COVID-19: Telehealth and SNF Admissions Dominate CMS Town Hall

EDITOR’S NOTE: RACmonitor asked Dr. Ronald Hirsch to monitor the CMS townhall conference call on Tuesday. The following is his summary of that call.

In a Centers for Medicare & Medicaid Services (CMS) town hall call on April 14, CMS took questions from across the country on COVID-19 billing and coding. As with many of the prior calls, there were a lot of questions about telehealth. The hot topic seemed to be the current restriction on physical, occupational, and speech therapists performing therapy via audio and visual communication with patients at other locations. Although therapy codes are approved for telehealth, therapists are not approved providers. The few codes that therapists are allowed to use are low-weighted, frequency-limited codes that are not the same as providing a session of therapy with a patient on a regular basis.

One questioner asked about a therapist who is employed in a physician practice, and whether they could bill for therapy “incident to.” There was some hesitation in answering, but the answer was ‘no.” RACmonitor editorial board member David Glaser feels that “incident to” does apply here, and he discussed this on the last Monitor Mondays broadcast.

That aside, CMS did indicate, as they did on several other calls, that they are actively working on allowing therapists, both employed by hospitals and in private practice, to be able to perform telehealth therapy and bill for it with the approved codes. They also noted, in response to a question, that once approved, the billing will be retroactive, so many take that to mean that therapy providers could start performing tele-therapy now, keep records, and then bill for the services once the codes are formally approved.

CMS was also asked about the great variability in the use of the DR “disaster related” condition code and the CR “crisis related” modifier, by payer. They were informed that every payer and even the National Uniform Billing Committee (NUBC) have different instructions. For Medicare, their publications indicate that they want the DR used if a Skilled Nursing Facility (SNF) is admitting a patient without a three-day stay; if a Critical Access Hospital (CAH) is admitting a patient with an expectation of a stay over 96 hours; if a Long-Term Acute-Care Hospital (LTACH) patient who would normally be paid under the site-neutral payment program has an expected length of stay (LOS) of under 25 days; or if a hospital patient is cared for in a “hospital without walls” location. If a hospital is caring for a COVID-19 Medicare patient as an inpatient and no waiver applies to their care, the DR is not applied.

But other insurers want the DR or CR on every COVID-19 claim. And of course it is easy to confuse the CR and the CS modifier. The CS modifier is used for the visit during which the COVID-19 test was ordered. The CS means the payer will pay 100 percent of the approved amount, and not 80 percent. It’s confusing for sure, and CMS said that they will address this in a future document.

Hospitals continue to have difficulty getting patients into SNFs. This is a nationwide problem, and understandable, from the SNF side. They have facilities full of patients who are at high risk of death if they get COVID-19, and they want to protect their residents. They also have more limited resources than a hospital. The states and CMS have been working hard to address this by setting guidelines for admitting patients, caring for patients in separate wings, and even transferring patients between facilities. As a reminder, if you cannot find a suitable discharge destination for an inpatient, the days are considered medically necessary by Medicare and covered. For other insurers, although many have waived prior authorization for post-acute care, they may be able to assist you in placing the patient, so enlist their help to take care of them.

On the other hand, on the call, CMS was asked about a scenario in which an observation patient is ready to go to a SNF, but there is no accepting SNF that can accept them as an inpatient, so that the hospital will get paid a DRG to compensate for the extra days of care. Unfortunately, the answer was no. Hospitals are still responsible for getting admission status right. CMS clearly heard that such a patient will cost a lot to care for, but the existing regulations do not allow them to approve inpatient admission if the need for hospital care exceeding two midnights is not present.

The next CMS call is scheduled for April 16, and RACmonitor will be listening.

Programming Note:

Dr. Hirsch is a permanent panelist on Monitor Mondays. Listen to his live reporting this coming Monday during a special 60-minute townhall edition of Monitor Mondays, 10 -11 a.m. EST.