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  • CMS: Potential Flexibility for Hospital Outpatient Department PTs and PTAs in Care Delivery; PTAs can Furnish Telehealth in Private Practices

    CMS representatives say hospitals could opt for a process to designate outpatients' homes as "temporary expansion locations" to allow for remote care.


    [Note: This story was updated with new information on May 11.]


     The U.S. Centers for Medicare & Medicaid Services provided more clarity on recent guidance related to COVID-19 waivers, and the new details are mostly good news for PTs, PTAs, and patients. Among the answers provided by CMS representatives: PTAs working in private practices can furnish telehealth under Medicare Part B with services billed by the supervising PT, and hospitals could choose a pathway that would allow their outpatient department PTs and PTAs to provide care remotely.

    The clarifications were provided in a May 5 conference call with APTA and other stakeholders about recent guidance from CMS that, among other provisions, established a private practice PT's ability to provide services delivered via real-time, face-to-face telehealth technology under Medicare Part B. That guidance was issued to better articulate CMS' interpretation of an interim rule that includes multiple waivers to respond to the COVID-19 public health emergency.

    Not surprisingly, even after the interim rule was released and subsequent guidance issued, APTA and providers had questions. CMS has now provided some — but not all —of the answers. A recording of the call and a transcript will be posted on the CMS Podcasts and Transcripts webpage.

    [Editor's note: Need an even deeper dive into the CMS guidance and interim rule? Join APTA regulatory affairs and practice staff for a Facebook Live Q&A session at 2 p.m. ET on May 7.]

    PTAs, Telehealth, and Direct Supervision

    PTAs can furnish telehealth. According to CMS representatives, PTAs are included among the providers who can furnish services by way of telehealth, with the supervising therapist able to bill for those services. The allowance only applies to professional services under Medicare Part B, meaning that only PTs and PTAs in private practice can make use of the telehealth provision.

    Virtual direct supervision of PTAs may be allowed under certain circumstances. CMS reps acknowledged that during the public health emergency, "direct supervision" includes real-time interactive audio and visual communications "when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider" (that's the language from the April 6 interim final rule). During the May 5 conference call, CMS said this flexibility could be applied in the context of the PT directly supervising the PTA in private practice.

    APTA's advice: Until CMS provides written confirmation and more details, don't make a switch to virtual direct supervision. And regardless of policy, PTs and PTAs must still comply with state supervision requirements.

     UPDATE, May 11, 2020: Since the May 5 conference call, CMS clarified that virtual direct supervision is possible. During a May 7 conference call, the agency confirmed that the supervision changes explained in an earlierFAQ did in fact apply to PTs and PTAs in private practices. 

    Remote Care Provided by Hospital-Employed PTs and PTAs to Hospital Outpatients

    Hospitals could choose to follow a process that would enable PTs and PTAs who furnish therapy in the hospital outpatient department and whose services are billed by the hospital through the UB-04 claim form to furnish remote care to registered outpatients — provided the hospital registers the patient's address as a temporary expansion location. It's up to each hospital to determine whether it's necessary and feasible to add a temporary expansion location to its provider-based department, but if it's within scope of practice and doesn't run counter to state laws and regulations, hospital-employed PTs and PTAs could be eligible to provide remote therapy to patients registered as hospital outpatients, and the hospital would bill as if the services were provided in person. But the hospital first must register the patient’s home as a temporary expansion location of the hospital’s outpatient department, referred to as the provider-based department or PBD, during the public health emergency. Registration includes justifying the need to add a relocation site such as a patient’s home.

    This shouldn't be interpreted as a green light for hospital-based PTs and PTAs to engage in remote therapy. While CMS says it is providing this flexibility to allow hospitals to maintain treatment capacity and deliver needed care for patients, a hospital may choose to maintain the status quo.

    CMS needs to be notified if a hospital chooses to add patients’ homes as temporary expansion locations. According to guidance that can be found on page 41 of the CMS interim final rule released on April 30, the hospital must notify its CMS regional office by email of the addresses it plans to identify as temporary expansion locations. That notification should be made within 120 days of beginning to furnish and bill for services at the relocation, and should include:

    • Hospital's CMS certification number.
    • Address of the current PBD.
    • Addresses of the temporary expansion locations (referred to as relocated PBDs in the interim rule).
    • Date on which services began at the relocated PBD.
    • Brief justification for the relocation and role it plays in the hospital's response to the public health emergency.
    • Attestation that the relocation is consistent with the relevant state's emergency preparedness or pandemic plan.

    APTA will ask CMS if the hospital must submit a unique request each time it registers a hospital outpatient’s home as a PBD. Until a definitive answer is provided, we suggest hospitals pose this question to their CMS regional offices.


    UPDATE, May 11, 2020: Since the May 5 conference call, CMS clarified that hospitals have flexibility in how they send the emails to CMS regional offices — as a single email with all patient addresses, or separate emails with each patient's address. The important thing is to send in the patients' addresses.

    Use the DR condition code and CR modifier. Because the allowances are part of an official response to the public health emergency, hospitals must use both the "Disaster-Related" condition code and the "Catastrophe/Disaster-Related" modifier on claims. Details are available in this CMS guidance document.

    SNFs, HHAs, Rehab Agencies, and Telehealth

    SNFs and HHAs can't bill for telehealth services provided by PTs or PTAs. CMS was clear that for Medicare Parts A and B, SNFs and HHAs are not included among the providers with new, albeit temporary, telehealth flexibility. The new flexibilities apply only to professional services on a professional claim, or by way of the hospital rules involving PBD expansion sites (see above).

    Rehab agency use of telehealth will be discussed, but for now the answer is no. During the call CMS representatives said the agency would consider the possibility of telehealth for rehab agencies and will provide clarification in the future. APTA recommends that for the time being, rehab agencies assume that telehealth is not billable.

    APTA and other stakeholders are advocating for the expansion of telehealth provisions to SNFs, HHAs, rehab agencies, and other institutional settings. The association continues to press for changes and expansions, including a call for CMS to make its telehealth allowances permanent.


    • Timely and great information from the recent call. Kara Gainer - thank you for addressing these on APTA's behalf on the call.

      Posted by Alan Lee on 5/6/2020 6:55 PM

    • I cannot find the podcast mentioned in the 5/6/20 article. Can you give me any assistance.

      Posted by Amy Bush -> DNVZ?O on 5/7/2020 1:46 PM

    • Hi. Do you know if a hospital based OP therapist can treat a hospital patient from home using UB04 claims, similar to private practice PTs? "You can provide services from your home. During this public health emergency, CMS is allowing PTs in private practice (as well as other providers) to furnish telehealth services from their homes without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location."

      Posted by Lauren on 5/8/2020 3:48 AM

    • @Amy: The podcast will be posted by end of today (May 8).

      Posted by APTA staff on 5/8/2020 8:21 AM

    • @Lauren: We believe the flexibility for hospital-based OP therapists only applies if they are on site of the hospital delivering care to a patient who also is in a location that is part of the hospital (the patient’s location must be added as part of the provider-based department of the hospital).

      Posted by APTA staff on 5/8/2020 8:22 AM

    • Glad CMS really cares about our elderly population in continuing care retirement communities who are able to use technology for delivery of treatment. Way to go! Honestly the fight for SNFs (CCRCs in particular) is already a lost cause. They must think retirees over 65 are incompetent. In addition, APTA is pro private practice.....they always have been. They’ve already gotten their wish. The rest will more than likely fall to the wayside.

      Posted by Bob M on 5/8/2020 1:45 PM

    • If the patient's home is declared part of the provider based dept. of the hospital, and therefore remote care is allowed, will all the other rules that CMS has set for Telehealth by Private Practice apply (such as the 95 Modifier? I know the HOD will use UB-04, and the DR/CR modifiers. Anything else different? Thank you.

      Posted by JR on 5/9/2020 5:01 PM

    • @JR: No. The care is billed as if it were furnished in-person.

      Posted by APTA staff on 5/11/2020 8:05 AM

    • Can anyone explain the apparently intentional barrier CMS is placing on HHA's providing telehealth? So many of our assisted living facilities and individual homes are inaccessible due to lockdowns and fear. Patients need interaction and encouragement to keep moving! These are some of our most vulnerable citizens, and they are being intentionally neglected!

      Posted by Travis Hand on 5/12/2020 12:52 AM

    • @Travis: For Medicare Part A, CMS does not have the statutory authority to allow HHAs to furnish and bill telehealth. For Medicare Part B, APTA is continuing to advocate that CMS recognize HHAs and other institutional settings to furnish and bill telehealth under Medicare Part B. We encourage individuals to submit comments to CMS on its most recent interim final rule, urging the agency to recognize institutional settings as eligible to bill for outpatient therapy furnished via telehealth using APTA’s unique template letter found on our regulatory take action webpage. An explanation and the template letter can be found under the "Current Regulatory Advocacy Efforts" header at this page: http://www.apta.org/RegulatoryIssues/TakeAction/

      Posted by APTA staff on 5/12/2020 8:10 AM

    • Does Telehealth therapy visits count towards the Medicare therapy cap?

      Posted by Ricky on 5/26/2020 3:48 PM

    • @Ricky: Real-time, face-to-face telehealth visits count towards the therapy threshold.

      Posted by APTA staff on 5/27/2020 8:07 AM

    • How does mobile therapy fit into this? Since it is billed under Med B, not a HHA/SNF but also not a private practice or a “temporary expansion” of a hospital.....? Seems to me that mobile therapy should be able to provide telehealth? I feel the need to add that all settings-HHA, SNF, mobile therapy, outpatient- could provide valuable and necessary patient care via telehealth. “Skilled and necessary” certainly does not pertain only to the hospital setting. Thank you for taking these questions and comments.

      Posted by Leslie Angus on 5/30/2020 3:39 PM

    • @Leslie: CMS recently announced that institutional settings can also furnish and bill for telehealth under Medicare Part B. See: http://www.apta.org/PTinMotion/News/2020/5/29/TelehealthInstitutionalSettings/. Whether you enrolled as a private practice or rehabilitation agency, you would be eligible to furnish and bill for telehealth services under Medicare Part B. If you would like to discuss further, please email us at advocacy@apta.org.

      Posted by APTA staff on 6/1/2020 7:55 AM

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