On April 9, 2020, the Centers for Medicare and Medicaid Services (CMS) focused part of its “Office Hours on COVID 19” on answering providers’ questions on a wide range of changes in otherwise applicable CMS requirements, in light of the COVID-19 pandemic.  Below are CMS’ responses on a number of the pressing concerns raised by providers during the call.  ‘Questions and Answers’ have been rearranged to group similar questions and responses together.

Powers law firm represents numerous post-acute care providers and has significant expertise in Medicare requirements applicable to this health care sector. If you have any questions about changes applicable to post-acute care facilities during the pandemic, please contact Diane Millman (Diane.Millman@PowersLaw.com); Leela Baggett (Leela.Bagett@PowersLaw.com) or your regular Powers attorney.

POST-ACUTE CARE

>> Participant: … My question pertains to the waiver you issued to allow excluded inpatient rehabilitation units to be cared for in the acute care unit of the hospital. Taking a close look at the language you provided, it says that it allows acute care hospitals with these units that need to relocate inpatients from the unit to the acute care bed to do so, and our question focuses on the word “relocate” and whether that means this is only permitted in the case when the patient was once in the unit and has moved to the acute-care side of the hospital or if, for example, an acute care inpatient who becomes ready from discharge for their acute care services but then needs rehabilitation services could just stay in the acute care bed and receive their rehabilitation services like they normally would in the unit, but in there acute care bed. …

>>CMS: … When exercising that blanket waiver, it is acceptable to move the patient to a bed for the reason that the hospital may need to for its surge capacity or as part of an infection control program and so let’s say in this case, you are moving a patient for rehab in the IRF to a more typical IPPS bed, you would then continue to perform the rehab functions there in the IPPS bed for as long as you found that appropriate before discharge. If you wanted to move the patient back to the IRF distinct part unit at some point, you are also welcome to do that, and we recommend that you just document in the medical record that this movement has occurred and indicate that it’s related to the blanket waiver and the functions or needs of the hospital with regard to bed capacity at that time.

>> Participant: … Just to clarify, do they ever have to be in the unit to begin with or say, for example, that unit has been repurposed because of surge capacity, could they just begin and finish the rehab service care in that acute care unit without ever having to be moved in and then move out?

>>CMS: I think what you are talking about in that type of a circumstance is more with regard to what are the total numbers of units or total numbers of beds that are part of the IRF unit and, in that case, you need to look at the Medicare regulations and policies with regard to expanding the total number of units….

>> Participant: … I have a follow-up question that I asked on Tuesday regarding hospice initial assessment visits being done through telehealth, and I want to — I’m wondering if you could clarify if both the initial assessment for hospice and the required comprehensive assessment could both be rendered via telehealth and, if so, are the fiscal intermediaries prepared to process claims that may have absolutely no visits on them because all disciplined visits are being rendered either through telephone or telehealth?

>>CMS: …If there’s a claim that is submitted to the fiscal intermediaries or the medical administrative contractors, will the claim process?  Is that your question?

>> Participant: So, if a hospice is unable to render physical visits to patients, … but they are able to meet the patient need with telehealth initial assessments and comprehensive assessments, we’ve been instructed not to put it on the claim, so when a claim has been submitted, there are zero visits on the claim. I just — I’m just checking to ensure that … initial and comprehensive assessments can be done via telehealth, your instructions to not put them on the claims are still in place, and that then the claims will process without issues.

>>CMS: … As long as you are putting the level of care on the claim along with the unit for that like the number of days for that level of care plus the “Q” codes location, the claim will process without a “G” code for the visit, so you should be okay.

>> Participant: Wonderful and the ability to do the assessments both comprehensive and/or initial via telehealth does that apply to home health as well? …

>>CMS: There is nothing in the COPs for other providers that dictates how an assessment is performed, whether it’s done in-person, by telehealth, or anything, to that level of specificity. So, there’s nothing in the regulations that prohibit this from being done. What the regulations do require is that the assessment — it pre-divides a comprehensive view of the patient status at that moment–psychosocial status, their physical status, their functional status– so to the extent that telehealth can be used to accomplish the assessment, then the answer is yes, it can be done. To the extent that there may need to be an in-person contact in order to assess some of these key areas, that would also need to be done. So, we can’t give you a blanket yes or no. It’s really going to come down to what the patient need, with the caregiver needs, what their care preferences are and how to balance all of that.

>> Participant: And my next question is that getting some guidance on wound care in a nursing home and how to bill for that. So, for example, if the patient cannot leave the nursing facility, if the provider is willing to go there to perform the debridement procedure and does not want the wound to deteriorate, how can that be billed for?

>> CMS: … Is it a physician office setting you are talking about or outpatient?

>> Participant: Nursing facility.

>> CMS: Would this normally be packaged under consolidated billing for a SNF stay or would this normally be billed under Part B.

>> Participant: I am not sure of that.

>> CMS: Okay, yeah, we would need that type of detail to be able to provide you some advice….

>> Participant: … My question is regarding the COVID-19 stimulus payments for skilled nursing facilities. If a skilled nursing facility submits a request for the accelerated advanced payments, will the SNF still be able to apply for the COVID-19 stimulus $1.5 billion fund grant…? In other words, can a SNF request both — both of these or only one?

>>CMS: Generally, the accelerated payment provisions don’t — I don’t believe they have a limitation like that in them …

>> Participant: It says … federal government this week announced hospitals and other healthcare providers will receive the first disbursement for $100 billion emergency COVID-19 funds and it talks about skilled nursing facilities derive their income from Medicare, and the windfall could be significant, and they estimate allocation of about $1.5 billion to skilled nursing based on this system. …

>>CMS: Okay, so the details on the grant program haven’t been released beyond some of the statements that have been made at the high level. You will have that when they are out. I think you will be able to see how that is in terms of exactly how the money will be distributed. The accelerated payment program is really a different creature, and so I think I can tell you that from the CMS side with regard to the accelerated payment program, there would not be a preclusion …

And I would draw your attention to those when they come out to see if there’s any particular preclusion, but I would say the high level — two separate programs. …

>> Participant: … We are a rural hospital offering a number of rural health clinics, and to be exempted from the rural health clinic cost limit, we are limited to 50 beds, and the Hospitals Without Walls concept, we are trying to determine how we might put more beds into service if needed, but we need to know that the 50 bed rule will be waived during the period of the emergency. I have asked that question a few weeks ago trying to get an update on that has not been resolved yet?

>>CMS: It is not resolved yet, but we are — it’s definitely on our list of things we are working on so including some of the other things you heard it before, but definitely something we are working on….

>> Participant: …Are you going to consider places of residence like a patient’s home or apartment as an inpatient or temporary extension within the guidance of the Hospitals Without Walls?

SPECIMEN COLLECTION FOR COVID-19 DIAGNOSTIC TESTS

>> Participant: … One other question: What office is used to record the specimen collection for a COVID-19 test? I don’t believe CMS pays the 9900 code. … If a physician office or an urgent care center work to be conducting the swab -based test for COVID-19 testing, is there a code CMS is recognizing for that specimen collection, just like they would recognize a blood draw for a normal laboratory test like something specific for the COVID swab?

>>CMS: I don’t know that there is a specific code for the swab. I think you would bill the most appropriate code for the swab test and, in some cases, I would imagine the best service will be bundled or packaged into a visit service.

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>> Participant: … My second question referencing an earlier call. The gentleman was questioning specimen collection for our locations at our hospitals urgent care sites that are actually doing the swab testing. G2023 is a code that is available, and it is specimen collection for severe acute respiratory syndrome and any specimen source.  Will CMS consider allowing hospitals and/or providers to utilize that HCPCS code for the swab test?…

>>CMS: …That is the code that has finalized recently and specimen collection by independent labs, so I think this is a good question. That is a concern that numerous providers have been asking about. When we finalize that code, it was to a parallel — an existing policy where the we pay for …. required by statute for specimen collection when they send qualified personnel and that’s blood draws and puncture and of the COVID-19 crisis and there’s been multiple reasons asked to consider why a lab may need to send collections whether they are isolated or whatever other reason and also consider the increased costs associated with that travel and other requirements … so just wanted to clarify our thinking and certainly happy to take the question back and, typically, to the extent hospitals and physicians are collecting these specimens regardless of how and where they are choosing to manage infection control on their end, typically, we consider that to be part of the office visit physician or clinic visit and have not necessarily paid separately for and don’t see it certainly in the context G2023 would not be used in the hospital setting and happy to take the concern back and think about that a little more fully on our side.

>> Participant: That would be very much appreciated because it is the hospital staff and the physicians performing the swab test and lab technicians are not going to patient’s homes and doing this. It’s happening hundreds of times daily at our hospitals just like a venipuncture. A blood draw specimen collection, we are not able to charge anything for this right now, but that would be the code that we should be able to utilize if CMS could give consideration to that we would certainly appreciate it ….

Since its April 9th “Office Hours,” CMS posted a new Q&A addressing some of the issues that were raised by participants, and this Q&A supersedes any conflicting guidance provided above.

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