Regulatory Flexibility for an Overburdened System
The COVID-19 pandemic has been an all-hands-on-deck moment for the healthcare community, pushing the limits of capacity and forcing systems to suddenly adapt to a new reality. To help face the crisis, a Public Health Emergency (PHE) was officially declared for all 50 states on January 31st, a move that enabled the Centers for Medicare & Medicaid Services (CMS) to provide regulatory flexibility to help the overburden U.S. healthcare system meet the challenges. One notable area that has seen tremendous impact — quickly expanding access and capacity—is telehealth.
Blanket Waivers to Lift Telehealth Restrictions
The use of telehealth services in Medicare has been greatly expanded through two waves of blanket waivers issued by CMS between March and May of this year. They apply to all areas within the PHE – in this case, the entire country. By definition, they last no longer than the duration of the PHE, however the pandemic PHE has been renewed every 60 days, with no end currently in sight.
The first wave of blanket waivers, effective since March 6th, opened the lid on telehealth. Previously, telehealth appointments had been restricted to Medicare recipients living in rural areas. The March waivers opened that up to all areas of the country and health settings. In addition, the restriction on conducting a telehealth appointment as “first contact” was waived, and the types of practitioners permitted to provide their services by telehealth was greatly expanded to any provider who could bill Medicare — now including physical therapists, occupational therapists, speech language therapists, and others.
In total, 85 telehealth services were made payable in the first wave of relief, covering a broad spectrum from emergency room care to group psychotherapy, but that was only the beginning. Responding to the provider community, CMS provided further relief in April and May, bringing the number of billable telehealth services up to 231.
The second wave of relief continued to free up the use of telehealth services. Payment for telehealth services was increased to reflect the reality that these services were in many situations fully replacing the traditional in-office visits. Furthermore, blanket waivers were issued that enabled hospitals to bill certain telehealth services as outpatient care. This has allowed physicians to provide telehealth services from home with facility support. In addition, the requirement to have video on the call was waived for 89 of the 231 services listed, removing additional barriers where appropriate. Last but not least, this second wave also included a crucial clarification that smartphones could be used to conduct telehealth services (not just laptops/computers).
Further Developments and the Continued Use of Telehealth
CMS is now releasing proposed rules for next year that could continue to expand the list of billable telehealth services and make many of them permanent. CMS is also proposing a change in the definition of direct supervision to allow the supervising physician to be remote and use real-time, interactive audio-video technology rather than in-person. This reflects a huge shift in regulation, because physician supervision is a condition of payment for many outpatient services. Right now, any service performed incident-to a physician’s service cannot be performed via telehealth because of the need for direct supervision. For example, if a physician sees a patient via telehealth and determines that along with their new medication, the patient needs education on how to self-inject that medication, the education is considered an “incident-to” service and – by the current regulations – could not be performed via telemedicine unless the physician did it themselves. If a nurse did it, it wouldn’t be paid because of the direct supervision requirement. With the proposed change, so long as the physician is available via video, the training could be done via telemedicine. If finalized, the change would be in effect through December 31, 2021, or the end of the Public Health Emergency (PHE), whichever is later.
In addition, CMS is looking at frequency limits for nursing facility and hospital inpatient services provided via telemedicine, proposing to cover subsequent nursing facility care services furnished via telehealth to once every 3 days (the current rule covers it only once every 30 days). And finally, CMS is adding more services to the list, including the prolonged services code, group psychotherapy, neurobehavioral status exams, care planning for patients with cognitive impairment, and home visits.
Staying Current with Evolving Guidance
Regardless of whether a service is provided in-person or via telemedicine, the National Coverage Determinations (NCDs), National Coverage Analyses (NCAs), and Local Coverage Determinations (LCDs) for those services still must be applied. Fortunately, MCG Health offers the Medicare Compliance solution, which cuts through the many layers to optimize the search experience for Medicare coverage determinations. It is a comprehensive offering which includes all NCDs, LCDs, NCAs, and memos, and retains the ability to search determinations by CPT or HCPCS codes. The content is updated regularly to maintain alignment with CMS, and it’s managed with the same attention to detail by the same physician editor team that publishes MCG’s evidence-based care guidelines. These are the same guidelines used by nine of the largest U.S. health plans and over 2,000 hospitals.
You can learn more about MCG and request a demo of the Medicare Compliance solution by submitting an inquiry here.
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