COVID-19 Impacts Regulations on SNF Waivers and Telehealth

The regulatory landscape is rapidly changing in the wake of the coronavirus.

EDITOR’S NOTE: As with last week, RACmonitor asked Dr. Ronald Hirsch, vice president of R1 RCM, to summarize the most pertinent regulatory changes recently arising. The following is a transcript of his reporting today on Monitor Mondays.

“First, thank you, everyone, for continuing to care for patients and continuing to take this pandemic seriously,” Dr. Ronald Hirsch told Monitor Mondays audience members today. “We can all only hope that we will look back at this and decide we overreacted, but even that will have taught us valuable lessons for the next pandemic.”

Noting that the regulatory landscape has been changing daily – and, unfortunately, there has been a lot of misinterpretation of the waivers issued by the Centers for Medicare & Medicaid Services (CMS) –  Hirsch explained that the three-day inpatient admission requirement for the Part A skilled nursing facility (SNF) benefits has been waived for all Medicare fee-for-service (FFS) patients.

“It (the waiver) applies to every SNF, everywhere in the country,” Hirsch said, explaining that “no SNF or state needs to apply for the waiver … (and) there does not even need to be COVID-19 cases in the community to use the waiver.”

According to Hirsch, an SNF needs to simply determine whether there is a skilled need, and if so, they can accept the patient. The SNF would then put the DR condition code on the claim, and it will be paid. The waiver has no inclusion or exclusion criteria, and even patients who have exhausted their 100 days during the benefit period may continue to receive Part A SNF care.

“While the three-day SNF rule is waived, it should be noted that waivers for the Preadmission Screening and Resident Review (PASRR) required for SNF admission require a state-by-state waiver, and so far, only Washington and Florida have been granted (them),” Hirsch said.

Hirsch explained that, although not part of the waiver, the Important Message to Medicare (IMM) and the Medicare Outpatient Observation Notice (MOON), and all other notices of verbal explanation to the patient, can be provided by telephone.

“Personal protective equipment should not be wasted on a registration clerk or case manager simply to explain the notice, get a signature, and hand the document to the patient,” Hirsch said. “Provide a telephone explanation, note that on the form, and have a copy delivered when someone enters the room for necessary care.”

During the broadcast, Hirsch also said that the status of swing beds was not as clear as the guidance for SNF beds.  Swing beds are beds in a rural or critical access hospital (CAH) that can be used for acute care or for rehabilitation care. Swing beds provide SNF-like care, but are classified and paid differently.

“When I inquired if the three-day inpatient admission requirement waiver applies to swing beds, the answer from CMS was that it did not,” Hirsch said. “When a colleague asked the same question, it was routed to a different person, who said that the waiver does apply to swing beds.”

Hirsch said that he asked the same question again, to what he described as a “high-ranking” CMS director, and was told the “official” answer for now is that the waiver does not apply.

“But note that when the SNF waiver was issued on March 13, it was retroactive to March 1,” Hirsch said. “That means that if swing beds do get included in the waiver, it would likely also be retroactive. If a swing bed has admitted a patient already, just apply the DR condition code to the claim, and if denied, the contradictory answers from CMS can be used to dispute the denial.”

Hirsch told audience members that although CMS has been asked, there is still no word on delaying the new IMM, the MOON, and Detailed Notice of Discharge forms, which become effective April 1. He added that he would find it hard to believe that a hospital would be cited for using the old forms in April.

“As you likely have already heard, all hospital and post-acute care provider quality payment program data reporting is suspended until July 1,” Hirsch, said, noting that “it appears the Merit-based Incentive Payment System (MIPS)will follow shortly. While CMS has not yet addressed a request to exclude all claims during the pandemic from audit, New York state has put significant restrictions on all insurers who issue policies in the state about prior authorizations and denials of care.”

Hirsch noted that with the new telehealth waiver, many physicians have been given the ability to use FaceTime and other video/audio applications to conduct “office visits” without concern about HIPAA, and they are permitted to bill office visit codes 99201-99215 for these visits, with 02- telehealth to be listed as the site of service.

“As of this date,” Hirsch said, “CMS has not permitted payment for phone calls without video, but physicians would be wise to keep a log of all phone calls, since CMS has been asked to approve payment for these, and often approvals include a retroactive date, as did the waiver for the use of FaceTime.”

Noting that many hospitals have rightly ceased all elective procedures, and there will be a significant decrease in revenue accompanying this, Hirsch said that with the stress on every provider, it may be a good time to hold off on all clinical documentation integrity (CDI) queries.

“A physician who is being asked to reuse single-use personal protective equipment should not also be asked if a patient on oxygen has acute respiratory failure,” Hirsch said.

Programming Note: Listen to Dr. Ronald Hirsch live reporting every Monday on Monitor Mondays, 10-10:30 a.m. EST.