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  • The Good Stuff: Members and the Profession in the Media, March 2020

    "The Good Stuff" is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. More than ever these days, we need to know there’s good stuff out there. Enjoy!

    There's no place but home: Jacob Kmiecik, PT, DPT, provides tips on wellness for people working from home during the coronavirus pandemic.(KING5 News, Seattle)

    When tech's a pain: Colleen Louw, PT, offers five tips that can help undo muscle tension associated with the use of phones, computers, and other tech. (Real Simple)

    Custom tai chi: Jennifer Penrose, PT, DPT, has developed tai chi and yoga programs customized to her patients and clients.(Thurston County, Washington, Thurston Talk)

    Wii will rock you: Jeanette Tousignant, PT, explains how her clinic uses videogame technology to help address balance deficits.(UPMatters.com)

    Bike to fight cancer: Catherine Kennedy, PT, DPT, MS, explains her approach to encouraging stationary bike exercise to patients in the Comer Children's Hospital pediatric unit in Chicago, which has received a donated bike as part of "Bike to Fight," an initiative started by a pediatric cancer survivor.(Washington Post)

    Dilation training: Sara Reardon, PT, DPT, outlines why vaginal dilators can help decrease vaginismus pain. (insider.com)

    Data dive: Lee Marinko, PT, BSPT, ScD, is part of a Boston University Physical Therapy Center project that collects extensive patient data to create personalized plans of care. (Mirage News)

    Ruck and roll: Michael Polascik PT, BSPT, ATC, DScPT, and Don Walsh PT, DPT, MS, are part of a research team monitoring the physiological responses of U.S. Army Corps of Cadets soldiers during "ruck marches" conducted in full combat gear while shouldering a 35-pound sack. (University of North Georgia News)

    Exercising with joint pain: Anne Marie Bierman, PT, DPT, suggests five workouts that should be considered by individuals who are experiencing joint pain. (sheknows.com)

    Improving batting averages: Kelly Chance, PT, helps a local quilt guild understand how to reduce muscle strain while working on their projects.(Victoria, Texas, Advocate)

    Protecting and serving the protectors and servers: Sarah Greytak, PT, DPT, and Daniel Jonte, PT, are part of a newly created program that has embedded a physical therapy program within the Denver Police Department. (CBS4 News, Denver)

    Quotable: "While I personally enjoy utilizing a variety of body-work professionals, I do believe physical therapists are the movement specialists. They are trained to look at muscular balance, fatigue, neuromuscular control and much more. Physical therapists are not just for surgical recovery anymore! In many areas your physical therapist can be your first entry point into medical care and help get you back to moving pain-free! "– Dana Reid, on the importance of seeking out a PT for treatment of running-related injuries. (womensrunning.com)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    Coronavirus Update: March 18, 2020

    APTA answers questions about e-visits and schedules an online town hall; experts offer recommendations for rehab providers; CDC offers guidance on return-to-work for health care providers, and more.

    Practice Guidance

    March 18: APTA Answers 25 Questions on "E-Visit" Waiver From CMS
    Many questions from PTs and PTAs have arisen since the CMS announcement of waivers that would allow for limited digital communication by PTs. APTA offers answers to 25 of the most frequently asked questions about the still-evolving system.

    March 18: E-Visit Online Town Hall and Q&A March 19
    Join APTA regulatory affairs experts on Thursday, March 19, for a town-hall style webinar and Q&A session on the e-visit waivers. The webinar begins at 8:00 p.m. ET and will be delivered via Adobe Connect; toll-free access numbers are 1-646-560-7802 or 1-888-407-5039, participant code 76560988. The event is open to members and nonmembers, but seats are limited. A Facebook Live event covering the same issues will be held Friday March 20 at 2:00 pm, ET. Recordings of both sessions will be available afterwards.

    March 17: Experts Offer Recommendations for Rehab Providers During COVID Crisis
    A Special Communication in the journal Archives of Physical Medicine and Rehabilitation (pre-proof version) offers recommendations for rehabilitation providers during the outbreak, including advice for addressing patient deconditioning and infection risk, as well as best practices for staff infection control, occupational risks, business continuity planning, and staff communication.

    From CMS

    March 18: CMS Publishes Guidance for Programs of All-Inclusive Care for the Elderly (PACE) Organizations
    The guidance document recognizes that "there may be circumstances where a [provider organization] may need to implement strategies that do not fully comply with CMS PACE program requirements to provide benefits to participants while ensuring they are also protected from the spread of COVID-19."

    From the CDC

    March 16: CDC Issues Guidance for Return to Work for Health Care Personnel With Confirmed or Suspected COVID-19
    The Centers for Disease Control and Prevention has issued interim guidance for occupational health programs and public health officials responsible for making decisions about return to work for health care personnel with confirmed or suspected COVID-19. The guidance includes recommendations for return-to-work criteria, return-to-work practices and work restrictions, and strategies for mitigating staffing shortages. CDC notes that these guidelines may be adapted by state and local health departments.

    In The Media

    March 17: NSAIDs Okay for COVID Patients?
    In recent days the French government recommended against the use of ibuprofen in COVID patients, citing potential adverse outcomes. Other researchers say there is no evidence to back the claim, but agree that acetaminophen is preferable to treat a fever. [Free account required]

    March 16: Predictive Analytics May Help Hospitals Identify COVID-19 Needs
    Data scientists at University of Pennsylvania have built a mathematical model to help hospitals predict future COVID-19 patient load and severity. The model uses best current estimates of a variety of data points, such as how long people are contagious, to project a hospital’s needed capacity for beds, equipment, and other resources.

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

    Furnishing and Billing E-Visits: Addressing Your Questions

    Waivers by CMS that allow for limited digital communication with patients, known as e-visits, have triggered a wave of questions. Here are our answers to the ones we hear most often.

     

    [NOTE: No updates will be made to this article after April 16, 2020. Updated information can be found at this dedicated webpage.]

     

    APTA is receiving many questions about the regulatory waivers announced by CMS related to digital communication between providers and patients, particularly regarding e-visits and the use of HCPCS codes G2061-G2063. We've compiled this list of the most common questions we're receiving, and we're updating it as new information becomes available and new questions emerge.

    The Q&As below are grouped within these areas: general, coding and billing, the seven-day period, practice, documentation, and HIPAA.

    If you have a handle on e-visits and just want a brief review of the basics, see our "Quick Reference to Using E-Visits for Physical Therapist Services." But if the new waivers leave you with questions, continue below.

    Please note that e-visits are NOT the same as telehealth or telerehab services. Congress and CMS have not modified Medicare to add physical therapists to the roster of providers who can be reimbursed for telehealth services. Although CMS announced on March 30 that it would now include PT, OT, and SLP services as being covered under the Medicare physician fee schedule when furnished as telehealth, the agency did not add PTs, OTs, and SLPs to the list of providers eligible to furnish telehealth. With that said, APTA regulatory and payment staff are working directly with CMS and private payers to seek expansion of coverage of telehealth services to include physical therapy services.

    Also important to keep in mind: If you don’t find the answer to your question here, continue to consult trusted sources such as APTA (advocacy@apta.org). Avoid acting on conjecture or recommendations that you don’t know to be reliable.

    In addition the information here, CMS also has answers to Frequently Asked Questions about e-visits. You can find reimbursement rates for the e-visit related codes using the CMS Physician Fee Schedule Look-Up Tool.

    [Editor's note: The parenthetical dates at the end of each answer indicate either the date it was created or the last time it was updated.]

    In General

    1. What is an e-visit?
    In its 2020 physician fee schedule final rule, CMS describes e-visits as “non face-to-face patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office.” The code descriptors for the HCPCS codes related to e-visits suggest that the codes are intended to cover short-term (up to seven days) assessments and management activities that are conducted online or via some other digital platform and include any associated clinical decision-making. (March 18)

    2. Is an e-visit a telehealth service?
    No. An e-visit is considered a service furnished remotely using technology but is not considered a Medicare telehealth service. Under Medicare physical therapists are still not recognized as telehealth providers. An e-visit does not constitute telehealth under the Medicare definition. Under commercial payer policies, the answer varies, so check with your payer. (March 20)

    3. Are PTs required to complete an 1135 waiver to bill for an e-visit?
    No, it's a blanket waiver. But you must use the CR modifier. See question 15 below. (March 20)

    4. What is an online patient portal?
    The HHS Office of National Coordinator for Health Information Technology (ONC) describes a patient portal as a secure online website that gives patients convenient, 24-hour access to personal health information from anywhere with an internet connection. A patient portal requires a secure username and password to allow patients to securely message their provider. (March 18)

    5. Is an online patient portal the only medium PTs can use for an e-visit? Can a phone call encounter without video qualify?
    Under the original code description, an online patient portal is required. Although CMS has implied that they are giving providers flexibility in the platform used, please check with your Medicare Administrative Contractor (MAC) for guidance.  (March 20)

    6. Is there a way for a PT to establish a new patient using an e-visit, for patients who do not want to come in person for an evaluation? Similarly, can a physician transfer a new patient or establish a new patient under a PT’s care in order for the PT to use the e-visit codes for an evaluation?
    No, but see the caveat below. The patient must already be under the care of the therapist. E-visits are intended to be furnished to established patients that the PT is currently treating under a plan of care.

    Note: CMS says it is "exercising enforcement discretion" on an interim basis and will not conduct reviews to consider whether e-visits were furnished to established patients. However, APTA advises providers to continue to comply with their state practice acts and any other applicable state or local laws, which generally require the PT to have evaluated a patient before providing any recommendations or care. (March 30)

    7. How does the assessment work? Are G2061, G2062, and G2063 the codes to use?
    The assessment and management codes G2061-G2063 allow a provider to respond to a patient-initiated request for an e-visit. The term is misleading, as this is not a “visit” in the traditional sense but rather activities and correspondence that support a patient over a maximum of a seven-day period. (March 20)

    8. CMS originally said there would be leniency with providing e-visits across state lines. Does this hold true for other insurances?
    The 1135 provisions include a "waiver of provider licensure," but it doesn't mean much unless a state creates a waiver, too. The 1135 system wasn't created solely for pandemics — it's also used to respond to regional disasters, where out-of-state providers may be needed to respond to an emergency. That's where the licensure waiver has the most effect. While the provisions do include a waiver that allows authorized providers to render services outside their states of Medicare enrollment, in order for the provider license waiver to be of practical use, states need to create their own licensure waivers because state requirements take precedence. However, many states are passing legislation related to licensure requirements. (March 20)

    Coding and Billing

    9. What codes can a physical therapist bill for an e-visit?
    Physical therapists are eligible to use these HCPCS codes:

    • G2061: Qualified nonphysician health care professional online assessment and management, for an established patient, for up to seven days; cumulative time during the seven days, 5-10 minutes.
    • G2062: Qualified nonphysician health care professional online assessment and management service, for an established patient, for up to seven days; cumulative time during the 7 days, 11-20 minutes.
    • G2063: Qualified nonphysician qualified health care professional assessment and management service, for an established patient, for up to seven days; cumulative time during the 7 days, 21 or more minutes. (March 18)

    10. What place of service (POS) code do PTs use when billing e-visits?
    The POS is the location of the billing practitioner. In the case with remote services, the locality that is assigned to the claim is based on the place where the claims service was rendered. Therefore, in this situation, if the physician/practitioner doing the monitoring is in, for example, Maryland, and the beneficiary is in New York, the locality or POS is Maryland. The issue is “where the service was rendered,” and in the example above, the service was rendered in Maryland, because that’s where the physician/practitioner is located. That would come in on the claim as the place where the service was rendered. It does not matter where the corporate address of the billing provider is, nor does it matter what the beneficiaries’ addresses are. It matters where the service was rendered; that is, where the biller is located. (March 18)

    11. Should POS code 02 be used when billing an e-visit? What about using the 95 modifier vs. the GT modifier?
    For Medicare you can only bill for an e-visit. An e-visit does not meet the definition of telehealth under Medicare, and PTs should not use POS code 02. Nor should a PT use GT modifier when billing an e-visit under Medicare. (March 20)

    12. What POS code should be used if the PT has a mobile or home office?
    In this instance, we believe POS code 12 would be correct. (March 20)

    13. Alternatively, what POS code should be used if the PT has a brick and mortar office but is responding to the e-visit while at home?
    In this instance, we believe the POS code 11 would be correct. (March 20)

    14. Can a PTA in an outpatient clinic use one of the codes for this service if under direct supervision in the clinic?
    No. (March 20)

    15. What modifier is required to be appended to the claim?
    Because a public health emergency has been declared, CMS guidance instructs providers to apply the CR (catastrophe/disaster related) modifier. (March 30)

    16. Is the GP modifier required to be appended to the claim?
    Yes, CMS is designating HCPCS codes G2061, G2062, or G2063 as "sometimes therapy" services that require the private practice PT to include the corresponding GP modifier on claims for these services.  (March 30)

    17. Can institutional settings bill these codes?
    It doesn't appear so, because CMS has described these as "sometimes therapy" services that require the private practice PT to include the GP modifier on the claim. As we continue to seek clarification from CMS, please check with your Medicare Administrative Contractor. (March 30)

    18. Will Medicare coinsurance and the annual Part B deductible apply to these codes?
    Yes. According to the CMS fact sheet, the annual Medicare Part B deductible and 20% coinsurance apply to these codes. (March 18)

    19. If someone has a secondary insurance with a per-visit copay, does this apply to the e-visit?
    This varies by payer. Many payers are waiving copays and deductibles for these services, but PTs will need to check their payers’ policies. (March 20)

    20. Can PTs bill CPT codes 99421, 99422 and 99423 for an e-visit?
    No. These are evaluation and management, or E/M, codes, for e-visits and PTs are not permitted to independently bill for E/M visits. The non-physician e-visit codes are CPT codes 98970-98972 for commercial payers and HCPCS codes G2061-G2063 for Medicare. (March 18)

    21. Can PTs bill CPT codes 99441-99443?
    99441-99443 are E/M codes for telephone services that cannot be billed by physical therapists. The non-physician codes for telephonic assessments are 98966-98968. Medicare has not provided any guidance on the use of these codes by physical therapists at this time. (March 18)

    22. When can I use CPT code 98966, Under Non-Face-to-Face Nonphysician Telephone Services?
    CPT code 98966 is a medical procedural code under the Non-Face-to-Face Nonphysician Telephone Services. Generally, this code has not been approved for use by PTs. APTA is seeking clarification from payers regarding PTs’ use of this code, and we will continue to provide updates. PTs also can contact their payers directly. (March 20)

    23. Will commercial payers pay for an e-visit?
    Payer policies may vary, so check with each insurance carrier, including Medicare Advantage plans, as to whether they will pay for an e-visit with HCPCS codes G2061, G2062, and G2063, or CPT codes 98970, 98971, and 98972. (March 18)

    APTA is urging any private payers that are not already covering telehealth services delivered by PTs to remove those limitations now. APTA is in direct contact with several large commercial payers advocating for expanded remote and/or telehealth policies that would allow PTs and PTAs to maintain contact with and care for patients who are unable to come to the clinic. APTA is also providing resources for PTs to use to communicate directly with payers regarding provision of and payment for remote and/or telehealth services. (March 18)

    Seven-Day Period

    24. What is meant by “established patient”? Can the PT put something on their website to state this is currently available, or if a patient calls to schedule an appointment would the PT notify them of this option?
    CMS has stated that e-visits include services furnished to an established patient that the PT is currently treating under a plan of care. (March 30)

    25. If the patient came in person for an evaluation visit, could they switch to telehealth for the second visit?
    Keep in mind that these are not telehealth visits in the truest sense. This is a means by which a PT can manage the care of a patient over a period of up to seven consecutive days when the patient is unable to or does not need to come into the clinic. (March 20)

    26. What is meant by “for up to seven days; cumulative time for the seven days”?
    The PT would bill the appropriate code based on the cumulative amount of time spent over a seven-day period. (March 18)

    27. When does the seven-day period begin? Is it defined, such as always Sunday to Saturday, or is it from the start of the first e-visit to seven consecutive days thereafter?
    The seven-day assessment and management period begins when the provider responds to the patient's request for an e-visit. The period ends after seven consecutive calendar days. (March 20)

    28. Does the seven-day period mean the seven days between the first e-visit to the last e-visit? Can there be multiple e-visits within the seven-day period?
    The seven-day period is seven consecutive calendar days beginning when the provider responds to the patient’s request for an e-visit. All of the cumulative activities occurring within the seven-day period support the selection of the appropriate code for that seven-day period based on the time spent. (March 20)

    29. Can a PT bill more than one code per seven-day period?
    No. You can only bill one code per seven-day period. (March 18)

    30. Can other CPT codes be billed in the seven-day period when an e-visit is performed?
    An e-visit cannot be billed if a face-to-face visit occurs within seven days before or within seven days after the e-visit. When the e-visit originates from a related service provided within the previous seven days by the same qualified health care professional, then the e-visit would be considered bundled into that previous service and owuld not be separately billable.As a reminder, an e-visit is not a treatment session. It is the means by which a provider addresses a specific question or outreach from a patient, and it is an aggregate of interactions and actions taken over a period of a maximum of seven consecutive days. (March 30)

    31. Can the codes only be used once within a given episode of care, or can they be billed more than once (during two or more different seven-day periods within the episode of care)?
    An e-visit code can be billed more than once, i.e., during tow or more different seven-day periods within the episode of care. There is not a frequency limitation over an episode of care. (April 15)

    32. Does the PT have to make sure that the patient is not seen for at least seven days before or after the e-visit?
    The comparable CPT codes do limit the use of these codes to seven days after and before a face-to-face visit. PTs should follow the rules about the number of visits that limit the use of these codes to seven days after and before a face-to-face visit. (March 20)

    33. If the patient’s issue is resolved in three days, does the PT have to wait seven days to document or bill the e-visit?
    No. For example, if the PT determines via the assessment and management e-visit that the patient needs to be referred to another provider and the PT will not continue interaction with the patient, then the PT can document and bill the assessment and management activities at that time. The seven-day period is a maximum. (March 20)

    34. Does this also mean a PT can only submit this code every seven days?
    Yes, the appropriate code would be submitted once for the seven-day period for the same patient within the same episode of care. (March 18)

    35. Does "seven days" refer to seven consecutive days or to up to seven different visits spread out?
    The seven days is a period of time over seven consecutive days during which the assessment and management services occur as needed for the individual patient. The patient must generate the initial inquiry, and communications can occur over a seven-day period. (March 18)

    Practice

    36. What if patients need regular consultation? Can the PT set up a weekly e-visit with them?
    Remember, the patient must initiate [emphasis added] the e-visit, which is intended to serve as an alternative to the traditional in-person visit for nonurgent medical issues. The online digital assessment and management is also intended to address a specific patient issue, problem, or need and is not intended to be an ongoing consultation model. (March 18)

    37. Does an "in-person" evaluation refer to one performed by an MD or by a physical therapist? If an MD does an E/M, can the PT then do e-visits and use the G-codes?
    For a therapist to bill for this cumulative assessment and management service, the patient must already be under the care of the physical therapist, meaning the physical therapist must have already performed the evaluation. (March 18)

    38. What if a patient’s start of care was two months ago, before the pandemic started, and the physical therapist did not educate them about an e-visit then; is the therapist unable do it now and bill for it?
    The physical therapist can educate the patient about the availability of an e-visit any time during the episode of their care. (March 18)

    39. If the evaluation has been cosigned by the referring provider and it did not include e-visits within the developed plan of care, can an e-visit be performed?
    An e-visit does not need to be delineated in a developed plan of care; it is the exception to the plan of care. (March 20)

    40. Does an e-visit count against the number of visits permitted under a NCD, such as for cardiac rehab?
    We do not believe an e-visit counts against the number of visits permitted under Medicare coverage rules. (March 20)

    41. How does an e-visit affect the count toward the 10-visit requirement for a progress report? Does each encounter count toward the 10, or does billing the code once for all the encounters within the seven-day period count as one visit?
    E-visit services do not count toward the 10-visit progress report requirement. (March 20)

    42. Can a hospital or home health agency use e-visits?
    An e-visit is a Medicare Part B covered service that can be billed by a professional, such as a PT in private practice. See question 17 for more information. (March 30)

    Documentation

    43. What are the documentation requirements to support the billing of these codes?
    Document that the patient initiated the e-visit and the service(s) provided, including your clinical decision-making associated with the service. Since the services may be intermittent over a seven-day period, document all components of patient assessment and management performed during the time period. (March 18)

    44. Do PTs still follow the plan of care regarding frequency of visits per week?
    APTA suggests documenting the reason why the patient is unable to come in for an office visit and then document the e-visit. The e-visit would not need to be done in compliance with the frequency of the plan of care, as the visit would be documented as inability to come for in-person visit/cancellation. (March 18)

    45. Are daily notes required for reimbursement for these e-visit CPT codes? What if the CPT code was not approved under the original plan of care?
    The e-visit code does not have to be part of the original plan of care. Document all activities and interactions that occur within the seven-day period as you do them. Also document that the patient initiated and consented to the e-visit, as well as your clinical decision making. (March 20)

    46. What if plan of care is expired or it has been over 30 days since the patient’s last visit?
    This is a gray area without a clear answer. We are seeking clarification from CMS. (March 20)

    HIPAA

    47. Does the online patient portal need to be HIPAA-compliant?
    APTA advises using a secure, HIPAA-compliant platform. However, per the CMS Fact Sheet issued on March 17, 2020, "Effective immediately, the HHS Office for Civil Rights will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency." However, for purposes of e-visits FaceTime or Skype is not appropriate. CMS’ mention of FaceTime and Skype refers to the delivery of telehealth services. (March 20)