COVID-19 Regulatory Changes and Resources

In these trying times, it is important to keep informed. We will be providing a summary of regulatory changes in this article. Please keep in mind that these changes are considered temporary and will be effective from 3/30/2020 through as long as the COVID-19 Public Health Emergency declaration remains in effect. Other legislation is being considered so it’s important to keep updated with the sources below for the most current information. For any clinical practice changes, clinicians are still subject to state regulations including scope of practice.

Telehealth Services under Medicare

For telehealth coverage by Medicaid and private payers, please see Telehealth Services under Medicaid and private insurance further down.

CMS has published a list of CPT codes that, when provided by telehealth, are reimbursable under the Medicare Physician Fee Schedule. However, according to the CMS telehealth FAQs question 6, nurses and therapists are still not considered Qualified Providers. Keep checking regulatory updates, though, as this may change – especially since some therapy CPT codes have been included in the approved telehealth list. The only significant billing change to telehealth at this time is that Qualified Professionals may provide telehealth services to patients in their homes. Again, nurses and therapists are currently not considered telehealth Qualified Professionals.

CMS will allow home health agencies to provide “more services to beneficiaries using telehealth within the 30 day episode of care, so long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care.” These services are not specifically listed in the summary but as long as the service is ordered by the physician, appropriate for telehealth and included in the plan of care, it should be allowed. Telehealth services provided through a home health plan of care are NOT billable by the home health agency so be careful about LUPA thresholds which are still calculated based on billable in-person visits.

While telehealth services are not allowed to be performed by therapists at this time, there are other classifications of services called remote evaluations and virtual check-ins that are allowed to be performed and billed by therapists (not assistants). Remote evaluations are billed under code G2010 and virtual check-ins are billed under code G2012. E-visits (“non face-to-face patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office”) continue to be allowed and are billed under codes G2061, G2062 and G2063 which require the GP, GO or GN modifier in addition to a CR (catastrophe/disaster related) modifier when billing. For e-visits, do not use place of service 02 (telehealth) as this service does not meet the definition of a telehealth service. You may use 12 (home) or 11 (clinic/office) for place of service for these codes. Make sure you thoroughly document your communication and actions. See the APTA telehealth article and APTA E-Visits article for more information about these services.

Homebound definition expanded

Patients whose physicians have advised them not to leave home because (1) they have a confirmed COVID-19 diagnosis, (2) they have a suspected COVID-19 diagnosis, or (3) they are more vulnerable to contract COVID-19 due to a medical condition are considered homebound. Beneficiaries who require skilled services and meet any of the temporary COVID-19 homebound requirements are considered homebound and eligible for home health care.

Certifying/Recertifying professionals expanded

A nurse practitioner, clinical nurse specialist or a physician assistant may “(1) order home health services; (2) establish and periodically review a plan of care for home health services (e.g., sign the plan of care), (3) certify and re-certify that the patient is eligible for Medicare home health services.” CMS states that they will not enforce the requirement that only physicians sign orders and plans of care for claims submitted during the COVID-19 emergency.

Reporting, assessment and payment

CMS is allowing providers to complete the comprehensive OASIS assessment within 30 days (instead of the original 5 days) and have allowed delayed submission of OASIS files. The submission timeframe has not been indicated in the summary. Providers still must complete the comprehensive assessment and submit it to CMS as they are able.

CMS has waived 42 CFR §484.55(a). This allows home health agencies to assess patients remotely or by record review to determine appropriateness for home health. This record or remote assessment would not be billable, it will only help to minimize home health visits to patients who do not qualify for home health services.

CMS has allowed the extension of the auto-cancel date for RAPs. This will be determined by the MAC so agencies should follow up with their MAC to find out more details. Previously, RAPs were subject to auto-cancellation if a final claim was not received within 120 days after the start of episode or 60 days after the RAP payment date.

Medical reviews including the Review Choice Demonstration

Most Medicare Fee-For-Service medical review have been suspended during the COVID-19 emergency period. This includes Targeted Probe and Educate (TPE) by the MACs, Supplemental Medical Review Contractor (SMRC) and Recovery Audit Contractor (RAC) reviews. Claims currently suspended for these types of audits will be released and paid unless the review is a result of suspected fraud.

For those states subject to the Review Choice Demonstration, the program is paused for the duration of the Public Health Emergency. To clarify, claims with effective dates prior to March 29, 2020 and after the emergency declaration has ended will still be subject to review choice demonstration. Providers who have chosen the pre-claim review option may continue to submit pre-claim review documentation to ensure that those claims will be excluded from future medical review. However, claims submitted without the UTN with dates of service during the Public Health Emergency will not be subject to the 25% payment reduction penalty. Agencies who opted for prepayment or postpayment review will not receive ADRs during the pause. For more information, check out Palmetto’s 2019 COVID-19 Provider Burden Relief FAQs.

Cost Report filing deadlines

Cost reports for fiscal year end 10/31/2019 (normally due by 3/31/2020) and fiscal year end 11/30/2019 (normally due by 4/30/2020) will be due by 6/30/2020. Fiscal year end 12/31/2019 cost reports normally due by 5/31/2020 will now be due by 7/31/2020.

COVID-19 lab testing

A current home health patient may have a laboratory sample for COVID-19 drawn by their home health nurse during the course of a covered visit.

HHA supervision

CMS has waived 42 CFR §484.80(h) which requires an onsite supervisory visit for a home health aide at least every two weeks. Virtual supervision is encouraged during this period so make sure that nurses are still documenting that they are speaking with aides and patients to gauge satisfaction and effectiveness of services.

Face-to-Face encounters

According to this resource from NAHC and this CMS fact sheet, physicians may perform their face-to-face encounter via telehealth as long as it is a two-way audiovisual communication system such as Skype, Facetime, Zoom, etc.

Telehealth Services under Medicaid and Private Insurance

States and private payers have issued their own notices specific to telehelth. Most are allowing telehelth sessions in place of face-to-face visits. Please consult your state’s health and family services department’s website for additional information pertaining to COVID-19. With CMS waiving penalties for “HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies”, such technologies are in fact okay to use. CMS is providing examples of what they are in this communication. A recent update to therapyBOSS added a designated telehealth activity type with the ability to document “Telehealth” as the place of service.

Helpful Resources

• CMS Current Emergencies page
• CMS Coronavirus Waivers with links to state’s waivers
• WHO COVID-19 page
• CDC COVID-19 page
• NAHC COVID-19 page
• NHPCO COVID-19 page
• APTA COVID-19 page
• AOTA COVID-19 page
• ASHA COVID-19 page
• therapyBOSS blog State and National Resources for Clinicians – this is from our past blog
• Medicare MACs – check with your local MAC for any region-specific regulatory guidance
• Clinical best practices webinar from APTA HPA – some nice clinical resources for therapists

The Wrap-Up

This article summarized some of the main points in the COVID-19 public health emergency waiver provisions but there is more information to view. For further and up-to-date details, including guidance for infection control and prevention for specific health care environments, please keep monitoring the CMS Current Emergencies page. Keep up with your MACs and state health departments as well.

Mr. Rogers famously said “When I was a boy and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’ To this day, especially in times of ‘disaster,’ I remember my mother’s words and I am always comforted by realizing that there are still so many helpers – so many caring people in this world.” Our entire therapyBOSS family thanks you for being those helpers and hopes you remain safe and healthy.