CMS releases additional interim final rule, creating more telehealth flexibility and featuring significant regulatory changes

On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released a second Interim Final Rule with new flexibilities and changes relevant to home-based medical care providers. The changes in this most recent Interim Final Rule are effective immediately, with many modifications retroactively effective as of 3/01/2020. These include the following:

• CMS increased the payment for telephone Evaluation and Management (E/M) visits to be similar to payment for an office visit. This was done to accommodate providers who are caring for patients without access to two-way audio and video technology. When seeking reimbursement for telephone visits, physicians and other qualified healthcare professionals (i.e., nurse practitioners and physician assistants) may use the Telephone E/M CPT codes listed below. CMS also designated these telephone E/M services as “Medicare telehealth services,” and as such, they will require modifier 95.
• • CPT 99441Telephone E/M 5-10 minutes; Increased Non-Facility Payment $46.19; wRVU 0.48
  • CPT 99442Telephone E/M 11-20 minutes; Increased Non-Facility Payment $76.15; wRVU 0.97
  • CPT 99443Telephone E/M 21-30 minutes; Increased Non-Facility Payment $110.43; wRVU 1.50
• In addition, the following services can also now be billed when using audio only:
• • Advance Care Planning (CPT 99497, 99498)
  • Annual Wellness Visits (HCPCS G0438, G0439)
  • Smoking Cessation Services (CPT 99406, 99407)
  • Alcohol and/or substance abuse (other than tobacco) structured assessment (e.g., AUDIT*, DAST**), and brief intervention services (HCPCS G0396, G0397)
  • Annual Alcohol Misuse Screening and Counseling (HCPCS G0442, G0443)
  • Annual Depression Screening (HCPCS G0444)
  • Chronic Care Management (CCM) Care Planning Services; please note this service is only to be used one time for new patients or patients who are not seen within a year when first enrolled in CCM (HCPCS G0506)

*Drug Abuse Screening Test
**Alcohol Use Identification Test

• Be aware Medicare has designated additional services, e.g., psychotherapy and other therapy-related, nutrition, and education services, that allow for payment when provided via audio-only telehealth. To review the full list of Medicare audio-only telehealth services, visit the Medicare list of telehealth services.
• The home and domiciliary E/M codes still require a two-way audio and video telecommunication method. Please review the CMS Fact Sheet and the revised FAQ that was released on 4/30/2020 for additional details.

Additional Key Updates:

• CMS has officially adopted the regulation allowing for nurse practitioners, physician assistants, and clinical nurse specialists to order, establish and monitor plans of care, and certify and re-certify patients for home health services as mandated under the CARES Act. This change is permanent and applies to any service provided on or after 3/01/2020. (Click here for a guide to the CARES Act.)
• CMS finalized on an interim basis that they will not enforce the clinical indications for therapeutic glucose monitors and they’re not subject to National Coverage Determinations (NCDs) and Local Coverage Determinations (LCSs). CMS had previously finalized on an interim basis that they will not enforce the clinical indications for respiratory devices, anticoagulation management, and infusion pumps. CMS did remind clinicians that services must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member to be paid under Medicare. Physicians, practitioners, and suppliers are required to continue documenting the medical necessity for all services.
• CMS waived the 16-day minimum requirement to bill for Remote Patient Monitoring (RPM) services, but only for patients who have suspected or confirmed COVID-19. In such cases, CMS recognized the value of short-term monitoring (no less than two days) for acute conditions and is allowing payment for CPT codes 99453, 99454, 99091, 99457, and 99458.
• Until now, CMS used only its rulemaking process to add new services to the list of approved Medicare telehealth services. However, CMS is changing its process during the Public Health Emergency and will add new telehealth services on a sub-regulatory basis.
• CMS waived some restrictions on the types of healthcare professionals that can furnish Medicare telehealth services for the remainder of the Public Health Emergency. Physical therapists, occupational therapists, and speech-language pathologists are now added to the list of eligible providers, which had already included physicians, nurse practitioners, physician assistants, licensed clinical social workers, and clinical psychologists. These providers can bill for telehealth services subject to the scope of practice laws.
• CMS will no longer require a practitioner’s written order for patients to receive a COVID-19 test or other certain testing (e.g., serology testing) to diagnose and treat COVID-19. Pharmacists can also now perform COVID-19 tests if they’re enrolled in Medicare as a laboratory. Additionally, pharmacists can work with qualified healthcare professionals who are credentialed to bill Medicare to provide assessment and specimen collection services relating to a COVID-19 diagnosis. The physician or other qualified healthcare professional can bill Medicare for the test. This allows for parking-lot test sites and more rapid testing. (This is subject to state scope of practice laws.)
• CMS is allowing hospitals to bill as the originating site for telehealth services, even if the patient is located at home. This applies to hospital-based practitioners for Medicare patients who are registered as hospital outpatients. This may be impactful for Hospital at Home® providers.
• CMS is adjusting the financial methodology used for COVID-19 costs incurred by Accountable Care Organizations (ACOs) so they will be treated equitably regardless of the extent to which their patient populations are affected by the pandemic. ACOs can also forgo the annual application process; if their participation is set to end this year, they have the option to extend for another year. ACOs that are required to increase their financial risk during the current agreement period will have the option to maintain their current risk level for next year, instead of advancing automatically to the next risk level. CMS also includes virtual services, including virtual check-ins, remote evaluations, and telephone E/M services, as primary care services considered for beneficiary attribution.
• CMS announced a new Coronavirus Commission for Safety and Quality in Nursing Homes. Read the Fact Sheet here.

Disclaimer: This information is current as of 5/05/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses its content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region. Medicare Advantage and commercial payor policies will vary.