CMS payment policies & regulatory flexibilities

CMS payment policies & regulatory flexibilities

Last updated: 4/13/2020


The AMA has been working constantly with the Centers for Medicare & Medicaid Services (CMS) to identify issues arising due to COVID-19 and to recommend specific actions to improve Medicare coverage of services and reduce regulatory burdens on physicians during this crisis.


Below are key actions CMS has taken in response to AMA advocacy. Topics include telehealth, the Merit-based Incentive Payment System (MIPS), enrollment, elective surgery and regulatory relief. For the complete list of CMS payment and policy guidance related to COVID-19, please access the CMS website.


HHS Emergency Fund disbursement

On April 10, the Department of Health and Human Services (HHS) announced the immediate disbursement of the first $30 billion out of the $100 billion that Congress allocated to hospitals, physicians and other health care providers in the Public Health and Social Services Emergency Fund in the Coronavirus Aid, Relief and Economic Security (CARES) Act. The distribution policy adopted by HHS reflects the recommendations from organized medicine made to Secretary Azar by the AMA and 137 medical societies earlier this week, although it is not exactly what we proposed. In part, the difference stems from the administration’s approach of first disbursing $30 billion and later determining how the remainder of the funds will be allocated.


This initial $30 billion is being directed to hospitals and physician practices in direct proportion to their share of Medicare fee-for-service spending. The total amount of Medicare FFS spending in 2019 was $484 billion. Hypothetically, if a Medicare provider with a Taxpayer ID Number (TIN) accounted for 1% of total Medicare FFS spending in 2019, the TIN would receive 1% of the $30 billion.


This allocation method is similar to the recommendation from organized medicine because we recommended that the distribution be tied to physicians’ Medicare FFS spending from a portion of 2019, pre-COVID-19. It differs from our recommendation in several respects: instead of using a one-month average of three months of Medicare spending, it uses spending for the entire year 2019; and it does not multiply that amount by three to average all-payor revenue for a month. Also, it does not employ any methodology to pay physicians who may have no or few Medicare claims but rely significantly on Medicaid funding; but, at a White House Coronavirus Task Force briefing earlier this week, Administrator Verma indicated that a subsequent distribution from the Emergency Fund will be directed to pediatricians, children’s hospitals, and others who rely on Medicaid.


All facilities and health professionals that billed Medicare FFS in 2019 are eligible for the funds. These are grants, not loans, and do not have to be repaid. Note that the funds will go to each organization’s TIN which normally receives Medicare payments, not to each individual physician. The automatic payments will come to the organizations via Optum Bank with “HHSPAYMENT” as the payment description.


Additional details about the allocation are available.


This website also includes a link to terms and conditions (PDF) for receipt of the funds that each organization receiving the grants will need to attest to within 30 days of receiving the grant. The funds may be used either for health care related expenses or for lost revenues that are attributable to coronavirus.


CMS updates FAQs about regulatory waivers and telehealth flexibilities

On April 9, CMS released answers to common questions (PDF) about the regulatory and telehealth flexibility available during the COVID-19 emergency, including:


Question: Can Remote Physiologic Monitoring (RPM) services be furnished to new patients as well as established patients?

Answer: Starting March 1 and for the duration of the PHE, RPM services can be furnished to both new and established patients. We suspended, under present circumstances, the requirement that there be an established relationship between the health care provider and the patient because it could impede access to the RPM services


Question: Should on-site visits conducted via video or through a window in the clinic suite be reported as telehealth services? How could a physician or practitioner bill if this were telehealth?

Answer: Services should only be reported as telehealth services when the individual physician or practitioner furnishing the service is not at the same location as the beneficiary. If the physician or practitioner furnished the service from a place other than where the beneficiary is located (a “distant site”), they should report those services as telehealth services. If the beneficiary and the physician or practitioner furnishing the service are in the same institutional setting but are utilizing telecommunications technology to furnish the service due to exposure risks, the practitioner would not need to report this service as telehealth and should instead report whatever code described the in-person service furnished.


Medicare advanced payments

To assist with cash flow challenges during the COVID-19 pandemic, CMS has expanded its Advanced Payment Program to provide qualifying physicians an emergency upfront payment of up to three months’ Medicare payments based on historical claims information from Oct-Dec 2019. Physicians will need to repay this advance, and CMS has extended the repayment to give physicians 210 days from the date the Medicare Administrative Contractor issues the payment.


AMA resources

  • Fact sheet explaining the Advanced Payment Program
  • FAQs answer common questions about timing, interest, and submitting a request

CMS resources

  • Fact Sheet on advanced payments during the COVID-19 pandemic

AMA releases special coding advice related to COVID-19

New guidance from the AMA provides special coding advice during the COVID-19 public health emergency. One resource outlines coding scenarios (PDF) to help health care professionals apply best coding practices.

The scenarios include telehealth services for all patients.

There is also a quick-reference flowchart that outlines CPT reporting for COVID-19 testing (PDF).


Medicare expands telehealth during COVID-19 emergency

The Centers for Medicare & Medicaid Services (CMS) lifted Medicare restrictions on the use of telehealth services during the COVID-19 emergency. Key changes include:

  • Effective March 1 and throughout the national public health emergency, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19.
  • Medicare will pay physicians for audio-only telephone calls and has greatly expanded the list of covered telehealth services to include emergency department visits, for example.
  • Physicians utilize telehealth for both new and established patients.
  • Reporting and documentation for office visits performed via telehealth may be based on medical decision-making or time on date of encounter, utilizing 2020 definitions and CMS total time data.
  • Allowing medical screening exams (MSEs), a requirement under Emergency Medical Treatment and Labor Act (EMTALA), to be performed via telehealth.
  • Patients can receive telehealth services in all areas of the country and in all settings, including at their home.
  • CMS will not enforce a requirement that patients have an established relationship with the physician providing telehealth.
  • Consent for telehealth services may be obtained by staff or the practitioner at any time, required only once on an annual basis.
  • Physicians can reduce or waive cost-sharing for telehealth visits.
  • Physicians licensed in one state can provide services to Medicare beneficiaries in another state. State licensure laws still apply.
  • Physicians can provide telehealth services from their home. Physicians do not have to add their home to their Medicare enrollment file.
  • HHS Office for Civil Rights (OCR) offers flexibility for telehealth via popular video chat applications, such as FaceTime or Skype, during the pandemic.

AMA tools and resources:

  • AMA’s telemedicine quick guide has detailed information to support physicians and practices in expediting implementation of telemedicine.
  • AMA’s coding scenarios (PDF) provide real-world examples of how to code for telehealth services.
  • AMA fact sheet goes into detail about Medicare’s payment and coverage expansion.
  • List of telehealth services (PDF) covered by Medicare and included in the CPT code set

CMS and HHS guidance:

  • CMS interim final rule and fact sheet detail new regulatory flexibility, relaxed enrollment requirements, expanded telehealth services, and revised physician supervision policies to help physicians and patients during the COVID-19 pandemic
  • HHS Office of Inspector General FAQs (PDF) clarify the Administration is allowing broad flexibility for physicians to reduce or waive Medicare beneficiary cost-sharing
  • OCR guidance on telehealth communication methods during the COVID-19 nationwide public health emergency
  • OCR issued FAQs about its use of enforcement discretion related to HIPAA and telehealth

CMS extends MIPS deadline, expands automatic hardship exceptions

CMS extended MIPS data submission deadline for physicians and accountable care organizations from March 31, 2020 until April 30, 2020. MIPS eligible clinicians who do not submit any MIPS data by April 30, 2020 will qualify for an automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment in 2021.


CMS is evaluating options for providing relief around participation and data submission for the 2020 MIPS performance year.

CMS resources:

Medicare provides enrollment relief

During the national emergency due to COVID-19, CMS will:

  • Allow licensed physicians to provide services to Medicare beneficiaries outside their state of enrollment as long as the physician is licensed in another state. State licensure requirements still apply.
  • Temporarily suspend certain Medicare enrollment screening requirements, including criminal background checks and site visits.
  • Postpone all revalidation actions.
  • Expedite any pending or new enrollment applications.

CMS guidance:

  • CMS fact sheet discusses the Medicare enrollment flexibilities in place during the public health crisis

Medicare recommends postponing adult elective surgeries and non-essential procedures

CMS issued guidance on postponing non-essential adult elective surgery and medical and surgical procedures to conserve critical resources, such as ventilators and Personal Protective Equipment (PPE), and to minimize the spread of COVID-19 to patients and physicians.


CMS’ recommendations include a tiered framework to evaluate how best to provide surgical services and procedures to patients whose condition requires emergent or urgent attention, while postponing elective and non-essential procedures to conserve resources. Decisions remain the responsibility of hospitals, surgeons, and state and local officials. CMS expects to refine the recommendations over the course of this emergency.

CMS guidance:

CMS relieves regulatory burdens

CMS has also issued several regulatory burden waivers to provide additional relief, including:

  • CMS is temporarily waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of disaster or emergency.
  • For durable medical equipment and prosthetics, orthotics, and supplies (DMEPOS) that is lost, destroyed, or otherwise unusable, Medicare contractors may waive replacement requirements such as: a face-to-face visit, obtaining new order from a physician, and new medical necessity documentation.

CMS guidance:

Medicare payment and coverage policies related to COVID-19



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