The Centers for Medicare & Medicaid Services formally announced Tuesday afternoon that it has finalized its calendar 2021 physician pay rule, which cuts physical, occupational and speech/language therapy payments for nursing homes patients by 9%.

Long-term care advocates have sounded the warning over such forecast reductions for months after the proposal was first released in early August. They have said they will appeal to lawmakers for relief. Last year, therapy providers took an 8% cut

The rule was written to give certain primary care physicians a pay boost. Nurse practitioner services will also get a pay increase (7%) but only in an office setting; when billed in a nursing facility, there will be a decrease.

“The action that CMS took to finalize these policies that impact nursing facility patients is shocking in that CMS is significantly cutting services that help our patients recover from COVID or keep themselves healthy and hopefully not succumb to COVID-19,” said Cynthia Morton, executive vice president of the National Association of Support for Long Term Care.

“Services like rehab therapies that patients need to strengthen their mobility after being in a bed for a long time, X-rays to detect problems in their lungs from COVID-19, and nurse practitioner services are being cut. CMS is very helpful to nursing facility providers on one hand, but with the other hand is cutting these vital services pretty deeply that are going to hurt provider’s abilities to provide these critical services,” she added. 

CMS is putting “significant” increases into chronic care and primary care for Medicare beneficiaries that see physicians in the office setting, Morton added. The increases are being offset by decreases to nursing facility care and about 40 other specialties paid for by the Physician Fee Schedule.

“This policy finalized today leaves me wondering about the chronic care for patients in nursing facilities,” Morton said.

Telehealth expansion praised

The administration played up the vast expansion of telehealth services it also has approved. CMS is bound by statutory limitations that curb how much it can do, something providers readily acknowledge. Congress would need to approve expansion of telehealth coverage for therapists, or to broaden coverage beyond nursing homes in rural locations.

“During the COVID-19 pandemic, actions by the Trump administration have unleashed an explosion in telehealth innovation, and we’re now moving to make many of these changes permanent,” said Health and Human Services Secretary Alex Azar on Tuesday afternoon. “Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we’ll keep exploring ways to deliver Americans access to healthcare in the setting that they and their doctor decide makes sense for them.”

CMS Administrator Seema Verma said the pandemic “accentuated just how transformative” telehealth could be — beyond the permissions given previously only to rural health providers. Before the public health emergency was declared, telehealth services were used by 15,000 fee-for-service beneficiaries per week. The administration added more than 140 telehealth services to the coverage list, and more than 24.5 million (out of 63 million) and enrollees received a Medicare telemedicine service between mid-March and mid-October — about 60 times the rate of pre-pandemic levels — officials reported.

“Several months in, it’s clear that the healthcare system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in healthcare delivery,” Verma said in a statement.

Included in Tuesday’s actions are favorable responses to long-term care stakeholder concerns that a limit of once-monthly, follow-up telehealth visits was too restrictive. CMS had considered revising the frequency limit from one visit every 30 days to once every three days. However, facing concerns about not getting enough in-person contact, the agency said it reconsidered and landed at a frequency limitation of one visit every 14 days.

CMS also said that it has created two new permanent payment codes to cover billings for the remote evaluation of patient-submitted video or images and virtual check-ins. They will benefit clinical social workers, psychologists, physical and occupational therapists and speech language pathologists, who may provide short online assessments and management services, as well as virtual check-ins and evaluations services.

The agency further clarified that services may be reported as telehealth even if a physician or practitioner is in the same building as the beneficiary but is using telecommunications to stay apart to limit infection exposure risks.

A CMS fact sheet on the expansive pay rule can be found here. It explains, among other things, new lists of coverage areas through the end of the calendar year when the public health emergency ends.

The final physician pay rule also makes permanent the expansion of Medicare practice permissions for certain non-physician practitioners.

Under the flag of the administration’s “Patients Over Paperwork” initiative, CMS finalized these changes:

  • Certain non-physician practitioners such as nurse practitioners and physician assistants can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
  • Physical and occupational therapists will be able to delegate “maintenance therapy” to a therapy assistant.
  • Physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. Officials say this will allow practitioners to have the flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before.