PHYSICAL THERAPY AND TELEHEALTH DURING THE COVID-19 PANDEMIC Recorded March 16, 2020
Transcript
PHYSICAL THERAPY AND TELEHEALTHDURING THE COVID-19 PANDEMIC
Recorded March 16, 2020
Presenter
Presentation Notes
Kate: Hello and welcome to a special APTA Presentation on physical therapy, telehealth and the COVID-19 outbreak. This presentation is designed to get you up to speed on the role that telehealth plays in the practice of physical therapy in light of the current public health emergency. Please keep in mid this is a rapidly developing situation, and the information may become out of date. Stay tuned to APTA.org for the latest news. This webinar in being conducted by APTA’s regulatory affairs team, including Director Kara Gainer, Senior Specialist Steve Postal, and me, Senior Specialist Kate Gilliard.
What Is Telehealth?HRSA:• The use of telecommunications and
information technologies to share information, and provide clinical care, education, public health, and administrative services at a distance
• Secure, live audio-video connection
Presenter
Presentation Notes
Before we jump into the latest developments, let’s ensure we have a common understanding as to what telehealth is. According to the Health Resources and Services Administration, telehealth is: The use of telecommunications and information technologies to share information, and provide clinical care, education, public health, and administrative services at a distance. The most common form of telehealth that we are seeing as applied to physical therapy is a live audio-video connection between therapist and patient. (Note that other terms, such telerehabilitation, telerehab, telemedicine, and telepractice are being used by various entities. They essentially mean the same thing when referring to use by PTs and PTAs.
APTA’s Position on TelehealthTelehealth:
• Is within scope of practice,• Reduces cost, disparities, and
shortages• Enhances physical therapy
practice, education, and research.
Presenter
Presentation Notes
APTA’s House of Delegates position on telehealth, which was last updated in 2019, recognizes telehealth as a well‐defined and established method of health services delivery that enhances patient and client interactions. It further states that telehealth is within the scope of a physical therapists’ practice and supports inclusion of physical therapist services in telehealth policy and regulation on the national and state levels. APTA also recognizes the value of advocating for state and federal telehealth policies to reduce cost, disparities, and shortages of care, and to enhance physical therapist practice, education, and research. APTA has made the advancement of telehealth one of its chief public policy priorities and will continue to advocate for increased recognition of the service.
Does Practice
Act Include Telehealth as Within Scope of Practice?
Yes, explicitly Possibly, given open language
Presenter
Presentation Notes
That said, physical therapists and physical therapist assistants must comply with their state practice act at all times. Currently, 16 states have regulation, either within the state practice acts or otherwise, that explicitly recognize that telehealth is within the PT’s scope of practice. In addition to those states, there are 2 other states (Iowa and Rhode Island) that have open language suggesting that telehealth may be within scope of practice
Federal Response to COVID-19• $8.3B emergency coronavirus package
– Signed into law 3/6/2020• Families First Coronavirus Response Act
– Passed House 3/14/2020; awaiting Senate vote as of 3/16/2020
• CMS waiver of federal licensure requirements****See CMS fact sheet for list of Medicare, Medicaid, & CHIP waivers: https://www.cms.gov/files/document/covid19-emergency-declaration-health-care-providers-fact-sheet.pdf
5
Presenter
Presentation Notes
The COVID-19 pandemic has forced policy makers at all levels of government to rethink the way the current health care system is suited to respond to such a crisis. The federal response is ongoing, but, to date, the following actions have been taken: On March 6, President Trump singed into the law an $8.3 billion dollar emergency coronavirus package. The legislation will bolster vaccine development, research, and equipment stockpiles, as well as boost state and local health budgets, as government officials and health workers fight to contain the outbreak. The Families First Coronavirus Response Act is the second congressional effort to provide relief. It was passed by the House of Representatives on March 14 and as of March 16 was awaiting a Senate vote, but it has the support of President Trump, meaning it’s likely to pass. The Families First Act does a number of things, including: Increasing Medicaid funding Providing emergency paid sick leave for employers with fewer than 500 employees Providing tax credits to employers to offset costs related to the paid sick leave Free COVID-19 testing The Department of Health and Human Services and the Centers for Medicare and Medicaid Services have also taken action. CMS issued a number of 1135 waivers that affect a broad range of activities and settings in Medicare, Medicaid, and the Children's Health Insurance Program, or CHIP. The waivers essentially suspend certain regulatory requirements to increase access to care during the emergency. The link displayed will take you to CMS’ fact sheet on these regulatory flexibilities and other actions CMS is taking to help health care providers and states respond to and contain COVID-19, including temporarily waiving federal licensure requirements that require out-of-state providers be licensed in the state where they are providing services, fast tracking enrollment, and easing requirements for critical-access hospitals, long-term care hospitals, and inpatient rehabilitation facilities. However, CMS cannot waive state or local licensure requirements and has thus far not increased physical therapists’ authority to practice telehealth. Stay tuned to APTA as we will continue to keep members updated on developments and issue guidance when necessary. Next, Steve is going to take you through some practical considerations for the practice of telehealth.
• Physical therapists need to: – Know available options and develop best
practices– Fulfill their legal and professional obligations
6
Presenter
Presentation Notes
Steve: Before providing telehealth, ensure that you meet all local, state, and federal laws and regulations. Ensure that when providing telehealth services or billing for them, you are practicing legally and ethically, and are adhering to state and federal practice guidelines and payer contract agreements. Review and understand your state's practice act regarding the delivery of physical therapist services via telehealth. Per APTA’s ethics documents, we recommend that physical therapists use their discretion as to the nature and frequency of using telehealth, and do so within their scope of practice while abiding by any state practice act restrictions as well as their obligations to the physical therapy profession. Although telehealth is not specifically codified within the APTA “Code of Ethics for the Physical Therapist” or the “Standards of Ethical Conduct for the Physical Therapist Assistant,” the entirety of the code applies to telehealth services delivered by PTs and PTAs. Ethical practice in telehealth must account for the biological, social, psychological, and cultural needs of the patient while working to improve their health. Additionally, knowing when to urge and how to persuade the patient to seek a face-to-face level of care is key. Also keep in mind that telehealth provision or use does not alter a covered entity’s obligations under HIPAA, nor does HIPAA contain any special section devoted to telehealth. Therefore, if a covered entity is using telehealth that involves PHI, the entity must meet the same HIPAA requirements that it would if the service was provided in person.
Telehealth in Medicare: CONNECT for Health Act (S 2741 / HR 4932)
• HHS can waive Medicare telehealth restrictions
• CMMI models can include PTs
• First step in Medicare coverage
Presenter
Presentation Notes
What is APTA doing to advocate on behalf of increased telehealth coverage? We support the CONNECT for Health Act, which was released in the House and Senate in October 2019. This bill includes a provision [Section 3] that will allow HHS to waive one or more of the restrictions on Medicare’s coverage of telehealth, paving the way for PT coverage. HHS can do this as long as doing so would either: Reduce spending without reducing quality; Improve quality without increasing spending; OR Would apply only to telehealth furnished in HPSAs. This means that, for example, HHS could allow the patient’s home to be the originating site and allow a PT to furnish telehealth by waiving the current restrictions. In this scenario, HHS would, of course, have to find that doing so would reduce spending without reducing quality or increase quality without increasing spending; or HHS could at least waive those restrictions in a HPSA. The bill also directs the Centers for Medicare and Medicaid Innovation [Section 14] to focus on testing models that allow licensed health professionals, including PTs, PTAs, OTs, OTAs, and audiologists to furnish telehealth services. This is a first step to greater coverage of Medicare in telehealth. We hope that the data that CMS will provide will assist us in eventually having an ability to be reimbursed for telehealth under all existing CPT codes. Our position paper on this bill, in addition to testimonials of our members’ successes with telehealth, and clinical studies demonstrating the efficacy of telehealth, are available on our telehealth webpage. The bill currently has 33 cosponsors in the Senate and 32 cosponsors in the House. As Kara will share in a few minutes, we have a call to action for PTs, PTAs, students, and patients to urge Congress to include this legislation in any future coronavirus legislation.
Telehealth in Medicare (Continued)
• Under Medicare:– PTs are not authorized providers– PT services are not covered under the PFS
when furnished via telehealth– PTs can consider collecting OOP payment
• Reach out to your MAC & CMS RO for opinion
Presenter
Presentation Notes
We recently issued a notice indicating that because Medicare doesn’t cover physical therapy furnished via telehealth, providers could consider collecting out-of-pocket payment (and issue a voluntary ABN). However, we encourage providers to first reach out to their MAC or CMS Regional Office for an opinion on this practice to confirm this is appropriate. We recognize that for most patients, paying cash isn’t feasible, which is why it is critical that Congress give HHS the authority to waive Medicare telehealth coverage restrictions, including the types of providers eligible to furnish and bill for telehealth under Medicare.
Telehealth in MA and Commercial Insurance
• Medicare Advantage
• Commercial insurers
Presenter
Presentation Notes
It is essential to verify with all insurances ahead of time whether or not they cover telehealth. If an insurance company says it will not cover telehealth, you can choose to see the patient via telehealth and appeal if the visit does end up being denied. This is a fluid situation and insurance companies are is likely updating their policies in real-time. Under the most recent guidance issued by CMS, Medicare Advantage plans may provide their enrollees with access to Medicare Part B services via telehealth in any geographic area and from a variety of places, including beneficiaries’ homes. Medicare Advantage Organizations can expand coverage of telehealth services beyond those approved by CMS. On the commercial insurance side, check with individual payers to verify what is and is not permitted and what will be reimbursed. Confirm with each payer whether the originating site can be a private home or office, if services must be real-time or can be asynchronous, and any other limitations to your use of telehealth. Before reporting CPT codes you traditionally use for clinical visits, check with your payer. A payer also may require an addendum attached to the bill that identifies the service as being provided via telehealth, along with an explanation of the charges, so be prepared to outline your reasoning for using telehealth. Also be aware if your state has parity laws that require insurers to pay the same amount for telehealth services as they would for an in-person visit.
Does Medicaid
Reimburse Telehealth?
Yes, explicitly Possibly, given open language
Presenter
Presentation Notes
While 49 states define telehealth, we found only 9 states where Medicaid explicitly reimburses for some form of telehealth for rehab services. For example, Minnesota allows both PTs and PTAs to provide services via telehealth, while the PTAs must follow supervision requirements. New York Medicaid allows PTs to provide services via telehealth, but does not reimburse for telehealth used solely for the convenience of a practitioner when a face-to-face visit is more appropriate and/or preferred by the patient. An additional 11 states, shaded in light blue, have language that opens the possibility for Medicaid to reimburse for telehealth services. Ten of these states have Medicaid programs that do not specify eligible health care providers, or otherwise limit which health care providers can practice telehealth. Not in script, additional note Nebraska’s open language is a bit different. In Nebraska, health care providers must be specifically enrolled as a telehealth site with the state’s Medicaid program.
Coding Considerations• Some therapists use codes in 97000 series
and use POS code “02”
• No specific CPT codes available to PTs
• Verify with payers:– Codes – Modifiers– POS code “02”
11
Presenter
Presentation Notes
Kara: There are not specific CPT codes for telehealth services furnished by physical therapists. Some therapists use codes in the 97000 series that best describe the services being provided and then use the place-of-service code “02” to indicate that the services were provided remotely. Because the CPT codes are direct contact codes, it is important to verify that the payer allows you to use these codes when services are provided via telehealth, or if you must use a specific modifier. We also encourage you to check with each payer about using place-of-service code "02" when billing for telehealth services to specify the entity where service(s) were rendered. As Steve noted, before reporting CPT codes you traditionally use for clinical visits, check with your payer for their policy and guidelines on billing telehealth.
Status of the PT
Compact
Member State Enacted Legislation Legislation Introduced
Non-Member State, No Legislation Introduced
Presenter
Presentation Notes
One way in which PTs can increase their ability to practice telehealth is to be licensed in one state and have that license honored in another state that has adopted the PT compact. Currently 27 states are involved in the compact in some way 20 states are member states, meaning that they are actively issuing and accepting compact privileges. An additional seven states have enacted legislation, but are not yet issuing or accepting compact privileges. You heard Kate mention earlier the CMS COVID-19 emergency declaration health care providers fact sheet that lists multiple waivers that will help providers see patients in a more efficient and timely manner. For instance, CMS is temporarily waiving Medicare and Medicaid requirements that out-of-state providers hold licenses in the state where they are providing services. The requirement is waived as long as the provider has an equivalent license from another state — but keep in mind this does not waive state or local licensure requirements. Also, the waiver does not allow for payment for otherwise noncovered services — such as telehealth services provided by physical therapists.
• Payer advocacy for coverage of telehealth furnished by PTs and PTAs
• Access/share APTA’s resources
Presenter
Presentation Notes
The COVID-19 pandemic demands that health care providers and payers reconsider how care is delivered to reduce the risk of further spreading infection. Access to telehealth has become of paramount importance to ensure the safety of patients and their physical therapy providers. APTA supports waiving current restrictions that prevent physical therapists and other health care providers from delivering and billing for services provided via telehealth under Medicare. The CONNECT for Health Act (H.R. 4932/S. 2741), is bipartisan legislation that would expand the use of telehealth services and ease restrictions on telehealth coverage under the Medicare program. We are encouraging all PTs, PTAs, students, and patients to write to their members of Congress and encourage them to include the CONNECT for Health Act in any future coronavirus legislative package that would allow for a waiver to the current restrictions that prohibit physical therapists and other health care providers from delivering and billing for services provided via telehealth under Medicare. We also understand that there is a need for advocacy with payers beyond Medicare. APTA has developed a template letter that physical therapy providers can use to contact the payers they contract with, including commercial, Medicare Advantage, and Medicaid plans, to encourage them to cover telehealth for PT services during the COVID-19 pandemic. You’ll find a link to the letter within the Telehealth article on APTA’s coronavirus webpage: www.apta.org/coronavirus. Access APTA’s resources via the telehealth website and share them with others. Also, stay tuned for an upcoming webinar and live Q&A, both in April, on Digital Telehealth Practice - Connect for Best Practice, Compliance, and Health Care, that APTA staff will record with the Health Policy & Administration Section’s Tech SIG.
