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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.

    Comments

    • AuthoriZe PT and OT to provide services

      Posted by Angie Bolanos on 3/31/2020 10:04 PM

    • The link for the "Connect Act" on this page leads viewers to an info page with old bill numbers at the top.

      Posted by James Nowak -> DITaDK on 3/31/2020 10:59 PM

    • How does this mesh with the following CMS document which seems to indicate that physical therapists can conduct tele-health? Specifically: "Medicare Telehealth Clinicians can now provide more services to beneficiaries via telehealth so that clinicians can take care of their patients while mitigating the risk of the spread of the virus. Under the public health emergency, all beneficiaries across the country can receive Medicare telehealth and other communications technology- based services wherever they are located. Clinicians can provide these services to new or established patients. In addition, providers can waive Medicare copayments for these telehealth services for beneficiaries in Original Medicare. To enable services to continue while lowering exposure risk, clinicians can now provide the following additional services by telehealth: Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161- 97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507)" https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf?utm_source=podia&utm_medium=broadcast&utm_campaign=165504

      Posted by United States on 3/31/2020 11:19 PM

    • What about billing incident to under a Supervising MD (those of us that work in same practice with the MD who orders the PT) Medicare states clinicians can perform these codes and Medicare defines a clinician as "a healthcare professional qualified in the clinical practice of medicine. Clinicians are those who provide: principal care for a patient where there is no planned endpoint of the relationship; expertise needed for the ongoing management of a chronic disease or condition; care during a defined period and circumstance, such as hospitalization; or care as ordered by another clinician. Clinicians may be physicians, nurses, pharmacists, or other allied health professionals." Any thoughts from APTA on this?

      Posted by Elise Hirth on 4/1/2020 9:00 AM

    • Please address the issue that Rick Gawenda brought up that the additional allowances made by CMS may only apply to private practice (clinics billing with a 1500 Claim form) and NOT for hospital or "institutional based" clinics that bill with a UB-04 claim form. Is this how APTA is interpreting the interim rule? Thank you.

      Posted by Jeremy Ramage on 4/1/2020 9:51 AM

    • @United States: Although CMS announced on March 30, 2020, that it would add some PT, OT, and SLP CPT codes to the list of services covered under the Medicare Physician Fee Schedule when furnished as telehealth, CMS did not expand the types of providers eligible to furnish telehealth under Medicare. CMS noted in the interim final rule w/ comment period that current Medicare law does not allow telehealth services to be furnished by PTs, OTs, and SLPs under 1834(m). Thus, as of this writing, telehealth services furnished by PTs (and PTAs) are not covered under Medicare.

      Posted by APTA staff on 4/1/2020 9:58 AM

    • @Elise: Distant site practitioners who can furnish and get payment for covered telehealth services (subject to State law) are physicians and practitioners. We do not believe furnishing telehealth incident to the physician is eligible for reimbursement under Medicare.

      Posted by APTA staff on 4/1/2020 9:59 AM

    • @Jeremy: In the interim final rule released March 30, CMS described e-visits and other communication technology based services (CTBS) as “sometimes therapy” services that would require the private practice occupational therapist, physical therapist, and speech-language pathologist to include the corresponding GO, GP, or GN therapy modifier on claims for these services. Given this statement and reference to “private practice” therapists, it is unclear whether institutional settings can bill these codes. As we continue to seek clarification from CMS, we encourage providers to check with their Medicare Administrative Contractor. We also anticipate CMS will be releasing additional guidance in the very near future that will hopefully better address this question. We apologize we don’t have an explicit answer at this point. We were hoping CMS would further clarify in the rule, but instead they muddied the waters even further. Please stay tuned for additional information.

      Posted by APTA staff on 4/1/2020 11:07 AM

    • How about adding 97530 too...

      Posted by Trevor D’Souza, PT, DPT on 4/1/2020 12:04 PM

    • Could you please post where this information is located that PT's 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. I am getting daily communications from CMS that do not mention any such restriction.

      Posted by Andrew Heideman on 4/1/2020 1:05 PM

    • Do the links to the template refer to something different than the telehealth provider waiver?

      Posted by Katherine Baratta, PT, DPT on 4/1/2020 1:41 PM

    • Per the language on the prior rule and waiver they already gave us this info: Form CPTA website: Due to the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act, the Centers for Medicare and Medicaid Services (CMS) is expanding access to Medicare telehealth servicesso that beneficiaries can receive a wider range of services from their providers without having to travel to a healthcare facility. For the first time, PTs will be allowed to bill Medicare for E-visits under codes associated with online assessment and management services (HCPCS codes G2061: Qualified non-physician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes; G2062: Qualified non-physician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes; G2063: Qualified non-physician healthcare professional online assessment,for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes). Providers must use place-of-service code “02” and “CR” modifier. CMS guidance instructs providers to use the CR (catastrophe/disasterrelated) modifier for both institutional and non institutional Medicare Part B billing. (These are claims submitted using the ASC X12 837 professional claim format or CMS-1500.) Please note: For institutional billing, the DR condition code and CR modifier are required. For non institutional billing, only the CR modifier is required. The payment rates are significantly lower than the traditional payment for an in-person visit under the CPT 97000 code series. Not sure why the new rule would remove this prior ruling. Can you comment?

      Posted by Lorraine on 4/1/2020 3:26 PM

    • @Andrew: Although the March 30th CMS rule adds some PT, OT, and SLP CPT codes to the list of services covered under the Medicare Physician Fee Schedule when furnished as telehealth, CMS did not expand the types of providers eligible to furnish telehealth. CMS acknowledges in the rule that the majority of the therapy codes are furnished over 90 percent of the time by therapy professionals, but that therapists are not on the statutory list of eligible distant site practitioners. Specifically, CMS states on page 37 of the IFC that current Medicare law does not allow telehealth services to be furnished by therapists under SSA 1834(m): "However, it was noted that the statutory definition of distant site practitioners under section 1834(m) of the Act does not include physical therapists, occupational therapists, or speech-language pathologists, meaning that it does not provide for payment for these services as Medicare telehealth services when furnished by physical therapists, occupational therapists, or speech-language pathologists."

      Posted by APTA staff on 4/2/2020 10:10 AM

    • I strongly urge APTA to request CMS include CPT Code 97542, wheelchair management, assessment, fitting and training as a code that can be provided by therapists through TeleHealth once they actually allow therapists to perform TeleHeatlh! Physical therapists provide interventions using telehealth by observing how the patient moves and performs exercises and activities including the use of supportive seating and wheeled mobiity. They then provide verbal and visual instructions and cues to modify how the patient performs various activities. They also may recommend changes to the technology being used or the environment to encourage more optimal outcomes. Physical Therapists can assess a person’s mobility equipment and ensure safe mobility in their home during this crisis since most are on “stay at home” or “shelter in place” recommendations or orders. This will allow especially those who use complex Rehab Technology Wheelchairs to stay out of bed and prevent secondary medical complications of bed sores, bowel/bladder issues and skeletal deformities and pain. This can be done along with a skilled supplier to meet the wheelchair users se needs during in this current crisis.

      Posted by Barbara Crume -> >IYb? on 4/3/2020 8:37 PM

    • I don’t get why CMS would list physical and occupation therapy services under the expansion and then list typical PT/OT CPT codes but not include PT and OT to use these codes. Who else would bill them and how?!? If you’re in a hospital based system or POPs could a physician sign off on the note? https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf

      Posted by MJK on 4/5/2020 11:53 PM

    • @MJK: Currently, distant site practitioners of telehealth include only a physician as described in §1861(r) and a medical practitioner as described in §1842(b)(18)(C). Neither definition includes PTs. At the time that CMS wrote the rule and added therapy codes to the list of covered telehealth services, CMS did not have the authority to add therapists as distant site practitioners of telehealth, as CMS wrote the rule before the CARES Act was signed into law (March 27), in which CMS was granted the authority to expand the types of providers eligible to furnish telehealth during the public health emergency (but does not require them to). APTA is aggressively advocating for CMS to take immediate action to add therapists as telehealth providers during this public health emergency. We also encourage individuals to take action by submitting comments to CMS, urging the agency to use its waiver authority to add therapists as telehealth providers using the template letter provided here. https://www.apta.org/RegulatoryIssues/TakeAction/.

      Posted by APTA staff on 4/6/2020 8:52 AM

    • @APTA Thank you for the response. There is so much information that is constantly changing during these times. I'm curious where you can find the 80 different services that are now allowed for telehealth. Per a CMS document from 3/31: "Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth." https://www.cms.gov/files/document/mln-connects-special-edition-3-31-2020.pdf A document released on 3/30 from CMS also mentions expanded flexibilities for outpatient physical therapy as described below: "In addition to the flexibilities we are announcing today, we are also issuing new guidance for additional healthcare settings such as ambulatory surgery centers, community mental health centers, outpatient physical therapy and other settings of care. The guidance provides information taking appropriate action to address potential and confirmed COVID-19 cases including discussions on recommendations to mitigate transmission including screening, restricting visitors, and cleaning and disinfection and possible closures." However, it doesn't describe what these flexibilities include. Are you able to clarify this? https://www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient

      Posted by MJK on 4/6/2020 12:53 PM

    • @MJK: We believe this is in reference to the availability of communication technology-based services to be furnished by PTs (and OTs and SLPs) and just general relief in the form of the suspension of medical review, provider enrollment & licensure flexibilities, etc. For an overview of all of the flexibilities being offered to providers, see: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers

      Posted by APTA staff on 4/7/2020 8:21 AM

    • I am looking for some clarification as to whether PTA's (specifically in Maryland) are classified as qualified clinicians to provide telehealth services?

      Posted by Helen Saunders on 4/8/2020 3:36 PM

    • @Helen: Please refer to: https://www.aptamd.org/telehealth/

      Posted by APTA staff on 4/9/2020 8:28 AM

    • I’d like clarification for telehealth for the PTA in all settings and states ( Indiana). I’m assuming telehealth is covered nationwide however there’s no guidelines on telehealth services delivered by the Pta.

      Posted by Daria Bradley on 4/9/2020 2:32 PM

    • @Daria: Whether a PTA can furnish and bill for telehealth services hinges on your state practice act and each individual payer’s policy. Although many payers are currently covering telehealth services in light of COVID-19, you will have to verify each payer’s policy to determine what is/is not covered.

      Posted by APTA staff on 4/10/2020 8:18 AM

    • We keep getting denial for our telehealth billing for physical therapy. We using codes G2061, G2062 and G2063 and applying modifiers GP, 95 and CR. Reason for denial is CO16.

      Posted by Mary Bartus on 4/10/2020 9:30 AM

    • @Mary: Unfortunately, it appears that the MACs have not updated their claims processing systems to reflect the change in policy allowing PTs to bill e-visit codes G2061-G2063 during the public health emergency and/or the fact that CMS has described these codes as sometimes therapy services, meaning the GP modifier is required. APTA has brought this issue to the attention of CMS and asked that they work with the MACs to immediately address this issue. Please check with your MAC before submitting claims to ascertain when their systems might be set up to properly process these claims.

      Posted by APTA staff on 4/13/2020 8:44 AM

    • Can you please tell me, as now, how long these new rules will be in effect?

      Posted by Rachael on 4/17/2020 1:40 PM

    • @Rachel: These rules likely will be in effect for the duration of the public health emergency.

      Posted by APTA staff on 4/21/2020 8:46 AM

    • Can you bill a self-pay rate for a telehealth PT visit for a Medicare patient?

      Posted by Kelly on 4/22/2020 6:36 PM

    • Is anything being done in regards to this? Based on my understanding PTs can still not bill for traditional therapy codes via telehealth.

      Posted by Andrew Heideman on 4/28/2020 2:03 PM

    • @Kelly: In general, the charge should be based on what you determine the value to be and then establishing the fee. However, please keep in mind that in the coming days, we anticipate/hope that CMS will be adding therapists as authorized telehealth providers, allowing therapists to furnish and bill for telehealth services under Medicare. The agency is likely to make this policy change retroactive. Also, Medicare telehealth services are reimbursed at the same rate as if the services are furnished in-person.

      Posted by APTA staff on 4/29/2020 8:22 AM

    • @Andrew: Until the CARES Act was enacted on March 27, granting CMS the authority to waive restrictions on telehealth (Section 3703), CMS did not have the authority to add therapists as telehealth providers under Medicare during this public health emergency. Following the enactment of such legislation, APTA sent letters urging the Trump Administration use its authority per the CARES Act to add physical therapy practitioners as eligible telehealth providers under Medicare. APTA also submitted a formal comment letter to CMS in response to its initial interim final rule (released on March 30), urging CMS to use its 1135 waiver authority, as amended by the CARES Act, to issue a blanket waiver and add therapists as eligible telehealth providers under Medicare. APTA also has created a template for individuals to use to add their voice to this important debate. See: http://www.apta.org/RegulatoryIssues/TakeAction/ On April 6, APTA, along with AOTA and ASHA, met with CMS staff to discuss their ongoing request that CMS use its 1135 waiver authority, amended by Section 3703 of the CARES Act, to add therapists as telehealth providers under Medicare during the public health emergency. CMS indicated during the meeting and also subsequently on national town hall conference calls that they are actively engaged in pursuing approaches to give therapy providers regulatory relief/flexibility. Subsequently, on April 14, CMS sent to the Office of Management and Budget Office of Information and Regulatory Affairs (OIRA) for their review an interim final rule titled “Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.” (OIRA reviews all rules prior to publication to ensure the agency is acting within its statutory authority, to assess the economic effects of the rule on the economy, etc.). We expect that this interim final rule includes the Medicare telehealth policy changes we’ve been advocating for, particularly in relation to the addition of therapists as Medicare telehealth providers. We also expect CMS will address in this rule whether they are expanding the availability of institutional settings to bill for telehealth furnished by therapists via the UB-04 form. We do expect this rule to be retroactive. As soon as OIRA completes its review, the document will be published and we will know what changes CMS is implementing, including whether CMS will be adding therapists as telehealth providers under Medicare for the duration of this public health emergency. We will announce any new information via PT in Motion News and social media, and also update our telehealth webpage: https://www.apta.org/telehealth/.

      Posted by APTA staff on 4/29/2020 8:23 AM

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