CMS representatives say hospitals could opt for a process to designate outpatients' homes as "temporary expansion locations" to allow for remote care.

[Note: This story was updated with new information on May 11.]

 The U.S. Centers for Medicare & Medicaid Services provided more clarity on recent guidance related to COVID-19 waivers, and the new details are mostly good news for PTs, PTAs, and patients. Among the answers provided by CMS representatives: PTAs working in private practices can furnish telehealth under Medicare Part B with services billed by the supervising PT, and hospitals could choose a pathway that would allow their outpatient department PTs and PTAs to provide care remotely.

The clarifications were provided in a May 5 conference call with APTA and other stakeholders about recent guidance from CMS that, among other provisions, established a private practice PT's ability to provide services delivered via real-time, face-to-face telehealth technology under Medicare Part B. That guidance was issued to better articulate CMS' interpretation of an interim rule that includes multiple waivers to respond to the COVID-19 public health emergency.

Not surprisingly, even after the interim rule was released and subsequent guidance issued, APTA and providers had questions. CMS has now provided some — but not all —of the answers. A recording of the call and a transcript will be posted on the CMS Podcasts and Transcripts webpage.

[Editor's note: Need an even deeper dive into the CMS guidance and interim rule? Join APTA regulatory affairs and practice staff for a Facebook Live Q&A session at 2 p.m. ET on May 7.]

PTAs, Telehealth, and Direct Supervision

PTAs can furnish telehealth. According to CMS representatives, PTAs are included among the providers who can furnish services by way of telehealth, with the supervising therapist able to bill for those services. The allowance only applies to professional services under Medicare Part B, meaning that only PTs and PTAs in private practice can make use of the telehealth provision.

Virtual direct supervision of PTAs may be allowed under certain circumstances. CMS reps acknowledged that during the public health emergency, "direct supervision" includes real-time interactive audio and visual communications "when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider" (that's the language from the April 6 interim final rule). During the May 5 conference call, CMS said this flexibility could be applied in the context of the PT directly supervising the PTA in private practice.

APTA's advice: Until CMS provides written confirmation and more details, don't make a switch to virtual direct supervision. And regardless of policy, PTs and PTAs must still comply with state supervision requirements.

 UPDATE, May 11, 2020: Since the May 5 conference call, CMS clarified that virtual direct supervision is possible. During a May 7 conference call, the agency confirmed that the supervision changes explained in an earlierFAQ did in fact apply to PTs and PTAs in private practices. 

Remote Care Provided by Hospital-Employed PTs and PTAs to Hospital Outpatients

Hospitals could choose to follow a process that would enable PTs and PTAs who furnish therapy in the hospital outpatient department and whose services are billed by the hospital through the UB-04 claim form to furnish remote care to registered outpatients — provided the hospital registers the patient's address as a temporary expansion location. It's up to each hospital to determine whether it's necessary and feasible to add a temporary expansion location to its provider-based department, but if it's within scope of practice and doesn't run counter to state laws and regulations, hospital-employed PTs and PTAs could be eligible to provide remote therapy to patients registered as hospital outpatients, and the hospital would bill as if the services were provided in person. But the hospital first must register the patient’s home as a temporary expansion location of the hospital’s outpatient department, referred to as the provider-based department or PBD, during the public health emergency. Registration includes justifying the need to add a relocation site such as a patient’s home.

This shouldn't be interpreted as a green light for hospital-based PTs and PTAs to engage in remote therapy. While CMS says it is providing this flexibility to allow hospitals to maintain treatment capacity and deliver needed care for patients, a hospital may choose to maintain the status quo.

CMS needs to be notified if a hospital chooses to add patients’ homes as temporary expansion locations. According to guidance that can be found on page 41 of the CMS interim final rule released on April 30, the hospital must notify its CMS regional office by email of the addresses it plans to identify as temporary expansion locations. That notification should be made within 120 days of beginning to furnish and bill for services at the relocation, and should include:

• Hospital's CMS certification number.
• Address of the current PBD.
• Addresses of the temporary expansion locations (referred to as relocated PBDs in the interim rule).
• Date on which services began at the relocated PBD.
• Brief justification for the relocation and role it plays in the hospital's response to the public health emergency.
• Attestation that the relocation is consistent with the relevant state's emergency preparedness or pandemic plan.

APTA will ask CMS if the hospital must submit a unique request each time it registers a hospital outpatient’s home as a PBD. Until a definitive answer is provided, we suggest hospitals pose this question to their CMS regional offices.

UPDATE, May 11, 2020: Since the May 5 conference call, CMS clarified that hospitals have flexibility in how they send the emails to CMS regional offices — as a single email with all patient addresses, or separate emails with each patient's address. The important thing is to send in the patients' addresses.

Use the DR condition code and CR modifier. Because the allowances are part of an official response to the public health emergency, hospitals must use both the "Disaster-Related" condition code and the "Catastrophe/Disaster-Related" modifier on claims. Details are available in this CMS guidance document.

SNFs, HHAs, Rehab Agencies, and Telehealth

SNFs and HHAs can't bill for telehealth services provided by PTs or PTAs. CMS was clear that for Medicare Parts A and B, SNFs and HHAs are not included among the providers with new, albeit temporary, telehealth flexibility. The new flexibilities apply only to professional services on a professional claim, or by way of the hospital rules involving PBD expansion sites (see above).

Rehab agency use of telehealth will be discussed, but for now the answer is no. During the call CMS representatives said the agency would consider the possibility of telehealth for rehab agencies and will provide clarification in the future. APTA recommends that for the time being, rehab agencies assume that telehealth is not billable.

APTA and other stakeholders are advocating for the expansion of telehealth provisions to SNFs, HHAs, rehab agencies, and other institutional settings. The association continues to press for changes and expansions, including a call for CMS to make its telehealth allowances permanent.