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  • Washington Highlights

    CMS Issues Additional Waivers For Flexibility During COVID


    Gayle Lee, Director, Physician Payment & Quality
    Mary Mullaney, Director, Hospital Payment Policies
    Andrew Amari, Hospital Policy and Regulatory Specialist
    Kate Ogden, Physician Payment & Quality Specialist
    Phoebe Ramsey, Director, Physician Payment & Quality

    In response to AAMC and other organizations’ calls to address several administrative and regulatory hurdles, the Centers for Medicare & Medicaid Services (CMS) issued additional waivers and rules changes on April 30 to allow flexibility to hospitals and other providers delivering care during the COVID-19 pandemic. This follows the AAMC’s March 20 letter to CMS outlining regulatory relief recommendations [see Washington Highlights, March 20].  

    AAMC President and CEO David Skorton, MD, issued a press statement on May 1 thanking CMS for the additional regulatory relief which will “remove barriers to care and improve access for patients by allowing teaching hospitals to increase surge capacity without being penalized, relocate outpatient clinics to better serve their communities, and more efficiently deploy the nation's health care workforce by clearing a path for medical residents to support community hospitals with workforce needs.”

    CMS changes ensure that teaching hospitals are not penalized when they add beds for surge capacity, remove barriers so teaching hospitals can lend available medical staff support to other hospitals, increase access to telehealth, make it easier for Medicare and Medicaid beneficiaries to be tested for COVID-19, expand the workforce by removing barriers, enable hospitals and health systems to treat COVID-19 patients through temporary expansion sites, and give accountable care organizations (ACOs) greater financial stability and predictability during the COVID-19 pandemic.

    Key highlights from the rule include:

    Direct Graduate Medical Education (DGME)/Indirect Medical Education (IME)

    • Holding hospitals harmless from reductions in IME payments due to increases in bed counts as a result of COVID-19.
      • IME regulations (42 CFR 412.105(d)(1)) will be amended to exclude beds temporarily added from the IME payment calculation for the duration of the COVID-19 public health emergency (PHE).
      • A hospital’s bed count for determining the IME calculation during COVID-19 PHE will be altered; the calculation will use a hospital’s available bed count from the day before the COVID-19 PHE was declared (Jan. 31, 2020).
    • Holding harmless inpatient rehabilitation facilities (IRFs) and inpatient psychiatric facilities (IPFs) for increases in patients.
      • Teaching status adjustment payment for IRFs and IPFs will be the same as it was on the day before the COVID-19 PHE was declared.
    • Addressing time spent by residents at another hospital during the COVID-19 PHE.
      • Regulations will be revised on claiming time for DGME and IME to permit teaching hospitals that send residents to another hospital on an emergency basis to claim the time their residents spend training at the other hospital during the COVID-19 PHE.
      • Regulations require either the sending or receiving hospital to be treating COVID-19 patients but do not require that the resident be involved in COVID-19 patient care activities.
      • If residents are sent to a non-teaching hospital, their presence will not trigger the establishment of a per resident amount or FTE resident cap at that hospital.
    • Addressing time spent by residents at alternative location during the COVID-19 PHE.
      • Hospitals paying the resident's salary and fringe benefits for the time that the resident is at home or in a patient's home but performing duties within the scope of the approved residency program and meeting appropriate physician supervision requirements can claim that resident for IME and DGME purposes.


    • The reimbursement rate for the telephone-only evaluation and management codes (99441-43) will be increased, paying them at rates equivalent to evaluation and management codes 99212-99214. This would increase payments for these services from a range of about $14-$41 to about $46-$110, and the payments are retroactive to March 1, 2020.
    • The types of health care providers who can furnish telehealth services will be expanded to include speech-language pathologists, occupational therapists, and physical therapists.   
    • Hospitals will be reimbursed for an originating site fee when the patient is located in their home or a temporary hospital expansion site and receives services via telehealth. The patient needs to be a registered patient in an outpatient hospital department.

    Hospital Outpatient Departments (HOPDs)

    • Clarifying the treatment of certain relocating provider-based departments (PBDs) during the COVID-19 PHE.
      • Certain provider-based HOPDs that relocate off-campus will be permitted to obtain a temporary exception and continue to be paid under the outpatient prospective payment system (OPPS) rate during the COVID-19 PHE. They must apply for an “extraordinary relocation exception” and notify the appropriate CMS regional office as detailed in the rule.
      • Hospitals that relocate PBDs during the COVID-19 PHE must use modifier “PO” for claims furnished at the relocated site.
      • Hospitals will be allowed to relocate HOPDs to more than one off-campus location or partially relocate off-campus while still furnishing care at the original site. This addresses hospitals that develop temporary expansion sites and repurpose existing clinical and nonclinical space for patient care.
      • Hospitals will also be permitted to treat a patient’s home as a relocated PBD when providing certain outpatient therapy, counseling, and educational services and receive the OPPS payment rate during the COVID-19 PHE.

    Medicare Shared Savings Program (MSSP)

    • Payment amounts for COVID-19 episodes of care (identified by inpatient acute care) will be removed to mitigate the impact of COVID-19 care on various financial performance calculations.
    • Telehealth specific codes, including virtual check-ins, e-visits, and telephone services will be added to the definition of primary care services used in patient attribution to ACOs beginning in January 2020 through the remainder of the public health emergency (including potentially subsequent performance years) to acknowledge the increases in services provided virtually. CMS clarified that codes previously included in the definition of primary care that may be provided and billed as telehealth were already included in attribution determinations.
    • A prior misstatement on the timeline for the application of the program’s extreme and uncontrollable circumstances policy will be corrected, effective beginning January 2020 (not March) based on the timing of the secretary’s declaration of the public health emergency.
    • The 2021 application cycle will be canceled, and ACOs whose current agreements expire at the end of 2020 will be allowed to extend those agreements through 2021 to decrease administrative burden. Similarly, ACOs participating in the BASIC track’s glidepath will have the option to remain at their current risk level for 2021 rather than automatically having to assume a higher level of risk.