April 1,2020— STFM and other family medicine organizations have been advocating for more flexible requirements to allow faculty to continue to provide quality education to residents, while also addressing the escalating needs of patients. On March 30, the Centers for Medicare & Medicaid Services (CMS) issued temporary waivers and rules in response to the COVID pandemic. Below is a summary of key points that affect academic family medicine practices and resident training.
Temporary Medicare supervision requirements allow for remote precepting and resident provision of telehealth. This is retroactive to March 1.
Typically, Medicare pays for services provided by residents only if the physician is physically present for the service or procedure. The temporary change allows teaching physicians to provide direct supervision of medical residents remotely through audio/video real-time communications technology for E/M services. This is not allowed in the case of surgical, high risk, interventional, or other complex procedures, services performed through an endoscope, and anesthesia services.
For the primary care exception, the rule specifically states, “The use of real-time, audio and video telecommunications technology allows for the teaching physician to interact with the resident through virtual means while the resident is furnishing services via telecommunications technology, and thus, in the circumstances of the [public health emergency] PHE, would meet the requirement for teaching physician presence for office/outpatient E/M services furnished in primary care centers.” However, the billing codes specified for phone visits are not currently codes that can be used by residents under the primary care exception. We need more clarity from CMS as to whether billing for residents’ use of phone visits is acceptable.
Direct supervision is no longer required for therapeutic services provided in hospital outpatient departments and critical access hospitals. General supervision, which doesn’t require a physician to be immediately available, is acceptable.
Telehealth rules expand.
Telehealth services can be provided and received at any location, for/by both new and established patients. Access a list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth.
Clinicians can provide remote patient monitoring services to patients with acute and chronic conditions, including patients with only one disease. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry.
Clinicians can provide virtual check-in services (HCPCS codes G2010, G2012) to both new and established patients. Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits (HCPCS codes G2061-G2063). A broad range of clinicians, including physicians, can now provide certain services by telephone to their patients (CPT codes 98966 -98968; 99441-99443).
Additional waivers/rules provide more flexibility.
Most of the waivers below can be implemented if they are not inconsistent with a state’s emergency preparedness or pandemic plan:
Counting resident time in alternate locations: A hospital that is paying a resident’s salary and fringe benefits for the time the resident is at home or in a patient’s home, performing duties within the scope of the approved residency program, can claim that resident for IME and DGME purposes. This allows medical residents to perform their duties in alternate locations as long as they meet requirements for appropriate supervision.
Physician services: CMS is waiving Medicare requirements that patients be under the care of a physician, and that a physician be on call at all times. This allows hospitals to use other practitioners, such as physician assistants and nurse practitioners, to the fullest extent possible.
Respiratory care services: CMS has waived the requirement that hospitals designate in writing the personnel qualified to perform specific respiratory care procedures and the amount of supervision required for personnel to carry out specific procedures. CMS states that this will allow qualified professionals to operate to the fullest extent of their licensure and training in providing patient care for respiratory illnesses.
Critical Access Hospital Length of Stay: CMS is waiving the Medicare requirements that Critical Access Hospitals limit the number of beds to 25, and that the length of stay be limited to 96 hours.
Critical Access Hospital Status and Location: CMS is waiving the requirement that the Critical Access Hospital be located in a rural area or an area being treated as rural, as well as their location relative to other hospitals to allow the hospitals flexibility in the establishment of surge site locations.
Accelerated/Advance Payments: Any Medicare provider/supplier may apply to their Medicare Administrative Contractor for these payments and should receive a payment within 7 days. Repayments, which traditionally were due within 90 days, will now be due 120 days after the advance payment is issued. Learn more.