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  • Coronavirus Update: April 6, 2020

    HIPAA enforcement relaxed, PTs and PTAs among the health care workers who could be "exempted" from expanded sick leave, COVID-19's link to CVD, and more.

    HIPAA

    April 2: HHS Allows Disclosure of Some Protected Information
    The U.S. Department of Health and Human Services has issued notification that it is "exercising discretion" in how it applies HIPAA privacy rules during the COVID-19 national health emergency. HHS says it won't impose penalties against covered entity or business associate disclosure of private health information if the disclosure was made in "good faith" by the business associate as a part of public health efforts, and if the business associate notifies the covered entity of the disclosure within 10 days. Those "good faith" disclosures include information shared with the CDC "for purposes of preventing or controlling the spread of COVID-19," or with CMS in efforts to provide "assistance for the health care system."

    From CMS

    April 3: New CMS Nursing Home Recommendations Stress Collaboration, Consistent Staffing Assignment
    The U.S. Centers for Medicare & Medicaid Services issued new recommendations for nursing homes around the COVID-19 pandemic that urge states to attend to the personal protection equipment needs of long-term care facilities, and press nursing homes to establish separate staff teams for COVID-19-positive residents. The recommendations also include universal testing in the facilities and use of PPE "to the extent PPE is available."

    From the U.S. Department of Labor

    April 3: PTs, PTAs Could be "Exempted" From Receiving Additional COVID-19 Leave
    Emergency paid sick leave and expanded family and medical leave provisions will be implemented broadly in response to the COVID-19 pandemic, but PTs, PTAs, and other health care providers employed in certain settings can be prevented from receiving the additional relief if their employers say so: That's how the U.S. Department of Labor has laid out its plans for implementing the Families First Coronavirus Response Act signed into law on March 18. The exemption provisions could also be applied to first responders.

    April 3: OSHA Issues Guidelines to Permit Extended Use and Reuse of Respirators
    In a memorandum to its compliance safety and health officers, OSHA announced that it is seeking greater "enforcement discretion" that would allow for extended use and reuse of respirators. In the case of N95 masks, the same worker is now permitted to continue using the respirator "as long as the respirator maintains its structural and functional integrity" and the filter remains undamaged. The relaxed requirements also allow for use of N95 respirators that have passed their expiration dates—although the agency does not recommend the use of expired N95s when performing surgery on patients with diagnosed or suspected COVID-19, or when procedures are likely to create poorly controlled respiratory secretions.

    In the Media

    April 6: COVID-19 Virus May Damage Heart
    From Kaiser Health News: “As more data comes in from China and Italy, as well as Washington state and New York, more cardiac experts are coming to believe the COVID-19 virus can infect the heart muscle. An initial study found cardiac damage in as many as 1 in 5 patients, leading to heart failure and death even among those who show no signs of respiratory distress." Some cardiac specialists think that the virus could damage the heart in multiple ways.

    April 5: Researchers Investigating Links Between COVID-19 and Neurologic Effects
    According to Medscape, U.S. neurologists "are now reporting that COVID-19 symptoms may also include encephalopathy, ataxia, and other neurologic signs." In late March, doctors in Michigan reported on the first case of encephalitis linked to COVID-19, while researchers in China linked the development of Guillain-Barre syndrome to COVID-19 in a 61-year-old woman in China.

    Visit APTA's Coronavirus webpage for more information and updates.

    PTs, PTAs Could Be 'Exempted' From Receiving Additional COVID-19 Leave

    A final rule from the Department of Labor includes PTs and PTAs among the health care providers whose employers — depending on the setting — could opt to deny expanded sick and FMLA leave.

    In this review: U.S. Department of Labor, Temporary Rule: Paid Leave under the Families First Coronavirus Response Act
    Fact sheet: employee paid leave rights
    Fact sheet: employer paid leave requirements
    Families First Coronavirus Response Act: Questions and Answers

    Emergency paid sick leave and expanded family and medical leave provisions will be implemented broadly in response to the COVID-19 pandemic, but PTs, PTAs, and other health care providers employed in certain settings can be prevented from receiving the additional relief if their employers say so: That's how the U.S. Department of Labor has laid out its plans for implementing the Families First Coronavirus Response Act signed into law on March 18. The exemption provisions could also be applied to first responders.

    At issue is a requirement in the Families First Act that employers with fewer than 500 employees provide up to 80 hours of paid sick leave and additional FMLA leave related to COVID-19—and in particular, instances in which an employer would have the option to exempt employees from the extra leave provisions. In health care, DOL is allowing that option to be exercised by employers from a list of health care settings, to be applied on a case-by-case basis to any of their health care providers.

    For the physical therapy profession, the term "health care provider" is key, because PTs and PTAs fall into that category for purposes of the rule.

    The rule provides the exemption option to employers in the following settings:

    • Doctor’s office.
    • Hospital.
    • Health care center.
    • Clinic.
    • Post-secondary educational institution offering health care instruction.
    • Medical school.
    • Local health department or agency.
    • Nursing facility.
    • Retirement facility.
    • Nursing home.
    • Home health care provider.
    • Facility that performs laboratory or medical testing, pharmacy, or "any similar institution."

    The list applies to any permanent or temporary institution, and extends to any listed setting that contracts with a health care provider or contracts with an entity that employs a health care provider. Bottom line: PTs and PTAs employed or under contract with a facility on the list could face the possibility of being exempted from receiving the additional leave.

    It's Optional and Intended for Case-by-Case Use
    According to the DOL, the agency is encouraging employers to be "judicious" in use of the exemption "to minimize the spread of the virus associated with COVID-19." Additionally, DOL says that the exemptions are intended to be used on a "case-by-case" basis, meaning that employers could apply the exemptions to certain types of health care providers and allow others to receive the extended benefits.

    It's Not the Only Exemption Path
    The requirements to provide the extended leave don't apply to business with 500 or more employees, and employers with 50 or fewer employees can apply to opt out if providing the extra leave would jeopardize the viability of the business.

    The "Health Care Provider" Definition is Intentionally Broad
    In the rule DOL states that it considered using a more narrow definition of "health care provider," but decided to go with the broad definition to give employers flexibility to maintain staffing to respond to the health emergency. According to DOL, a more narrow definition could leave health care facilities without staff to perform critical services needed to battle COVID-19.

    New CMS Nursing Home Recommendations Stress Collaboration, Consistent Staffing Assignment

    The new recommendations underscore existing CDC and CMS guidance and call for extensive use of masks and other PPE.

    The U.S. Centers for Medicare & Medicaid Services issued new recommendations for nursing homes around the COVID-19 pandemic that urge states to attend to the personal protection equipment needs of long-term care facilities, and press nursing homes to establish separate staff teams for COVID-19-positive residents. The recommendations also include universal testing in the facilities and use of PPE "to the extent PPE is available."

    According to CMS, the recommendations were created after CDC and CMS experts working in nursing homes "emphasized that even more must be done" to underscore guidance already provided by CMS around response to the pandemic.

    The recommendations address five major areas:

    Compliance with existing CDC and CMS guidance. The recommendations stress the importance of following instructions from the CDC and CMS in areas such as hand hygiene, infection control, and conservation of PPE.

    Collaboration between states and nursing homes to meet PPE needs. CMS emphasizes the importance of state and local health departments to stay in close communication with long-term care facilities to "address … needs for PPE and/or COVID-19 tests."

    Symptom screening for all. The agency reiterates its position that every person entering a nursing home be asked about COVID-19 symptoms and have their temperature checked. Symptom assessment and temperature checks should also be performed on every resident.

    Appropriate PPE use. The recommendations urge the use of facemasks by all nursing home personnel on site, as well as donning of full PPE when caring for any resident known or suspected to have COVID-19. CMS also calls for all residents "to cover their noses and mouths when staff are in their rooms," and suggests that they could use tissues or non-medical masks to do this.

    Separate staff teams for residents with COVID-19, and consistent assignment. CMS recommends that facilities try to assign the same staff to the same residents to increase the chances of "detect[ing] emerging condition changes that unfamiliar staff may not notice" and to decrease the number of different staff interacting with residents. Residents diagnosed with COVID-19 should be separated from other patients, and have separate staff teams "when possible."

    CMS also recommends that state agencies, hospitals, and nursing home associations help to "ensure coordination among facilities to determine which facilities will have a designation [as a facility for COVID-19 patients] and provide adequate staff supplies and PPE."

    APTA Learning Center Offers Free Online Courses

    The opportunities include both live and recorded telehealth webinars, as well as self-paced courses on a range of topics — all free to APTA members.

    In these challenging times, PTs, PTAs, and students face multiple pressures — including the pressure to keep up with changing practice dynamics in the wake of a global pandemic.

    APTA's Learning Center can help. The association's online continuing education platform now offers a collection of webinars and courses that can provide you with insight into telehealth, where some of the most significant changes are happening to the profession in response to the COVID-19 emergency. APTA has also collected self-paced courses on a variety of other topics that are perfect for when you need to give yourself time away from the current crisis.

    All listed offerings are free to APTA members; some are free to everyone. Unless otherwise noted, all offerings include the opportunity to earn CEUs.

    Courses include:

    Live Online Telehealth Webinar

    Recorded Webinars on Telehealth


    Self-Paced Courses on Other Topics

    From ChoosePT.com: Telehealth, Now More Than Ever

    A new Move Forward Radio podcast features a PT who relies on telehealth to meet the needs of veterans in rural areas.

    As a lead telehealth physical therapist for the U.S. Department of Veterans Affairs, Christi Crawford, PT, DPT, works hard to meet the physical therapy needs of veterans who live in rural areas. The VA offers a growing number of video-to-home personalized care and other remote services to reduce the need for patients to travel long distances for in-office care.

    Crawford's perspectives are timely. Because of the coronavirus pandemic, interest in telehealth services is changing the way patients see their health care providers.

    Now available through ChoosePT.com's Move Forward Radio podcast: an interview with Crawford on the many benefits and opportunities telehealth offers for patients, caregivers, and providers; what types of services work well through remote visits; and how to determine whether a patient or client is a good candidate for telehealth services.

    For patients in rural areas, "the increased access to someone that specializes in the area they need is so crucial," says Crawford. "Telehealth can get people back to what they need to do to stay healthy and functional."

    Noting the obstacles to care that the current pandemic presents and APTA's advocacy efforts for current legislation being considered by Congress, Crawford sees "change coming quickly. It's so important that telehealth for physical therapy becomes a reimbursable service. It's going to take our community of PTs and patients to use their voices" to ensure that it does.

    Move Forward Radio is hosted at ChoosePT.com, APTA's official consumer information website, and can be streamed online or downloaded as a podcast via the Apple Podcast app, Google Play, or Spotify. Other recent additions to the Move Forward Radio podcast library include:

    Latest Relief Package: Unemployment Provisions

    The CARES Act signed into law on March 27 is aimed at providing relief in a wide range of areas in response to the COVID-19 pandemic. Here's what the package offers related to unemployment benefits.

    The recently enacted CARES Act aimed at providing relief during the COVID-19 pandemic contains some important provisions related to unemployment that include relaxing some of the qualifications to receive benefits, allowing for circumstances specifically related to the pandemic, and adding $600 to weekly benefit checks.

    Called the Pandemic Unemployment Assistance Program, the new provisions allow for financial assistance to individuals who wouldn't ordinarily receive unemployment benefits, such as the self-employed, independent contractors, part-time workers, and those who have already finished their unemployment benefits. This new offering is effective January 27 through December 31, 2020.

    To receive the benefit, individuals in categories that normally wouldn't qualify for benefits must prove that they can no longer work due to activity related to COVID-19. Examples include:

    • Diagnosis of COVID-19, a COVID-19 diagnosis of a member of the household, or providing care for a member of the household who has been diagnosed with COVID-19.
    • Primary caregiving responsibility for a family member who is unable to attend school or another facility that has been closed due to the national emergency.
    • Inability to work because of a quarantine imposed by the national emergency or self-quarantine advised by a health care provider.
    • Inability to begin recently gained employment or being forced to end employment as a direct result of the national emergency.

    In addition to the expanded range of individuals who may qualify for unemployment benefits, the program adds $600 per week to regular unemployment benefits for up to 39 weeks. The additional money will be provided to everyone receiving unemployment benefits.

    Individuals able to telework or receive paid sick leave are ineligible for the program. If a state has a defined workshare program or short-time compensation, the CARES Act provides additional funding to keep employees working on a reduced-hours schedule and receive prorated unemployment benefits.

    For more information visit the U.S. Department of Labor website, which includes an unemployment benefits finder by state.

    Aetna Now Covers Telehealth Delivered by PTs

    Aetna joins UnitedHealthcare among the commercial insurers that have expanded coverage from more limited e-visit provisions.

    UPDATE (April 3): Aetna has advised that telehealth services delivered by physical therapists may be billed on a UB04 using the modifier GT or 95. Please contact advocacy@apta.org with any issues or questions associated with this billing.

    Private insurer Aetna announced that it will now cover a range of services delivered by PTs through telehealth—a significant expansion of its earlier COVID-19-related policy that limited coverage to e-visits. The change comes after APTA engaged in collaborative work with the company to rethink its temporary benefits policy.

    The insurer, officially known as CVS Health/Aetna, will cover the telehealth-based delivery of the services and procedures by PTs for CPT codes 97161, 97162, 97163, 97164, 97110, 97112, 97116, 97535, 97755, 97760, and 97761. The telehealth care must be provided as a two-way synchronous (real-time) audiovisual service. Providers are required to append the GT modifier to the codes. Aetna's expansion follows a similar move by UnitedHealthcare.

    Aetna will also continue its policy that reimburses PTs for the provision of e-visits, virtual check-ins, and telephone services. The use of the GT or 95 modifier is not required for e-visit CPT codes (98970, 98971, 98972), the store-and-forward code (G2010), virtual check-in codes (G2012), and telephone assessment CPT codes (98966, 98967, 98968). Visit Aetna's provider website and follow instructions for accessing detailed policy information on the provider portal.

    Check out APTA’s frequently updated telehealth webpage for the latest information on payer and regulatory changes.

    Coronavirus Update: April 1, 2020

    CMS moves toward telehealth for physical therapy, FCC announces telehealth initiative, new resources available for physical therapy educators, and more.

    Practice Guidance

    March 31: CMS Rule Includes Therapy Codes in Telehealth, But Stops Short of Allowing PTs to Conduct Telehealth Services
    Rule changes recently announced by CMS in response to the COVID-19 pandemic add codes commonly associated with therapy to those that may be delivered through telehealth, but CMS has made no related changes to allow PTs, occupational therapists, and speech-language pathologists to actually provide services through telehealth.

    The apparent contradiction may be partly because the new rules were written prior to the passage of the CARES Act last week — the $2 trillion COVID-19 relief package that granted CMS the authority to use waivers to expand the range of providers permitted to conduct services through telehealth. To date, CMS has not extended telehealth authority to PTs, OTs, and SLPs. But with coding rules now in place, such an expansion would be easier to implement quickly. APTA is pursuing the CMS disconnect.

    March 31: Joint Commission Statement Supports Provider Use of Personal Face Masks From Home
    The commission issued a statement supporting the use of standard face masks and/or respirators provided from home when health care organizations cannot provide access to protective equipment that is commensurate with the risk that health care workers are exposed to amid the COVID-19 pandemic.

    Telehealth

    March 30: FCC Announces $200 Million Plan for Telehealth
    The Federal Communications Commission announced a COVID-19 Telehealth Program to support health care providers responding to the ongoing coronavirus pandemic. As part of the CARES Act, Congress appropriated $200 million to the FCC to support health care providers’ use of telehealth services in combating the COVID-19 pandemic. If adopted by the commission, the program would help eligible health care providers purchase telecommunications, broadband connectivity, and devices necessary for providing telehealth services.

    Physical Therapy Education

    March 31: American Council of Academic Physical Therapy Establishes Collaboration Center
    A new offering from ACAPT offers possibilities for open-source resource sharing and communication among the clinical education community.

    Advocacy

    March 31: Tell Congress That Improvements in Telehealth, Reimbursement Should be Part of Pandemic Response
    The COVID-19 relief package signed into law last week wasn't the last word on temporary changes that could help blunt the impact of the pandemic: There's another package being worked on in Congress right now, and the physical therapy community needs to make its voice heard. Visit a dedicated page in the APTA legislative action center to quickly contact your lawmakers and remind them to help the profession respond to the pandemic by establishing telehealth for PTs and addressing reimbursement reductions.

    Research

    March 30: Case Fatality Rate for COVID-19 Near 1.4 Percent, Increases With Age
    A new study published in The Lancet shows that both hospitalization and fatality rates in patients with COVID-19 are higher in older patients. In an analysis of patient data from inside and outside of China, researchers estimated that it takes 17.8 days on average from onset of symptoms until death, and 24.7 days until hospital discharge. The fatality rate in China was 1.38%, but substantially higher in patients older than 60 years of age and as high as 13.4% among those aged 80 years and up.

    March 13: PubMed Central Provides Links to Open-Access COVID-19-Related Research
    The online archive is providing links to all research that has been designated as open-access by various publishers.

    In the Media

    March 31: U.S. Stockpile of PPE Nearly Gone
    From Reuters: "An emergency stockpile of medical equipment maintained by the U.S. government has nearly run out of protective gear that could be useful to combat the coronavirus pandemic, according to two officials with the U.S. Department of Homeland Security."

    Visit APTA's Coronavirus webpage for more information and updates.

    Latest Relief Package: Options for Small Businesses

    The CARES Act signed into law on March 27 is aimed at providing relief in a wide range of areas in response to the COVID-19 pandemic. Here's what the package offers to small businesses.

    The federal government has acknowledged that small businesses may be especially hard hit by the COVID-19 pandemic and has responded by establishing provisions aimed at lessening some of the impact. The latest measure, known as the CARES Act, includes some of the most extensive small business relief to date. Here's an overview of the small business-related relief provisions in the CARES Act.

    Details on these provisions, as well as on other pandemic-related resources, are available from the U.S. Small Business Administration, the U.S. Chamber of Commerce, the U.S. Department of the Treasury, and the Internal Revenue Service.

    Paycheck Protection Program Loans
    The legislation creates the Paycheck Protection Program, a new loan product within the Small Business Administration’s 7(a) Loan Program. Existing and new SBA lenders will be able offer these loans to eligible small businesses.

    The new loan, with an interest rate of up to 4%, will be 100% guaranteed by the SBA. Funds may cover payroll costs, including continuation of group health care benefits during periods of paid sick, medical, or family leave, and insurance premiums; employee salaries and commissions; payments of interest on any mortgage obligation, rent, and utilities; and interest on any other debt obligation incurred before February 15, 2020.

    Businesses and charitable nonprofits with fewer than 500 employees, sole proprietors, independent contractors, and self-employed individuals are eligible for the loans.

    A business can borrow up to 2.5 times the average monthly payroll based on the business’s prior year’s payroll, capped at $10 million. All borrower and lender fees for Paycheck Protection loans will be waived, as well as collateral requirements, the Credit Elsewhere Test, and all requirements for personal guarantees. Deferrals of principal, interest, and fees for six months will be built into the loans.

    Emergency Economic Injury Grants
    The CARES Act allows $10,000 of SBA economic injury disaster loans (EIDLs) to be provided to small businesses and nonprofits without a requirement for repayment. EIDLs are loans of up to $2 million that carry interest rates up to 3.75% for companies and up to 2.75% for nonprofits, as well as principal and interest deferment for up to four years. The loans may be used to pay for expenses that could have been met had the disaster not occurred, including payroll, paid sick leave to employees, increased production costs due to supply chain disruptions, and business obligations, including debts, rent and mortgage payments.

    The $10,000 grant portion of an EIDL does not need to be repaid, even if the grantee is subsequently denied an EIDL for amounts beyond the $10,000. Eligible grant recipients must have been in operation on January 31, 2020. The grant is available to small businesses, private nonprofits, sole proprietors and independent contractors, tribal businesses, as well as cooperatives and employee-owned businesses.

    Loan Forgiveness
    The relief package establishes that the borrower of an SBA loan is eligible for loan forgiveness equal to the amount spent by the borrower on payroll costs, interest payment on any mortgage incurred prior to February 15, 2020, payment of rent on any lease in force prior to February 15, 2020, and payment on any utility for which service began before February 15, 2020. The loan forgiveness period extends to eight weeks after the origination date of the loan.

    Debt Relief for Existing and New SBA Borrowers
    The stimulus package includes $17 billion to provide immediate relief to small businesses through standard SBA 7(a), 504, or microloans. Under this provision, SBA will cover all loan payments for existing SBA borrowers, including principal, interest, and fees, for six months. This relief will also be available to new borrowers who take out an SBA loan within six months after March 27, 2020.

    The measure also encourages banks to provide further relief to small business borrowers by allowing them to extend the duration of existing loans beyond existing limits, and enables small business lenders to provide a temporary extension on certain reporting requirements for new and existing borrowers. While SBA borrowers are receiving the six months of debt relief, they also may apply for a Paycheck Protection Program loan that provides capital to keep their employees on the job. Borrowers may not apply the six months of SBA payment relief to Paycheck Protection loan payments.

    Employee Retention Credit for Employers Subject to Closure due to COVID-19
    The CARES Act provides a refundable payroll tax credit for 50% of wages paid by employers during the COVID-19 crisis. The credit is available to employers whose operations were fully or partially suspended due to a COVID-19-related shut-down order, or whose gross receipts declined by more than 50% compared with the same quarter in the prior year.

    For employers with greater than 100 full-time employees, the credit is based on wages paid to employees while they are not providing services due to the COVID-19-related circumstances described above. For eligible employers with 100 or fewer full-time employees, all employee wages qualify for the credit, whether the employer is open for business or subject to a shut-down order. The credit is provided for the first $10,000 of compensation, including health benefits, paid to an eligible employee between March 13, 2020, and December 31, 2020.

    Delay of Payment of Employer Payroll Taxes
    The stimulus package allows employers and self-employed individuals to defer payment of the employer share of the Social Security tax on employee wages. The provision allows for half of the amount to be paid by December 31, 2021, and the other half by December 31, 2022.

    Modification of Limitation on Losses for Taxpayers Other Than Corporations
    This provision of the act modifies the loss limitation applicable to pass-through businesses and sole proprietors, so they can use excess business losses to access critical cash flow.

    Modification of Limitation on Business Interest
    The relief legislation temporarily increases the amount of interest expense businesses are allowed to deduct on their tax returns from 30% to 50% of taxable income (with adjustments) for 2019 and 2020. This provision allows businesses to increase liquidity with a reduced cost of capital.

    Modifications for Net Operating Losses
    Net operating losses are typically subject to a taxable income limitation, and they cannot be carried back to reduce income in a prior tax year. The legislation allows a net operating loss arising in a tax year beginning in 2018, 2019, or 2020 to be carried back five years. The provision also temporarily removes the taxable income limitation to allow an NOL to fully offset income. These changes will allow companies to amend prior year returns to take advantage of operating losses.

    APTA Wants To Hear From You About Your COVID-19 Experiences

    Are you on the frontlines of the COVID-19 pandemic? APTA would like to hear from PTs, PTAs, and students about their experiences.

    The COVID-19 pandemic continues to change lives in dramatic ways, with more to come even after the crisis ends. APTA wants to know how you're doing.

    For example:

    • How are you meeting the needs of your patients under current conditions?
    • Are you volunteering to make a difference in your community?
    • Are you transitioning to or retraining for a new setting?
    • What challenges are you overcoming in your clinic or facility that are specific to your setting or patient population?
    • What advice would you give to other PTs facing similar challenges?

    “APTA is committed to helping all PTs, PTAs, and students navigate this crisis," says Heidi Kosakowski, PT, DPT, APTA senior practice specialist. "One PT’s experience could help another in their decision-making process — and help APTA elevate the collective voice of our members.”

    If you would like to share your story, you can submit via APTA Engage. Responses may be published in APTA publications or on APTA's website.