On April 30, the Centers for Medicare & Medicaid Services (CMS) released a second interim final rule (IFR) along with a press release to further modify and support regulatory changes implemented during the COVID-19 public health emergency (PHE). CMS will accept comments on the IFR until June 1, 2020.
Audio-only Telephone Telehealth Visits: The IFR acknowledges that Medicare patients are using audio-only telehealth services more frequently than video-audio telehealth services. As a result, CMS increased relative value units (RVUs) and direct practice expense inputs for telephone service (99441, 99442 and 99443) for the duration of the COVID-19 PHE to align payment rates with established patient office/outpatient Evaluation and Management (E/M) visits (99212, 99213 and 99214), respectively. This will increase payments for telephone services from about $14-$41 to about $46-$110 retroactive to March 1, 2020.
CMS declined to increase payment rates for telephone assessment and management services (CPT codes 98966, 98967 and 98968) approved for on an interim basis for non-physician providers, who under usual circumstances are not allowed to bill independently for E/M visits.
The rule reiterates that patients are still responsible for co-pays and other cost-sharing responsibilities associated with telehealth services, but reminds physicians of the flexibility to waive out-of-pocket fees during the PHE.
Payment for COVID-19 Specimen Collection: In the IFR, CMS clarifies that it will allow use of CPT code 99211 (Level 1 established patient office/outpatient E/M visit) for COVID-19 assessment and specimen collection by a physician, qualified health care professional or clinical staff for new or established patients for the duration of the PHE. CMS notes in the rule that the direct supervision requirements for services performed by clinical staff “incident to” a physician’s service can also be met through use of interactive audio and video telehealth technology. CMS also finalized coverage of FDA-authorized COVID-19 serology (antibody) tests on an interim basis.
Hospitals and Teaching Facilities: Effective April 30, the IFC will apply the Extraordinary Circumstances Exceptions policy to the Hospital Value-based Purchasing (VBP) Program, and permit teaching hospitals to include residents sent to another hospital during the PHE in their resident fulltime equivalent (FTE) count for Graduate Medical Education (GME) payment. Under current regulations, a hospital cannot claim on their Medicare cost report the time spent by residents training at another hospital for GME purposes. CMS has waived certain provisions of this requirement for the duration of the PHE.
CMS also expanded the Primary Care Exception list of services allowed to be furnished by residents via telehealth to include telephone evaluation and assessment (99441, 99442 and 99443), transitional care management (99495 and 99496), online digital E/M services (99421, 99422 and 99423), interprofessional telephone/internet/electronic health record assessment and management service (99452) and communication technology-based services (G2010 and G2012). For billing purposes, the IFR allows the level of service to be determined based on medical decision making (MDM) or time, to be consistent with the E/M documentation changes finalized in the Medicare Physician Fee Schedule for calendar year 2021. Documentation requirements for history and physical do not apply for the duration of the PHE.
Provider Enrollment for Medicare Home Health Services: Section 3708(f) of the CARES Act authorizes CMS to implement regulatory changes to allow licensed non-physician practitioners to certify the need for home health services, in accordance with state law.
Coverage of Medicaid Tests and Home Care Services: To make Medicaid coverage of COVID-19 testing more available, CMS will cover laboratory and X-ray services, including laboratory tests administered in non-office settings such as such as parking lots or other temporary outdoor locations, and coverage for laboratory processing of self-collected COVID-19 tests that are FDA-authorized. This policy is effective retroactive to March 1, 2020. The coverage terms would also apply during any subsequent periods of active surveillance, to allow for continued surveillance as part of strategies to detect recurrence of the COVID-19 virus in individuals and populations to prevent further spread of the disease.
The rule also makes permanent revisions to the Medicaid Home Health Program to allow other licensed practitioners, in addition to physicians, to order medical equipment, supplies and appliances, when practicing in accordance with state laws. Non-physician licensed practitioners serving as the ordering clinician are now permitted to perform face-to-face visits independently, and will no longer have to communicate to the ordering physician clinical findings from face-to-face encounters. These provisions also are retroactive to March 1, 2020.
National and Local Coverage Determinations: In the COVID-19 IFC issued on March 31st, CMS specified that national coverage determination (NCD) and local coverage determination (LCD) clinical indications required for respiratory, home anticoagulation management and infusion pumps, and requirements for face-to-face encounters would not be enforced during the PHE. In this rule, CMS clarifies that physicians, practitioners, and suppliers must continue to document medical necessity for patient services in the patient medical record, if required by NCD or LCD. CMS also will not enforce the clinical indications for therapeutic continuous glucose monitors in LCDs.
Qualified Clinical Data Registry: In consideration of clinicians responding to the COVID-19 pandemic, CMS will delay for one year measure testing and collection requirements for qualified clinical data registry (QCDR) approved for the Merit-based Incentive Payment System (MIPS) program until the 2022 performance year.
For additional background information on the waivers and rule changes, please visit CMS.gov.
For more information on the COVID-19 waivers and guidance, and the Interim Final Rule, please go to the CMS COVID-19 flexibilities webpage.
Physicians and other eligible clinicians treating patients with COVID-19 can now earn credit in the Merit-based Incentive Payment System (MIPS) program under the Improvement Activities performance category for the 2020 performance period by attesting to this new activity through participation in a clinical data repository or registry. This update supports the MIPS extreme and uncontrollable circumstances policy and procedures for MIPS eligible clinicians affected by COVID-19 update issued by CMS on April 20, 2020.
The following COVID-19 Clinical Trials Improvement Activity has been added to the 2020 CMS QRDA III IG: