Telehealth and Physical Rehabilitation: The Therapy Equivalent of the ‘Odd Couple’

As the pandemic has continued, it is clear that the most vulnerable in our country are the frail elderly living in institutional settings. One account I read recently said that one-third of all COVID-19 deaths in the country involved long-term care residents or workers.¹ As you know, the level of contact and intimacy that occurs when one is providing personal care or transfer assistance to a resident is such that it is nearly impossible to stop the spread of this virus once it has taken a foothold in your facility. The CDC has indicated that “social distancing” along with proper PPE is the best way to combat the spread of the virus. Of course, social distance when providing hands-on care to a resident is impossible, as we are often up close and personal with our residents as we provide care.

However for situations when up close and personal is not required, a new option is now available: telehealth for therapy providers. (Read on for some limitations.)

On April 6, CMS issued an Interim Final Rule² (IFR) that added PT, OT, and SLP as qualified providers for telehealth services. Unfortunately, due to language in the rule, that really only applied to private practice and hospital settings. Thus began the advocacy effort on the part of trade associations such as APTA, AOTA, ASHA, NARA, NASL, and more, attempting to have telehealth added to the institutional settings (Skilled Nursing Facilities, Rehab Agencies, and Home Health). Yesterday on June 2nd, during one of the twice weekly CMS Office Hours calls, when asked if telehealth could be provided to a Part A SNF patient, CMS stated, “At this point, we haven’t spoken to it not being permissible.”

By CMS not responding with a direct “No” answer, their response communicates that providing Part A telehealth is possible at this time. This is the full Q & A exchange from the closed caption feature on the CMS Office Hours call weblink for Tuesday, June 2, 2020: 

>>CMS: The next question is from Mark McDavid from Seagrove Rehab Partners.

>>Mark: Thank you so much for taking my call and holding office hours these are great. I want to follow up on Bob's question about telehealth therapy services and skilled nursing facilities. In the FAQ that was published last week it talked about outpatient therapy services and that is where we see that new therapy language on the FAQ unless I missed it somewhere else which is possible. But as it relates to Part A services as Bob points out that's not a separately billable service and we are not asking to do that we are asking for access to beneficiaries or for the beneficiaries who have access to care and his example he talked about speech therapy or PT or OT who is unable to be in the building due to health reasons. Could we be providing a telehealth service to a Part A patient from outside the building and count those minutes on the MDS? The evaluation minutes don't count on MDS that's clear in the manual but treatment minutes do. So, you know, if we had an OT who was out of the building doing an evaluation via telehealth maybe an OTA is with the patient, then the OTA is kind of the hands of the therapist so to speak but the OT is making that assessment and evaluation judgment as they see and respond back and forth with what the OTA is reporting. So those evaluation minutes would not count, but any follow-up treatment minutes would? we just want to clarify that those minutes would be counted and the only reason is because of the telehealth piece. It's clear in the RAI that treatment minutes count for MDS. I want to be clear that telehealth treatment minutes would also count since the FAQ addressed outpatient and not Part A. 

>>CMS: Part A is not expressly addressed in those questions as you noted it's related to outpatient therapy and so we would just note that the Part A therapy is required to be reasonable and necessary and the responsibility of the skilled nursing facility and just receiving the payment as part of Part A consolidated billing and we would defer to them and the manual in working through that. I don't know if you have any colleagues on from the quality group that would have anything further to add. 

>>Mark: So assuming we meet the requirements in the RAI manual, obviously the RAI does not address telehealth because that wasn't a thing the last time RAI was updated. Assuming we meet all of those requirements medically necessary and, so on and so forth, then those treatment minutes via telehealth could be included correct? I think that's what you are saying. 

>>CMS: I think at this point, we haven't spoken to it not being permissible. 

>>Mark: Not being permissible. Okay, got it. I can work in the gray area. Got it. Thank you so much for taking my call. 

You might be thinking, “Why is this a big deal?  Why would we need to do telehealth with a Part A patient?” 

Let me propose a scenario we have heard:

A small, rural facility only has a PRN PT or OT, and that PT or OT was exposed to COVID-19 in another facility or from the community.  The therapist feels fine, but due to the exposure must be quarantined for a period of time and/or at least until a negative test is received. During that time, the facility has a Part A admission that needs a PT or OT evaluation. In this scenario, the PT or OT could complete that evaluation via telehealth to allow the PTA or OTA to get started treating this patient.

So the big news is that if you are trying to stop the spread or limit the exposure to your residents, telehealth for both Part A and Part B is available to Medicare SNF residents. That said, there are some limitations: when CMS posted the IFR mentioned above and linked below, it outlined the CPT codes that could be billed by PT, OT, and SLP using telehealth. That list includes all the regular therapy modalities, but conspicuously did not include 92526 (treatment of swallowing dysfunction) and 92610 (evaluation of oral and pharyngeal swallowing function). Several of the therapy organizations have begun efforts to lobby CMS to include those two codes to also be available for speech telehealth treatment. 

We are following all of these updates closely, so stay tuned for more information as it becomes available!

Written by: Mark McDavid, OTR, RAC-CT, CHC

References

1. Yourish K, Lai KKR, Ivory D, and Smith M. One-third of all U.S. coronavirus deaths are nursing home residents or workers. New York Times. https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html. Publication date unavailable. Updated May 11, 2020. Accessed June 3, 2020.

2. The full Interim Final Rule can be read here: https://www.federalregister.gov/documents/2020/04/06/2020-06990/medicare-and-medicaid-programs-policy-and-regulatory-revisions-in-response-to-the-covid-19-public