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  • Win: CMS Says SNFs, Hospitals, HHAs, Rehab Agencies, Other Institutional Settings Can Bill Telehealth Outpatient Therapy Claims

    The clarification from CMS applies to settings that use institutional claims such as UB-04.

    It's settled: Medicare Part B institutional claims for outpatient therapy services furnished through telehealth are permitted for hospitals, skilled nursing facilities, critical-access hospitals, comprehensive outpatient rehab facilities, rehabilitation agencies, and home health agencies. APTA pressed CMS for recognition of institutional settings that provide outpatient therapy for months; CMS' May 27 answer is a clear win for PTs, PTAs, and their patients.

    News of the clarification came by way of an update to CMS' lengthy Frequently Asked Questions resource on fee-for-service billing, a document with a particular focus on so-called 1135 waivers that CMS adopted in response to the COVID-19 public health emergency. Those waivers included allowances for telehealth by PTs, occupational therapists, and speech-language pathologists in certain circumstances, but details of exactly who could do what vis a vis remote care have only emerged over time.

    The specific answer to the institutional setting question appears near the end of the document (page 70 at the time of this article, but citing a specific page number isn't always helpful as CMS updates the FAQs on a regular basis).

    In CMS' own words, "Outpatient therapy services that are furnished via telehealth, and are separately paid and not included as part of a bundled institutional payment, can be reported on institutional claims with the "-95" modifier applied to the service line." The guidance goes on to say that this applies to hospitals for outpatient therapy services (bill type 12X or 13X), SNFs (bill type 22X or 23X), CAHs (bill type 85X), CORFs (bill type 75X), ORFs (rehabilitation agencies) (bill type 74X), and HHAs (bill type 34X).

    When use of the waivers were announced in mid-March, it was unclear to what extent remote services would be permitted for PTs and PTAs. Over the following months, CMS clarified its interpretation of the waivers, first by permitting therapy "e-visits," then clarifying that PTs and PTAs in private practices could engage in real-time video telehealth with patients. In early May, the agency acknowledged a pathway for hospital outpatient department PTs and PTAs to furnish remote services under Medicare. However, the ability of institutional settings to bill outpatient therapy furnished via telehealth was not directly addressed — until this week.

    "Until now, CMS did not specifically address a major area of care that encompasses a large number of PTs and PTAs, so we're grateful that we were able to help spark these clarifications," said Kara Gainer, APTA director of regulatory affairs. "The answer CMS provided is good news for PTs and PTAs in these settings whose primary concern is to be able to safely deliver effective, high-quality services to Medicare beneficiaries."

    The waivers are temporary and will be withdrawn when the public health emergency is officially ended. In the meantime, APTA is advocating to HHS and CMS about the importance of extending the telehealth policy flexibilities after the emergency declaration ends. Supporters can lend their voices to this effort by submitting comments on CMS’ additional policy revisions in response to the COVID-19 public health emergency interim final rule.

    In addition, APTA also continues press Congress for permanent telehealth allowances for PTs and PTAs. That effort includes grassroots opportunities to add your voice to calls for lasting change.

    U.S. Reps Urge House Leadership to Stop Proposed 2021 Payment Cuts

    A letter from 46 U.S. representatives calls the cuts "reckless."

    The push to avoid a proposed 8% cut to therapy payment under Medicare in 2021 has gained significant momentum: Thanks to strong grassroots efforts and advocacy from organizations including APTA, the American Occupational Therapy Association, and the American Speech Language Hearing Association, 46 bipartisan members of the U.S. House of Representatives have signed on to a letter urging House leadership to create a path that would allow CMS to drop the potentially devastating proposed cuts.

    On May 28, Reps. Bobby Rush (D-IL) and Susan Brooks (R-IN) submitted a bipartisan letter to Speaker of the House Nancy Pelosi and Minority Leader Kevin McCarthy decrying the January 1, 2021, proposed cuts to the Medicare Physician Fee Schedule and urging action by the House to prevent them.

    "If these cuts are allowed to go into effect, they will be devastating and will limit access to care for patients, including seniors, who rely on these services," the letter states. "Ultimately, these cuts will force physical and occupational clinics to close, resulting in thousands of qualified professional clinicians, especially those in rural and urban areas in our districts, to lose their jobs." The results, authors write, could lead to large-scale losses in access to care, including "the over 50 million Americans who suffer from acute and chronic pain conditions [that] will be unable to access these important, non-opioid services."

    The letter also points out that the effects of the COVID-19 pandemic "could be felt for years" in the health care system, adding, "Now is not the time to implement these reckless cuts when our health care system is under such tremendous financial strain."

    The proposed cuts are an attempt by CMS to maintain "budget neutrality" while increasing payment for primary care provider evaluation and management codes, referred to as E/M codes. To find the money to pay for the increase without exceeding budget limits, CMS proposed to reduce reimbursement for codes commonly used by more that three dozen health care provider types. Reimbursement cuts to codes associated with physical therapy are estimated to result in an 8% payment drop.

    The letter to House leadership urges enactment of a legislative proposal that would waive budget neutrality requirements so that CMS could move ahead with the E/M increases without putting payment to other professions on the chopping block.

    Since the CMS announcement of the proposed cuts that accompanied the 2020 physician fee schedule, more than 60 health care provider organizations launched advocacy efforts to block or blunt the damage. Those efforts are ongoing at APTA, which offers members and other stakeholders online opportunities to make their voices heard in pushing for elimination of the cuts.

    “We are grateful for the leadership of Representative Rush and Representative Brooks on this important issue,” said Justin Elliott, APTA's vice president of government affairs.“When therapists, clinics, and rehabilitation facilities are struggling, particularly in rural and underserved areas, it's clear that this is no time to implement payment cuts that will negatively hurt patient access to care and exacerbate the instability of health care providers' practices."

    Be sure to check out APTA’s resources on this issue.

    UnitedHealthcare, Aetna Temporarily Drop 2% Cuts in Medicare Advantage Plans

    The insurers are mirroring CARES Act provisions that suspended the sequestration cut in Medicare payments.

    Two of the nation's largest commercial insurers — Aetna and UnitedHealthcare — are following CMS' lead and temporarily suspending this year's 2% sequestration cuts to provider payments in Medicare Advantage plans. For both companies, the suspension applies to payments made between May 1 and December 31.

    The shift comes in the wake of changes brought about through CARES Act COVID-19 relief provisions that temporarily halted a 2% cut in Medicare provider payments. Those annual cuts, mandated through the 2011 Budget Control Act, often have been passed along to providers participating in private insurers' Medicare Advantage plans. Now at least two insurers are following in kind by suspending the reductions for a limited time.

    This isn't the first time commercial payers have mirrored — and even expanded on — CMS coverage and payment changes related to the COVID-19 pandemic. Most major insurers now accept claims for therapy delivered via telehealth, and BlueCross BlueShield Tennessee recently became the first major payer to include telehealth by PTs as a permanent benefit.

    Carmen Elliott, APTA's vice president of payment and practice management, says that continued communications between professional organizations such as APTA and the insurers are helping the payers make informed decisions about coverage during the pandemic and beyond.

    "APTA and other provider associations have continued to share information with insurers to work toward collaborative approaches such as therapy via telehealth, and how the pandemic has impacted individual providers," Elliott said. "We certainly appreciate the ways in which these payers are closely following federal guidelines."

    APTA Advisory: TRICARE Reimbursement for TENS Treatment for LBP Stops on June 1

    The health program used throughout the U.S. Department of Defense announced that it would make the change after questioning the effectiveness of the treatment.

    Are you a provider in the TRICARE system? Don't forget that beginning June 1, the program will no longer pay for transcutaneous electrical nerve stimulation as a treatment for low back pain. The changes are reflected in TRICARE's policy manual.

    This March 6 PT in Motion News story provides more details on TRICARE's stated reasons for the change.

    APTA Report: 44% of PTs, 54% of PTAs Say They Lost Income During Pandemic

    Results of a nationwide APTA survey show how the COVID-19 pandemic is impacting the profession — and sparking changes in care delivery.

    The physical therapy profession has experienced some significant setbacks during the COVID-19 pandemic — many of them on a personal level. But results of a new nationwide survey conducted by APTA also reveal how PTs and PTAs are using their resilience to adapt to a changed professional landscape.

    APTA summarized results of the survey conducted April 24-May 11 in a new report titled "Impact of COVID-19 on the Physical Therapy Profession." The report is also the first resource to be released using APTA’s new logo and brand, which will be officially adopted in June.

    The report, based on a survey results from 6,500 PTs and PTAs across the country, makes it clear that the COVID-19 pandemic has exacted a literal cost on PTs and PTAs, with 44% of PTs and 54% of PTAs reporting decreased income during the health crisis. Furloughs also were disturbingly high, affecting 17% of PTs and 27% of PTAs. Layoffs were less frequent — though no less troubling — with 5% of PTs and 13% of PTAs reporting job loss.

    Although much of the survey was focused on income and employment, respondents also were asked to provide information on the reasons behind clinic closures, use of PPE, telehealth adoption, clinic revenue, and other topics.

    Among the Findings

    Setting made a difference in reduction in work hours and income.
    For PTs, work hour reductions were most common in private outpatient or group practice settings, with 68% of respondents reporting a drop, followed by PTs in home care (65%), and PTs working in hospital-based outpatient facilities or clinics (57%). As for actual income declines, PTAs in home care were hardest hit, with 81% reporting a reduction in income, followed by 66% of PTAs in private outpatient settings. The setting reporting the highest rate of income reduction among PTs was in private outpatient settings, with 65% of respondents reporting a drop.

    PTAs were most affected by furloughs — also depending on setting.
    PTAs reported furloughs in private outpatient or group practice settings at a rate of 37%, with hospital-based outpatient clinics not far behind at 35%. The private practice clinic setting was also the leading setting for PTs who experienced furloughs, at a rate of 23%.

    PTs generally felt they were providing essential treatment.
    Only 16% of PTs felt that their employers had asked them to provide PT services they considered nonessential.

    The use of telehealth rose dramatically.
    According to the report, use of telehealth by PTs was nearly nonexistent prior to the health emergency, with 98% of respondents reporting that they provided no live video consult with patients. The pandemic — and resultant changes to telehealth payment policies and regulations — changed all that. At the time of the survey, 50% of PTs reported using telehealth during the pandemic. The most dramatic change? School system PTs, whose use rose from near 0% levels to a 93% use rate.

    When facilities closed, professional judgment was the most common reason.
    Practice-owner respondents who closed their clinics during the pandemic overwhelmingly cited professional judgment as the primary reason for make the decision, at 76%. The next most-frequently cited reason was patient cancellations and no-shows, at 48%, followed by mandatory state orders, cited by 40% of practice owners as the top reason for the shutdown.

    “This report is a snapshot of a specific moment in time, starting about six weeks after a national emergency was declared,” said APTA CEO Justin Moore, PT, DPT. “We will continue to research this topic, both to measure how this health crisis is affecting our profession and to ensure that our association can respond to pressing needs to support the physical therapy community.” APTA will conduct a follow-up survey sometime in June or July.


    The APTA report also makes recommendations for the profession, and recaps recommendations APTA made to Congress involving legislation related to the pandemic and beyond. The recommendations for the profession include:

    • A "better-leveraged" physical therapy workforce through improved patient access to PTs and PTAs.
    • Elimination of direct access restrictions.
    • Universal PT and PTA access to personal protective equipment.
    • Development of long-term strategies for use of telehealth.

    A New Look

    Readers also may notice something different about the way the report looks. That's because the document is the first to fully reflect APTA's new brand, including use of the association's new logo.

    The report provides a sneak peek into changes that will fully take effect in June, changes that will touch nearly every aspect of APTA's products, communications, and messaging.

    "This health crisis has put a spotlight on APTA's commitment to serving as the trusted leader for the physical therapy profession," Moore said. "Releasing this report under our new logo, ahead of formal adoption of our brand next month, not only helps us maintain consistency as we release more COVID-19 reports in the future but underscores our readiness to live out our brand promise."

    Coronavirus Update: May 26, 2020

    Expanded private payer telehealth coverage for physical therapy, employer tax credit, guidance for PT education programs, and more.

    From PT in Motion News

    May 15: BCBS of Tennessee Makes PT Telehealth Service Coverage Permanent
    BlueCross BlueShield of Tennessee announced that is making coverage of in-network telehealth service a permanent part of its benefit packages, including telehealth delivered by PTs. The change is the first time a major insurer has extended telehealth coverage beyond the length of the current public health emergency.

    May 19: Humana Adopts Telehealth for PTs, OTs, SLPs
    Humana announced that it has expanded its temporary telehealth provisions to include a wider range of providers — PTs, occupational therapists, and speech-language pathologists among them. The expansion applies to both participating/in-network providers and specialty providers, so long as the services don't violate state laws and regulations.

    From the U.S. Department of Internal Revenue Services

    May 8: U.S. CARES Act Provides Tax Credit to Help Employers Retain Staff
    The IRS recently shared information about the Employee Retention Credit authorized under the CARES Act. Designed to encourage employers to keep employees on their payroll, the credit allows an eligible employer whose business has been affected by COVID-19 to receive a refund for 50% of wages paid, up to $10,000.

    Guidance and Recommendations

    May 26: Considerations for Outpatient Physical Therapy Clinics During a COVID-19 Public Health Crisis
    APTA, the APTA Private Practice Section, and APTA Rhode Island created a guidance document aimed at helping outpatient physical therapy clinics minimize the risk of spreading the novel coronavirus. The resource contains more than 60 recommendations that impact nearly every area of operations, from treatment to office administration.

    May 13: ACC Sports Section Endorses "Game Plan" on Athlete Return to Play Post COVID-19
    Authors of a JAMA Viewpoint present a return-to-play algorithm for "competitive athletes and highly active people." The consensus document was endorsed by the American College of Cardiology Sports and Exercise Cardiology Section.

    May 14: CDC Issues Advisory on Inflammatory Syndrome in Children Associated With COVID-19
    The CDC Health Alert Network issued an official advisory on multisystem inflammatory syndrome in children (MIS-C) with background on the condition and reporting recommendation for any health care providers who have cared or are caring for patients younger than 21 years of age who meet criteria for MIS-C criteria. For additional information, providers can contact the CDC’s 24-hour Emergency Operations Center at 770-488-7100 or their state health department's after-hours hotline.

    May 18: ACAPT Offers Strategies for PT Education Program Classrooms and Labs
    The American Council of Academic Physical Therapy published a "living document" with strategies and considerations for managing safe in-person education programs.

    May 18: Trump Administration Issues Guidance to States for Safe Reopening of Nursing Homes
    A memorandum from CMS provides criteria to help state and local officials decide how and when to relax current restrictions for nursing homes, including factors such as number of new cases in the community and the facility, adequate staffing, and access to testing and personal protective equipment.

    In the Media

    May 15: COVID-19 Infection Rate Potentially 35 Times Greater in Areas Without Social Distancing Policies
    From Washington Post: Counties without mandatory social distancing policies experience 35 times more cases of COVID-19, according to a new study in the journal Health Affairs. Researchers found that the daily rate of infection decreased the longer a policy was in effect.

    May 15: World Health Organization: Coronavirus May Be Here for the Long Term
    From CBS News: WHO Emergencies Director Mike Ryan warns against trying to predict the end of the COVID-19 pandemic, saying "this virus may become just another endemic virus in our communities, and this virus may never go away."

    20: U.S. Nursing Homes "Plagued by Infection" Before COVID-19, Says GAO
    From Reuters: According to the U.S. Government Accountability Office, 82% of nursing homes were cited for an infection prevention and control deficiency between 2013 and 2017 — and 48% were cited more than once.

    Outpatient Clinic COVID-19 Recommendations Created Through Collaborative Effort

    APTA, the association's Private Practice Section, and APTA Rhode Island developed guidelines that could help clinics stay safe during the pandemic.

    Imagine you're a patient and it's time for your physical therapy appointment. You drive to the clinic, but instead of heading through the clinic doors, you text your arrival to staff, and then wait in your car until you receive a text telling you to come inside. Once inside, your temperature and oxygen saturation are checked, and as quickly as possible, you're taken from the (magazine-free) waiting area to the treatment area. Your PT and PTA are probably wearing masks (you, too, most likely), and should you be directed to use cardio equipment, you'll be at least 12 feet away from any other patient doing the same. Afterwards you'll be encouraged to leave as quickly as you came. You might not even need to stop to work out your copay because your credit card is on file already.

    Welcome to the PT clinic of the (very) near future — or, more precisely, the clinic as it might be today, according to APTA, the APTA Private Practice Section, and APTA Rhode Island. The association and its components collaborated on a new guidance document aimed at helping outpatient physical therapy clinics minimize the risk of spreading the novel coronavirus responsible for the COVID-19 pandemic. The scenario above is one possibility based on the recommendations.

    "Considerations for Outpatient Physical Therapy Clinics During the COVID-19 Public Health Crisis" envisions a clinic that takes infectious disease precautions that impact nearly every area of operations, from treatment to office administration. The resource is framed as a set of general recommendations, with the understanding that individual facility implementation may vary depending on mandated operational requirements, CDC guidance, and the clinic's own evaluation of cost vs. benefit.

    The guidance document contains more than 60 recommendations around six broad areas: scheduling and workflow, safe workspace distancing (including treatment areas, waiting areas, and front desk operations), patient screening (prior to and while in clinic), staff screenings, considerations on return-to-work after COVID-19, patient triage (in-clinic versus telehealth), and cleaning standards.

    Also recommended: reliance on important federal and APTA resources including CDC and OSHA guidelines, APTA online offerings, and information available through the APTA Private Practice Section. The pdf document includes hyperlinks to many of these additional sources of information.

    The clinic guidance document joins a wealth of other resources on APTA's webpage devoted to COVID-19 and the physical therapy profession. In addition to practical guidance and links to additional information, the webpage also includes news articles and opportunities to advocate on behalf of the profession and its patients.

    New Details Emerge on Delivery of Remote Services by Outpatient Department PTs and PTAs in Medicare

    In early May, PT in Motion News reported about CMS guidance on a way for hospital outpatient department PTs and PTAs to provide remote care delivery to Medicare beneficiaries. More details have surfaced since then.

    The original story is still worth a read, because it lays out the basics of how hospitals can use a patient's address as a "temporary expansion location." But since publication, additional information has come to light:

    If the department is "non-excepted": The CMS interim final rule doesn't change the status of any non-excepted off-campus departments — they are still considered to be non-excepted during the COVID-19 public health emergency, even if they relocate. That means these non-excepted departments will continue to be paid the physician fee schedule rate. It also means they don't need to apply for the relocation approval outlined in the earlier PT in Motion News story.

    If the department is "excepted": It doesn't matter whether the provider-based department — referred to as the PBD — is on or off campus: As long as the department is excepted, hospitals that opt to establish temporary expansion locations need to notify the relevant CMS Regional Office as outlined in the earlier PT in Motion News story.

    However, here's what CMS recently indicated during conference calls on May 19 and May 21: If the hospital outpatient department intends to bill for services under the hospital's outpatient prospective payment system, it must follow the guidance for establishing temporary expansion locations. If the only services that the department bills are paid under the physician fee schedule, such as PT, OT, and SLP furnished under a therapy plan of care, then the relocation process doesn't have to be followed.

    PO or PN Modifier

    Another question APTA has received recently is whether the PO or PN modifier is required on the hospital claim for therapy services furnished remotely but billed as if in person.

    The PO modifier is reported with every HCPCS code for all outpatient hospital items and services furnished in an excepted off-campus PBD of a hospital. CMS requires non-excepted off-campus provider-based departments of a hospital to report the PN modifier on each claim line with a HCPCS code for non-excepted items and services. The use of modifier PN will trigger a payment rate under the physician fee schedule. CMS expects the PN modifier to be reported with each non-excepted line item and service, including those for which payment will not be adjusted, such as therapy services.

    Bottom line: If your excepted or non-excepted off-campus hospital PBD was billing with the applicable modifier before the COVID-19 health emergency, the off-campus PBD continues to bill with the same modifier, whether or not the services are furnished in person or remotely. Hospital outpatient therapy services furnished under a therapy plan of care will continue to be reimbursed under the physician fee schedule.

    Other Modifiers

    In addition to adding the GP modifier when care is furnished by PTs and PTAs under a physical therapy plan of care, hospitals must use the DR condition code and CR modifier. Because the allowances are part of an official response to the public health emergency, both the "Disaster-Related" condition code and the "Catastrophe/Disaster-Related" modifier are required on claims. Details are available in this CMS guidance document.

    APTA also continues to advocate for the recognition of hospital outpatient departments and other facility-based providers as eligible providers that can furnish and bill for services furnished via telehealth under the physician fee schedule. Add your voice by visiting APTA's regulatory take-action webpage and using APTA's unique template letter to comment on the COVID-19 public health emergency interim final rule.

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    PTJ Virtual Issue Puts COVID Research and Perspectives on the Fast-Track

    The association's journal launched a project that brings new rehab-related information to readers as quickly as possible.

    The COVID-19 pandemic demands that PTs, PTAs, and other rehabilitation professionals stay on top of what's being learned about the disease and how the role of physical therapy is evolving because of it. PTJ, APTA's scientific journal, is doing its part to deliver the latest research with minimal delays. In fact, says PTJ editor-in-chief Alan Jette, PT, PhD, FAPTA, the journal's latest project is offering information in ways that are about as "real-time" as you can get.

    Now available on the PTJ website: the PTJ COVID-19 Virtual Issue, a platform that allows the journal to share its latest COVID-19-related research and perspectives at a rate not possible through the normal PTJ publication process. The journal is free to members, and the virtual issue contains open-access work, free to everyone.

    The virtual issue isn't a static resource. Instead, PTJ will add new manuscripts on a regular basis. The result is a collection of articles that, while not in final copyedited form, are as fresh from authors as possible.

    Bookmark the site to keep up with its growth. Here's what's available now:

    APTA Advisory: Humana Adopts Telehealth for PTs, OTs, SLPs

    PTs can now bill the insurer for common therapy codes, delivered via telehealth, for the duration of the public health emergency.

    Another major commercial payer has acknowledged the value of telehealth provided by PTs: this time, it's insurance giant Humana, which is now reimbursing PTs for services delivered via real-time video-based telehealth. Humana is among the last large national payers to make the shift.

    In a May 15 update, Humana announced that it has expanded its temporary telehealth provisions to include a wider range of providers — PTs, occupational therapists, and speech-language pathologists among them. The expansion applies to both participating/in-network providers and specialty providers, so long as the services don't violate state laws and regulations.

    Similar to CMS, Humana previously had adopted many of the CPT codes commonly used by therapists as billable through telehealth, but didn't include PTs, OTs, and SLPs among the providers able to bill for telehealth services using the codes. That's no longer the case — even for Medicare — and PTs are now able to bill for telehealth services.

    For Humana, the affected codes are 97161-97164, 97110, 97112, 97116, 97535, 97750, 97755, 97760, and 97761. The codes should be accompanied by a place-of-service code — 11, or where services would normally have been furnished — as well as the 95 modifier.

    Humana joins Cigna, UnitedHealth, and Aetna among the payers allowing telehealth by PTs for the duration of the public health emergency. Recently, BlueCross Blue Shield Tennessee became the first large insurer to make physical therapy delivered via telehealth a permanent part of its benefits package.