Pulmonology Coding Alert

Read on to learn the details and tips on how to prepare, so your pulmonology providers can continue to receive accurate reimbursement.

Look to CMS for Guidance

On February 1, the Centers for Medicare & Medicaid Services (CMS) updated its “CMS Flexibilities to Fight COVID-19” documents for different provider types and programs in light of the PHE sunsetting. The updates, which include when specific flexibilities will expire, also offer helpful links to policy histories and legislative actions that may have extended a waiver beyond the PHE end date.

Plus: On February 9, the Department of Health and Human Services (HHS) issued a letter to state governors announcing the final extension of the COVID PHE. The renewal went into effect on February 11 and was accompanied by a fact sheet titled the “COVID-19 Public Health Emergency Transition Roadmap.”

“Addressing COVID-19 remains a significant public health priority for the Administration, and over the next few months, we will transition our COVID-19 policies, as well as the current flexibilities enabled by the COVID-19 emergency declarations, into improving standards of care for patients,” HHS explains in the fact sheet. Additionally, HHS offers a quick review of what flexibilities won’t be affected, how it is continuing to monitor policies and whether to make them permanent, and what will ultimately change at the federal healthcare level when the PHE ends.

Expect Medicare Guidance to Continue to Evolve

In the CMS fact sheet introductions, the agency explains its “cross-cutting initiative,” which is a three-prong approach to evaluating waivers and flexibilities as the nation transitions to a post-COVID PHE landscape. According to CMS, the three concurrent phases include:

1. Analyzing whether to continue with certain blanket waivers and if ending them would present barriers to communities.

2. Evaluating which flexibilities would prove “most useful” in future PHEs.

3. Collaborating with the healthcare industry, other federal agencies, and stakeholders on future PHEs.

“As CMS identifies barriers and opportunities for improvement, the needs of each person and community served will be considered and assessed with a health equity lens to ensure our analysis, stakeholder engagement, and policy decisions account for health equity impacts on members of underserved communities and health care professionals disproportionately serving these communities,” the fact sheets note.

Pinpoint the Takeaways

With more than a dozen separate fact sheets, CMS offers a comprehensive look at what’s been extended and what’s set to expire across the various parts of Medicare. Here are a few examples from the “Physicians and Other Clinicians” fact sheet:

Telehealth: The Medicare telehealth expansion has been a boon to providers during the pandemic — and the waivers and flexibilities associated with the PHE have been the subject of much discussion at every level of government and across the healthcare industry. As part of the COVID PHE, Medicare beneficiaries “have been able to receive Medicare telehealth and other communications technology-based services wherever they are located;” moreover, providers were able to furnish these services to both new and established patients, the fact sheet says.

Some of the Medicare telehealth waivers and flexibilities were slated to end 151 days after the COVID-19 PHE ends. The Consolidated Appropriations Act, 2023, modified or extended specific Medicare telehealth waivers through Dec. 31, 2024, as follows:

• Continue the temporary suspension of geographic site requirements;
• Expand and allow a patient’s home to be an originating site for telehealth services;
• Allow Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to provide telehealth services to patients;
• Add occupational therapist, physical therapist, speech-language pathologist, and audiologist to the list of eligible telehealth providers;
• Extend Medicare coverage and payment of audio-only telehealth services; and
• Defer the in-person behavioral health visit requirement for six months for patients not covered under the geographic eligibility provisions.

RPM: With the current 1135 waiver, clinicians can bill for remote patient monitoring (RPM) services furnished for both new and established patients — that is set to expire when the PHE ends. Post-PHE, providers will need to have an established relationship with patients before they can render RPM services to them.

Stark Law: On March 30, 2020, the feds instituted a variety of blanket waivers to address financial relationships and referrals under the Physician Self-Referral Law, or Stark for short. “During the PHE, CMS permitted certain referrals and the submission of related claims that would otherwise violate the Stark Law, if all requirements of the waivers were met,” the fact sheet reminds. But, “when the PHE ends, the waivers will terminate and physicians and entities must immediately comply with all provisions of the Stark Law,” warns CMS.

Resources: You can review the various provider- and program-specific fact sheets from CMS at www.cms.gov/coronavirus-waivers and find the HHS roadmap at www.hhs.gov/about/ news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html.