On March 30, CMS issued the Interim Final Rule with Comment (IFC) entitled, Medicare & Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency Interim Final Rule with Comment Period (CMS-1744-IFC). The rule gives individuals and entities that provide services to Medicare beneficiaries “needed flexibilities to respond effectively to the serious public health threats” posed by the spread of COVID-19. Because this regulation is an interim final rule with comment period, comments to the rule will be allowed and accepted from stakeholders; however, the Interim Rule provides that these regulations are retroactive to March 1, and will remain effective through the duration of the declared national public health emergency (PHE) for the COVID-19 pandemic.
On an interim basis, the IFC allows for more than 80 additional services to be provided via telehealth across all healthcare settings, including nursing facility physician visits in the SNF/NF. Though telehealth services can be provided in settings around the country (no longer limited to certain settings & geographical locations), the services remain subject to the list of practitioners who can provide the service. This list, set in statute, includes several practitioners who typically provide services in the SNF/NF, including physicians, nurse practitioners, physician assistants, clinical nurse specialists, clinical psychologists, clinical social workers, and registered dietitians or nutrition professionals (not OTs, PTs, SLPs).
In this Interim Final Rule, CMS adds on a temporary basis many CPT codes commonly associated with skilled therapy to the list of telehealth services. Unfortunately, CMS made no related changes to allow physical therapists, occupational therapists, and speech-language pathologists to the list of practitioners authorized to actually provide telehealth. CPT codes common in the SNF/NF setting that were added to the approved telehealth code list on a temporary basis, during the PHE, include the following: PT Initial Eval and Re-evaluation; OT Initial Eval and Re-evaluation; Therapeutic exercise; Neuromuscular reeducation; Gait training; Self-care/home management; Orthotics management and training, initial encounter; Prosthetic training, initial encounter; Speech-language evaluations; and Treatment of speech and language. During the April 7 Call on Provider Waivers, CMS reported they anticipate clarification very soon based on new authorities following the passage of the CARES Act last Friday, March 27. See the full list of eligible telehealth services payable under the Medical Physician Fee Schedule here. In addition, professional associations such as NARA, AOTA, APTA, and ASHA continue to advocate to add rehab therapists to the list of distant site practitioners.
For the duration of the PHE, interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site practitioner. In addition, the HHS Office for Civil Rights (OCR) is exercising enforcement discretion and waiving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the PHE for the COVID-19 pandemic.
Providers should continue to operate abiding by HIPAA Rules whenever possible, and implement reasonable HIPAA safeguards to limit incidental uses or disclosures of protected health information (PHI).
Communication Technology-Based Services (CTBS)
In cases where a visit cannot be considered Medicare telehealth services, on an interim basis, the IFC allows CTBS for new and established patients. On an interim basis, the IFC allows virtual check-ins and e-visits to be furnished practitioners such as licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists for new and established patients. CMS designates HCPCS codes G2010, G2012, G2061, G2062, or G2063 as CTBS “sometimes therapy” services that would require the private practice therapist to include the corresponding GO, GP, or GN therapy modifier on claims for these services. *CMS refers to the private practice physical therapists, occupational therapist and speech-language pathologist, which may be indicative that these codes should not be used in the institutional setting.
For additional information related to telehealth see:
Fact Sheet: Medicare Telemedicine Health Care Provider
MLN Booklet: Telehealth Services
CMS Video: Medicare Coverage and Payment of Virtual Services
Direct Supervision by Interactive Telecommunications Technology
As currently defined in the Act, direct supervision means that the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. CMS states that given the current circumstances under the PHE, the physical proximity of the physician or practitioner may not be possible without additional risks for both the provider and for the patient.Therefore, CMS is revising the definition of direct supervision (for physicians/practitioners) to allow supervision to be provided via “real-time interactive audio and video technology” for the duration of the COVID-19 PHE. CMS does not specify a similar allowance for clinician supervisory visits of therapist assistants in the therapy setting. Again, rehab advocates are seeking clarification from CMS on this issue as well.
Payment for Specimen Collection Related to COVID-19
The IFC also allow CMS to provide Medicare payment of a nominal specimen collection fee and associated travel allowance to independent laboratories for collection of specimens related to COVID-19 clinical diagnostic laboratory testing for homebound and nonhospital inpatients. Under this policy, the nominal specimen collection fee for COVID-19 testing for homebound and nonhospital inpatients generally will be $23.46, and for individuals in a skilled nursing facility (SNF) or individuals whose samples will be collected by laboratory on behalf of an HHA will be $25.46. To identify specimen collection for COVID-19 testing, CMS is establishing two new Level II HCPCS codes. Independent laboratories must use one of these HCPCS codes when billing Medicare for the nominal specimen collection fee for COVID-19 testing for the duration of the PHE for the COVID-19 pandemic. The new HCPCS codes are:
- G2023, specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source; and
- G2024, specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a SNF or by a laboratory on behalf of a HHS, any specimen source.
Advance Payments to Suppliers Furnishing Items and Services under Part B
In an effort to be more responsive to situations in which Part B suppliers could request advance payments from CMS makes several technical modifications to existing advance payments rules. The definition is revised to state that a contractor (not carrier as is currently written) will make the conditional partial payment. CMS adds language to specifically address emergency situations in which it will be able to make advance payments. Additionally, existing rules limit CMS to no more than 80% of the anticipated payment for that claim based upon the historical assigned claims payment data for claims paid to the supplier. Under exceptional circumstances, CMS is increasing this limit to 100% of the anticipated payment for that claim based upon the historical assigned claims payment data for claims paid to the supplier. CMS also adds criterion to § 421.214 that suppliers in bankruptcy would not be eligible to receive advance payments to ensure that, with such expanded authority, CMS is able to appropriately pay and recover advance payments made to Part B suppliers. CMS’s fact sheet on expansion of the accelerated and advance payments program.
For information on the COVID-19 waivers and guidance, and the Interim Final Rule, please go to CMS COVID-19 flexibilities webpage.
(4/3/2020) PDF CMS List of Blanket Waivers
(3/30/2020) Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities) Fact Sheet on new waivers and flexibilities