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  • New CMS Rule Includes Therapy Codes in Telehealth, Stops Short of Allowing PTs to Conduct Telehealth Services

    CMS has announced "sweeping" temporary changes that give a nod to the potential for true telehealth by PTs even though regulatory barriers still prevent that from happening. Could it be a sign of more to come?

    In this review: Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (interim final rule)
    Effective date: March 1, 2020 (backdated)
    CMS press release
    CMS fact sheet
    Additional CMS guidance


    It's true that the 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 there's one problem: CMS has made no related changes to allow PTs, occupational therapists, and speech-language pathologists to actually provide services through telehealth, even though the codes have now been okayed for that use.

    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, urging the agency to use it waiver authority to expand telehealth recognition to PTs. In the wake of the interim rule just released, APTA is requesting a meeting with CMS, and will submit formal comments on the interim rule in the weeks ahead. APTA has also joined with the American Occupational Therapy Association and the American Speech-Language-Hearing Association in a statement calling on CMS to "take immediate steps to ensure patient safety and protect health care providers."

    In the meantime, APTA advises members to assume that PTs are not recognized as telehealth providers by CMS, and the association calls on member to press the agency to expand telehealth waivers, using an APTA-developed template letter. In addition, the association is pushing for permanent inclusion of PTs in telehealth through advocacy for the CONNECT Act.

    More from the Interim Rule

    In addition to the nod toward therapy delivered via telehealth, the rule makes it easier for PTs to conduct some forms of digital communications with patients, and relaxes some supervision requirements. The changes also include allowances in home health and inpatient rehabilitation facilities, and they allow for hospitals to provide services outside existing facilities. Those hospital changes would make it possible for hospitals to transfer COVID-19 patients to ambulatory surgery centers, inpatient rehabilitation hospitals, and hotels.

    Video and Virtual Check-Ins, Telephone Assessments and Management
    Medicare routinely pays for many kinds of services that are furnished by way of telecommunications technology but are not considered Medicare telehealth services. These communication technology-based services (CTBS) include, for example, certain kinds of remote patient monitoring (either as separate services or as parts of bundled services) and interpretations of diagnostic tests when furnished remotely — essentially, services ordinarily furnished in person but are routinely delivered using a telecommunications system.

    The interim rule includes PTs among the providers eligible to provide remote evaluations (G2010) and virtual check-ins (G2012), as well as so-called "e-visits" that were earlier permitted through a waiver process to established patients, although the agency notes that “while some of the code descriptors refer to 'established patient,' during the [emergency] we are exercising enforcement discretion on an interim basis to relax enforcement of this aspect of the code descriptors.” The codes are designated by CMS as “sometimes-therapy” services that require the GP modifier, with patient consent able to be obtained at the same time the service is furnished.

    Supervision
    For the duration of the COVID-19 public health emergency, CMS is allowing direct supervision to be provided using real-time interactive audio and video technology. The change clearly applies to "incident to" situations in which PTs are working under the direct supervision of physicians; APTA is seeking clarification as to whether it also applies to PTAs working under the supervision of PTs in private practice.

    Similar allowances are applied to supervision services associated with pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services.

    The interim rule makes it clear that the change only deals with the method used to provide the supervision; it doesn't alter policies related to the scope of Medicare benefits or any rules around safe transportation and proper waste disposal.

    Home Health
    The rule expands the definition of a "homebound" patient as someone whose physician advises them to not leave home because of a confirmed or suspected COVID-19 diagnosis, or who has a condition that makes them more susceptible to COVID-19. The change means that home health agencies will be able to provide services under the Medicare Home Health benefit. The allowance does not apply to a patient who is self-quarantining but doesn't have the physician acknowledgement of COVID-19 or risk factors associated with COVID-19.

    The announced changes also allow HHAs to use additional telecommunications technologies in conjunction with in-person visits but stop short of allowing telecommunications-delivered communications to replace in-person visits.

    CMS also is pausing the "Review Choice Demonstration" for home health services in Illinois, Ohio, and Texas, the program that requires home health providers in those states to participate in preclaim or postpayment reviews, or to choose a third option that would involve reduced postpayment review but cut payment by 25%. The demonstration will not begin in North Carolina and Florida on May 4, 2020, as previously scheduled.

    See the CMS guidance on home health changes for more details.

    Inpatient Rehabilitation Facilities
    CMS is allowing IRFs experiencing staffing shortages and disruptions to back away from following the "three-hour rule," which requires that the IRF patients participate in three hours of rehabilitation therapy per day, five days per week—or, in certain well-documented cases, at least 15 hours of intensive rehabilitation therapy within a 7-consecutive day period that begins on the date of admission to the IRF.

    See the CMS guidance on IRF changes for more details.

    Medical Reviews
    The interim rule suspends most Medicare medical review during the emergency period, including prepayment medical reviews conducted by Medicare Administrative Contractors under the Targeted Probe and Educate program, as well as postpayment reviews. In addition, CMS announced that it won't issue additional documentation requests through the emergency period and will suspend all Targeted Probe and Educate reviews in process, and claims will be released and paid. Other postpayment reviews will also be suspended and released from review. CMS warns, however, that it may still conduct reviews during the emergency period if it finds indications of potential fraud.

    Tell Congress: Improvements in Telehealth, Reimbursement Should be Part of Pandemic Response

    As lawmakers craft the next COVID-19 relief package, now's the time to make the case for the profession's role in telehealth services and the need for easing reimbursement cuts.

    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.

    APTA is making it easy. 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.

    Your patients can do the same, by way of APTA's patient action center.

    Take a few minutes now to create long-lasting change.

    Where Things Stand: COVID-19 and Practice Guidance

    Information and resources around physical therapy and COVID-19 continue to develop. Here's what we're recommending. (April 21 update)

    While APTA continues to point PTs, PTAs, and physical therapy students to the latest CDC guidance related to the COVID-19 pandemic, the association and other groups are creating more refined guidance related to specific practice settings and situations. Here are recommended resources to date.

    Outpatient (Added April 21)
    Here's a recap of resources APTA has developed to help outpatient practices.

    Home Health(Added April 14)
    HPSO, APTA's official provider of professional liability insurance for members, has created a resource that emphasizes the importance of CDC guidance and PT professional judgment, but dives deeper into considerations that need to be weighed when considering home health physical therapy — particularly during the COVID-19 health emergency.

    Nursing Homes (Added April 6)
    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."

    Physical Therapist Management of Patients With Diagnosed or Suspected COVID-19 (Updated April 8)
    This APTA resource provides perspectives on issues such as when a PT should tell patients not to come in for their outpatient PT visits, as well as management of patients diagnosed with COVID-19 in inpatient facilities, home health settings, experiencing post-intensive care syndrome, and in need of wound care. The guidance also includes information on preparation of physical space to reduce infection risk, use of PPE, and helping patients to stay active while at home.

    Pediatric Physical Therapy
    Physical therapist services to the pediatric population may have special considerations during the COVID-19 pandemic. APTA put together this information for PTs and PTAs who manage these patients, particularly in school settings. Topics include school closings and IEP services, remote learning, and a discussion of factors that need to be considered in providing pediatric physical therapy via telehealth.

    Acute Hospital Physical Therapy
    A new set of recommendations for provision of physical therapist services related to COVID-19 in the acute hospital setting acknowledges the necessity of involvement of PTs well-trained in respiratory physical therapy, but cautions that facilities should be judicious in their use. The recommendations have already been endorsed by APTA, its Cardiovascular and Pulmonary Section, and the APTA Academy of Acute Care Physical Therapy, albeit with a few caveats that not all of the Australia-based guidance will apply in the U.S.

    Long-Term Care Facilities
    The American Health Care Association and the National Center for Assisted Living released a joint document focused on changes to physical therapy, occupational therapy, and speech-language pathology services to reduce the spread of COVID-19. Recommended changes to be considered by LTC facilities include discontinuation of group and concurrent therapy, delivery of therapy in resident rooms rather than therapy gyms, and the use of social distancing "as practicable." AHCA and NCAL also advise against therapists moving between buildings if COVID-19 is discovered in one building.

    Wound Care
    The Alliance of Wound Care Stakeholders, a group that includes APTA, the American Association of Nurse Practitioners, the Amputee Coalition, and others, issued a statement countering hospital decisions to shut down outpatient-based wound care departments as "non-essential" during the coronavirus pandemic.

    Dementia Caregivers
    The Alzheimer’s Association, in collaboration with Academy of Geriatric Physical Therapy and others, developed tips for dementia caregivers in long-term or community-based settings.

    AHCA/NCAL: Making Decisions on Essential Staff Entering Your Building
    The guidance helps nursing facilities assess the risks versus benefits in working with various essential services such as rehabilitation therapy, labs, and portable x-ray.

    Responding to Patient Concerns About Workers' Comp During the COVID-19 Pandemic

    Some patients may be understandably concerned about losing WC benefits if they choose to reduce travel during the national health emergency.

    APTA has received several communications from patients who are seeing a PT through workers' compensation but who are having reservations about continuing treatment during the COVID-19 pandemic. They feel at risk, yet they don't want to lose their WC benefits.

    In the event individual providers are hearing the same concerns, here's our advice to share with those patients:

    1. Contact your case manager. There may already be guidance available during the health emergency.
    2. Contact your employer — specifically, your employer's human resources department or your union representative. Again, guidance may already be there for you.
    3. Find out if your state has initiated emergency rules that allow for telehealth for purposes of treatment through workers' compensation. If the answer is yes, contact your provider to set up a telerehab plan.
    4. If you can't find definitive answers, keep making your concerns known and exploring possible solutions with your case manager and employer.

    For more information on physical therapy and workers' compensation, including links to individual state information, visit APTA's workers' compensation webpage.