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  • APTA Advisory: CMS Opens the Possibility of Providing Care to a Patient in the Same Building — But Not in the Same Room

    Details are in short supply, but in a recent communication with APTA, CMS seems to say that a PT's evaluation or treatment visit via real-time video, if delivered to a patient in a different room of the same building, could be billed as in-person services.

    During a national stakeholder call on April 8, CMS opened up the possibility that it would allow a clinician to provide services remotely to a patient in the same building, but not in the same room, and bill the encounter as an in-person visit. A follow-up question submitted by APTA via email seems to indicate that CMS thinks the allowance applies to PTs.

    APTA provided two examples for CMS' consideration: a PT performing an evaluation via Facetime or Skype in the same building but a different room, and a PT performing a treatment visit via Facetime or Skype in the same building but a different room.

    APTA asked if the evaluation and treatment would be considered to have been done in person and thus be billable to Medicare; and whether, if the same approach is taken in a skilled nursing facility, the minutes could be coded on the minimum data set.

    CMS' response:

    "Both of these instances you mention, where a PT performs an evaluation or treatment visit via Facetime or Skype when in the same building but in different locations describe services that can be billed as in-person services."

    “While this policy has enormous potential to help ensure continued access to therapists and other health care providers when attempting to limit contact between patients and their health care providers to prevent the spread of the COVID-19 virus, this is the only information we have on this development at the moment," said Kara Gainer, APTA director of regulatory affairs. "We don't know how this might be applied across the many health care settings, including home health. And the CMS response didn't clearly answer our question about coding these minutes in the skilled nursing facility setting."

    This is important: The allowance from CMS is not a recognition of PTs as eligible telehealth providers under Medicare. Medicare still doesn’t include PTs among the providers who can provide face-to-face telehealth; and APTA continues to urge CMS to use its authority to issue a blanket waiver to include PTs among the types of providers eligible to furnish telehealth services during the COVID-19 public health emergency.

    APTA staff will continue to pursue this information from CMS and provide more information as it becomes available.

    Update, April 10, 2020: CMS' position on how to bill services delivered in the same facility but different rooms was recently reiterated in this CMS FAQ resource (see question 9 under the "Medicare Telehealth" header).

    Visit APTA's telehealth webpage for regularly updated information and resources.

    Study: Physical Therapy Bests Steroid Injections for Treatment of Knee OA

    A new study in the New England Journal of Medicine finds a significant difference in WOMAC scores after one year and more positive patient perceptions of improvement for patients treated through physical therapy versus glucocorticoid injections.

    In this review: Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee (New England Journal of Medicine, April 9, 2020)

    [Editor's note: this review was revised to include remarks from Gail Deyle,one of the study's authors.]

    The Message
    A study of beneficiaries in the military health system concludes that patients with knee osteoarthritis treated through physical therapy experienced lower pain and higher physical function after one year than did patients who received steroid injections. In addition to challenging assumptions about the effectiveness of the widely used injections, the results also hint at the possibility that benefits of physical therapy for knee OA may be more long-lasting than earlier believed.

    The Study
    Researchers analyzed data from 156 patients (average age, 56, 48% female) diagnosed with knee OA between 2012 and 2017 who were active duty or retired service members or their family members from two military hospitals. The patients were divided into two treatment groups: One received physical therapist services, and the other received intraarticular glucocorticoid injections. Physical therapist services were provided in up to eight sessions over an initial four- to six-week period with the possibility of one to three sessions later on; steroid patients received an injection of a mixture of triamcinolone acetonide and lidocaine at outset, with the possibility of receiving as many as three injections over the one-year study period. Patients completed the Western Ontario and McMaster Universities Osteoarthritis Index, known as WOMAC, as well as the Global Rating of Change assessments at baseline and at the four-week, eight-week, six-month, and one-year marks. Researchers compared the results among patients at baseline and one year. APTA members Gail Deyle, PT, DPT, DSc, and Dan Rhon, PT, DPT, were among the authors of the study.

    Findings

    The physical therapy group reported a bigger improvement in WOMAC scores. Patients in the physical therapy group averaged a 37 on the WOMAC after a year — a 70-point drop in the 0-to-240 scale in which lower scores indicate less pain and better function. The injection group also reported improvements in WOMAC scores but to a lesser extent — from an average score of 108 at outset to 55.8 after one year.

    Perceived improvement was also greater in the physical therapy group. Both groups reported a perception of improvement, but the physical therapy group averaged a plus-five score ("quite a bit better"), while the injection group averaged a plus-four ("moderately better").

    Step and up-and-go test results were better for the physical therapy group. Patients in the physical therapy group performed better than injection group patients by an average of one second for the alternate step test, and by 0.9 seconds for the timed up-and-go test.

    The rate of improvement, based on WOMAC, seemed to keep increasing for the physical therapy group. Researchers note a fairly typical pattern of short-term improvement in pain and function for the physical therapy group, but they also note an increasing rate of improvement at one year — a finding inconsistent with other studies that have indicated that improvement tends to level off after a year or even begin moving back in the direction of baseline WOMAC scores.

    Why It Matters
    Authors of the study point out that "clinical practice guidelines vary regarding the use of glucocorticoid injections … with a recent clinical practice guideline providing the highest level of endorsement." Use of injections to treat knee OA could be as prevalent as 50% of patients, they write, while the use of physical therapy for treatment of knee OA declined between 2007 and 2015, despite increasing practice guideline acknowledgment of its effectiveness.

    More From the Study
    Although authors didn't perform a cost and utilization analysis comparing the two approaches, they did track average cost for all knee-related medical care during the one-year period, and found similar totals — $2,113 for the injection group and $2,131 for the physical therapy group.

    As for the physical therapist intervention, PTs generally "would implement hands-on, manual techniques immediately before the patient performed reinforcing exercises to help the patient perform the movement with little or no pain." Those exercises depended on the functional deficits and pain being experienced by the patient. Patients received up to eight sessions over a four- to six-week period and could request an additional one to three sessions at the four-month and nine-month reassessments. Patients averaged 11.2 treatment visits.

    Authors point out that the trend toward increased improvement after one year, as opposed to a significant short-term increase and then a gradual slow down in improvement as patients approached the one-year mark, was a result that differed from previous studies. They speculate that the pattern "may have been the result of educational sessions, additional provider contact at four months and nine months, and the use of interim treatment visits as needed."

    "What was different in this trial was the use of a small number of interim visits to reinforce home exercise performance, provide additional manual treatment, and have discussions on knee osteoarthritis management as needed," said Deyle. "The primary reason we were showing increasing benefit with physical therapy that far out from baseline was most likely the interim visits. Intermittent work with a physical therapist to better control symptoms of knee osteoarthritis is the key to reducing the need for invasive higher-risk strategies. No one would question the value of regular periodic treatment by a pulmonary specialist for a disorder like chronic obstructive pulmonary disease—this is essentially the same concept of care."

    Deyle believes there's an opportunity for more research to be done around physical therapy versus more common treatment for knee OA, but says that the pervasive use of steroid injections will make it hard to establish trial cohorts.

    "Trials like these comparing medical interventions to physical therapy are very difficult to perform because patients are frequently offered steroid injections in primary care and specialty clinics," Deyle said. "Even when enrolled in a clinical trial, providers still offer injections at nearly every visit, so finding patients who had not received but were willing to receive injections was difficult. What I'd like to see is a comparative study of patients with knee osteoarthritis randomized to primary contact with a physical therapist, receiving the care detailed in this trial, compared with the normal primary care pathway."

    Keep in Mind …
    The researchers acknowledge several limitations in their study, including differences in the number of visits with providers in the two groups (the physical therapy patients had more visits), some crossover between the groups (18% of the injection group also received physical therapy, and 9% of the physical therapy patients received injections), and a recruitment effort that allowed recruitment based on an initial physical therapy visit as well as from a primary care physician visit — a difference that may have "influenced patients' perceptions of the interventions." Authors of the study also point out that the physical therapy group had a higher proportion of patients with severe OA.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    CDC Issues Recommendations on Workers Who May Have Been Exposed to COVID-19

    The latest guidance says that critical workers, including health care providers, who may have been exposed to COVID-19 may continue to work under very controlled circumstances that include mask use (but must leave if they begin experiencing symptoms).

    As the COVID-19 pandemic continues to grow, discussions are expanding beyond how to avoid exposure to the virus and toward what should happen after potential exposure occurs. The U.S. Centers for Disease Control and Prevention says that for "critical infrastructure workers" including health care providers, that response should include consistent employer efforts to pre-screen, monitor, disinfect, and support the use of masks and other PPE.

    In a recently released interim guidance document, CDC says that while critical infrastructure workers may be allowed to work after potential exposure to COVID-19—provided they don't develop symptoms — it's important for the workers and their providers to take certain precautions. According to CDC, "potential exposure" is defined as "being a household contact or having a close contact within six feet of an individual with confirmed or suspected COVID-19," with a timeframe of 48 hours before the infected individual became symptomatic.

    The CDC recommendations call for:

    Pre-screening. "Employers should measure the employee’s temperature and assess symptoms prior to them starting work. Ideally, temperature checks should happen before the individual enters the facility."

    Regular monitoring. "As long as the employee doesn’t have a temperature or symptoms, they should self-monitor under the supervision of their employer’s occupational health program."

    Use of masks. "The employee should wear a face mask at all times while in the workplace for 14 days after last exposure. Employers can issue facemasks or can approve employees’ supplied cloth face coverings in the event of shortages."

    Social distance. "The employee should maintain 6 feet and practice social distancing as work duties permit in the workplace."

    Disinfection and cleaning. "Clean and disinfect all areas such as offices, bathrooms, common areas, shared electronic equipment routinely."

    CDC also advises that employees who begin feeling sick during the day should be sent home immediately and their workspaces thoroughly cleaned. Employers should also collect information on the employee's activities for two days before the symptoms emerged, and consider others in a facility who were within six feet of the infected employee during that time to be exposed.

    Bill Boissonnault, PT, DPT, DHSc, FAPTA, APTA's executive vice president of professional affairs, says that the CDC recommendations make it clear that providers and their employers shouldn't take chances — or cut corners — when it comes to responding to the COVID-19 emergency.

    "These guidelines need to be taken seriously," Boissonnault said. "It's everyone's responsibility to take whatever precautions possible to limit the spread of the virus — including wearing PPE and making PPE available to workers."

    he recommendations echo recent CMS guidelines for outpatient facilities that acknowledge the role employer discretion plays in minimizing risk of infection while providing necessary care — but strongly support the use of masks and other PPE when potential exposure has occurred. The U.S. Occupational Safety and Health Administration advises employers that they are "obligated to provide their workers with PPE needed to keep them safe while performing their jobs," leaving employers to decide the types of PPE to be issued "based on the risk of being infected with the SARS-CoV2 virus while performing job tasks that may lead to exposure."

    The advisories from CDC and CMS are also consistent with guidance APTA provides on management of patients to minimize the risk of COVID-19 transmission.