guidance and based on the wording of the law, however, it would be inappropriate to assign modifier CS to injections or infusions since those services would not result in an order for COVID-19 testing. CMS has stated that more information regarding modifier CS, Cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test, should be forthcoming; however, there has been no additional guidance provided yet. (05/06/2020)

¹“Families First Coronavirus Response Act”, page 134, Stat 201 (March 18, 2020)

Modifier QW may be applied to HCPCS code U0002 and CPT® code 87635. Do you need to be under a CLIA waiver in order to assign modifier QW?

HCPCS code U0002, 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, and CPT® 87635, Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, were recently added to the list of tests that are waived through the Clinical Laboratory Improvement Amendment of 1988 (CLIA) amendments. In order to submit claims for the services, all providers must have a CLIA certificate. According to the CMS CLIA Fact Sheet, “CLIA mandates nearly all laboratories, including those in physician offices, must meet applicable Federal requirements and have a current CLIA certificate. CLIA applies to all entities providing clinical laboratory services including those that do not file Medicare test claims.”¹ (05/06/2020)

¹MLN® Fact Sheet, “CLIA Program and Medicare Laboratory Services”, page 2 (October 2018)

Would a modifier be needed with Q3014 for an on-campus provider-based clinic?

If the patient is physically located in the on-campus provider-based clinic, no modifier would be necessary when reporting Q3014, Telehealth originating site facility fee. Modifier PO, Services, procedure and/or surgeries provided at off-campus provider-based outpatient departments, would be assigned when items and services are provided to registered patients of a hospital on-campus department or to registered patients of an excepted hospital off-campus provider-based department that has temporarily relocated under the extraordinary circumstances exception outlined in the interim final rule, CMS-5531-IFC. (05/06/2020)

If the patient is in the ED for trauma, needs surgery, and the COVID-19 test is performed, is a CS modifier appropriate since the ED E/M is more about the trauma?

This was (somewhat) addressed at the May 7, 2020 CMS Office Hours call, and the CMS subject matter expert stated that there is no national policy at this time and providers should check with their Medicare Administrative Contractor (MAC).¹ (05/06/2020)

¹CMS Outreach and Education, “Thursday, May 7, 2020 CMS Office Hours”

Would you explain the difference between modifiers 95 and GT?

Modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, is appended to the Current Procedural Terminology (CPT®) codes for professional services provided via telehealth, and reported on the professional claim form (CMS-1500).

Modifier GT, Via interactive audio and video telecommunication systems, is only allowed on institutional claims billed under Critical Access Hospital (CAH) Method II, as of October 1, 2018. The current public health emergency has not changed the use of modifier GT.¹ (4/9/2020)

¹Transmittal R2095OTN, “Revisions to the Telehealth Billing Requirements for Distant Site Services” (June 20, 2018)

If only audio services are provided without video, we would use codes 99441-99443. What modifier is required for these?

If the telephone services were provided due to conditions caused by the current public health emergency, modifier CR, Catastrophe/disaster related, should be assigned. According to COVID-19 Frequently Asked Questions on Medicare Fee-for-Service Billing, modifier CR is mandatory for providers in billing situations related to COVID-19 for any claim for which Medicare payment is conditioned on the presence of a “formal waiver”.¹ (4/9/2020)

¹COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, page 36 (April 10, 2020)

Can you give an example of using modifier GT?

If the patient is located in a Critical Access Hospital and has an audio/visual telehealth visit with the physician, who is at a remote location, the facility may submit a claim with Healthcare Common Procedure Coding System (HCPCS) code Q3014, Telehealth originating site facility fee, with modifier GT, Via interactive audio and video telecommunication systems, appended. Per R2095OTN, the GT modifier is only required on institutional claims billed under CAH Method II for claims with dates of service on or after October 1, 2018. (4/9/2020)

Can clarification be given about billing with POS 02 and modifier 95? Most of our research has said that modifier 95 is not necessary, but in the last two days we have found some information stating otherwise.

CMS has not specifically addressed the use of modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, when reported with place of service code 02, Telehealth. However, the assignment of place of service code 02 tells payers that the service was reported via telehealth, making the modifier 95 redundant information.

CMS is currently requiring that modifier 95 be assigned to identify telehealth services that are being provided using a place of service code other than 02, as providers are permitted to use the place of service code that reflects the location where the service would have been provided in the absence of the current public health emergency when reporting telehealth services.¹ It may be necessary to consult with individual payers as they may have different requirements regarding the use of modifier 95. (4/9/2020)

¹COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, page 21 (April 10, 2020)

Does someone have to test positive for COVID-19 in order to utilize the CS modifier?

At this time, there is no requirement for the patient to test positive in order to append modifier CS, Cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test, to the lab services or to the office visit which prompts the performance of a lab test. The modifier signals to the payer that the line item should be adjudicated at 100% of the allowed amount with no deductible, coinsurance, or copayment required from the patient.¹ (04/09/2020)

¹COVID-19: Telehealth Video, Coinsurance and Deductible Waived, ASC Attestations, Ambulance Modifiers, Lessons From Front Lines, MLN Call Today

Do all telehealth codes, both the originally approved and the temporary telehealth codes, need to have modifier CR?

Modifier CR, Catastrophe/disaster related, is not required to be reported on telehealth services.¹ (04/09/2020)

¹Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19), page 2

With limited screening services available in some areas, does someone have to test positive for COVID-19 to utilize certain condition codes?

No, the patient does not have to test positive to use condition codes, such as condition code DR Disaster Related. CMS has directed hospitals to add condition code DR to inpatient and outpatient claims for patients treated in temporary expansion sites during the public health emergency. To provide hospitals with the greatest possible flexibility to provide care for all patients, temporary expansion sites are not currently limited to treating COVID-19 patients.¹ (4/9/2020)

¹COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, pages 5-6 (April 10, 2020)

Are there any modifiers, like modifier 95, that need to be added when billing HCPCS code Q3014?

HCPCS code Q3014, Telehealth originating site facility fee, is used only when the patient is physically located in your facility. According to the Centers for Medicare & Medicaid Services (CMS) Transmittal Number R2095OTN, Modifier GT, Via interactive audio and video telecommunication systems, would be appended to HCPCS code Q3014 when Q3014 is billed under CAH Method II on the facility claim form (CMS-1450, UB-04). (04/09/2020)

Should modifier CR and modifier CS both be assigned for facility charges?

Both modifiers may be assigned for outpatient facility charges when reporting conditions are met for each modifier.¹ Modifier CR, Catastrophe/Disaster Related, is mandatory for institutional providers in billing situations related to COVID-19 to identify line item services that are related to a formal waiver.² Modifier CS, Cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test, is used to identify line items for which cost-sharing should be waived under the Families First Coronavirus Response Act. (04/23/2020)

²COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, pages 35-35

Should hospitals assign condition code DR for patients who have not been diagnosed with COVID-19 due to the possibility of meeting one of the waivers?

Use of condition code DR, Disaster Related, is not based upon the diagnosis of the patient. Rather, the condition code is used when all items and services submitted on a claim are related to a COVID-19 waiver. If the patient’s visit is impacted by COVID-19, then the condition code is appropriate. Examples provided by CMS are instances where a patient is housed in a separate unit to keep the patient from the COVID-19 positive population. Medical record documentation that explains how the patient’s care was impacted by COVID-19 should be available.¹ (04/23/2020)

¹COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, page 10

Should we report modifier CS for commercial payers as well?

Yes; modifier CS, Cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test, should be appended for all payers. The Families First Coronavirus Response Act states that the cost-sharing waiver for COVID-19 testing applies to group health plans and to individual health plans, as well as Medicare, Medicaid, Tricare, and contracted Indian Health Services.¹ Additionally, most private insurance payers have followed suit in waiving cost-sharing for COVID-19 services, although it may be necessary to check with each payer regarding their specific policies related to COVID-19 cost-sharing. (04/23/2020)

¹Families First Coronavirus Response Act, page 134, Stat 201

Our physicians do their own coding for our private practice. We do our best to check the submitted charges, codes, and modifiers, but sometimes we don’t catch an incorrect code or modifier until the remittance advice comes back from the payer. Do you have any recommendations on the best way to ensure that modifier CS is applied to all necessary visits?

Physician education on the use of the modifiers would be Vitalware Best Practice. If that is not feasible at this time, consider reviewing accounts that result in additional services, particularly laboratory tests, for review. You may also wish to review accounts that contain diagnosis codes for COVID-19, such as U07.1, COVID-19, or that contain diagnosis codes for signs/symptoms frequently associated with possible COVID-19 infections, such as Z20.828, Contact with and (suspected) exposure to other viral communicable diseases, Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out, Z11.59, Encounter for screening for other viral diseases, R05, Cough, R06.02, Shortness of breath, or R50.9, Fever, unspecified. (04/23/2020)

Can you expand on the use of modifier CR? Should it be hard-coded in the CDM for the new telephone services 99441-99443 and 98966-98968?

Modifier CR, Catastrophe/Disaster Related, is to be reported on outpatient institutional claims (CMS-1450, UB-04) or non-institutional claims (CMS-1500) and is mandatory for applicable HCPCS codes where payment is based upon a formal waiver, such as the blanket waivers now in effect for the COVID-19 Public Health Emergency.¹ You may choose to hard code the modifier in your charge description master (CDM), but will need to update the line items when the public health emergency has officially ended. Medicare has stated that they will not deny claims due to the presence of this modifier for items or services not related to a COVID-19 waiver, but you may wish to check with other payers before adding this modifier to your CDM. (04/23/2020)

Do critical access hospitals always use the GT modifier for telehealth services?

Modifier GT, Via interactive audio and video telecommunication systems, is required for telehealth services billed under Critical Access Hospital (CAH) Method II on institutional claims. The current public health emergency has not changed the use of modifier GT.¹ (04/23/2020)

¹Transmittal R2095OTN, “Revisions to the Telehealth Billing Requirements for Distant Site Services

Do we apply modifier CR and modifier CS to CPT® code 87635 and HCPCS code U0003?

Modifier CR, Catastrophe/Disaster Related, should be appended to CPT® code 87635, Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, and HCPCS code U0003, Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R, since both of these services are related to the COVID-19 public health emergency.¹ Modifier CS, Cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test, should be appended to items and services that have a cost-sharing amount, to indicate that the cost-sharing portion should be waived. If the payer will adjudicate the claim without applying a cost-sharing amount to the patient, then the modifier is not necessary. CMS has stated that laboratory services generally have no cost-sharing amount, so the modifier may not be necessary. However, if the patient’s deductible has not have been met yet, appending the modifier will ensure the service isn’t applied to the patient’s deductible.² (04/23/2020)

²Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19), page 3

Can you explain the difference between modifier CR and modifier 95?

Modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, should be applied to line items billed on non-institutional claims that describe services furnished via telehealth with dates of service on or after March 1, 2020 and for the duration of the public health emergency. Modifier CR, Catastrophe/disaster related, is used by both institutional and non-institutional providers to identify Part B line items that are provided based upon a formal waiver. It should be noted that CMS is not requiring modifier CR on telehealth services.¹ (04/23/2020)

¹MLN Matters Number SE20011, Medicare Fee-for-Service (FFS) Response to the Public health Emergency on the Coronavirus (COVID-19), page 2

Is it your understanding that condition code DR would apply to inpatient claims and that modifier CS would apply to outpatient claims? Would condition code DR and modifier CS both need to be applied to the same claim?

Condition code DR, Disaster Related, and modifier CS, Cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test, are used for different purposes and therefore may both need to be applied to the same claim based upon the circumstances surrounding each individual account and care setting. Condition code DR would be assigned by institutional providers at the claim level when all of the items and services billed on the claim are related to a COVID-19 waiver on both inpatient and outpatient claims.¹ Modifier CS is used to identify line items on both institutional and non-institutional claims for which cost-sharing should be waived under the Families First Coronavirus Response Act. (04/23/2020)

Is modifier CR required when billing for COVID-19 lab tests?

Are modifiers GT and 95 required in addition to modifiers PO and PN?

There are no circumstances in which modifiers GT and 95 would be used with modifiers PO or PN. Modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, is appended to CPT® and HCPCS codes for professional services provided via telehealth, and reported on the CMS-1500 professional claim form. Modifier GT, Via interactive audio and video telecommunication systems, is only allowed on institutional claims billed under Critical Access Hospital Method II, as of October 1, 2018. The current public health emergency has not changed the use of modifier GT[1]. Modifier PO, Services, procedure and/or surgeries provided at off-campus provider-based outpatient departments, and modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, may only be reported by OPPS hospitals. (05/05/2020)

Is modifier CR strictly for billing on the CMS-1500 for professional claims, or can it be used on both the facility claim (UB-04) and the professional claim (CMS-1500)?

Modifier CR, Catastrophe/Disaster Related, is for use on both the CMS-1500 claim form for professional services and on the UB-04 facility claim form (CMS-1450). The modifier should be applied to all line items that are related to a COVID-19 waiver.[1]

(05/06/2020)

Can you clarify when to use Condition Code DR? Is that used only if you have an extended facility site?

Condition code DR, Disaster related, is used when all items and services submitted on a claim are related to a COVID-19 waiver. If the patient’s visit is impacted by COVID-19, then the condition code is appropriate. Examples provided by CMS include instances where a non-COVID-19 patient is housed in a separate unit to keep the patient from the COVID-19 positive population. Medical record documentation that explains how the patient’s care was impacted by COVID-19 should be available.[1] (05/06/2020)

We’re looking for some clarification on modifier CS. CMS states modifier CS is appropriate for use with E/M levels and labs. Can we add it to chest x-rays if done as part of the workup for COVID-19? How about any other services during the Emergency Department visit, such as infusions and injections?

The Families First Coronavirus Response Act (FFCRA) states that cost sharing is waived for “items and services furnished to an individual…that result in an order for or administration of.…”^[1] This verbiage is causing some confusion regarding which specific items and services should be provided without cost sharing. In the absence of further guidance and based on the wording of the law, however, it would be inappropriate to assign modifier CS to injections or infusions since those services would not result in an order for COVID-19 testing. CMS has stated that more information regarding modifier CS, Cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test, should be forthcoming; however, there has been no additional guidance provided yet.

(05/06/2020)

Modifier QW may be applied to HCPCS code U0002 and CPT® code 87635. Do you need to be under a CLIA waiver in order to assign modifier QW?

HCPCS code U0002, 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, and CPT® 87635, Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, were recently added to the list of tests that are waived through the Clinical Laboratory Improvement Amendment of 1988 (CLIA) amendments. In order to submit claims for the services, all providers must have a CLIA certificate. According to the CMS CLIA Fact Sheet, “CLIA mandates nearly all laboratories, including those in physician offices, must meet applicable Federal requirements and have a current CLIA certificate. CLIA applies to all entities providing clinical laboratory services including those that do not file Medicare test claims.”[1]

(05/06/2020)

Would a modifier be needed with Q3014 for an on-campus provider-based clinic?

(05/06/2020)

Could you provide more information on the CS modifier and what CPT® codes this modifier should be applied to?

Modifier CS, Cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test, was updated for use in identifying medical visits and other diagnostic tests which result in the need for 2019 Novel Coronavirus (COVID-19) testing. You may need to copy & paste the link into your browser. The lists of codes below contain applicable Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding System (HCPCS) codes, but may not be an exhaustive list:

The list of codes for physician and non-physician practitioners (NPPs) is available at

https://www.cms.gov/files/zip/cs-modifier-hcpcs-codes-physicians-non-physician-practitioners.zip

The list of codes for providers reimbursed under the Outpatient Prospective Payment System (OPPS) is available here:

https://www.cms.gov/files/document/cs-waiver-opps-codes.pdf

There is no specific list for Critical Access Hospital (CAH) services. CMS is directing CAH facilities to use the OPPS list. CAH Method II facilities may use the OPPS list or the physician/NPP list, as appropriate.

Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) list is available here:

https://www.cms.gov/files/zip/cs-codes-rhc-fqhc.zip ^[1]

(08/27/2020)

[1] MLN Matters™ “Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)”, available at https://www.cms.gov/files/document/se20011.pdf, page 11 (August 26, 2020)

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