By Lauren Riplinger, JD
(New 5/4/20) Flexibility for Medicare Telehealth Services
Eligible Practitioners.Pursuant to authority granted under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), the Secretary has authorized additional telehealth waivers. CMS is waiving the types of practitioners that may bill for their services when furnished as Medicare telehealth services from the distant site. The waiver of these requirements expands the types of healthcare professionals that can furnish distant site telehealth services to include all those that are eligible to bill Medicare for their professional services. This allows health care professionals who were previously ineligible to furnish and bill for Medicare telehealth services, including physical therapists, occupational therapists, speech language pathologists, and others, to receive payment for Medicare telehealth services.
Additionally, CMS is modifying the process to add services to the Medicare telehealth services list and instead, will consider adding appropriate services as they are requested, on a subregulatory basis as practitioners are actively learning how to use telehealth as broadly as possible. A complete list of all Medicare telehealth services can be found here.
Audio-Only Telehealth for Certain Services. Pursuant to authority granted under the CARES Act, CMS is waiving the requirements of section 1834(m)(1) of the ACT and 42 CFR § 410.78(a)(3) for use of interactive telecommunications systems to furnish telehealth services, to the extent they require use of video technology, for certain services. This waiver allows the use of audio-only equipment to furnish services described by the codes for audio-only telephone evaluation and management services, and behavioral health counseling and educational services (see designated codes). Unless provided otherwise, other services included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.
Guidance for Processing Attestation Statements from Ambulatory Surgical Centers (ASCs) Temporarily Enrolling as Hospitals during the COVID-19 Public Health Emergency1
During the COVID-19 public health emergency (PHE), Centers for Medicare and Medicaid Services (CMS) is allowing all Medicare-enrolled ambulatory surgical centers (ASCs) to enroll as hospitals and provide inpatient and outpatient hospital services to help address the urgent need to increase hospital capacity to take care of patients.
Any Medicare-certified ASC wishing to enroll as a hospital during the COVID-19 PHE should notify the Medicare Administrative Contractor (MAC) that serves their jurisdiction of its intent by calling the MAC’s provider enrollment hotline and following the instructions noted in the 2019- Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs) document.
The ASC will be asked by the MAC to submit a signed attestation statement to the MAC. It should be noted that the provider cannot be certified/enrolled both as an ASC and hospital at the same time. If an ASC enrolls as a hospital, it must meet the hospital Conditions of Participation, to the extent not waived, and would receive hospital payments, not ASC payments. Therefore, any ASC that is enrolled as a hospital will have its ASC billing privileges deactivated for the duration of the time it is enrolled as a hospital.
The MAC will review and forward the signed attestation statement to the CMS RO mailbox, consistent with normal processes for ASC/hospital certification for further review. Within two business days, the CMS Regional Office (RO) will review all survey activity of the facility from the previous three years (recertification and/or complaint), to determine if Immediate Jeopardy (IJ)-level deficiencies were cited. For deemed status ASCs, CMS Central Office (CO) will provide a list to the CMS Survey Operations Group of those ASCs with IJ-level deficiencies cited within the previous three years.
If no IJ-level deficiencies were found in the previous three years, or if IJ-level deficiencies were found but subsequently removed through the normal survey process, the CMS RO will:
- Review and approve the attestation statement
- Create a new facility profile and certification kit in the Automated Survey Process Environment (ASPEN) and assign a hospital CMS Certification Number (CCN)
- Send a tie-in notice as a hospital to the MAC. The effective date of enrollment is the date when the attestation was accepted by the MAC
Note that an onsite survey is not required for approval. However, the CMS RO may authorize a survey by the State Survey Agency at a later date to ensure quality and safety. If survey activity is warranted, it will be a focused infection control survey based on QSO-20-20-ALL, and the availability of PPE as needed. Any need for enforcement actions would follow what is outlined in the referenced memo or any subsequent updates to the memo.
If IJ-level deficiencies are found within the last year and enforcement activities are currently ongoing, then the CMS RO will not accept the attestation and notify the MAC of denial of temporary hospital enrollment. No further actions will be taken to enroll the ASC as a hospital under this process.
Once the Secretary of the Department of Health and Human Services (Secretary) determines there is no longer a PHE due to COVID-19, the CMS RO will terminate the hospital CCN and send a tie-out notice to the applicable MAC. The MAC will deactivate the hospital billing privileges and reinstate the ASC billing privileges effective on the date the ASC terminates its hospital status. If the temporarily enrolled hospital decides to revert to an ASC prior to the end of the PHE period, they must notify their MAC in writing. Note that once there is no longer a need for the ASC to be a hospital under their state’s emergency preparedness or pandemic plan, the ASC should come back into compliance with all applicable ASC federal participation requirements, including the Conditions for Coverage.
If the ASC wishes to participate as a hospital after the PHE has ended, it must submit form 855A to begin the process of enrollment and initial certification as a hospital under the regular processes. An initial survey, either done by the State Agency or Accreditation Organization, will be conducted to determine compliance with all applicable hospital Conditions of Participation. CMS will provide any additional updates if this process changes as the PHE progresses or ends.
Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs), including Cancer Centers and Long-Term Care Hospitals (LTCHs)2
Verbal Orders. CMS is waiving the requirements of 42 CFR §482.23, §482.24 and §485.635(d)(3) to provide additional flexibility related to verbal orders where readback verification is required, but authentication may occur later than 48 hours. The following requirements are waived:
- 482.23(c)(3)(i) – If verbal orders are used for the use of drugs and biologicals (except immunizations), they are to be used infrequently.
- 482.24(c)(2) – All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient.
- 482.24(c)(3) – Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders. This would include all subparts at §482.24(c)(3).
- 485.635(d)(3) – Although the regulation requires that medication administration be based on a written, signed order, this does not preclude the CAH from using verbal orders. A practitioner responsible for the care of the patient must authenticate the order in writing as soon as possible after the fact.
(Revised 5/4/20) Emergency Medical Treatment & Labor Act (EMTALA). CMS is waiving the enforcement of section 1867(a) of the Act. This will allow hospitals, psychiatric hospitals, and critical access hospitals (CAHs) to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan. Additional guidance related to the establishment of drive through testing sites, clarification of expectations in relation to the triage process and the medical screening examination, and use of telehealth can be found here.
Reporting Requirements. CMS is waiving the requirements at 42 CFR §482.13(g) (1)(i)-(ii), which require hospitals to report patients in an intensive care unit whose death is caused by their disease, but who required soft wrist restraints to prevent pulling tubes/IVs, no later than the close of business on the next business day. Due to current hospital surge, CMS is waiving this requirement to ensure that hospitals are focusing on increased patient care demands and increased patient census, provided any death where the restraint may have contributed is still reported within standard time limits (i.e., close of business on the next business day following knowledge of the patient’s death).
Emergency Medical Treatment & Labor Act (EMTALA). CMS is waiving the enforcement of section 1867(a) of the Act. This will allow hospitals, psychiatric hospitals, and critical access hospitals (CAHs) to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan.
Patient Rights. CMS is waiving requirements under 42 CFR §482.13 only for hospitals that are considered to be impacted by a widespread outbreak of COVID-19. Hospitals that are located in a state which has widespread confirmed cases (i.e., 51 or more confirmed cases*) as updated on the CDC website, CDC States Reporting Cases of COVID-19 would not be required to meet the following requirements:
- 482.13(d)(2) – With respect to timeframes in providing a copy of a medical record.
- 482.13(h) – Related to patient visitation, including the requirement to have written policies and procedures on visitation of patients who are in COVID-19 isolation and quarantine processes.
- 482.13(e)(1)(ii) – Regarding seclusion.
*The waiver flexibility is based on the number of confirmed cases as reported by CDC and will be assessed accordingly when COVID-19 confirmed cases decrease.
Detailed Information Sharing for Discharge Planning for Hospitals and CAHs. CMS is waiving the requirement 42 CFR §482.43(a)(8), §482.61(e), and §485.642(a)(8) to provide detailed information regarding discharge planning, described below:
- The hospital, psychiatric hospital, and CAH must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term care hospital (LTCH) quality measures and resource use measures. The hospital must ensure that the post-acute care data on quality measures and resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.
- CMS is maintaining the discharge planning requirements that ensure a patient is discharged to an appropriate setting with the necessary medical information and goals of care as described in 42 CFR §482.43(a)(1)-(7) and (b).
Limiting Detailed Discharge Planning for Hospitals. CMS is waiving all the requirements and subparts at 42 CFR §482.43(c) related to post-acute care services so as to expedite the safe discharge and movement of patients among care settings, and to be responsive to fluid situations in various areas of the country. CMS is maintaining the discharge planning requirements that ensure a patient is discharged to an appropriate setting with the necessary medical information and goals of care as described in 42 CFR §482.43(a)(1)-(7) and (b). CMS is waiving the more detailed requirement that hospitals ensure those patients discharged home and referred for HHA services, or transferred to a SNF for post-hospital extended care services, or transferred to an IRF or LTCH for specialized hospital services, must:
- 482.43(c)(1): Include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient.
- 482.43(c)(2): Inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services.
- 482.43(c)(3): Identify in the discharge plan any HHA or SNF to which the patient is referred in which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare.
Medical Records. CMS is waiving requirements under 42 CFR §482.24(a) through (c), which cover the subjects of the organization and staffing of the medical records department, requirements for the form and content of the medical record, and record retention requirements, and these flexibilities may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan. CMS is waiving §482.24(c)(4)(viii) related to medical records to allow flexibility in completion of medical records within 30 days following discharge from a hospital.
Telemedicine. CMS is waiving the provisions related to telemedicine at 42 CFR §482.12(a) (8)–(9) for hospitals and §485.616(c) for CAHs, making it easier for telemedicine services to be furnished to the hospital’s patients through an agreement with an off-site hospital.
Utilization Review. CMS is waiving certain requirements under 42 CFR §482.1(a)(3) and 42 CFR §482.30 which address the statutory basis for hospitals and includes the requirement that hospitals participating in Medicare and Medicaid must have a utilization review plan that meets specified requirements.
- CMS is waiving the entire utilization review condition of participation Utilization Review (UR) at §482.30, which requires that a hospital must have a UR plan with a UR committee that provides for a review of services furnished to Medicare and Medicaid beneficiaries to evaluate the medical necessity of the admission, duration of stay, and services provided. These flexibilities may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.
Written Policies and Procedures for Appraisal of Emergencies at Off Campus Hospital Departments. CMS is waiving 42 CFR §482.12(f)(3), emergency services, with respect to surge facilities only, such that written policies and procedures for staff to use when evaluating emergencies are not required for surge facilities. These flexibilities may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.
Emergency Preparedness Policies and Procedures. CMS is waiving 42 CFR §482.15(b) and §485.625(b), which requires the hospital and CAH to develop and implement emergency preparedness policies and procedures, and §482.15(c)(1)–(5) and §485.625(c)(1)–(5) which requires that the emergency preparedness communication plans for hospitals and CAHs to contain specified elements with respect to the surge site. The requirement under the communication plan requires hospitals and CAHs to have specific contact information for staff, entities providing services under arrangement, patients’ physicians, other hospitals and CAHs, and volunteers. This would not be an expectation for the surge site. This waiver applies to both hospitals and CAHs.
Quality Assessment and Performance Improvement Program. CMS is waiving 42 CFR §482.21(a)–(d) and (f), and §485.641(a), (b), and (d), which provide details on the scope of the program, the incorporation, and setting priorities for the program’s performance improvement activities, and integrated Quality Assurance & Performance Improvement programs (for hospitals that are part of a hospital system). These flexibilities, which apply to both hospitals and CAHs, may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan. CMS expects any improvements to the plan to focus on the Public Health Emergency (PHE). While this waiver decreases burden associated with the development of a hospital or CAH QAPI program, the requirement that hospitals and CAHs maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program will remain. This waiver applies to both hospitals and CAHs.
Flexibility for Inpatient Rehabilitation Facilities Regarding the “60 Percent Rule”. CMS is allowing IRFs to exclude patients from the freestanding hospital’s or excluded distinct part unit’s inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the “60 percent rule”) if an IRF admits a patient solely to respond to the emergency and the patient’s medical record properly identifies the patient as such. In addition, during the applicable waiver time period, CMS will also apply the exception to facilities not yet classified as IRFs, but that are attempting to obtain classification as an IRF.
Long-Term Care Facilities and Skilled Nursing Facilities (SNFs) and/or Nursing Facilities (NFs)3
Three-Day Prior Hospitalization. Using the authority under Section 1812(f) of the Act, CMS is waiving the requirement for a three-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).
Reporting Minimum Data Set. CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission.
Resident Transfer and Discharge. CMS is waiving requirements in 42 CFR 483.10(c)(5); 483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv), (c)(9), and (d); and § 483.21(a)(1)(i), (a)(2)(i), and (b) (2)(i) (with some exceptions) to allow a long term care (LTC) facility to transfer or discharge residents to another LTC facility solely for the following cohorting purposes:
- Transferring residents with symptoms of a respiratory infection or confirmed diagnosis of COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents;
- Transferring residents without symptoms of a respiratory infection or confirmed to not have COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents to prevent them from acquiring COVID-19; or
- Transferring residents without symptoms of a respiratory infection to another facility that agrees to accept each specific resident to observe for any signs or symptoms of a respiratory infection over 14 days.
- These requirements are only waived in cases where the transferring facility receives confirmation that the receiving facility agrees to accept the resident to be transferred or discharged. Confirmation may be in writing or verbal. If verbal, the transferring facility needs to document the date, time and person that the receiving facility communicated agreement.
- In § 483.10, CMS is only waiving the requirement, under § 483.10(c)(5), that a facility provide advance notification of options relating to the transfer or discharge to another facility. Otherwise, all requirements related to § 483.10 are not waived. Similarly, in § 483.15, CMS is only waiving the requirement, under § 483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv), and (d), for the written notice of transfer or discharge to be provided before the transfer or discharge. This notice must be provided as soon as practicable.
- In § 483.21, CMS is only waiving the timeframes for certain care planning requirements for residents who are transferred or discharged for the purposes explained in 1–3 above. Receiving facilities should complete the required care plans as soon as practicable, and CMS expects receiving facilities to review and use the care plans for residents from the transferring facility and adjust as necessary to protect the health and safety of the residents the apply to.
- These requirements are also waived when the transferring residents to another facility, such as a COVID-19 isolation and treatment location, with the provision of services “under arrangements,” as long as it is not inconsistent with a state’s emergency preparedness or pandemic plan, or as directed by the local or state health department. In these cases, the transferring LTC facility need not issue a formal discharge, as it is still considered the provider and should bill Medicare normally for each day of care. The transferring LTC facility is then responsible for reimbursing the other provider that accepted its resident(s) during the emergency period.
- If the LTC facility does not intend to provide services under arrangement, the COVID-19 isolation and treatment facility is the responsible entity for Medicare billing purposes. The LTC facility should follow the procedures described in 40.3.4 of the Medicare Claims Processing Manual to submit a discharge bill to Medicare. The COVID-19 isolation and treatment facility should then bill Medicare appropriately for the type of care it is providing for the beneficiary. If the COVID-19 isolation and treatment facility is not yet an enrolled provider, the facility should enroll through the provider enrollment hotline for the Medicare Administrative Contractor that services their geographic area to establish temporary Medicare billing privileges.
CMS reminds LTC facilities that they are responsible for ensuring that any transfers (either within a facility, or to another facility) are conducted in a safe and orderly manner, and that each resident’s health and safety is protected. CMS also reminds states that under 42 CFR 488.426(a)(1), in an emergency, the State has the authority to transfer Medicaid and Medicare residents to another facility.
(New 5/4/20) Detailed Information Sharing for Discharge Planning for Long-Term Care (LTC) Facilities. CMS is waiving the discharge planning requirement in §483.21(c)(1)(viii), which requires LTC facilities to assist residents and their representatives in selecting a post-acute care provider using data, such as standardized patient assessment data, quality measures and resource use. This temporary waiver is to provide facilities the ability to expedite discharge and movement of residents among care settings. CMS is maintaining all other discharge planning requirements, such as but not limited to, ensuring that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident; involving the interdisciplinary team, as defined at 42 CFR §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan address the resident’s goals of care and treatment preferences.
(New 5/4/20) Quality Assurance and Performance Improvement (QAPI). CMS is modifying certain requirements in 42 CFR §483.75, which requires long-term care facilities to develop, implement, evaluate, and maintain an effective, comprehensive, data driven QAPI program. Specifically, CMS is modifying §483.75(b)–(d) and (e)(3) to the extent necessary to narrow the scope of the QAPI program to focus on adverse events and infection control.
(New 5/4/20) Clinical Records. CMS is modifying the requirement at 42 CFR §483.10(g)(2)(ii) which requires long-term care (LTC) facilities to provide a resident a copy of their records within two working days (when requested by the resident). Specifically, CMS is modifying the timeframe requirements to allow LTC facilities ten working days to provide a resident’s record rather than two working days.
LTC Facility Transfer Scenarios. In response to the recent questions related to cohorting, CMS is providing supplemental information for transferring or discharging residents between facilities. In general, if two or more certified LTC facilities want to transfer or discharge residents between themselves for the purpose of cohorting residents based on COVID-19 status (i.e., positive, negative, unknown/under observation), they do not need any additional approval to do so. However, if a certified LTC facility would like to transfer or discharge residents to a non-certified location for the purposes of cohorting, they need approval from the State Agency. A depiction and explanation of “LTC Facility Transfer Scenarios” can be found here. For questions or concerns, contact DNH_Triageteam@cms.hhs.gov.
(New 5/4/20 Home Health Agencies (HHAs)
Detailed Information Sharing for Discharge Planning for Home Health Agencies. CMS is waiving the requirements of 42 CFR §484.58(a) to provide detailed information regarding discharge planning, to patients and their caregivers, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, (another) home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term care hospital (LTCH) quality measures and resource use measures.
- This temporary waiver provides facilities the ability to expedite discharge and movement of residents among care settings. CMS is maintaining all other discharge planning requirements.
Clinical Records. CMS is extending the deadline for completion of the requirement at 42 CFR §484.110(e), which requires HHAs to provide a patient a copy of their medical record at no cost during the next visit or within four business days (when requested by the patient). Specifically, CMS will allow HHAs 10 business days to provide a patient’s clinical record, instead of four.
Medicare Fee-For-Service (FFS) Medical Review4
CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current post-payment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.
State Surveyors and Accrediting Organizations5
Beginning March 4, 2020, CMS is suspending non-emergency survey inspections across the country. In response to the coronavirus threat (COVID-19), CMS urges State Survey Agencies (SAs) and Accrediting Organizations (AOs), as well as healthcare facilities, to maintain compliance with current CMS requirements and safety standards, specifically infection control procedures. Medicare/Medicaid certified providers and suppliers are strongly urged to monitor the COVID-19 CDC website as well as their State public health website and follow recommended guidelines and acceptable standards of practice.
Medicare Parts C and D and PACE Program Audits6
CMS has reprioritized its scheduled program audits for Medicare Advantage organizations, Part D sponsors, Medicare-Medicaid Plans, and PACE organizations until further notice. CMS will continue its oversight of these organizations, but will temporarily shift our oversight activities from conducting routine audit activities to prioritizing the investigation and resolution of:
- Instances of noncompliance where the health and/or safety of beneficiaries are at serious risk (for example, lack of access to critically needed health services or prescription drugs); and
- Complaints alleging infection control concerns, including COVID-19 or other respiratory illnesses.
Pace organizations may send PACE audit questions to PACEAuditQs@cms.hhs.gov
Contract-Level RADV Audits7
CMS is suspending RADV activities related to the payment year 2015 audit and will not initiate any additional contract-level audits until after the public health emergency has ended. Organizations should immediately suspend soliciting RADV-related medical records from providers. An organization may submit to CMS any medical record documentation that has already been obtained from providers. The Central Data Abstraction Tool (CDAT) will remain open for that purpose. The RADV mailbox and CDAT help desk will also remain open. CMS will continue reviewing medical records that have been submitted, including submissions for the 2014 audit, and providing feedback to organizations though CDAT. Questions related to contract level RADV audits should be sent to RADV@cms.hhs.gov.
*NEW* Medicare Appeals in Fee for Service (FFS), Medicare Advantage (MA) and Part D
(Updated 4/15/20) Medicare Appeals in Fee for Service (FFS), Medicare Advantage (MA), and Part D
CMS is allowing Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) in the FFS program pursuant to 42 CFR §405.942 and 42 CFR §405.962 (including for MA and Part D plans), as well as the MA and Part D Independent Review Entities (IREs) under 42 CFR §422.562, 42 CFR §423.562, 42 CFR §422.582 and 42 CFR §423.582, to allow extensions to file an appeal. CMS is allowing MACs and QICs in the FFS program under 42 CFR §405.950 and 42 CFR §405.966 and the MA and Part D IREs to waive requests for timeliness requirements for additional information to adjudicate appeals.
- CMS is allowing MACs and QICs in the FFS program under 42 CFR §405.910 and MA and Part D plans, as well as the MA and Part D IREs, to process an appeal even with incomplete Appointment of Representation forms as outlined under 42 CFR §422.561 and 42 CFR §423.560. However, any communications will only be sent to the beneficiary.
- CMS is allowing MACs and QICs in the FFS program under 42 CFR §405.950 and 42 CFR §405.966 (also including MA and Part D plans), as well as the MA and Part D IREs, to process requests for appeals that do not meet the required elements using information that is available as outlined within 42 CFR §422.561 and 42 CFR §423.560.
- CMS is allowing MACs and QICs in the FFS program under 42 CFR §405.950 and 42 CFR §405.966 (also including MA and Part D plans), as well as the MA and Part D IREs under 42 CFR §422.562 and 42 CFR §423.562 to utilize all flexibilities available in the appeal process as if good cause requirements are satisfied.
Learn more here.
Quality Reporting Programs8
CMS is implementing additional extreme and uncontrollable circumstances policy exceptions and extensions for upcoming measure reporting and data submission deadlines for the following CMS programs:
|Provider Programs||2019 Data Submission||2020 Data Submission|
||Deadline extended from March 31, 2020 to April 30, 2020.
MIPS eligible clinicians who have not submitted any MIPS data by April 30, 2020 will qualify for the automatic and extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year.
|CMS is evaluating options for providing relief around participation and data submission for 2020.|
|Hospital Programs||2019 Data Submission||2020 Data Submission|
Deadlines for October 1, 2019- December 31, 2019 (Q4) data submission are optional.
If Q4 is submitted, it will be used to calculate the 2019 performance and payment (where appropriate). If data for Q4 is unable to be submitted, the 2019 performance will be calculated based on data from January 1, 2019- September 30, 2019 (Q1-Q3) and available data.
CMS will not count data from January 1, 2020 through June 30, 2020 (Q1-Q2) for performance or payment programs. Data does not need to be submitted to CMS for this time period.
*For the Hospital Acquired Condition Reduction Program and the Hospital Value-Based Purchasing Program, if data from January 1, 2020-March 31, 2020 (Q1) is submitted, it will be used for scoring in the program (where appropriate).
|Post-Acute Care (PAC) Programs||2019 Data Submission||2020 Data Submission|
Deadlines for October 1, 2019-December 310, 2019 (Q4) data submission are options
If Q4 is submitted, it will be used to calculate the 2019 performance and payment (where appropriate.)
Data from January 1, 2020 through June 30, 2020 (Q1-Q2) does not need to be submitted to CMS for purposes of complying with quality reporting program requirements.
*Home Health and Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from January 1, 2020 through September 30, 2020 (Q1-Q3) does not need to be submitted to CMS.
*For the Skilled Nursing Facility (SNF) Value-Based Purchasing Program, qualifying claims will be excluded from the claims-based SNF 30-day all-cause readmission measures (SNFRM; NQF #2510) calculation from Q1-Q2.
For those programs with data submission deadlines in April and May 2020, submission of those data will be optional, based on the facility’s choice to report. In addition, no data reflecting services provided January 1, 2020 through June 30, 2020 will be used in CMS’ calculations for the Medicare quality reporting and value-based purchasing programs.
Payment for Medicare Telehealth Services9
Medicare will pay for telehealth services, including office, hospital and other visits furnished by physicians and other practitioners to patients located anywhere in the country, including a patient’s place of residence. CMS has released a video on Medicare Coverage and Payment of Virtual Services.
Site of Service Differential for Medicare Telehealth Services
- If telehealth services are furnished under the waiver to beneficiaries located in places that are not identified as permissible originating sites in section 1834(m)(4)(C)(ii)(I) through (IX) of the Act, no originating site facility fee is paid.
- Physicians and practitioners who bill for Medicare telehealth services must report the POS code that would have been reported had the service been furnished in person.
- Finalizes on an interim basis the use of the CPT modifier, modifier 95 which should be applied to claim lines that describes services furnished via telehealth.
- Maintains the facility payment rate for services billed using the general telehealth code POS code 02 should practitioners choose, to maintain their current billing practices for Medicare telehealth during the public health emergency (PHE) for the COVID-19 pandemic.
Adding Services to the List of Medicare Telehealth Services
- Adds over 80 additional services to the Medicare telehealth list on a Category 2 basis for the duration of the PHE. The full list can be found here.
Telehealth Frequency Limitations on Subsequent Care Services10
- Removes frequency restrictions for certain codes for subsequent inpatient visits and subsequent nursing facility visits furnished via Medicare telehealth for the duration of the PHE for the COVID-19 pandemic.
- Removes restriction that critical care consultation codes may only be furnished to a Medicare beneficiary once per day. The full list can be found here.
- Permits clinical examination of the vascular access site for ESRD-related services to be furnished as a Medicare telehealth service during the PHE for the COVID-19 pandemic. Relaxes CMS enforcement discretion in connection with the requirements under section 1881(b)(3)(B) of the Bipartisan Budget Act of 2018 that certain visits be furnished without the use of telehealth for services furnished during the PHE.
Telehealth Modalities and Cost-Sharing11
- For the duration of the PHE, “interactive telecommunication system” defines multimedia communications equipment to include, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.
Communication Technology -Based Services (CTBS)12
- Communication technology-based services (including remote physiologic monitoring) may be furnished to both new and established patients on an interim basis. Consent to receive these services must continue to be obtained annually but may be obtained at the same time the service was furnished and can be documented by auxiliary staff under general supervision as well as by the billing practitioner.
- Retains requirements that in instances where the CTBS originates from a related E/M service (including one furnished as a telehealth service) provided within the previous 7 days by the same physician on other qualified healthcare professional, the service will be considered bundled into the previous E/M service and would not be separately billable.
- Broadens the availability of HCPCS codes G2010 and G2012 that describe remote evaluation of patient images/video and virtual check-ins.
Direct Supervision by Interactive Telecommunications Technology13
- Revises the definition of direct supervision to state that the necessary presence of the physician for direct supervision includes virtual presence through audio/video real-time communications technology when use of such technology is indicated to reduce exposure risks for the beneficiary or provider. Includes the supervision of diagnostic services furnished directly or under arrangement in the hospital or in an on-campus or off-campus outpatient department of the hospital and pulmonary rehabilitation, cardiac rehabilitation and intensive cardiac rehabilitation described in the regulations at section 410.47 and 41049 respectively.
- Includes instances where the physician enters into a contractual arrangement for auxiliary personnel as defined in sec 410.26(a)(1) to leverage additional staff and technology necessary to provide care that would ordinarily be provided incident to a physician’s services (including services that are allowed to be performed via telehealth).
IRF Post-Admission Physician Evaluation Requirement for the PHE and Clarification of “3-hour” Rule14
- Removes post-admission physician evaluation requirement for all IRFs during the PHE for the COVID-19 pandemic.
- Clarifies in cases where an IRF’s intensive rehabilitation therapy program is impacted by the PHE for the COVID-19 pandemic, (e.g.—staffing disruptions resulting from self-isolation, infection, or other circumstances related to the PHE), the IRF is not obligated to meet the “3 hour” rule and instead a note should be made to this effect in the medical record.
Requirements for Opioid Treatment Programs (OTP)15
- Allows therapy and counseling portions of the weekly bundles, as well as the add-on code for additional counseling or therapy to be furnished using audio-only telephone calls rather than two-way interactive audio-video communication during the PHE for the COVID-19 pandemic if beneficiaries do not have access to two-way audio/video communications technology, provided all other applicable requirements are met.
Application of Teaching Physician and Moonlighting Regulations16
- Allow all levels of an office/outpatient E/M service provided in primary care centers to be provided under direct supervision of the teaching physician by interactive telecommunications technology. Exceptions will not apply in the case of surgical, high risk, interventional or other complex procedures, services performed through an endoscope, and anesthesia services
- Specifies that Medicare may make payments under the Physician Fee Schedule for teaching physician services when a resident furnishes telehealth services to beneficiaries under direct supervision of the teaching physician which is provided by interactive telecommunications technology.
- States that services of residents that are not related to their approved GME 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 PFS provided the services are identifiable physicians’ services and meet the conditions of payment for physicians’ services to beneficiaries, the resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed and the services are not performed as part of the approved GME program.
Remote Physiologic Monitoring17
- Clarifies that remote physiologic monitoring (RPM) codes can be used for physiologic monitoring of patients with acute and/or chronic conditions
Level Selection for Office/Outpatient E/M Visits when Furnished Via Medicare Telehealth18
Office/outpatient E/M level selection for services furnished via telehealth can be based on MDM or time, with time defined as all of the time associated with the E/M on the day of the encounter; and removes any requirements regarding documentation of history and/or physical exam in the medical record.
Stark Law Waivers19
The physician self-referral law (also known as the “Stark Law”) prohibits a physician from making referrals for certain healthcare services payable by Medicare if the physician (or an immediate family member) has a financial relationship with the entity performing the service. There are statutory and regulatory exceptions, but in short, a physician cannot refer a patient to any entity with which he or she has a financial relationship. CMS will permit certain referrals and the submission of related claims that would otherwise violate the Stark Law. They include:
- Hospitals and other health care providers can pay above or below fair market value to rent equipment or receive services from physicians (or vice versa). For example, a physician practice may be willing to rent or sell needed equipment to a hospital at a price that is below what the practice could charge another party. Or, a hospital may provide space on hospital grounds at no charge to a physician who is willing to treat patients who seek care at the hospital but are not appropriate for emergency department or inpatient care.
- Health care providers can support each other financially to ensure continuity of health care operations. For example, a physician owner of a hospital may make a personal loan to the hospital without charging interest at a fair market rate so that the hospital can make payroll or pay its vendors.
- Hospitals can provide benefits to their medical staffs, such as multiple daily meals, laundry service to launder soiled personal clothing, or childcare services while the physicians are at the hospital and engaging in activities that benefit the hospital and its patients.
- Allowing the provision of certain items and services that are solely related to COVID-19 Purposes (as defined in the waivers), even when the provision of the items or services would exceed the annual non-monetary compensation cap. For example, a home health agency may provide continuing medical education to physicians in the community on the latest care protocols for homebound patients with COVID-19, or a hospital may provide isolation shelter or meals to the family of a physician who was exposed to the novel coronavirus while working in the hospital’s emergency department.
- Physician-owned hospitals can temporarily increase the number of their licensed beds, operating rooms, and procedure rooms, even though such expansion would otherwise be prohibited under the Stark Law. For example, a physician-owned hospital may temporarily convert observation beds to inpatient beds to accommodate patient surge during the COVID-19 pandemic in the United States.
- Loosen some of the restrictions when a group practice can furnish medically necessary designated health services (DHS) in a patient’s home. For example, any physician in the group may order medically necessary DHS that is furnished to a patient by a technician or nurse in the patient’s home contemporaneously with a physician service that is furnished via telehealth by the physician who ordered the DHS.
- Group practices can furnish medically necessary MRIs, CT scans or clinical laboratory services from locations like mobile vans in parking lots that the group practice rents on a part-time basis.
(Updated 4/15/20) COVID-19 Frequently Asked Questions on Medicare FFS
CMS has created a number of COVID-19 waiver FAQs, which can be accessed here.
CMS notes that in many instances, the general statements of the FAQs referenced above have been superseded by COVID-19-specific legislation, emergency rules, and waivers granted under section 1135 of the Act specifically to address the COVID-19 public health emergency (PHE). The policies set out in this FAQ are effective for the duration of the PHE unless superseded by future legislation.
A few answers in this FAQ explain provisions from the Coronavirus Aid, Relief, and Economic Security (CARES) Act, (March 27, 2020). CMS is thoroughly assessing this new legislation and new and revised FAQs will be released as implementation plans are announced.
(Updated 4/15/20) Medicare Accelerated and Advance Payments
The CMS Accelerated and Advance Payment Program is designed to increase cash flow to Medicare providers and suppliers impacted by the 2019 Novel Coronavirus (COVID-19) pandemic. These payments are funded from the Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) trust funds, which are the same fund used to pay out Medicare claims each day. The advance and accelerated payments are a loan that providers must pay back. It is important to note, this funding is separate from the $100 billion provided in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The CARES Act appropriation is a payment that does not need to be repaid. Details on eligibility and the request process can be found here. A state-by-state breakout of these payments as of Friday, April 4, 2020 can be found here.
(Updated 4/22/20) Guidance on Re-Opening Facilities to Provide Non-emergent Non-COVID-19 Care: Phase I
Non-COVID-19 care should be offered to patients as clinically appropriate and within a state, locality, or facility that has the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases, if necessary. Decisions should be consistent with public health information and in collaboration with state public health authorities. Careful planning is required to resume in-person care of patients requiring non-COVID-19 care, and all aspects of care must be considered — for example:
- Adequate facilities, workforce, testing, and supplies
- Adequate workforce across phases of care (such as availability of clinicians, nurses, anesthesia, pharmacy, imaging, pathology support, and post-acute care)
Healthcare systems or clinicians have flexibility to re-start clinically necessary care for patients with non-COVID-19 needs or complex chronic disease management requirements in accordance with the following general considerations:
- In coordination with State and local public health officials, evaluate the incidence and trends for COVID-19 in the area where re-starting in-person care is being considered
- Evaluate the necessity of the care based on clinical needs. Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.
- Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area)
- Sufficient resources should be available to the facility across phases of care, including PPE, healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity
Personal Protective Equipment
- Consistent with CDC’s recommendations for universal source control, CMS recommends that healthcare providers and staff wear surgical facemasks at all times. Procedures on the mucous membranes including the respiratory tract, with a higher risk of aerosol transmission, should be done with great caution, and staff should utilize appropriate respiratory protection such as N95 masks and face shields
- Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks
- Every effort should be made to conserve personal protective equipment
- Staff should be routinely screened for symptoms of COVID -19 and if symptomatic, they should be tested and quarantined. Staff who will be working in these NCC zones should be limited to working in these areas and not rotate into “COVID-19 Care zones” (e.g., they should not have rounds in the hospital and then come to an NCC facility)
- Staffing levels in the community must remain adequate to cover a potential surge in COVID-19 cases
- In a region with a current low incidence rate, when a facility makes the determination to provide in-person, non-emergent care, the facility should create areas of NCC which have in place steps to reduce risk of COVID-19 exposure and transmission; these areas should be separate from other facilities to the degrees possible (i.e., separate building, or designated rooms or floor with a separate entrance and minimal crossover with COVID-19 areas)
- Within the facility, administrative and engineering controls should be established to facilitate social distancing, such as minimizing time in waiting areas, spacing chairs at least 6 feet apart, and maintaining low patient volumes
- Visitors should be prohibited but if they are necessary for an aspect of patient care, they should be pre-screened in the same way as patients
- Ensure that there is an established plan for thorough cleaning and disinfection prior to using spaces or facilities for patients with non-COVID-19 care needs
- Ensure that equipment such as anesthesia machines used for COVID-19 (+) patients are thoroughly decontaminated, following CDC guidelines
- Adequate supplies of equipment, medication and supplies must be ensured, and not detract for the community ability to respond to a potential surge
- All patients must be screened for potential symptoms of COVID-19 prior to entering the NCC facility, and staff must be routinely screened for potential symptoms as noted above
- When adequate testing capability is established, patients should be screened by laboratory testing before care, and staff working in these facilities should be regularly screened by laboratory test as well
All facilities should continually evaluate whether their region remains a low risk of incidence and should be prepared to cease non-essential procedures if there is a surge.
(Updated 4/22/20) Nursing Home Requirements for Notification of Confirmed COVID-19 Among Residents and Staff
Current requirements at 42 CFR 483.80 and CDC guidance specify that nursing homes notify State or Local health department about residents or staff with suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or ≥ 3 residents or staff with new-onset respiratory symptoms within 72 hours of each other.
At present, these data are not collected by CMS, CDC, or the Federal Emergency Management Agency (FEMA). CMS and CDC will soon provide nursing homes with specific direction on standard formatting and frequency for reporting this information through the CDC’s National Health Safety Network (NHSN) system. Currently, this information is provided optionally by nursing homes. The required collection of this information will be used to support surveillance of COVID-19 locally and nationally, monitor trends in infection rates, and inform public health policies and actions. This information may be retained and publicly reported in accordance with law.
Resident and Resident Representative Reporting
In addition to requiring reporting to CDC, in rule-making that will follow, CMS will also be requiring that facilities notify its residents and their representatives to keep them informed of the conditions inside the facility. This is separate from the reporting required to CDC in that this information will be shared by the nursing home directly with residents and their representatives. At a minimum, once these requirements are in place, nursing homes must inform residents and their representatives within 12 hours of the occurrence of a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours. Also, updates to residents and their representatives must be provided weekly, or each subsequent time a confirmed infection of COVID-19 is identified and/or whenever three or more residents or staff with new onset of respiratory symptoms occurs within 72 hours. Facilities will include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations in the nursing home will be altered. This information must be reported in accordance with existing privacy regulations and statute.
In rule-making that will follow this memorandum, failure to report resident or staff incidences of communicable disease or infection, including confirmed COVID-19 cases (or Persons Under Investigation for COVID-19), or provide timely notification to residents and their representatives of these incidences, as required, could result in an enforcement action against the nursing home by CMS.
Ongoing Public Health Surveillance
Nursing homes are reminded of the requirement at 42 CFR 483.10(f) (4)(i)(A) and (B) which mandates immediate access to any residents by any representative of the Secretary or State. The purpose of these visits will be for CDC (or its agents) to perform on-site infectious disease surveillance, testing of healthcare personnel and residents, or other related activities, as permitted under law. The full CDC guidance to prepare nursing homes for COVID-19 can be found here.
These actions are necessary to ensure Federal, State and Local public health surveillance systems, and residents and their representatives, have the most complete information on COVID-19 cases in nursing homes to mitigate the spread and impact of COVID-19 on our most vulnerable citizens. Contact Questions about this memorandum should be addressed to DNH_TriageTeam@cms.hhs.gov.
Effective date of this guidance is April 19, 2020.
(Updated 4/22/20) CMS Interoperability and Patient Access Final Rule
CMS is extending the implementation timeline for the admission, discharge, and transfer (ADT) notification Conditions of Participation (CoPs) by an additional six months. In the version of the rule displayed on March 9, 2020 on the CMS website, it stated these CoPs would be effective 6 months after the publication of the final rule in the Federal Register. CMS has changed this in the final rule now displayed on the Federal Register to state that the new CoPs at 42 CFR Parts 482 and 485 will now be effective 12 months after the final rule is published in the Federal Register.
CMS also finalized the Patient Access API and Provider Directory API policies for Medicare Advantage (MA), Medicaid, and the Children’s Health Insurance Program (CHIP) effective January 1, 2021. CMS will exercise enforcement discretion for a period of six months in connection with these two API provisions. Therefore, as a result of COVID-19, and to provide additional flexibility to payers, CMS will not enforce the new requirements under 42 CFR Parts 422, 431, 438, and 457 until July 1, 2021.
Finally, CMS finalized the Patient Access API for Qualified Health Plan (QHP) issuers on the individual market Federally-Facilitated Exchanges (FFEs) beginning with plan years beginning on or after January 1, 2021. CMS will not enforce the new requirements under 45 CFR Part 156 until July 1, 2021.
Other policies contained in the final rule will be implemented and enforced on schedule.
Lauren Riplinger, JD, (Lauren.Riplinger@ahima.org) is Vice President, Policy & Government Affairs, at AHIMA.
- CMS. Center for Clinical Standard and Quality/Quality, Safety & Oversight Group. Guidance for Processing Attestation Statements from Ambulatory Surgical Centers (ASCs) Temporarily Enrolling as Hospitals during the COVID-19 Public Health Emergency. www.cms.gov/files/document/qso-20-24-asc.pdf.
- CMS. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf.
- CMS. 2019-Novel Coronavirus (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). www.cms.gov/files/document/provider-burden-relief-faqs.pdf.
- CMS. Coronavirus: Updates for State Surveyors and Accrediting Organizations. www.cms.gov/medicare/quality-safety-oversight-general-information/coronavirus.
- CMS. Reprioritization of PACE, Medicare Parts C and D Program, and Risk Adjustment Data Validation (RADV) Audit Activities. www.cms.gov/files/document/covid-19-programauditsradv-memo.pdf.
- CMS. CMS Announces Relief for Clinicians, Providers, Hospitals and Facilities Participating in Quality Reporting Programs in Response to COVID-19. https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting.
- CMS. Department of Health and Human Services. Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. www.cms.gov/files/document/covid-final-ifc.pdf.
- CMS. Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19. www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf.
Bookmark AHIMA’s COVID-19 Resources
- Journal of AHIMA—COVID-19. An authoritative source for healthcare-relevant news and perspectives on the global response to the COVID-19 pandemic. Click here.
- AHIMA.org COVID-19 Index. Continuously updated with resources, AHIMA news, and navigable links to public health and professional organizations. Click here.
- AHIMA Engage—COVID-19 Community. A digital networking page to exchange ideas, information, and perspectives. Click here.