Therapists Find Some COVID-19 Telehealth Opportunities — But Remain Off Medicare List

The federal government has waived multiple regulations around telehealth with an eye toward making it as easy as possible to stay home and receive medical care.

It’s a move that seems well-suited to benefit the Medicare beneficiaries living in skilled nursing facilities across the U.S., who need care while minimizing contact with visitors during the COVID-19 pandemic.

But therapists — who provide essential services to patients in the SNF setting — are not currently on the statutory list of eligible providers, or “distant site practitioners,” as designated under fee-for-service Medicare, Cynthia Morton, the executive vice president of the National Association for the Support of Long-Term Care, said on a Thursday webinar hosted by Skilled Nursing News.


The list of eligible practitioners includes:

  • Physicians
  • Nurse practitioners
  • Physician assistants
  • Nurse-midwives
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Clinical social workers
  • Registered dietitians or nutrition professionals

“This list is set in statute,” Morton said on the webinar. “And you’ll note there that the rehab therapists, the physical therapists, the occupational and speech therapists, they are not included on that statutory list. We sure would like them to be.”

The waivers have made some difference; telehealth was originally only intended to provide care to those living in rural areas, she noted.


But with the COVID-19 pandemic upending life across America, the Centers for Medicare & Medicaid Services (CMS) issued a wide set of waivers at the end of March “essentially eliminating all barriers and adding services in other sites of care to the telehealth list,” according to a statement from AMDA, the Society for Post-Acute and Long-Term Care Medicine. The waivers allowed providers to perform initial and discharge services remotely, and removed a requirement that telehealth visits in the SNF setting take place only every 30 days.

Under the waiver from CMS, any nursing facility can use telehealth, and some of the restrictions around the type of technology involved have been lifted.

Rehab therapists are still not authorized to provide services through telehealth, even under the waivers. That said, some Medicare Advantage plans and commercial plans have allowed it — just not original Medicare, Morton noted.

But even with the billing challenges, Key Rehab, which is based in Murfreesboro, Tenn., has been able to utilize telehealth for physical therapy, occupational therapy, and speech therapy.

“It’s not something that we’re able to bill for, but we do it as consultation and training,” Michael Gorman, Key’s senior vice president of clinical and regulatory affairs said.

For instance, a clinician looking for extra training is partnered with a more experienced practitioner for a session, and the technology allows the mentoring therapist to watch the session with the patient and give suggestions, Gorman said.

Some states do allow for physical, occupational, and speech therapy to be done via telehealth, so Key has established “non-billable telehealth” in some areas. As an example, some states that have strict supervisory visit requirements allow those visits to be done via telehealth, so Key was practicing this even before the COVID-19 pandemic.

It was also using an encrypted platform that was compliant with the standards of the Health Insurance Portability and Accountability Act (HIPAA), Gorman noted, since prior to the waivers from CMS, technologies such as FaceTime or Skype wouldn’t have been compliant.

Telecommunications vs. telehealth

Morton also broke down a difference between telehealth and “services furnished via telecommunications technology, [that] are not considered Medicare telehealth services,” or communication technology-based services (CTBS) in CMS’s terms.

This includes remote patient monitoring, interpretations of diagnostic tests when furnished remotely, virtual check-ins, e-visits, and telephone assessment and management. CMS has said that therapists are allowed to do virtual check-ins and e-visits, Morton said, but how these could be done in the institutional setting is not clear.

The e-visits and virtual check-ins are designed to make an in-person visit unnecessary, but they don’t constitute full treatment.

“CMS kind of muddied the waters a little bit, because CMS has put out little bits of FAQ-type guidance, saying that rehab therapists can provide e-visits, and they can provide virtual check-ins,” she said on the webinar. “What they’ve said is that practitioners who do not bill these E&M codes, who do not bill these evaluation and management codes —and that means rehab therapists and other providers — can bill these virtual check-ins and e-visits.”

But what isn’t clear is how those things would be applied in the nursing home setting, Morton said.

She also emphasized that these two types of visits are not paid at a full rate like a telehealth visit would be, so these wouldn’t be considered treatment sessions.

There are several organizations trying to get rehab therapists added to the distant practitioner list, but this probably wouldn’t come to fruition for some time, Morton said. But it’s an urgent issue as SNFs try everything they can to keep COVID-19 out of their buildings and maintain their residents’ safety.

“We’ve got this tool of telehealth right there, that we can use to perhaps have a therapist in the building and then perhaps a therapist outside the building at a distant site, communicating with the therapist in the building,” she said. “And we can reduce the number of clinicians that need to go into that building.”

Gorman noted, for his part, that Key Rehab is trying to use telecommunications and “taking them [CMS] at their word.”

In an FAQ posted April 9, CMS said a physician or practitioner in the same physical setting as a Medicare beneficiary who used telecommunications technology because of fear of COVID-19 exposure — for instance, a video link to a separate room with the same facility — would not need to report this as a telehealth service.

That means Key will use telecommunication technology for evaluations for new patients, for instance.

“We are looking at ways to work with our facilities, and saying: Hey, have you got a ‘clean’ room that we can come into, something that’s right near the door … we’ll be staying isolated, but we’ll be using telecommunications to talk to the therapy assistant, and that therapy assistant will be with the patient,” he explained. “And between the therapist utilizing the telecommunication technology and the therapist working with the actual patient, we’ll get that evaluation done.”

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