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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?

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.

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.

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