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<p>On March 30, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an interim <a href="https://www.cms.gov/files/document/covid-final-ifc.pdf">final rule</a> that outlined additional flexibilities for providers to address the ongoing global COVID-19 pandemic. CMS believes that these “sweeping regulatory changes” will enable providers to focus on expected surges in patient care needs. Among the changes, CMS will now allow hospitals to provide certain routine services to inpatients through arrangements outside the hospital walls. Here are some key considerations for providers as they introduce these temporary measures into daily operations.</p>  <h5>VIRTUAL SERVICES</h5>  <p>Based on stakeholder feedback and the increased need to promote social distancing, CMS continues to build on the existing telehealth evaluation and management (E/M) codes to enable greater flexibilities for providers to render services. CMS addressed telemedicine criteria for inpatient rehabilitation facilities (IRFs), home health agencies, hospices, and expanded access for hospitals and healthcare practitioners. CMS stated that it “expect[s] physicians and other practitioners to use the E/M code that best describes the nature of the care they are providing, regardless of the physical location or status of the patient.” CMS added emergency department visit codes CPT 99281-99285, observation codes CPT 99217-99220 and CPT 99224-99226, and several hospital care codes to those services that may be rendered via telehealth. Below are important clarifications addressed in the final rule:</p>  <ul> 	<li>To ensure that the term “phone” is not narrowly interpreted, CMS temporarily revised 42 C.F.R. § 410.78(a)(3) to include telecommunications with a two-way, real-time interactive communication.</li> 	<li>The Office of the Inspector General does not intend to seek administrative sanctions against providers who forgo patient cost-sharing responsibilities for any virtual services, including check-ins, e-visits and telehealth visits.</li> 	<li>Patient consent for these services is required, and the final rule clarified that consent may be obtained by “auxiliary staff under general supervision, as well as by the billing practitioner.” Providers should also ensure that state Medicaid and private payer consent requirements are met.</li> 	<li>Practitioners such as licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists and speech-language pathologists may provide services through virtual check-ins and remote evaluations instead of through other, in-person means.</li> 	<li>For telehealth services, “office/outpatient E/M level selection can be based on medical decision making or time, with time defined as all of the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and/or physical exam in the medical record.”</li> </ul>  <h5>DIRECT SUPERVISION</h5>  <p>CMS provided a temporary makeover to the definition of direct supervision for purposes of teaching physician billing requirements, “incident to” requirements, pulmonary rehabilitation, cardiac rehabilitation, intensive cardiac rehabilitation services and diagnostic testing. Specifically, CMS has temporarily expanded the definition to permit the physician presence component through audio/video real-time communications technology, if necessary. These services can include telehealth services and services performed by auxiliary personnel, including contracted personnel, where appropriate.</p>  <h5>‘CONFINED TO THE HOME’ OR ‘HOMEBOUND’</h5>  <p>CMS is soliciting comments regarding its clarification that the definitions of “confined to the home” or “homebound” may be certified by a physician through references to recommendations for the Centers for Disease Control and Prevention. CMS noted that based on current guidelines, many Medicare beneficiaries may be considered confined to the home, but the physician must review and document this conclusion in the medical record. For home health services, the patient must meet the other Medicare home health eligibility requirements to receive Medicare home health services.</p>  <h5>CODING</h5>  <p>Providers currently use code POS 02 on the claim to identify Medicare telehealth services; however, CMS is finalizing on an interim basis the use of the CPT telehealth modifier, modifier 95, which should be applied to claim lines that describe services furnished via telehealth. CMS stated that it will maintain the facility payment rate for services billed using the general telehealth code POS 02 for practitioners that choose to maintain their current billing practices for Medicare telehealth.</p>  <h5>INPATIENT REHABILITATION FACILITIES</h5>  <p>Recognizing the potential for staffing shortages and facility operational shifts, CMS stated that IRFs are no longer required to document a post-admission physician evaluation in a patient’s medical record unless the provider believes that an evaluation is warranted within the first 24 hours of admission. IRFs that experience staffing fluctuations may also note the COVID-19 pandemic in a patient’s medical record where therapy services are not provided under the general three-hour requirements.</p>  <h5>SPECIMEN COLLECTION</h5>  <p>Independent laboratories will now be reimbursed a higher specimen collection fee. Importantly, these fees will apply only when the laboratory professional is drawing the specimen. A fee is not applicable where the technician is receiving a pre-drawn specimen. CMS also finalized a policy that technicians will receive the specimen collection fee and travel allowance for conducting COVID-19 testing from the location of a homebound patient or nonhospital inpatient. Notably, CMS’ guidance regarding the definitions of confined to the home and homebound may be an important consideration in determining patient eligibility for these services. The following CPT codes are available:</p>  <ul> 	<li>G2023, specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), any specimen source.</li> 	<li>G2024, specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), from an individual in a Skilled Nursing Facility or by a laboratory on behalf of a Home Health Agency, any specimen source.</li> </ul>  <h5>MOONLIGHTING</h5>  <p>CMS recognizes that resident physicians may be available to provide a broader array of services to assist with hospital response to the COVID-19 pandemic. Therefore, CMS stated that it is “amending our regulation in § 415.208 to state that the services of residents that are not related to their approved Graduate Medical Education programs and are performed in the inpatient setting of a hospital in which they have their training program are separately billable physicians’ services for which payment can be made under the Physician Fee Schedule provided that the services are identifiable physicians’ services and meet the conditions of payment for physicians’ services to beneficiaries.” Residents must still be allowed to provide these services under state law licensing requirements.</p>  <p>CMS continues to reassess and refine its policies through guidance documents, stakeholder calls and interactive calls with Medicare Administrative Contractors. For the most current official guidance, the CMS Current Emergencies pages is found <a href="https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page">here</a>.</p>  <p><em>Authorship Credit: Amy Fouts and Ernessa McKie</em></p>




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CMS Continues to Create Additional Regulatory Flexibilities in Efforts to Reduce Provider Burden and Focus on Patient Care

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