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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.

    'Don't Miss' COVID-19 Resources, Recommendations From APTA Components

    The association's sections and academies have been creating invaluable resources and curating offerings from other agencies and organizations. Here's what they recommend.

    The COVID-19 pandemic triggered an unprecedented effort among APTA components to provide resources that deliver expert perspectives and insights on a wide variety of topics. Sometimes from a single component and at other times through collaboration like never before, the offerings are proof that the physical therapy profession is committed to responding to the health emergency with tenacity and compassion, through a unique set of skills and expertise.

    Here's a sampling of what's available, as recommended by the components themselves. All are free and open access.

    [Editor's note: Components are continually adding resources, including notices of upcoming online events such as this webinar titled "Overview of Prone Positioning: Why It Works" a collaborative effort from the Academy of Acute Care Physical Therapy, the Cardiovascular and Pulmonary Section, and the Academy of Clinical Electorphysiology and Wound Management set for May 9 from 3 p.m.- 5 p.m. CT, and "How COVID-19 Has Exposed Our Nation's Structural Inequities," an online townhall on May 9, 11 a.m-1 p.m. ET, sponsored by the APTA Section on Health Policy and Administration.]

    Collaborations

    COVID-19: Minimizing the Impact of Social Distancing for the Older Adult
    Recorded webinar
    Representatives from the APTA Home Health Section, APTA Academy of Acute Care Physical Therapy, the APTA Section on Health Policy and Administration, and APTA Geriatrics and its Cognitive and Mental Health Special Interest Group discuss ways individuals, their families, caregivers, and PTs and PTAs can help minimize the impact of isolation being experienced by many older adults.

    Post-Acute Exercise and Rehabilitation (PACER) Series
    Webinar Series
    This continually growing series of webinars is an initiative shared by multiple APTA sections and academies to increase practitioner proficiency in cardiovascular and pulmonary physical therapy. Currently available modules include information on examination, geriatric considerations, pediatric considerations, cardiovascular anatomy and physiology, pulmonary rehabilitation, and COVID-19-specific considerations. See information on specific modules under the component headings.

    Academy of Acute Care Physical Therapy

    Laboratory Values Interpretation Guide
    Online resource
    The academy's Practice Committee updated the Laboratory Values Interpretation Resource to better align with emerging evidence, current practice, and practitioners’ clinical decision-making needs.

    Clinical Best Practices in Physical Therapy Management
    Recorded webinar
    Highlights current insight into pathophysiology and medical management of COVID-19, including its widespread acute inflammatory microvascular changes resulting in multisystem effects.

    Academy of Clinical Electrophysiology and Wound Management

    Statement on Wound Care as an Essential Service
    Position statement
    This statement from the Alliance of Wound Care Stakeholders supports wound care as essential to help prevent worsening of complicated wounds and reduce the influx of patients in EDs and inpatient admissions.

    Statement on Preventing Injury With N95 Masks
    Position statement
    From the National Pressure Injury Advisory Panel are position statements and review of current evidence regarding facial pressure injuries associated with N95 mask use.

    Protecting Facial Skin Under PPE N95 Face Masks
    Infographic
    An easy-to-understand guide from NPIAP on protecting facial skin is suitable for printing out and displaying.

    Academy of Aquatic Physical Therapy

    Is COVID-19 Spread Through Water?
    Blog post
    The Academy of Aquatic Physical Therapy is referencing the CDC for the most-up-to date information on the question of whether or not COVID-19 is spread through swimming pools.

    Cardiovascular and Pulmonary Section

    PACER Series: Cardiovascular and Pulmonary Examination
    Recorded webinar
    This course will explain how to conduct an examination of the cardiovascular and pulmonary systems, including the four components of a chest examination.

    PACER Series: Cardiovascular and Pulmonary Anatomy and Physiology
    Recorded webinar
    This course describes the anatomy, histophysiology, and pathology of COVID-19.

    PACER Series: Pulmonary Rehabilitation
    Recorded webinar
    This course examines pulmonary rehabilitation for people with COVID-19 in the postacute setting, with a look toward outpatient pulmonary rehab.

    APTA Geriatrics

    PACER Series: Geriatric Considerations, COVID-19
    Recorded webinar
    This one-hour course will provide clinicians with an overview of how and why COVID-19 has had such a significant impact on older adults.

    Resources for PTs and PTAs Teaching Online Geriatric Content in Academic Programs
    Recorded webinar
    For PTs and PTAs working in academic settings who teach geriatric content and are affected by campus shutdowns related to the COVID-19 pandemic: sharing of knowledge and resources to promote immediate and effective online teaching resources and strategies.

    Home Health Section

    OSHA Guidance on Preparing Workplaces for COVID-19
    Guidance document
    These OSHA guidelines include information on personal protective equipment and protection of workers with high risk of exposure.

    Home Health Agencies: CMS Flexibilities to Fight COVID-19
    Guidance document
    A CMS roundup of the ways in which recent COVID-19-related waivers apply to home health agencies.

    American Council of Academic Physical Therapy

    Lessons from the Trenches: The Nuts and Bolds of Implementing a Lab Immersion Webinar
    Live webinar, May 21, 1 p.m.-2 p.m. ET
    Dr. Casey Unverzagt and Dr. Brian Young share the nuts and bolts of hybrid learning and immersive lab instruction developed by the Baylor University DPT Program.

    Open Forum for Clinical Education
    Discussion board
    The discussion board does not require ACAPT membership, but you will need to register with the ACAPT database to access the discussion.

    Clinical Education Communication Tips During COVID-19
    Guidance document
    Tips on being mindful in your approach to conversing with various clinical education stakeholders.

    Academy of Pediatric Physical Therapy

    PACER Series: Pediatric Considerations
    Recorded webinar
    This course explores the statistics of pediatric COVID-19, sequela of the disease including heart and lung function, how lung development plays a role in disease’s course, and appropriate outcome measures and interventions following the acute phase of the disease.

    Section on Health Policy and Administration

    Telehealth PT Patient Satisfaction Survey (scroll down on HPA's COVID-19 page and look for "Complete the Telehealth PT Patient Satisfaction Survey" header)
    Patient resource
    This patient satisfaction survey was developed to capture the voice of the customer related to their telehealth experience.

    Acute Care Physical Therapy and COVID-19: How Can We Add the Greatest Value? (part one)
    Recorded webinar
    A recording and handouts that provide considerations and tips for navigating health care in the acute care setting during the pandemic. Resources and links for additional information are included.

    Audio and Video Telecommunications Systems (scroll down on HPA's COVID-19 page to find)
    Blog post and related resources
    Resources and points to consider prior to engaging in telehealth, including a link to a spreadsheet of vendors that provide audio and video telecommunications services that could be used for telehealth.

    APTA Private Practice Section

    Managing Your Practice Through the Pandemic — Next Steps
    Recorded webinar
    A panel discussion looking at how five practices, from small to large and with varying situations, are each responding to keep their practices going through this crisis, especially as many states begin the early stages of lifting bans.