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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.

    Coronavirus Update: March 30, 2020

    Practice guidance for pediatric physical therapy, a new volunteer resource, accelerated Medicare payments, and more.

    Practice Guidance

    March 30: APTA Offers General and Pediatric-Focused COVID-19 Guidance for PTs, PTAs, Students
    Two new resources from APTA can help PTs, PTAs, and students looking for more detailed, profession-specific guidance related to providing care during the COVID-19 pandemic: one focused on general PT management of patients, and a second that specifically addresses pediatric physical therapy.

    March 30: New COVID-19 Volunteer Resource Connects PTs, PTAs, Students With Facilities in Need
    APTA has launched a new online service that helps connect members of the physical therapy profession with facilities looking for volunteers. The service offers two points of entry — one for facilities in need of PT, PTA, or student volunteers, and another for PTs, PTAs, and students willing to offer their services, by way of the APTA Engage volunteer portal.

    From CMS

    March 30: 39 States Have Been Granted Medicaid Waivers
    As of March 30, 39 states have received federal 1135 waivers on a range of Medicaid requirements including prior authorization, provider enrollment, public notice mandates, and fair hearing request timelines. A CMS press released dated March 27 reported that 34 waivers had been issued; by the afternoon of March 30, the number had risen to 39.

    March 28: CMS Expands Accelerated and Advance Payment Program for Medicare 
    "CMS is expanding the program for all Medicare providers throughout the country during the public health emergency related to COVID-19," CMS states in a press release. "The payments can be requested by hospitals, doctors, durable medical equipment suppliers and other Medicare Part A and Part B providers and suppliers." Qualifications include billing timelines and a requirement that the provider not be in bankruptcy, not be under active medical review or program integrity investigation, and not have outstanding delinquent Medicare overpayments.

    March 27: CMS Offers Long-Term Care Nursing Homes Telehealth, Telemedicine Toolkit
    According to CMS: "Most of the information is directed towards providers who may want to establish a permanent telemedicine program, but there is information here that will help in the temporary deployment of a telemedicine program as well." Resources include guidance on choosing telemedicine vendors, equipment, and software, as well as developing documentation tools.

    From the Department of Health and Human Services

    March 27: HHS Office for Civil Rights Issues Bulletin on Nondiscrimination Requirements
    The HHS OCR is reminding entities covered by civil rights authorities that the current COVID-19 national emergency does not change civil rights laws. "These laws, like other civil rights statutes that OCR enforces, remain in effect," the bulletin states. "As such, persons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative 'worth' based on the presence or absence of disabilities."

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

    APTA Offers General and Pediatric-Focused COVID-19 Guidance for PTs, PTAs, Students

    Topics addressed in the new resources include when a PT should tell patients to cancel an outpatient visit and factors to consider when providing remote school-based services as part of an IEP.

    Two new resources from APTA can help PTs, PTAs, and students looking for more detailed, profession-specific guidance related to providing care during the COVID-19 pandemic: one focused on general PT management of patients, and a second that specifically addresses pediatric physical therapy.

    The general guidance 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.

    The pediatric physical therapy resource is directed at PTs and PTAs who manage these patients, especially 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.

    Both guidance documents will join frequently updated resources available on the APTA Coronavirus webpage, which include practice guidelines for physical therapy and COVID-19 in the acute hospital settings.

    New COVID-19 Volunteer Resource Connects PTs, PTAs, Students With Facilities in Need

    APTA's new service allows facilities to share their needs and creates matches with volunteers able to provide key services.

    The physical therapy profession has never backed away from a challenge. Now there's a new opportunity for PTs, PTAs, and physical therapy students to respond to the current COVID-19 pandemic through volunteer efforts.

    APTA has launched a new online service that helps connect members of the physical therapy profession with facilities looking for volunteers. The service offers two points of entry — one for facilities in need of PT, PTA, or student volunteers, and another for PTs, PTAs, and students willing to offer their services, by way of the APTA Engage volunteer portal.

    Volunteers could serve in a wide range of capacities as areas around the world move through acute, response, and recovery phases: PTs and PTAs with appropriate experience can help to free up needed ICU beds and ventilators by providing treatments that can reduce some patients’ need for mechanical ventilation. As areas and people recover, there will also be a need for volunteers able to help individuals get back to work through improving mobility, function, and quality of life.

    Michel Landry, BScPT, MBA, PhD, a professor in the Doctor of Physical Therapy Division in the Department of Orthopaedic Surgery at Duke University School of Medicine and an affiliate in the Duke Global Health Institute, is coordinating volunteer-facility matches for the program. He can be reached through Twitter at @ptcovid19.

    For more insight into the pandemic, disaster response, epidemiological background, and the role the profession can play in care and recovery, check out this recording of a March 27 APTA FaceBook Live event at the bottom of the volunteer connection page.

    Coronavirus Update: March 27, 2020

    A Medicare payment increase, PT telehealth for UnitedHealthcare, APTA tracks telehealth payment changes, and more.

    Practice Guidance

    March 27: COVID Stimulus Package Includes Payment Increase, Opens Telehealth Possibility
    An increase to Medicare payment, temporary relief for some student loans, the potential expansion of telehealth allowances, and help for small businesses are among the provisions that are especially relevant for physical therapy.

    March 27: UnitedHealthcare Allows Telehealth for Physical Therapy
    UnitedHealthcare, the country's largest commercial health insurer, announced a major shift in its coverage policies during the COVID-19 pandemic: Beginning immediately, the payer will reimburse physical therapy delivered via telehealth services. The change is the most wide-ranging payer acknowledgement of PTs as qualified telehealth providers to date, and it moves UHC well past CMS' and a few other payers’ current waivers allowing for limited "e-visit" digital communications between PTs and patients.

    March 27: Charts From APTA Track Payer, Government PT Telehealth Policies
    Now available from APTA: a regularly updated set of resources that track payment and regulatory policies related to the provision of telehealth by PTs.

    March 30, 3 pm: APTA Hosts Facebook Live Event, "Implementing Telehealth in Your Practice STAT"
    APTA will host a Facebook Live version of its sold-out March 26 webinar that featured a panel discussion with experienced telehealth PTs providing insight on how they implement telehealth in their practices.

    From CDC

    March 25: CDC Releases PPE "Burn Rate Calculator"
    A new app helps providers calculate the rate at which PPE will be used in their facilities.

    In the Media

    March 27: What's Inside the Senate’s $2 Trillion Coronavirus Aid Package
    From National Public Radio: a breakdown of the six main groups that will receive relief through the stimulus.

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

    COVID Stimulus Package Includes Payment Increase, Opens Possibility of Increased Telehealth, More

    An increase to Medicare payment, temporary relief for some student loans, the potential expansion of telehealth allowances, and help for small businesses are among the provisions that are especially relevant for physical therapy.

    The $2 trillion stimulus package passed by Congress and signed into law by President Trump is comprehensive in its scope, and includes everything from sending direct payments to many individual Americans to some $32 billion in grants to airlines and airports. [Editor's note: check out these articles from National Public Radio and Axios for good summaries of the entire package]

    The legislation also includes provisions that may be of particular interest to PTs, PTAs, physical therapy students, and physical therapy patients.

    Medicare payment will increase.
    Normally, mandatory across-the-board cuts in federal spending enacted into law, known as sequestration, would require Medicare to reduce payments to providers by 2%. The stimulus temporarily lifts that reduction from May 1 through December 31, 2020. The effect: increased payments to PTs, hospitals, home health, and other care. The legislation also prevents scheduled reductions in Medicare payments for durable medical equipment through the length of the COVID-19 emergency period.

    Telehealth could expand under Medicare (if HHS can be convinced to do it).
    The package gives the Secretary of the Department of Health and Human Services the authority to waive restrictions on telehealth for providers, including PTs, who aren't currently allowed to provide and bill for telehealth services to Medicare beneficiaries. So far, that waiver hasn't happened, and APTA is urging its members and stakeholders to join a grassroots effort to press for the change.(Note that while CMS has approved the use of "e-visits" by PTs, that's a limited type of digital communication and not same as telehealth.)

    Federal student loan borrowers will be able to defer payments, and employers can offer repayment benefits tax-free.
    Payments on federal student loans can be deferred through September 30, 2020, with no accrual of interest during that period. Additionally, the stimulus allows employers to contribute up to $5,250 annually toward an employee's student loans without the benefit being taxed as employee income. The employer provision applies to any employer payments made between now and January 1, 2021.

    Providers able to order home health services now include PAs, NPs, and CNSs, potentially reducing delays in care.
    Until now, only physicians were able to certify the need for home health services. The legislation allows physician assistants, nurse practitioners, and clinical nurse specialists to order home health services for beneficiaries, reducing delays and increasing beneficiary access to care in the safety of their home.

    New loans are available to small businesses, along with payroll tax credits to boost employee retention and a deferment of Social Security tax payments.
    The stimulus creates a new type of loan through the Small Business Administration that could help to cover payroll costs (including health care), rent, utilities, and other debt obligations, at a 4% interest rate. Businesses and 501(c)(3) organizations with fewer than 500 employees are eligible, as are sole proprietors, independent contractors, and self-employed individuals.

    Some employers will also be able to take advantage of a refundable payroll tax credit for 50% of wages paid by employers to employees during the COVID-19 crisis. The offer is limited to employers whose operations were fully or partially suspended due to the pandemic, or whose gross receipts declined by more than 50% compared with the same quarter of 2019.

    The package also offers a payroll tax deferment. Employers (and the self-employed) are also able to defer payment of the employer share of the Social Security tax. The provision requires that the deferred employment tax be paid over the following two years, with half of the amount required to be paid by December 31, 2021, and the other half by December 31, 2022.

    Small businesses can receive grants and may be able to get limited debt relief on SBA loans.
    Small businesses and nonprofits that apply for an SBA economic injury disaster loan could receive an advance of $10,000 within three days of applying for the loan. Additionally, the stimulus includes $17 billion to provide immediate relief to small businesses with standard SBA 7(a), 504, or microloans, with the SBA covering all loan payments for existing SBA borrowers, including principal, interest, and fees, for six months. This relief will also be available to new borrowers who take out an SBA loan within the next six months.

    Transfers from acute care hospitals to IRFs will be easier.
    During the emergency period, acute care hospitals can transfer patients to inpatient rehabilitation facilities more easily, thanks to a waiver of the requirement that patients must participate in at least three hours of intensive rehabilitation at least 5 days a week in order to be admitted to the IRF.

    Higher education will get some relief, too.
    The legislation makes $14.2 billion available to higher education institutions to prevent, prepare for, and respond to the pandemic. The funds can be used to defray expenses associated with lost revenue, technology costs of transitioning to distance education, and providing grants to students for food, housing, course materials, and technology.

    APTA Vice President of Government Affairs Justin Elliott said that this package, though the largest, is actually the third set of relief measures enacted. And there's more to come.

    “Work has already begun on a fourth legislative relief a package that we expect will be considered by Congress in April," Elliott said. "APTA will continue to advocate for provisions that will help physical therapists, physical therapist assistants, physical therapy students, and the patients they serve.”

    Charts from APTA Track Payer, Government PT Telehealth Policies

    The new resources from APTA are intended to be used as quick-reference guides to help you stay on top of changes in whether and how telehealth can be used in physical therapy — PTs should still check with payers and state governments.

    Keeping up with the rapidly changing telehealth environment during the COVID-19 pandemic can be dizzying. APTA can help steady things.

    Now available from APTA: a regularly updated set of resources that track payment and regulatory policies related to the provision of telehealth by PTs The resources exist in five separate files:

    The pages are intended as quick reference only; PTs should still carefully review individual payer policies and state laws and regulations before making a decision on providing telehealth to any patient.

    APTA will update the content of the summaries weekly to keep up with changes.

    Visit APTA's Coronavirus webpage for more information on the pandemic as it relates to the profession.

    UnitedHealthcare Allows Telehealth for Physical Therapy

    The major change, effective until June 18, permits PTs to be reimbursed for telehealth services using the company's typical billing codes but is subject to state laws and regulations.

    UnitedHealthcare, the country's largest commercial health insurer, announced a major shift in its coverage policies during the COVID-19 pandemic: Beginning immediately, the payer will reimburse physical therapy delivered via telehealth services. The change is the most wide-ranging payer acknowledgement of PTs as qualified telehealth providers to date, and it moves UHC well past CMS' and a few other payers’ current waivers allowing for limited "e-visit" digital communications between PTs and patients.

    The new benefits are set to end on June 18 and are subject to state laws and regulations around telehealth, but, if permissible, they enable PTs, occupational therapists, and speech therapists to provide true telehealth services and use their typical billing codes. Eligible codes will be reimbursed by UHC with a place-of-service code 02 and the 95 modifier.

    The UHC change is a significant improvement for PTs. Until now, national private insurers including UHC and Aetna, have been following CMS' lead and allowing only e-visits, a limited form of digital communication restricted to only a portion of codes, and not truly considered telehealth.

    While the COVID stimulus package on the horizon allows the U.S. Department of Health and Human Services to apply a waiver permitting PTs to engage in telehealth for Medicare beneficiaries, those waivers are unlikely to happen without a strong advocacy effort from the physical therapy profession — an effort that APTA is facilitating through a template letter to send to CMS that makes the case for the change.

    Carmen Elliott, MS, APTA's vice president of payment and practice management, said that the UHC change is big news.

    "The fact that the largest insurer in the country has temporarily shifted its reimbursement policies around telehealth is important in terms of patient and provider care and safety during this pandemic," Elliott said. "But it's also a tremendous opportunity for the physical therapy profession to demonstrate its ability to operate effectively in the telehealth space."

    Coronavirus Update: March 26, 2020

    New PT practice guidelines for COVID patients in acute hospitals, Cigna opens up telehealth for PTs, a call for postacute care COVID preparedness, and more.

    Practice Guidance

    March 26: New Practice Guidelines for Physical Therapy and COVID-19 in Acute Hospital Setting
    A new set of recommendations for physical therapy 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 been endorsed by APTA, the Cardiovascular and Pulmonary Section, and the 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.

    The recommendations are limited to PTs and "other relevant stakeholders" in acute care settings who are providing care to patients with suspected or confirmed COVID-19. The guidance includes more than 60 recommendations ranging from shift planning to the specific types of PPE PTs should wear.

    March 26: Cigna Adopts Telehealth Policy for Physical Therapy
    Insurer Cigna announced a series of temporary changes that open the possibility for telehealth by PTs, occupational therapists, and speech-language pathologists. The measures allow for reimbursement of PT services that include codes 97161 (evaluation, low complexity, 20 minutes, telephone or virtual), 97162 (evaluation, moderate complexity, 30 minutes, virtual), and 97110 (therapeutic exercises, two unit limit). Codes must be appended with a GQ modifier and billed with a standard place-of-service code. Cigna recommends that providers follow CMS guidance on the use of a specific software program but states that it will not require the use an specific software for now.

    March 30, 3 pm: APTA Hosts Facebook Live Event, "Implementing Telehealth in Your Practice STAT"
    APTA will host a Facebook Live version of its sold-out March 26 webinar that featured a panel discussion with experienced telehealth PTs providing insight on how they implement telehealth in their practices.

    From U.S. Department of Health and Human Services

    March 25: HHS Says That Providers Can Share Patient's COVID Status With First Responders
    The U.S. Department of Health and Human Services has issued guidance that the HIPAA Privacy Rule allows health care providers to share protected health information on an individual who has been diagnosed with or exposed to COVID-19 with first responders without the individual's permission under certain circumstances. Situations under which HIPAA-covered entities can share this information with law enforcement, paramedics, and other first responders include but are not limited to: when the information is needed to provide treatment; when they are reporting to public health authorities; and when first responders may be at risk of infection.

    In the Media

    March 25: JAMA Viewpoint Stresses the Need to Address Postacute Care Challenges Related to COVID-19
    Authors of an opinion piece in JAMA warn that postacute care facilities may be overwhelmed in much the same way hospitals could soon experience as the COVID-19 pandemic progresses through the population. They stress the need for immediate capacity-building, and urge policymakers to implement additional policies such as paid sick leave for staff, enhanced Medicare rates, and reimbursement for hospital-at-home models "at parity with institutional hospital care."

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

    Practice Guidelines Emerge for Physical Therapy and COVID-19 in Acute Hospital Setting

    The Australian-based recommendations, endorsed by APTA, the APTA Cardiovascular and Pulmonary Section, and the APTA Academy of Acute Care Physical Therapy, emphasize proper PT training, careful patient screening, and the use of PPE.

    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. The guidance will be published soon in the Australian Journal of Physiotherapy.

    The recommendations are limited to PTs and "other relevant stakeholders" in acute care settings who are providing care to patients with suspected or confirmed COVID-19. The guidance focuses on workforce planning and preparation including screening for physical therapy as well as the actual delivery of interventions and personal protective equipment requirements, and includes more than 60 recommendations ranging from shift planning to the specific types of PPE PTs should wear.

    Among the recommendations:

    • Facilities should consider organizing separate teams to manage COVID-19 versus noninfectious patients.
    • PTs who are practicing within the ICU should have specialized knowledge of working in that setting, while other PTs in the facility who have ICU experience but aren't currently working in the ICU, as well as PTs without recent cardiorespiratory experience, should be facilitating rehabilitation and discharge planning for non-ICU/non-COVID-19 patients.
    • PTs with "advanced" ICU skills should be supported to screen patients with COVID-19, with some being identified as "clinical leaders."
    • Staff who are pregnant should avoid exposure to COVID-19.
    • Physical therapist examination and interventions should be provided only when there are clinical indications for need such as “mobilisation, exercise and rehabilitation e.g. in patients with comorbidities creating significant functional decline and/or (at risk) for ICU acquired weakness” with guideline authors writing that "unnecessary review of patients with COVID-19 within their isolation room/areas will also have a negative impact on PPE supplies."
    • If aerosol generating procedures (AGPs) are required, they should be conducted in a negative-pressure room, or at least in a single room with the door closed, with a minimum number of staff, all wearing PPE. Coming and going should be minimized during the AGP.
    • PTs should not implement AGPs, including humidification or noninvasive ventilation, without first obtaining agreement with a "senior doctor."
    • PTs should take droplet and airborne precautions, including the use of a high filtration mask, when providing mobilization exercise and there is a risk of the patient coughing or expectorating mucous.
    • Direct physical therapist interventions should be considered only when there are "significant functional limitations (e.g. [risk for] ICU-acquired weakness, frailty, multiple comorbidities, advanced age)" in the patient.
    • Staff should be trained in donning and doffing PPE, including N95 fit-checking.
    • For COVID-19 infected patients who may require AGPs, airborne precautions should be followed that include an N95/P2 mask, fluid-resistant long-sleeve gown, goggles/face shield, and gloves. The guidelines also recommend hair cover and shoes that are impermeable to liquids.

    The recommendations also include guidance on patient screening for the appropriateness of PT involvement and an overview of medical management of patients with COVID-19.

    Because the guidelines were developed in relation to the Australian physical therapy environment, some of the recommendations aren't directly applicable to typical U.S. acute settings, where respiratory therapists tend to perform some of the activities associated with physiotherapists in Australia.

    Still, says Bill Boissonnault, PT, DPT, DHSc, FAPTA, APTA's executive vice president of professional affairs, the resource should be carefully reviewed by physical therapists and facilities in the U.S.

    "These guidelines are solid, sensible, and timely," Boissonnault said. "During this crisis, the focus needs to be on connecting the PTs trained for ICU and respiratory physical therapy with only the COVID-19 patients who meet the criteria for treatment. Within the acute hospital setting, we can best respond to the pandemic by making careful, informed decisions that avoid needlessly risking the spread of this disease but also provide needed physical therapy care for patients. These recommendations can help facilities achieve that goal."

    In addition to endorsement from APTA, its Cardiovascular and Pulmonary Section, and the APTA Academy of Acute Care Physical Therapy, the recommendations also have received support from the World Confederation for Physical Therapy, The Australian Physiotherapy Association, the Canadian Physiotherapy Association, AIR (the association of Italian respiratory physical therapy), the UK's Association of Chartered Physiotherapists in Respiratory Care, and the International Confederation of Cardiorespiratory Physical Therapists.

    Visit APTA's Coronavirus webpage for more information on the pandemic as it relates to the profession.

    Coronavirus Update: March 25, 2020

    UnitedHealthcare allows e-visits, HHS presses states to ease regulations, HPA shares an interoperability opportunity, and more.

    Practice Guidance

    March 24: UnitedHealthcare Follows CMS Lead on "E-Visits"; Still Excludes "Telehealth" by PTs
    Although developments are happening too rapidly for posting on its website, UnitedHealthcare has announced that it will follow the CMS 1135 waiver policy allowing for a particular type of digital communication between a PT and patient known as an "e-visit." E-visits are not considered telehealth, and UHC explicitly statedthat it will still exclude reimbursement for outpatient therapy services delivered under telehealth. APTA offers an extensive Q&A resource on e-visits, including details on coding and the required "patient portal."

    E-visits through UHC will be paid as carve-outs, separate from the per-visit flat rate. Insurer fee schedules may take up to 60 days to complete fee schedule updates.

    UnitedHealthcare is the second major insurer to adopt the CMS e-visit policy for PTs: earlier in March, Aetna made a similar move. See the second item in the March 19 APTA Coronavirus Update for details and links.

    March 25: HPA Curates Resources on Interoperability, Telehealth Providers
    HPA the Catalyst, APTA's component focused on health policy and administration, now offers information for providers on how to gain free access to on-demand patient record retrieval service across the continuum from Kno2, one of the interoperability providers for most of the EHR vendors in postacute care and outpatient settings. Also available: a matrix on audio and video telecommunicationsto help you evaluate telehealth vendors, created by the HPA Technology Special Interest Group and the Frontiers in Science, Rehabilitation, and Technology Council.

    March 26, 2 pm: APTA Hosts Facebook Live Event on International PT Response to COVID-19
    Join APTA and physical therapists from the UK and Canada for a live discussion of how the physical therapy profession is responding to the COVID-19 pandemic internationally. Participants will include Michel Landry, BScPT, PhD, a professor at Duke University and affiliate in the Duke Global Health Institute, who will provide an overview of disaster management and epidemiology, and share experiences from working in other disasters.

    From Health and Human Services

    March 25: HHS Tells States to Ease State Laws and Regs
    The U.S. Department of Health and Human Services is calling on states to take "immediate actions" to relax laws and regulations that HHS thinks could get in the way of effective health care responses to the COVID-19 pandemic. The recommended actions include licensure exemptions and disciplinary moratoriums, waiver of telemedicine practice prohibitions, relaxation of scope-of-practice requirements, and easing of malpractice liability.

    From the Department of Labor

    March 24: Labor Department Provides More Information on Paid Sick Leave, FMLA Expansion
    With requirements now in place for employers with 500 or fewer employees to provide paid sick leave and expanded FMLA benefits, the Department of Labor is rolling out guidance for both employers and employees. The latest resources — a fact sheet for employers, a fact sheet for employees, and a questions and answers document — shed light on a number of issues, including how to count hours for part-time employees, employee information on qualifying reasons for leave, and how small business can obtain exemptions from the mandates.

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

    APTA Components Step up to the COVID-19 Challenge With Ever-Growing Resources

    From helping physical therapy faculty move their courses online to conducting a webinar on providing acute care physical therapy during a pandemic, association chapters and sections are keeping the profession informed and creating an impressive array of tools.

     

    "We are going through this, day by day, doing our best to make a positive impact on society in a moment in time when there are no easy solutions."

    That's how APTA President Sharon Dunn, PT, PhD, described the physical therapy community's response to the COVID-19 pandemic. And APTA's components — its sections, academies, and chapters — as well as its councils and academic groups, have been taking on the challenge by offering resources informed by their particular perspectives and expertise.

    Here's a roundup of just some of what's available so far from APTA components.

    [Editor's note: offerings from these and other APTA components are growing by the day — APTA's Chapters and Sections webpage provides direct links to all component websites.]

    American Council of Academic Physical Therapy's COVID-19 Response Webpage
    ACAPT's webpage collects a wealth of information, both from the council and related organizations including APTA, with a focus on online and distance learning. The place to go for lots of great information from individual universities and faculty members.

    APTA Colorado: Coronavirus Information for Providers
    The regularly updated site from APTA Colorado includes key information from local public health agencies, small business resources, and opportunities to volunteer. Another recent addition: a slide deck from a presentation on physical therapist practice and mechanical ventilation.

    APTA Geriatrics Webinar: Resources for Teaching Online Geriatric Content
    This webinar, which was held March 19 but is now available as a recording, is targeted at PTs and PTAs in academic programs who teach geriatric content and are interested in resources and strategies for delivering this content online. Topics include how to continue with labs and practicals, as well as online test-taking.

    California Physical Therapy Association: COVID-19 Webpage
    The California Chapter provides a mix of information specific to California and more general resources and guidance, including a recorded webinar on social distancing and APTA resources on telehealth. Upcoming: a March 26 virtual meeting, "Telehealth: Moving Digital Practice Forward in Physical Therapy."

    HPA The Catalyst: COVID-19 Updates and Resources
    APTA's component focused on health policy administration offers a COVID-19 webpage featuring an in-depth set of questions and answers related to telehealth and physical therapy, as well as links to a source for free access to an on-demand patient record retrieval service and a compiled listing of audio and video telecommunications services, an excel file that helps you sort out telehealth and e-visit vendors that may be a good fit for your practice.

    APTA Academy of Pediatric Physical Therapy: COVID-19 Updates
    The Academy's website has been reconfigured with a focus on COVID-19 and includes regular updates. Special features on the site: a multi-resource update on providing pediatric physical therapy via telehealth, and updates on the status of the Individuals with Disabilities Education Act—IDEA—as various legislative relief packages are being worked out on Capitol Hill.

    APTA Private Practice Section: Critical Resources for Managing Your Business During the COVID-19 Pandemic
    The Private Practice Section's extensive resources include frequently updated information on telehealth, plus perspectives on topics including cash flow modeling, paid sick leave, and making determinations around what is and isn't "essential care." The section has also created a special open-access issue of its Impact magazine solely devoted to COVID-19.

    APTA Rhode Island: Updates Regarding COVID-19
    The Rhode Island Chapter's COVID-19 page is arranged in an easy-to-follow format that divides regularly updated content into various buckets: telehealth, APTA statements, outpatient practice resources, school-based physical therapy resources, and more. Latest additions include resources on home care, with a section on care for the elderly coming in the near future.

    FiRST Council Telehealth Discussion Board
    Since its inception, APTA's Frontiers in Rehabilitation, Science, and Technology Council has been at the forefront of the conversation around telehealth in physical therapy. Its discussion board remains the go-to for insight and illuminating exchanges on what has become a crucial topic.

    Academy of Acute Care Physical Therapy and HPA, The Catalyst webinar: Acute Care Physical Therapy and COVID-19 — How Can We Add the Greatest Value?
    The APTA sections focused on acute care and health policy joined forces to deliver a March 19 webinar, now available as a recording that takes a close look at how to provide the best care in hospitals in light of the COVID-19 pandemic. Topics include managing and triaging physical therapy resources, caring for the critically ill, physical therapy in the ED and more. The slide presentation from the webinar is also available for download.

    Know of more component resources to share? Post them to APTA's Component Leaders discussion page or share them in the comments below.

    HHS to States: Ease State Laws and Regs Now

    The Department of Health and Human Services says that federal waivers can only go so far, and calls on states to quickly act to relax licensure, telehealth, and other requirements that may impede an effective response to the COVID-19 pandemic.

    The U.S. Department of Health and Human Services is calling on states to take "immediate actions" to relax laws and regulations that HHS thinks could get in the way of effective health care responses to the COVID-19 pandemic. The recommended actions include licensure exemptions and disciplinary moratoriums, waiver of telemedicine practice prohibitions, relaxation of scope-of-practice requirements, and easing of malpractice liability.

    In a March 24 letter to U.S. state governors, HHS Secretary Alexander Azar wrote that the requests are being made "to carry outa whole-America response to the COVID-19 pandemic," adding that "your help is needed to ensure health professionals maximize their scopes of practice and are able to travel across state lines or provide telemedicine to their communities or where they are needed most."

    While the federal government has initiated modifications of some Medicare, Medicaid, and CHiP requirements under so-called 1135 waivers, HHS explains that those exceptions only go so far: states still hold the cards when it comes to much of what providers can and can't do as part of the response to the pandemic. That's why HHS is urging states to take action.

    Among the HHS recommendations:

    Exceptions to various licensure requirements. HHS is calling on states to, among other actions, waive licensing fees, allow for free temporary licenses, and suspend disciplinary actions for certain licensure violations that prevent licensed providers from providing treatment.

    Telemedicine provisions. States should "waive statutes and regulations mandating telehealth modalities and/or practice standards not necessary for the application standard of care to establish a patient-provider relationship, diagnose, and deliver treatment recommendations utilizing telehealth technologies."

    Scope-of-practice waivers. HHS calls for easing scope-of-practice restrictions around supervision, collaboration, and disciplinary enforcement.

    Malpractice liability assistance. States should "provide guidance on liability protections available to health care professionals" that include :volunteers, services provided through telehealth, and services associated with expanded scopes of practice" during the emergency, according to HHS, which recommends that states work with state insurance commissioners to "modify or temporarily rescind any provision … issued in our state that may prevent insurance coverage of a health care professional's work."

    "I do not want state variations in liability protections to confuse or deter health professionals in this COVID-19 emergency," Azar writes. "I also ask that you take quick action to expand the flexibilities offered in this time of emergency by waiving restrictions such as state licensure, scope of practice, certification and recertification requirements."

    Coronavirus Update: March 24, 2020

    APTA joins effort for stepped up NPE response by Congress; new template letter for telehealth; wound care considered "essential," and more.

    Practice Guidance

    March 24: APTA Joins Push for PPE, More Consistent Recommendations for Use
    A letter endorsed by 19 health care professional organizations not only urges Congress to step up efforts to supply providers with PPE, but to get CDC and other agencies on the same science-based page, and to take steps to ensure that shortages won't happen again.

    "We need proper support to care for patients safely and effectively," the letter states. "This includes clear, evidence-based protocols and highest level of protection in order to care for infected individuals as well as prevent the spread of the coronavirus in health care facilities and the community. Congress and the Administration must exhaust every option available to increase PPE production and prioritize distribution to frontline providers and health care facilities."

    March 24: New Coalition Connects Health Care Organizations With PPE Suppliers
    The PPE Coalition and the US Digital Response Team are collaborating on Project N95, connecting personal protective equipment manufacturers with state and local governments and health care providers and institutions who submit a request. According to their website, they hope to have millions of units available for distribution within the coming weeks.

    March 24: APTA Offers Template Letter to CMS Advocating for Telehealth for PTs, PTAs
    APTA has developed a template letter for you to use in advocating to CMS for Medicare coverage of telehealth furnished by PTs and PTAs to ensure that patients continue to have access to the rehabilitative care they need amid the COVID-19 pandemic. Instructions are included at the top of the letter.

    March 24: Multiprofessional Group Including APTA Says Wound Care Is an Essential Activity
    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.

    "Nonhealing wounds, left untreated and unmanaged, can result in significant medical issues including infection, sepsis, the need for limb amputation, and even death," according to the statement. "As a result many procedures provided by wound clinics are essential — not elective — to protect the health of patients and prevent an escalation of their disease."

    From the CDC

    March 23: CDC Study on Cruise Ship COVID Transmissions Finds Virus Present on Surfaces 17 Days After Last Contact
    Testing on the Diamond Princess, the Grand Princess, and other ships found SARS-CoV-2 present on some surfaces after passengers — some asymptomatic — had vacated the ship 17 days earlier.

    From CMS

    March 23: CMS Approves Medicaid Waivers in 11 States
    Alabama, Arizona, California, Illinois, Louisiana, Mississippi, New Hampshire, New Jersey, New Mexico, North Carolina, and Virginia have received section 1135 waivers on a range of requirements including prior authorization, provider enrollment, public notice mandates, and fair hearing request timelines.

    In the Media

    Health Care, Tech, Nonprofits Collaborate in COVID-19 Response
    A group of high-tech firms, large health care systems, nonprofits, and others are partnering to utilize data analytics to evaluate the effectiveness of community mitigation efforts, identify at-risk populations who need diagnostic testing, and optimize health care delivery and supply chain operations.

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

    APTA Joins Push for PPE, More Consistent Use Recommendations

    A letter endorsed by 19 health care professional organizations not only urges Congress to step up efforts to supply providers with PPE, but to get CDC and other agencies on the same science-based page, and to take steps to ensure that shortages won't happen again.

    The federal government needs to not only do more to ensure that personal protection equipment is available to all health care workers, it needs to do a better job of providing consistent science-based advice on the use of PPE: That's the message APTA and 18 other health care professional organizations sent to Capitol Hill as the COVID-19 pandemic triggers shortages of crucial protective supplies.

    In a March 20 letter to the U.S. House of Representatives and the U.S. Senate, APTA and other organizations including the American Nurses Association, the American Academy of Physician Assistants, the American Association of Nurse Practitioners, and the American Occupational Therapy Association urged legislators to take steps to "ensure that personal protection equipment … is available to all health care systems, facilities, and providers to ensure safe working environments during the current COVID-19 pandemic and any future crisis."

    The letter doesn't simply address supply shortages, however. The organizations also press for "more definitive and aligned statements from the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) about the transmission of coronavirus." Right now, the letter states, "the recent guidelines from both agencies differ on what masks or respirators are needed for health care providers."

    "Before any new guidance is released, the appropriate agency must have clear scientific evidence that the change in standards is proven to keep clinicians and their patients safe," the letter states, adding that "we urge Congress to include language in the next supplemental package to ensure the CDC communicates to the public the data-driven transmission science behind this decision."

    In addition for increased PPE availability and more consistent, science-based usage recommendations, the organizations also press for a list of additional actions by Congress, including mandating that a sustainable inventory of PPE be maintained at the Strategic National Stockpile, requiring that the Department of Health and Human Services develop better reporting rules around PPE use, and commissioning studies from the Government Accountability Office to review "root causes" of the current shortages as well as worldwide supply chain issues that could be improved in anticipation of future pandemics.

    According to Justin Elliott, APTA vice president of government affairs, the PPE letter is just one piece of the association's advocacy efforts around the coronavirus pandemic. Other efforts include grassroots communication efforts to increase telehealth opportunities for PTs and PTAs, and a push to press Congress for additional relief to physical therapy providers and patients.

    "In these extraordinary times, we need to not just react to current challenges but also be forward-thinking, looking at every possible avenue to ensure safety," Elliott said. "PPE is certainly one key element, but we're also keenly aware of opportunities to reduce transmission risk through new ways of thinking about providing care, including via telehealth. At the same time, we need to anticipate the potential harm this crisis could do to clinicians' livelihoods."

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

    Coronavirus Update: March 23, 2020

    Tips on what to ask about telehealth; guidance on paid leave law; coronavirus "self-checker"; CMS enrollment relief, and more.

    Practice Guidance

    March 23: APTA Recommends PTs Ask Specific Questions About Telehealth Provisions
    As telehealth provisions evolve rapidly at the state, federal, and private payer levels, it's crucial that PTs fully understand what does and doesn't apply to them. Here are five questions to ask payers and state agencies.

    March 19: APTA Private Practice Section Provides Guidance on Paid Leave Law
    The Families First Coronavirus Response Act signed into law last week includes requirements for employers with fewer than 500 employees to provide paid sick time and extended FMLA leave. This resource from the APTA Private Practice Section provides a summary of the law, and suggestions on next steps for private practices.

    March 19: APTA Private Practice Section Publishes "General Considerations" Related to COVID-19
    There are growing list of "what ifs" that PTs in private practice need to consider around the coronavirus — this resource from the APTA Private Practice Section covers a range of possible scenarios, ranging from employee illness to responding to drops in demand.

    From the CDC

    March 23: CDC Debuts Online Coronavirus "Self-Checker"
    The CDC is now offering an app designed to help individuals who wonder if they're experiencing COVID-19 symptoms. Called "Clara," the program asks a series of questions that include symptoms being experienced, age, geographic location. Based on answers provided, Clara recommends actions to be taken, from calling 911 to staying home and contacting a health care provider.

    From CMS

    March 23: CMS Issues FAQs on Medicare Provider Enrollment Relief
    As part of the 1135 waiver process in place during the coronavirus pandemic, CMS is easing some requirements related to provider enrollment in Medicare, including waivers to site visits and criminal background checks associated with fingerprint-based background checks, as well as postponement of all revalidation actions. This recently published list of frequently asked questions about the waivers includes a list of Medicare Private Enrollment Hotline numbers.

    From the Department of Labor

    March 22: Labor Department Provides Information on Paid Leave Law, Fair Labor Standards Act
    With the Families First Coronavirus Response Act now signed into law, the U.S. Department of Labor has published resources that explain the essential elements of the mandated paid leave now in place for employers of fewer than 500 people. Also included on the page: questions and answers about the Fair Labor Standards Act and the Family and Medical Leave Act.

    In the Media

    March 23: IBM and DOE Launch COVID-19 Computing Consortium
    IBM has partnered with the Department of Energy to launch the COVID-19 High Performance Computing Consortium, which will combine supercomputing capabilities from 16 systems to help researchers better understand SARS-CoV-2 and develop potential therapies and a vaccine. Consortium partners include Lawrence Livermore National Laboratory, Oak Ridge National Laboratory, Los Alamos National Laboratory, the National Science Foundation, NASA, Massachusetts Institute of Technology, Amazon, and Google.

    March 22: FTC Warns of Coronavirus Scams
    The Federal Trade Commission is warning the public of malicious websites, robocalls, and other scams -- including dishonest websites selling disinfectants and medical supplies, and others selling unapproved products purporting to cure or prevent contracting the virus.

    March 22: Therapy Continues During Crisis, But Worries Over Protective Supplies and Employment Loom
    From Skilled Nursing News: "Even with heightened concern amid the spread of the virus, and with the threat of protective gear declining, therapists are still jumping in to help patients get well — in spite of great risk and putting in extra hours."

    March 19: Nursing Home Outbreaks Lay Bare Chronic Industry Problems
    From Associated Press: " Burgeoning coronavirus outbreaks at nursing homes in Washington, Illinois, New Jersey and elsewhere are laying bare the industry’s long-running problems, including a struggle to control infections and a staffing crisis that relies on poorly paid aides who can’t afford to stay home sick.”

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

    Asking the Right Questions About Telehealth

    It's not enough to ask if telehealth is permitted by a state agency or payer: You need to ask specific questions to understand what you can and can't do.

    As the coronavirus pandemic worsens, PTs and PTAs are looking for answers around what they can and can't do in terms of telehealth. APTA's advice: Get the right answers by asking the right questions.

    According to Alice Bell, PT, DPT, APTA senior payment specialist, in addition to federal-level changes around digital communications with patients, the telehealth environment is also evolving rapidly at both the private payer and state regulatory levels.

    "Right now, there's a great deal of confusion around the coverage of telehealth when provided by physical therapists," Bell said. "Some broad policies and federal and state legislation may be interpreted as including physical therapists even though this is not explicitly stated."

    Daniel Markels, APTA state affairs manager, says that miscommunication can make matters worse.

    "If a PT calls a payer and asks if telehealth is covered, the payer may say yes not knowing that it's a PT asking the question or what codes the physical therapist intends to bill," Markels said.

    That's why APTA recommends that, besides having a solid understanding of the limitations in state licensure scopes and relevant state and federal laws, PTs ask the following questions when communicating with a payer or state agency about whether telehealth is permitted for physical therapist services:

    • Will services provided by physical therapists (and PTAs working under the direction and supervision of the PT) be covered when provided via telehealth?
    • If so, what codes should be billed and what modifiers are required?
    • What device(s) or application(s) can be utilized?
    • What, if any, consents are required?
    • Are there any special documentation requirements?

    [Editor's note: Official guidance and best practices related to telehealth and e-visits could change rapidly as the COVID-19 outbreak continues to evolve. For the most current information from APTA, see our main Telehealth webpage and visit our APTA.org/Coronavirus/ webpage.]

    Coronavirus Update, March 22, 2020: CMS and US Treasury Announce Relief Measures for Clinicians

    Employers mandated to provide paid sick leave will be reimbursed, and quality reporting deadlines and requirements — including MIPS — have been relaxed.

    March 22: Feds Announce Reimbursement Program for Employers Required to Provide Leave
    The U.S. Treasury Department, Internal Revenue Service, and Department of Labor announced that small and midsize employers can begin taking advantage of two new refundable payroll tax credits, designed to immediately and fully reimburse them for the cost of providing coronavirus-related paid leave to their employees. The paid leave was mandated as part of the Families First Coronavirus Response Act signed into law on March 18.

    The relief measures include reimbursement for up to 80 hours of paid sick leave and expanded child care leave, with the Department of Labor asserting that the funds will be "quick and easy to obtain." Employers required to provide the leave also will be reimbursed for health insurance costs and will receive dollar-for-dollar tax offsets against payroll taxes.

    Employers with fewer than 50 employees are eligible for an exemption from the paid leave requirements. The labor department will be providing guidance to more clearly articulate this standard. Employers with 500 employees or more were not required to provide leave.

    March 22: CMS Relaxes Quality Reporting Deadlines
    Clinicians and facilities participating in CMS quality reporting programs, including the Merit-based Incentive Payment System, also known as MIPS, will have more flexibility in data submission.

    For the MIPS program, 2019 data submission deadlines have been moved to April 30. The previous deadline was March 31.

    In a number of postacute care settings, including inpatient rehab, home health, long-term care, and skilled nursing facilities, April and May submissions are now optional. In addition, CMS states, "no data reflecting services provided January 1, 2020, through June 30, 2020, will be used in CMS’s calculations for the Medicare quality reporting and value-based purchasing programs." CMS also announced reporting relief measures for various hospital programs.

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

    Coronavirus Update: March 20, 2020

    APTA's President issues a statement, updated e-visit Q&A and webinar recording available, telehealth grassroots advocacy, and more.

    Practice Guidance

    March 20: Letter From President Dunn on COVID-19 Impact
    APTA President Sharon Dunn, PT, PhD, released a statement on the coronavirus pandemic that calls on the physical therapy profession to rely on its unique ability to help society through a troubling period.

    March 20: E-Visit Q and A Resource Updated and Expanded; Recording and Slides Available
    Many questions from PTs and PTAs have arisen since the CMS announcement of waivers that would allow for limited digital communication by PTs. APTA regulatory affairs staff continue to expand and update the relevant questions and answers. In addition, APTA offers a recording of a March 19 webinar on the e-visit waiver, as well as the slide deck from the presentation.

    March 20: Members Send More than 53,000 Communications to Congress Over Telehealth (and Growing)
    A grassroots campaign to urge members of Congress to waive restrictions on the use of telehealth for physical therapy services has sparked more than 50,000 communications in less than week—one of the most impressive APTA advocacy efforts to date. A second grassroots campaign focused on congressional action to provide additional relief to physical therapists has generated more than 2,000 emails. Both initiatives continue to gain momentum.

    March 20: APTA Offers More Template Letters to Advocate for Telehealth to Payers, State Officials
    APTA has developed two template letters to use in advocating to states — your governor, state representatives, and Medicaid office director — for coverage by private payers and Medicaid of telehealth furnished by PTs and PTAs to ensure that patients continue to have access to the rehabilitative care they need amid the COVID-19 pandemic. One letter is for individual PTs and PTAs; the other letter is for state chapters. Instructions are included at the top of each letter. Also available: a template letter on telehealth designed to be sent to payers.

    March 18: TRICARE Expands Telemedicine Benefit
    A new announcement from TRICARE Humana Military states: "If a beneficiary meets all other criteria for a covered service for speech therapy and for continuation of PT/OT, (but not initiation of PT/OT), it is covered using telemedicine, using any coding modifiers as you would for a TRICARE network provider office visit."

    From OSHA

    March 19: OSHA Releases Guidance on Preparing Workplaces for COVID-19
    A recently released guide from OSHA covers topics including steps employers can take to reduce exposure, how to classify worker exposure to SARS-C0V-2, and contact information for OSHA regional offices.

    From the CDC

    March 16: NIOSH Publishes Guidelines on Proper N95 Respirator Use
    The Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health has released an illustrated guide to safe use of the N95 respirator. Topics include filtration, fit, and proper use, as well as situational strategies to achieve the best fit during serious outbreak conditions.

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

    Coronavirus Update: March 19, 2020

    AHCA and NCAL release guidelines for PTs, OTs, and SLPs in long-term care facilities; Aetna expands telehealth and e-visit coverage; APTA to host e-visit Facebook Live event, and more.

    Practice Guidance

    March 19: Guidelines Issued on the Role of PTs, OTs, and SLPs in Long-Term Care Facilities During Pandemic
    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 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.

    The statement is part of a broad coronavirus education effort for LTC facilities created by AHCA that's centered on an extensive and frequently updated webpage containing more detailed AHCA recommendations as well as links to resources from CMS, the CDC, and other organizations.

    March 19: Aetna Expands Telehealth and Remote Visit Coverage, Allows PTs to Bill for E-Visits
    Major commercial insurer Aetna announced that it would require no co-pay on telemedicine visits for any reason for 90 days—and would allow PTs to bill for e-visits consistent with the recent e-visit waiver policy announced by CMS. Collaborative efforts between APTA and Aetna led to the change and inclusion of PTs. All Aetna policy changes are retroactive to March 9.

    The Aetna e-visit approach is slightly different expanded from the CMS system, in that it allows PTs to bill for either codes associated with evaluation and management (98970, 98971, 98972) or as well as for assessment and management (G2061, G062, and G2063). CMS only allows PTs to bill for the G codes. Providers should check with Aetna's provider page for updates and changes.

    March 19: E-Visit Facebook Live Event to be Held March 20 at 2 pm
    Join APTA regulatory affairs experts on Friday, March 20 at 2 pm ET, for a Facebook Live townhall and Q&A session on the e-visit waivers for PTs recently announced by CMS. The event is open to members and nonmembers, but seats are limited. The Facebook Live event will repeat information shared in an APTA webinar set for March 19 at 8 p.m. ET. Recordings of both events will be available afterwards.

    March 18: WHO Begins Massive Open Online COVID Courses
    The World Health Organization has developed OpenWHO Massive Online Open Courses for COVID-19 to provide real-time training for health professionals, decision-makers and the public. The courses will be offered in several languages.

    From CMS

    March 18: CMS Publishes Revised Guidance on Fee-for-Service Response That Includes E-Visit Waiver Information
    CMS has revised its recent MLN Matters publication on its blanket waivers (1135 waivers) of various requirements to include more information on telehealth-related changes—and specifically for the physical therapy profession, waivers that would allow PTs to conduct digital communications with patients by way of "e-visits." Revised and additional language is indicated in red.

    March 17: CMS Says That Elective and Non-Essential Surgeries Should be Delayed
    The agency issued a statement pressing for facilities to carefully evaluate risk factors for the spread of COVID-19, and postpone—or consider postponing—a number of different types of surgeries. Carpal tunnel release, colonoscopy, cataract, and endoscopies are among the procedures CMS believes should be postponed; hip and knee replacements, elective spine surgeries, and procedures related to low-risk cancers are listed as surgeries that hospitals should "consider postponing."

    From the CDC

    March 15: CDC Offers "Get Your Practice Ready" Resources
    The Centers for Disease Control and Prevention's COVID-19 offerings now include a set of printable resources designed to be posted at clinics and other facilities to help providers and patients understand the symptoms of COVID-19, the steps that should be taken to minimize the risk of spreading the virus, and ways to manage respiratory symptoms at home. The materials include a sign providers can post outdoors.

    In The Media

    March 19: Scientists Say "Flattening the Curve" is Possible, but the Fight May Continue for Months
    Health researchers point out that reducing the rate of coronavirus infection will help steer the world away from a calamitous "peak," but doing so will mean that duration of the outbreak will be longer.

    March 18: White House Invokes Defense Production Act
    President Trump has invoked the World War II-era act to ramp up production of much-needed medical equipment such as N95 masks and ventilators.

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

    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)

    CMS Moves to Allow Digital Communications by PTs

    The new regulatory waivers will allow PTs, OTs, and SLPs to engage in patient-initiated "e-visits" for purposes of assessment and management services.

    In the federal government’s rapidly evolving response to the coronavirus pandemic, the U.S. Centers for Medicare and Medicaid Services has announced that it is easing Medicare telehealth restrictions in ways that could allow PTs to provide "e-visits," a limited type of service that must be initiated by the patient. Prior to this change CMS did not recognize PTs among the health care professionals allowed to bill codes associated with the visits.

    The change, announced midday on March 17, is part of a set of loosened requirements that CMS has adopted to expand the provision of telehealth and patient-initiated digital communications, such as e-visits, to help blunt the spread of COVID-19. For the most part, PTs remain outside the reach of these so-called "1135 waivers" related to telehealth, with one exception: a type of remote interaction CMS calls an e-visit under Medicare Part B.

    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 suggest the codes are intended to cover short-term (up to seven days) assessments that are conducted online or via some other digital platform, and include any associated clinical decision-making.

    Under the waivers guidance issued by CMS, Medicare beneficiaries can qualify for e-visits no matter their geographic region or physical location, meaning that the provisions have been expanded to nonrural areas and can take place with patients in their homes. The big news for PTs and their patients is that, for the first time, PTs will be allowed to bill for e-visits under codes associated with online assessment and management services (codes G2061, G2062, and G2063). To determine the reimbursement rates for G2061-G2063, visit the CMS Physician Fee Schedule lookup tool. Medicare coinsurance and deductible would apply to the services. A March 18 CMS MLN Matters article includes more information about the e-visits and telehealth waiver.

    To qualify as an e-visit, three basic qualifications must be met: the billing practice must have an established relationship with the patient, meaning the provider must have an existing provider-patient relationship; the patient must initiate the inquiry for an e-visit and verbally consent to check-in services; and the communications must be limited to a seven-day period through an "online patient portal."

    Although the patient must initiate, CMS writes in a fact sheet that "practitioners may educate beneficiaries on the availability of the service prior to patient initiation." For example, if a patient cancels treatment because they can’t come to the clinic or are concerned about leaving home, then the PT may advise the patient that she or her can reach out to the therapists as needed.

    Alice Bell, PT, DPT, APTA senior payment specialist, says that the waiver has some very practical implications for PTs, and offers a possible scenario in which the e-visit could be useful.

    "Let's say that, as a PT, I've been seeing a patient for an orthopedic condition and I am progressing the patient’s exercises," Bell said. "The patient is unable to come into the clinic but calls me to say she's having difficulty with one of the exercises and that the other two seem to be too easy. I could arrange an e-visit with the patient and discuss her performance of the exercises. And I could then make a determination — maybe I find that the patient is performing one of the exercises incorrectly — and I could direct the patient on the correct performance. Perhaps I also determine that two of the exercises can be progressed because the patient is improving, so I could instruct the patient in the two new exercises. After that I could advise the patient to contact me for a follow-up e-visit as needed until the patient can return to the clinic."

    The HHS Office of the Inspector General has also issued a policy statement that provides guidance on how it interprets the new telehealth waivers. APTA regulatory affairs staff will continue to monitor these waivers and other developments and share news with members.

    "As we've seen over the past few weeks, and especially during the past few days, we're dealing with an extremely fluid situation in terms of response to the coronavirus pandemic," said Kara Gainer, APTA's director of regulatory affairs. "This waiver and other changes have the potential to make a difference, and we hope that CMS continues to take steps that can help providers and their patients stay healthy."

    APTA has issued a statement on patient care and practice management during the COVID-19 outbreak, and offers a webpage to keep members up to date with the latest news on the pandemic.

    Coronavirus Update: March 17, 2020

    APTA provides a statement, resources, and guidance; CMS allows limited digital services by PTs; the CDC says gatherings should be fewer than 50 people, and more.

    Practice Guidance

    March 17: APTA Statement on Patient Care and Practice Management During COVID-19 Outbreak
    "Physical therapists have a responsibility to review CDC guidance, to understand who is at highest risk and how to best reduce exposures, and to use their professional judgment in the best interests of their patients and clients and local communities," writes the APTA Board of Directors.

    March 17: APTA Offers Template Letter to Advocate to Payers on Telehealth
    The association has developed a template letter for you to use in advocating to your payers — private, Medicare Advantage, and Medicaid (both fee for service and MCOs) — for coverage of telehealth furnished by PTs and PTAs to ensure that patients continue to have access to the rehabilitative care they need amid the COVID-19 pandemic. Instructions are included at the top of the letter.

    March 16: APTA Shares Guidance on Telehealth for PTs, PTAs
    The use of telehealth can help keep providers and patients safe, but the current regulatory and payer landscape can be confusing. We've created guidance and links to resources that can help you decide whether telehealth is appropriate — or even a possibility.

    From CMS

    March 17: CMS Moves to Allow Limited Digital Services by PTs
    New regulatory waivers will allow PTs, OTs, and SLPs to engage in patient-initiated "e-visits" for the purposes of assessment and management services.

    March 17: CMS Offers Coronavirus Partner Toolkit
    CMS has created a portal that centralizes updated resources related to COVID-19, including topical areas aimed at clinicians, Medicare beneficiaries, health care settings, and more, along with information from the CDC.

    March 16: National Health Emergency Triggers CMS Waivers for Medicare, Medicaid, CHIP
    The "blanket waiver" system now in effect eases a wide range of requirements, but CMS still won't reimburse for telehealth by PTs.

    From the CDC

    March 15: CDC Recommends Ban on Gatherings of More Than 50 People
    The Centers for Disease Control and Prevention has updated its guidance on mass gatherings and community events.

    In The Media

    March 16: White House Issues Advisory to Avoid Gatherings of More Than 10 People
    The guidelines also urge the elderly and individuals with serious underlying health conditions to stay home and avoid contact with other people.

    March 16: As Coronavirus Spreads, So Do Malware and Phishing Scams
    Beware emails and websites that offer information about the pandemic — an increasing number of seemingly helpful apps and emails are actually damaging ransomware or phishing attempts, including harmful hacks sponsored by nation states.

    March 15: Gov't Testing for COVID-19 Will Prioritize Medical Professionals, Elderly
    According to government officials, testing for individuals with COVID-19 symptoms will first focus on health care workers and older adults. According to an administration spokesman, testing sites could potentially screen anywhere from 2,000 to 4,000 per day.

    March 13: Experts Identify Risk Factors for More Severe Outcomes
    Patients with COVID-19 are at higher risk of developing acute respiratory dysfunction if they are of older age, have neutrophilia, and/or have organ and coagulation dysfunction.

    March 13: Researchers Learn More About SARS-CoV-2 Transmission
    Preliminary research findings indicate that the aerosolized virus could be found in the air up to three hours later. The virus was present for four hours on copper, two to three days on plastic and stainless steel, and up to 24 hours on cardboard. The article should not yet be used to guide clinical practice, as it has not yet been peer-reviewed.

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

    National Health Emergency Triggers CMS Waivers for Medicare, Medicaid, CHIP

    The "blanket waiver" system now in effect eases a wide range of requirements, but CMS still won't reimburse for telehealth by PTs.

    President Donald Trump's declaration of a national emergency in response to the coronavirus pandemic has resulted in enactment by the Centers for Medicare and Medicaid Services of special waiver provisions that affect a broad range of activities and settings in Medicare, Medicaid, and the Children's Health Insurance Program, or CHIP. The so-called "1135 waivers" — a reference to section 1135 of the Social Security Act — are being offered temporarily to clinicians and facilities.

    CMS has issued a special edition of MLN Matters covering the 1135 waivers. Here are some important elements of the process you need to understand.

    These are "blanket waivers" that automatically authorize providers to take advantage of the changes — but CMS wants you to notify your survey agency and CMS regional office before you do.
    The waivers are available immediately and cover everything from general payment policies to admission requirements for facilities. CMS offers a fact sheet on the waivers available; if you believe a specific waiver would be helpful, contact your state survey agency as well as your CMS Regional Office.

    • ROATLHSQ@cms.hhs.gov (Atlanta RO): Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee
    • RODALDSC@cms.hhs.gov (Dallas RO): Arkansas, Louisiana, New Mexico, Oklahoma, and Texas
    • ROPHIDSC@cms.hhs.gov (Northeast Consortium): Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia, New York, New Jersey, Puerto Rico, Virgin Islands, Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont
    • ROCHISC@cms.hhs.gov (Midwest Consortium): Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin, Iowa, Kansas, Missouri, and Nebraska
    • ROSFOSO@cms.hhs.gov (Western Consortium): Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming, Alaska, Idaho, Oregon, Washington, Arizona, California, Hawaii, Nevada, and the Pacific Territories

    CMS also offers instructions on how to make a waiver request.

    The waivers don't affect state laws or regulations, or change the services reimbursed—or not reimbursed—by CMS. That means PTs still can't be reimbursed for telehealth.
    Services that weren't covered before the 1135 system was put in place still aren't covered. Even though recently passed legislation eased some Medicare telehealth restrictions, the changes didn't expand the list of health care professionals who can furnish telehealth—and PTs aren't on that list. Medicare Advantage plans have some flexibility when it comes to telehealth, but it’s up to the plan to just how flexible they want to be.

    HIPAA is still in effect.
    The HIPAA Privacy Rule, the HIPAA Security Rule, and the confidentiality provisions of the Patient Safety Rule aren't eased, but during the national emergency, HHS may waive sanctions against a covered hospital that does not comply with certain HIPAA provisions. In other words, when it comes to HIPAA, nothing has changed. The HHS Office for Civil Rights has produced a bulletin on the waivers as they related to HIPAA; additionally, OCR offers a webpage on how HIPAA rules apply in an emergency, and a "HIPAA Disclosures for Emergency Preparedness Decision Tool."

    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 much practical use, states would need to create their own licensure waivers — otherwise, the state requirements win out.

    Provider enrollment requirements have been eased.
    CMS has issued a blanket waiver of certain Medicare enrollment requirements, including application fees, fingerprint-based criminal background checks, and site visits. CMS has also postponed all revalidation actions. Additionally, CMS will establish a toll-free hotline PTs and other providers can use to enroll and receive temporary Medicare billing privileges, and the agency will expedite any new or pending enrollment applications.

    Facility surveys are being prioritized — but not eliminated.
    The waiver process doesn't end surveys, but CMS has prioritized the kinds of surveys that will be done, in coordination with state and local health departments, accrediting bodies, and the CDC. Effective immediately, survey activity is limited to the following (in priority order):

    • All immediate jeopardy complaints (cases that represent a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk) and allegations of abuse and neglect
    • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses
    • Statutorily required recertification surveys (nursing home, home health, hospice, and intermediate care facilities) for individuals with intellectual disabilities
    • Any re-visits necessary to resolve current enforcement actions
    • Initial certifications
    • Surveys of hospitals and other facilities that have a history of infection control deficiencies at the immediate jeopardy level in the last three years
    • Surveys of hospitals, dialysis centers, and other facilities that have a history of infection control deficiencies at lower levels than immediate jeopardy

    Available waivers also include eased requirements for critical-access hospitals, long-term care hospitals, and inpatient rehabilitation facilities, but those facilities still need to notify the state survey agency and CMS Regional Office.
    Bed limits, length-of-stay requirements, the IRF "60 percent rule" governing discharges, and other provisions can be eased under the waiver system, but just like individual clinicians, facilities must notify CMS of the waivers it will be implementing.

    It's up to individual states to request waivers related to Medicaid and CHIP.
    Unlike waivers available in Medicare, there is no specific form or format required to submit the request for a Section 1135 waiver under Medicaid, but states are being advised to clearly state the scope and impact of the issue. States and territories may submit a Section 1135 waiver request directly to the CMS Acting Director, Medicaid & CHIP Operations Group Center for Medicaid & CHIP Services. The types of relief that state Medicaid agencies can seek are outlined in the CMS fact sheet.

    There are additional resources worth checking out.
    In addition to a fact sheet on the blanket waivers, CMS offers a detailed set of common questions and answers related to the 1135 system, and a "waiver at a glance" document that takes a more big-picture approach.

    Visit APTA's Coronavirus webpage for information and updates.

    PTAs Will be Authorized TRICARE Providers Beginning Mid-April

    In a win for PTAs and OTAs, the Department of Defense has issued a final rule, effective April 16, that establishes them as providers in ways similar to Medicare provisions.

    In this review: TRICARE; Addition of Physical Therapist Assistants and Occupational Therapy Assistants as TRICARE-Authorized Providers (final rule)
    Effective date: April 16, 2020

    The Big Picture
    A big win is finally (nearly) here: The Department of Defense has issued a final rule that establishes PTAs and OTAs as authorized providers under TRICARE, the health insurance system used throughout the military. The rule, set to take effect on April 16, largely follows the PTA approach used by CMS, and includes requirements related to supervision, the reach of state and local law, and the scope of allowable PTA activities. The inclusion of PTAs in TRICARE was a major advocacy focus for APTA. DoD estimates that the cost of increased utilization, along with a first-year implementation cost of $350,000, will be $20 million over five years.

    Also Notable in the Final Rule

    • Qualification and supervision requirements for the most part mirror Medicare provisions for PTAs and OTAs.
    • Direct supervision will be required in the private practice setting, with the supervising PT required to be in the office suite where the PTA is working and immediately available to provide assistance and direction — but not required to be in the room with the PTA while the procedure is being performed.
    • Outside of private practice, the rule calls for "general supervision" that does not require the PT’s presence during the PTA's performance of the procedure. The supervising PT will have continuing responsibility for training the PTA.
    • Where state or local supervision laws are more stringent, PTs and PTAs will be required to follow those laws.
    • Physical therapy aides will not be covered, even if working under the supervision of a TRICARE authorized PTA or PT.
    • DoD adopted APTA's recommendation to change its terminology and is now using the term "physical therapist assistants" in reference to the PTA, abandoning its use of "physical therapy assistants."

    "Although we've known that this change would be happening since 2017, we're pleased that DoD issued the final rule slightly ahead of schedule, and with virtually all of the suggestions provided by APTA," said Kara Gainer, APTA's director or regulatory affairs. "PTAs are crucial members of the service delivery team, and their inclusion in TRICARE will significantly improve patient access to effective, needed care."

    Telehealth in Physical Therapy in Light of COVID-19

     

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

     

     

     The coronavirus pandemic demands that health care providers rethink how they deliver care in ways that reduce risk of further spreading infection.(Note: this article is also presented as a recorded webinar and accompanying slides).

    The use of telehealth is one approach that can help keep both patients and providers safe, but PTs and PTAs need to understand the current regulatory and payer telehealth landscape to decide whether telehealth is right — or even a possibility — for them.

    The information below can help you get a better sense of the issues surrounding physical therapy and telehealth, particularly related to the current viral outbreak. Keep in mind that circumstances are constantly changing and this information is current as of the publication date.

    In General

    • We recently updated our resources on telehealth related to areas such as legislation and regulation, risk management considerations, billing and coding considerations, and implementing telehealth in practice. You will find these on the APTA Telehealth webpage.
    • We also published a blog post, "Challenges and Opportunities in Telehealth: a Q&A."
    • We have received several questions related to Congress' coronavirus legislation signed into law last week. It gives the Department of Health and Human Services authority to waive certain Medicare telehealth restrictions (with stipulations) and continues to limit provider types who can furnish telehealth to Medicare beneficiaries. Physical therapists are not included as a provider type that can furnish telehealth as a covered service to Medicare beneficiaries under this legislation. Due to a number of questions related to this legislation, APTA issued a March 9 news advisory on telehealth.
    • A CMS fact sheet describes regulatory flexibilities and other actions the agency implemented in March to help health care providers and states respond to and contain COVID-19. The actions did not include expanding Medicare coverage to include telehealth services furnished by physical therapists. The actions did include temporarily waiving Medicare and Medicaid requirements that out-of-state providers hold licenses in the state where they are providing services. The requirement is waived as long as the provider has an equivalent license from another state — but keep in mind this does not waive state or local licensure requirements. Also, the waiver does not allow for payment for otherwise non-covered services — such as telehealth services provided by physical therapists.
    • In addition, the Center for Connected Health Encounters offers "Billing for Telehealth Encounters: An Introductory Guide on Fee-for-Service (.pdf)," a 21-page document that outlines billing procedures.
    • Note that other terms, such as telerehabilitation, telerehab, telemedicine, and telepractice are being used by various entities. They all can refer to use by PTs and PTAs; this article generally uses "telehealth."

    Practice via Telehealth

    Regardless of the payer or policy, PTs and PTAs must ensure that when providing telehealth services or billing for them, they are practicing legally and ethically, and are adhering to state and federal practice guidelines and payer contract agreements. You review and understand your state's practice act regarding the delivery of physical therapist services via telehealth.

    Per APTA's ethics documents (www.apta.org/Ethics/), we recommend that physical therapists use their discretion as to the nature and frequency of using telehealth, and do so within their scope of practice while abiding by any state practice act restrictions as well as their obligations to the physical therapy profession.

    Although telehealth is not specifically codified within the APTA "Code of Ethics for the Physical Therapist" or the "Standards of Ethical Conduct for the Physical Therapist Assistant," the entirety of the code applies to telehealth services delivered by PTs and PTAs. Ethical practice in telehealth must account for the biological, social, psychological, and cultural needs of the patient while working to improve their health. Additionally, knowing when to urge and how to persuade the patient to seek a face-to-face level of care is key. Before providing telehealth, ensure that you meet all local, state, and federal laws and regulations. To achieve the potential for patient benefit, you must consider the associated ethical issues; specifically, carefully assess the effect on relations between clinicians, patients and clients, and their families and/or caregivers.

    Telehealth provision or use does not alter a covered entity's obligations under HIPAA, nor does HIPAA contain any special section devoted to telehealth. Therefore, if a covered entity is utilizing telehealth that involves PHI, the entity must meet the same HIPAA requirements that it would if the service was provided in-person.

    The House of Delegates position on telehealth (.pdf), last updated in 2019, recognizes telehealth as a well‐defined and established method of health services delivery that enhances patient and client interactions. APTA also recognizes the value of advocating for state and federal telehealth policies to reduce cost, disparities, and shortages of care, and to enhance physical therapist practice, education, and research.

    PT Compact
    Through the Physical Therapy Compact, a compact privilege allows the holder to provide physical therapist services in a remote state under the scope of practice of the state where the patient or client is located, whether the practice is in-person or via telehealth. Compact privilege holders should consult the rules and laws for the state in which they seek to provide services to determine the specific telehealth requirements.

    Payer Policy

    Medicare
    Physical therapists are not statutorily authorized providers of telehealth under Original Medicare, and physical therapy services are not on the list of services covered under the Medicare physician fee schedule when furnished via telehealth. (See the Private Payer section below for information on services provided under Medicare Advantage plans.) APTA has continued to advocate for the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019 (H.R. 4932/S. 2741), legislation that would expand the use of telehealth services and ease restrictions on telehealth coverage under the Medicare program. Our position paper outlines APTA's stance on the legislation (.pdf). The COVID-19 pandemic makes our position all the more relevant; health care providers and payers must reconsider how care is delivered to reduce the risk of further spreading infection. Access to telehealth has become of paramount importance to ensure the safety of patients and their physical therapy providers. We have developed a template letter you can send to your legislators (.pdf) asking them to cosponsor these bills.

    APTA also has compiled research studies on telehealth (.pdf) and testimonials from APTA members on how they have balanced in-person and telehealth visits.

    Private Payer
    Check with individual payers to verify what is and is not permitted and what will be reimbursed. Confirm with each payer whether the originating site can be a private home or office, if services must be real-time or can be asynchronous, and any other limitations to your use of telehealth. Before reporting CPT codes you traditionally use for clinical visits, check with your payer. A payer also may require an addendum attached to the bill that identifies the service as being provided via telehealth, along with an explanation of the charges, so be prepared to outline your reasoning for using telehealth. Also be aware if your state has parity laws that require insurers to pay the same amount for telehealth services as they would for an in-person visit.

    Note: Under CMS guidance issued to Medicare Advantage organizations (.pdf), CMS is affording MAOs the flexibility to expand coverage of telehealth services.

    APTA developed a template letter for you to use in advocating to your payers--private, Medicare Advantage, and Medicaid (both fee for service and MCOs) for coverage of telehealth furnished by PTs and PTAs to ensure that patients continue to have access to the rehabilitative care they need amid the COVID-19 pandemic. Instructions are included at the top of the page.

    Medicaid
    States have the option to determine whether or not to cover telehealth services; what types of telehealth services to cover; where in the state such services can be covered; how services are provided and covered; which types of providers may be reimbursed for telehealth services (as long as they are "recognized" and qualified according to the state's Medicaid statute or regulation); and how much to reimburse for telehealth services, as long as payment does not exceed federal upper limits.

    Medicaid guidelines require all providers to practice within the scope of their state practice act. Some states' legislation requires providers using telehealth technology across state lines to have a valid state license in the state where the patient is located, and these requirements are binding under current Medicaid rules.

    Before you bill for telehealth services under Medicare, always check the regulations and policies of your state Medicaid fee-for-service (FFS) program and Medicaid managed care organizations to confirm whether or not the FFS program and/or MCOs reimburse for telemedicine services.

    The Center for Connected Healthcare Policy identified the following in a 2019 summary of state telehealth policies, including telerehabilitation:

    • 9 states (Arkansas, Connecticut, Delaware, Idaho, Kentucky, Minnesota, Missouri, New York and Oregon) explicitly reimburse for telerehab services.
    • 11 states (Iowa, Maine, Montana, Nebraska, New Mexico, North Dakota, Rhode Island, Tennessee, Utah, Vermont and Washington) contain open language in state regulation or reimbursement policies that may allow for Medicaid to reimburse for telerehab services.

    Medicaid policies on the originating site setting (private home or office) and real-time vs. asynchronous services also differ among states, so check your state's policy as well as each payer's policy.

    The Center for Connected Healthcare Policy has a good resource that identifies where the law stands with telehealth in the states (.pdf).

    Coding
    There are not specific CPT codes for telehealth services furnished by physical therapists. Some therapists use codes in the 97000 series that best describe the services being provided and then use the place-of-service code "02" to indicate that the services were provided remotely. Because the CPT codes are direct contact codes it is important to verify that the payer allows you to use these codes when services are provided via telehealth, or if you must use a specific modifier. We also encourage you to check with each payer about using place-of-service code "02" when billing for telehealth services to specify the entity where service(s) were rendered.

    Learn More
    In addition to the links to resources above, we will continue to develop education related to delivery of services via telehealth. For one thing, APTA staff will prerecord a webinar in early April with members of the Health Policy and Administration Section's Tech SIG. The webinar, Digital Telehealth Practice - Connect for Best Practice, Compliance, and Healthcare, will then be followed by a live online Q&A session later in the month.

    These resources should answer most of your questions on billing and coding, practice considerations, legislation and regulation, and other issues related to telehealth. If you still have a question that wasn't addressed, send it to advocacy@apta.org. We will update our resources accordingly to ensure we're providing the information the profession needs.

    CDC: Fall-Related TBI Death Jumped 17% 2008-2017

    Significant increases were reported in 29 states, with residents of rural areas and individuals 75 and older seeing the most dramatic annual rise in deaths.

    In this review: Deaths from Fall-Related Traumatic Brain Injury — United States, 2008-2017
    (U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, March 6, 2020)

    The Message
    The rate of deaths related to traumatic brain injury received in a fall has climbed 17% in 10 years, with 29 states recording what CDC officials call a 'significant" increase in deaths. The trend was present in all demographic groups, with males, those in rural areas, and individuals 75 or older seeing the most notable increases. Authors of the CDC analysis think that the country's aging population and better survival rates from cancer, stroke, and heart disease may have something to do with the increase. No matter the underlying causes, they say, the numbers point to a need for greater emphasis on falls prevention.

    The Study
    Using data from the National Vital Statistics System, a database of death certificates filed across the U.S., researchers looked at ICD-10 cause-of-death codes — first for codes indicating an unintentional fall as a cause of death, and then for multiple cause-of-death codes that included a diagnosis of traumatic brain injury, or TBI. Data was further analyzed for various demographic groups, including metropolitan versus nonmetropolitan settings, as well as by state. The study spanned 10 years of data, from 2008 to 2017.

    Findings

    Overall, national age-adjusted rates of fall-related TBI deaths rose from 3.86 per 100,000 individuals in 2008 to 4.52 per 100,000 in 2017, a 17% increase. Increases were present in nearly all demographic groups and in 49 of 51 jurisdictions.

    In 2017, the highest rate of fall-related TBI death was among adults 75 and older, at 54.08 per 100,000 — eight times higher than the 55-74 age group.

    Between 2008 and 2017, individuals living in "noncore nonmetropolitan counties" — mostly more rural areas — experienced the highest rate of annual increase in deaths, averaging a yearly 2.9% increase, followed by the 75-and-older cohort with an average annual increase of 2.6%.

    At the state level, the largest average annual increases in fall-related TBI deaths were recorded in Maine (6.5%), South Dakota (6.1%), and Oklahoma (5.2%), with "significant" increases reported in 26 other states and no changes reported in 21 states. Alabama reported the lowest 2017 death rate, at 2.25 per 100,000 individuals; South Dakota had the highest rate, at 9.09 per 100,000.

    In 2017, males had a higher rate of death than females, at 6.31 per 100,000 compared with 3.17.

    Why It Matters
    According to the CDC, 10% of U.S. residents 18 and older report falling annually, with falls now being estimated as the second leading cause of TBI. Authors of the study believe the rise in deaths attributed fall-related TBI point out the need for more focus on falls prevention programs, writing that "health care providers and the public need to be aware of evidence-based strategies to prevent falls."

    "Health care providers might consider prescribing exercises that incorporate balance, strength, and gait activities, such as tai chi, and reviewing and managing medications linked to falls," authors write. "Actions the public can take to prevent falls include talking to their health care provider about their or their parents' risk of falls, performing strength and balance exercises, having an annual eye exam, and making the home safer."

    [Editor's note: APTA and its components offer multiple resources on falls prevention: Check out this PT in Motion News story from 2019 for suggestions on ways to get up to speed.]

    More From the Study
    Authors offered a few theories to explain the higher death rates in certain groups and in the overall increase. The general increase, as well as the particularly notable increase among the 75-and-older population is likely attributable to the country's aging population and better survival rates after diseases such as cancer, stroke, and heart disease, they write. As for the higher rates among rural populations — in addition to an even higher aging rate in those areas compared with urban settings, rural areas tend to have greater "heterogeneity in the availability and accessibility of resources (e.g., access to high-level trauma centers and rehabilitative services)."

    Keep in Mind …
    The study has three main limitations, according to authors. First, it's possible that some deaths were misclassified; second, race and ethnicity may have been inaccurately recorded on death certificates; and third, when multiple trauma was experienced, a non-TBI factor may have contributed to the death.

    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.

    Alert: Suspect 'Checks' Are Making the Rounds

    It isn't really payment for services — it's a tactic that makes it easy for you to unwittingly agree to join a provider network.

    Did you recently receive what appears to be a check for payment of services from a national proprietary provider network? Be careful: It may not be what you think.

    APTA has been made aware that some PTs are receiving what looks like a check but is in fact an agreement to participate in a provider network. The fine print that accompanies the check makes it clear: Endorsing and cashing or depositing this check constitutes acceptance of network participation, and acceptance and agreement of all terms and conditions of the agreement. APTA is sharing this information with you as a reminder of the importance of thoroughly reading all information from a payer or third-party administrator, or TPA.

    Before cashing or depositing checks from payers or third-party administrators make sure you are aware of any conditions associated with its processing. If you have office staff that manages checks received by your clinic, it is strongly recommended that you inform them of this practice and the need for you to be alerted to this type of communication from a payer or TPA.

    If you have questions or concerns contact advocacy@apta.org. Additionally, if you have been solicited by a network such as the one described above please let us know. For more information regarding managed care contracting, visit the APTA Commercial Insurance webpage.

    Please share this information with your colleagues.

    CMS Issues COVID-19 Guidance on Infection Control, Protective Equipment

    The ever-growing list of resources from CMS includes guidance related to particular settings including hospice, SNFs, and home health.

    Note: This article was posted on March 11, 2020 and includes the latest information available at that time. For regularly updated resources, visit APTA’s webpage on physical therapist management of patients with diagnosed or suspected COVID-19 

    The Centers for Medicare and Medicaid Services has issued several statements recently with regard to infection control, patient care, and provider safety precautions in a variety of settings. To prevent further spread of the virus, "all health care providers must immediately review their procedures to ensure compliance with CMS’ infection control requirements," said CMS Administrator Seema Verma in a press release. Following is a summary CMS guidance.

    Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies
    These guidelines address how to screen home health patients for COVID-19, when staff should avoid home visits, if and when patients with confirmed COVID-19 should be transferred to a hospital, and special consideration for patients requiring therapeutic interventions, among others.

    Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED)
    CMS has provided recommendations for limiting transmission of the virus in skilled nursing facilities, including screening and/or restricting visitors. It also offers information on accepting residents from or transferring residents to hospitals.

    Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies
    The document provides guidelines for screening and treating patients, visitors, and hospice staff for COVID-19, as well as infection control and use of personal protective equipment. CMS recommends coordinating these actions with local health departments.

    Emergency Medical Treatment and Labor Act Requirements and Implications Related to Coronavirus Disease 2019 (COVID-19)
    CMS has published guidance to hospitals with emergency departments on patient screening, treatment, and transfer requirements to prevent the spread of infectious disease and illness, including COVID-19. Any hospital that participates in Medicare or Medicaid should follow both CDC guidance for infection control and Emergency Medical Treatment and Labor Act requirements.

    Medicare Advantage Organizations, Part D Sponsors, and Medicare-Medicaid Plans: Information Related to Coronavirus Disease 2019 – COVID-19
    This memo explains special requirements, permissive actions, relaxation of "refill-too-soon" edits in Medicare Part D, and business continuity plans in Medicare Advantage, among other topics.

    Interim Infection Prevention and Control Recommendations for Patients With Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
    The CDC recommendations include standard precautions, patient placement for those with known or suspected COVID-19, infection control, monitoring and managing personnel who are ill or have been exposed to the virus, and protocol for reporting between and within health care facilities.

    The document updates CMS guidance on personal protective equipment, stating that facemasks, which protect the wearer from splashes and sprays, are an acceptable temporary alternative to respirators, which filter the air, for most medical services until demand for respirators lessens.

    Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel With Potential Exposure in a Healthcare Setting to Patients With Coronavirus Disease (COVID-19)
    The CDC document describes how to assess a provider's level of exposure, risk factors, recommended monitoring, and type of work restrictions.

    Study: Even in After-Hours Settings, Seeing a PT First for MSK Conditions in the Emergency Department Saves Time, Reduces Opioid Prescriptions

    An Australian study found that when patients' primary ED contact was with a PT, treatment times, orthopedic referrals, and analgesic prescriptions decreased — all in an after-hours setting, and with most PTs having no prior ED experience.

    In this review: Emergency department after-hours primary contact physiotherapy services reduce analgesia and orthopedic referrals while improving treatment time.
    (Australian Health Review, February 2020)
    Abstract

    The Message
    The beneficial role PTs can play in emergency departments is fairly well-established in research, but now a study from Australia takes that support even further, with authors finding that even in after-hour settings, patients with musculoskeletal issues whose primary contact was with a PT tended to leave the ED with fewer orthopedic referrals and opioid prescriptions than did those for which the PT was a secondary contact, all in less time than for patients who were seen by another professional first. And those improvements were accomplished with a cohort of PTs who, with one exception, had no prior ED experience.

    The Study
    Researchers analyzed data from an Australian ED that treated patients between 4:30 and 8:30 p.m. from a Saturday through a Tuesday, focusing on patients who presented with a musculoskeletal or orthopedic diagnosis. Those patients, just over 1,000 included in the study, were divided into two treatment groups — one group that saw a PT as primary contact, and a control group of patients whose first contact was with an ED medical officer and only later with a PT. Authors of the study then compared rates of referral for orthpedic consultation, prescriptions for analgesics (defined as "any restricted medication requiring a script from a medical officer, primarily opioid-based medication"), and overall treatment times. A total of 12 physiotherapists provided ED services. Overall professional experience among the PTs ranged from three to 16 years, but only one had prior ED experience.

    Findings

    Orthopedic referrals. Among patients in the primary PT group, 36.7% were referred for orthopedic consultation in the ED; the rate was 57.1% among the secondary PT group. Just over 48% of patients in the primary PT group were referred to an orthopedic clinic after discharges from the ED, compared with 69.4% among the control.

    Analgesic prescriptions. In all, 16.2% of the primary PT patients received prescriptions for analgesia on discharge. That rate rose to 24.7% among patients in the secondary PT group.

    Treatment times. The percentage of patients discharged from the ED or admitted to the hospital within four hours — a goal in the Australian health care system — was 89.6% for the primary PT group. Fewer patients in the secondary PT group, 64.4%, were treated within that four-hour window.

    Why It Matters
    Authors of the study characterize the findings as not just consistent with previous research but also ones that "build on" earlier studies by demonstrating "similar outcomes … using an ED PCP [primary care physiotherapist] workforce consisting of less-experienced physiotherapists than in previous studies, and in an after-hour setting."

    More From the Study
    Researchers believe the findings reflect well on the diagnostic abilities of PTs in the ED, writing that the study "supports the notion that [PTs] may be more confident than ED medical officers with diagnostic accuracy for musculoskeletal and simple orthopaedic presentations, as well as in establishing an effective treatment regimen that may not require orthopaedic consultation." They add that the reduced analgesia rates suggest that "either patients managed by ED PCPs require less analgesia in general or that ED PCPs seek non-pharmacological forms of analgesia to manage soft tissue injuries."

    Authors also pointed out that the results were achieved by PTs without previous ED experience, a detail that "suggests that even physiotherapists without prior ED experience can provide a safe effective service."

    Keep in Mind …
    The researchers acknowledge a few limitations to their study, primary among them that the control group was composed of patients with secondary contact with a PT, a factor that could necessitate longer overall treatment times or point to more complex presentations. Still, they argue, the study was limited to patients with an ICD-10-AM diagnosis code, which mitigated some of those potential confounders, making them "highly unlikely" to explain the magnitude of differences noted in outcomes. Authors also acknowledge that the particular study setting — a hospital ED with after-hours radiology and orthpedic services on-site — may make generalizing findings more difficult, and they advise that "confirmation of findings of this study across a range of ED settings and times would be beneficial."

    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.

    New Rules Aim to Ease Patient Access to Their Health Data

    Two related rules touch health IT vendors, health care facilities, and providers — and come down hard on "information blocking" that prevents patients from accessing their electronic health records. 

    In this review: 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program  (ONC final rule); CMS Interoperability and Patient Access (CMS final rule)
    Effective dates: 60 days after publication in the Federal Register (ONC rule) and 6 months after publication for information-blocking and other rules; January 1, 2021 (provisions of the CMS final rule)
    ONC overview; CMS fact sheet
    ONC final rule timelines

    The big picture: Beginning 60 days after publication in the Federal Register, health IT will function under new requirements that will make it easy for patients to access their electronic health information through apps or other widely accessible technologies, at no cost.
    The pair of final rules — one from the Department of Health and Human Services' Office of the National Coordinator for Health Information Technology, and the other from CMS — help to flesh out provisions in the 21st Century Cures Act, which calls for changes to health IT provider certifications and wider patient access to electronic health information, or EHI. The new rules are described by HHS as "the most extensive health care data sharing policies the federal government has implemented, requiring both public and private entities to share health information between patients and other parties while keeping that information private and secure."

    "Delivering interoperability actually gives patients the ability to manage their health care the same way they manage their finances, travel, and every other component of their lives," Don Rucker, MD, HHS national coordinator for health information technology, said in an HHS press release. "This requires using modern computing standards … that give patients access to their health information and give them the ability to use the tools they want to shop for and coordinate their own care on their smartphones.'"

    Notable in the Final Rules
    Updates to ONC’s health IT certification program. Within the final rule, ONC made modifications toits health IT certification program, a voluntary certification program that establishes standards for functionality of health IT, including EHRs. Updates include adoption of the U.S. Core Data for Interoperability standard to replace the Common Clinical Data Set as the default data classes and data elements that health IT users should expect to be able to change between systems.

    Health IT developers will have to follow new requirements on application programming. At the heart of the rules are requirements for the development of application programming interface, or API, technologies that are more standardized and easier for patients to access. The 21st Century Cures Act requires that health IT developers publish APIs that allow “health information from such technology to be accessed, exchanged, and used without special effort through the use of APIs or successor technology or standards, as provided for under applicable law.” The law also states that a health IT developer “must, through an API, provide access to all data elements of a patient’s electronic health record to the extent permissible under applicable privacy laws.”

    Health care providers will have to do their part, too. The new API standards will in turn allow hospitals and other health care providers to more easily share EHI — as long as they are equipped with the technology that allows them to comply. The ONC rule has varying effective dates; the CMS rule doesn't take effect until January 1, 2021.

    There are penalties for "information blocking." Under the ONC rule, developers and providers (including physical therapists) will be required to avoid any EHI accessibility restrictions that constitute "information blocking" — everything from limits on patient access to their data to interoperability problems that make it difficult for providers to share data with each other when needed. The CMS rule also allows the agency to publish the names of clinicians and facilities it believes to be engaged in information blocking beginning in late 2020 — specifically providers participating in the Promoting Interoperability category of the Merit-based Incentive Payment System, or MIPS.

    The rule acknowledges the need for exceptions to the information-blocking requirements. The ONC rule also carves out exceptions for eight "reasonable and necessary" activities that "actors" (health care providers, health IT developers of certified health IT, health information exchanges, and health information networks) may engage in that could limit access to EHI. Only one exception needs to be met in order to avoid penalties for information blocking, but that exception must be met "at all relevant times," not just as a one-off occurrence. A practice that fails to meet all of the conditions of an exception will be evaluated on a case-by-case basis to assess the specific facts and circumstances to determine whether information blocking has occurred.

    The CMS rule applies principles regarding patient data sharing to Medicare, Medicaid, CHIP, and the insurance exchanges, with a January 1, 2021, implementation date. Patients in these programs will have the same level of access to their EHI as those covered by the ONC rule.

    Advisory: PTs, Telehealth, and the Coronavirus

    Wondering whether you can provide PT services via telehealth during the COVID-19 outbreak?

    As the coronavirus continues to spread globally, members are asking about the possibility of reducing infection risk by conducting PT services through telehealth. There are important factors to consider, particularly related to telehealth services to Medicare and Medicaid beneficiaries.

    Remember: Physical therapists are not statutorily authorized Medicare providers of telehealth, and physical therapy services delivered via telehealth are not payable under the physician fee schedule. Before you consider furnishing telehealth services to Medicare beneficiaries and collecting out of pocket payment, contact your Medicare Administrative Contractor or CMS regional office to ask for an opinion.

    As for commercial insurers, check with individual payers to verify what is and is not permitted. Be sure to confirm with each payer whether the originating site can be a private home or office, if services must be real-time or can be asynchronous, and any other limitations to your use of telehealth.

    APTA Launches Fundraising Campaign for Diversity, Equity, and Inclusion

    The first 10,000 people to contribute at least $10 will have their name included on the Community Wall at APTA’s new headquarters.

    APTA’s centennial is fewer than nine months away, but already the association is building a foundation for its next 100 years.

    Today, APTA opened online donations for the Campaign for Future Generations, a two-year fundraising initiative to support the association’s commitment to diversity, equity, and inclusion.

    The campaign aligns with the association’s current strategic plan, which includes a goal to foster the long-term sustainability of the profession by making APTA an inclusive organization that reflects the diversity of the society the profession serves.

    APTA has a long history of providing support to PT and PTA students and faculty of ethnic and racial minorities through the Minority Scholarship Fund, which is included in the campaign. In addition, the Dimensions of Diversity Fund has been established to support additional DEI initiatives, as approved by APTA’s Board of Directors. Unrestricted donations made to the association’s Physical Therapy Fund also would support the Dimensions of Diversity Fund or the Minority Scholarship Fund, as needed.

    APTA will also donate any net proceeds from its centennial year events and activities to support the Campaign for Future Generations.

    “As we think about the profession and association we want to be in our next century, we have to be intentional about DEI,” said APTA President Sharon Dunn, PT, PhD. “It was important to our board that we use our centennial year to establish a legacy gift that will support the stewardship of our association and profession.”

    APTA is already expanding its efforts on DEI. For example, last year APTA conducted or attended 25 recruitment events, reaching over 10,000 students, parents, teachers, and guidance counselors to improve pipelines to the profession. APTA also is advocating for the Allied Health Workforce Diversity Act, which creates a scholarship program for individuals from underrepresented populations for the fields of physical therapy, occupational therapy, audiology, and speech-language pathology.

    DEI was also a theme of President Dunn’s 2018 and 2019 annual addresses to the House of Delegates.

    What you can do:

    TRICARE Balks at Covering TENS and Dry Needling

    The TRICARE Health program used throughout the U.S. Department of Defense health care system has disallowed transcutaneous electrical nerve stimulation — TENS — as a reimbursable treatment for low back pain. And in another recent shift, the DoD agency that oversees TRICARE has decided that dry needling will not be covered if it's the sole purpose for a visit.

    The TENS decision was announced by the Defense Health Agency on February 26 and is effective June 1, 2020. In the notice of the change, the DoD says the TRICARE policy manual will now list TENS as an "unproven" treatment for low back pain and thus not eligible for coverage. Until now, TRICARE contractors were allowed to decide whether TENS was medically necessary for treatment of LBP.

    According to a recent article in Military.com, DoD arrived at its decision after reviewing multiple studies that found weak evidence for the effectiveness of TENS for LBP, with a TRICARE official telling the site that the findings indicated that "TENS for lower back pain is no more effective than … placebo."

    But the changes don't stop there. The revised TRICARE policy manual also lists dry needling as an "unproven" treatment — not just for LBP, but for any condition.

    The change means that TRICARE will not cover a PT visit if dry needling is the "sole purpose" for the session. This policy is effective immediately.

    TRICARE serves active duty and retired service members and their families worldwide.

    "APTA is disappointed in the Defense Health Agency’s decision and questions some of the evidence used to support its decision, and this doesn't change our commitment to advocating for coverage for these services across payers," said Kara Gainer, APTA's director of regulatory affairs. "Patient access to the most appropriate, evidence-based care and respect for the clinical decision-making skills of physical therapists remain at the heart of our policy efforts."

    Coronavirus Reports: What We Know, and What We Don't

    Every day there are new developments in the spread of coronavirus — also known as COVID-19 — but there are also debates among experts on how the disease is spread and its impact on people who become infected. While overall risk of catching the disease is low, health care professionals are at higher risk. APTA reminds PTs and PTAs to follow precautions for reducing the spread of infectious diseases — an important aspect of health care to be mindful of at all times, not just during periods of high risk.

    Since the disease first appeared in Wuhan, China, in December 2019, it has affected over 92,000 people in more than 70 countries on every continent. As of the afternoon of March 3, the Johns Hopkins University coronavirus tracker registered 108 COVID-19 cases in the United States, including six deaths.

    Note: at this time all APTA national events are continuing as scheduled. Contact APTA member services if you have questions related to attendance of an upcoming event.

    As with all public health situations, we primarily rely on the Centers for Disease Control and Prevention, the Occupational Health and Safety Administration, and the U.S. Office of the Surgeon General for the best information and preventive strategies.

    Here is a roundup of what is being reported by public health and infectious disease experts:

    The World Health Organization says risk of global spread "very high." (Bloomberg)
    On Monday, March 2, WHO increased its warning of global spread and impact risk from "high" to "very high." In response to the disease's spread, many countries have tightened border controls, restricted flights, shut down schools, and cancelled large events. (The CDC provides a travel update webpage.)

    The average infected patient spreads the virus to 2.2 others. (NEJM)
    Researchers in China estimate that on average individuals with COVID-19 have been spreading the illness to at least 2 people, compared with 3 with SARS. Authors write, "Measures to prevent or reduce transmission should be implemented in populations at risk." According to the CDC, among travel-related U.S. cases there has been "no sustained person-to-person transmission" of symptomatic COVID-19.

    The mortality rate is estimated around 3.4%, but some say it may be less than that. (Reuters)
    While the current mortality rate from COVID-19 is approximately 3.4%, some experts say that the mortality rate could be much lower because many carriers with mild or no symptoms may not be identified.

    Experts are unsure why some recovered patients appear to become reinfected. (Reuters)
    In confirmed cases in Japan and China, some recovered patients have again tested positive for COVID-19 but were not contagious. Experts are uncertain whether these are new infections. People could become reinfected because they didn't build up enough antibodies while they were infected the first time, but it's also possible that the virus could lie dormant and symptoms could reappear again later.

    Debate still is under way about transmission via hard surfaces. (Reuters)
    While experts agree that the virus is mainly transmitted by respiratory droplets in the air — coughing or sneezing on a person — research is ongoing on whether hard surfaces are a significant route of transmission. CDC Director Robert Redfield told Congress, "On copper and steel it's pretty typical, it's pretty much about two hours, but I will say on other surfaces — cardboard or plastic — it's longer, and so we are looking at this." (WHO recommends disinfecting any hard surfaces.)

    The Surgeon General discourages masks for non-health care providers. (CNN Health)
    U.S. Surgeon General Jerome Adams, MD, MPH, asks the public to stop buying face masks to prevent COVID-19 infection. According to Adams, it results in a shortage for the health care providers who need them, and people who wear them incorrectly could actually increase their chance of being infected.

    To keep abreast of evidence-based news on COVID-19, here a few free reputable sources:

    A Space Odyssey: Architects and PTs Talk Clinic Design

    When architect Maryam Katouzian says "one size does not fit all" in terms of physical therapy clinics, Lauren Lobert, PT, DPT, likely couldn't agree more. Katouzian is part of the architectural team that designed the Ivy Mountain Musculoskeletal Center, a 194,000-square-foot facility for the University of Virginia now under construction. Lobert, meanwhile, is the proud owner of a 1,300 square-foot clinic repurposed from a strip mall clothing store in Brighton, Michigan.

    Yet Katouzian and Lobert have a common vision: creating the most effective spaces for patients, no matter the scale of the endeavor.

    This month in PT in Motion magazine: "Designing for the Future" a Q&A session featuring six individuals — a mix of PTs, architects, and executives — who have been involved in creating or recreating clinic spaces. Those spaces range not only from large to small clinics, but from multifacility plans to a clinic subarea devoted to patients’ family and caregivers. In one case, the project even involved downsizing.

    Interviewees answer questions about their overall goals when designing the new space, use of architects in the process, involvement of patients in design, and lessons learned along the way. The range of perspectives and approaches makes it clear that the one-size-doesn't-fit-all concept applies to far more than just square footage.

    "Designing for the Future" is featured in the March issue of PT in Motion magazine and is open to all viewers — pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA.

    PT, PTA Education Leadership Institute Accepting Applications for Award-Winning Program

    Being a director for a PT or PTA education program can seem as lonely as it is overwhelming — but it doesn't have to be that way. Again in 2020, APTA is inviting a select group of emerging and current program directors to its Education Leadership Institute, a program that provides opportunities to learn from mentors and each other in ways that will enhance their own work and strengthen the profession. Applications are being accepted through March 15, 2020.

    The yearlong program, also known as ELI, uses a blended learning approach (online and onsite components) to help directors in physical therapy education programs develop the skills and resources they need to become innovative, influential, and visionary leaders. The institute is highly rated by past participants and in 2019 earned national recognition from the American Society of Association Executives for its innovative programming.

    ELI is a collaborative effort of APTA, the American Council of Academic Physical Therapy, the Academy of the Physical Therapy Education, and the Physical Therapist Assistant Educators Special Interest Group. It is accredited by the American Board of Physical Therapy Residency and Fellowship Education.

    Considering the fellowship experience? Check out video testimonials of ELI graduates. Questions? Contact annereicherter@apta.org.