Demystifying the National Emergency Declaration

On Friday, March 13, President Donald Trump issued a national emergency declaration due to the COVID-19 pandemic, creating several key implications for care management and utilization review professionals. This declaration led to what is called a 1135 waiver, which gives the Centers for Medicare & Medicaid Services (CMS) broad authority to waive many rules and regulations, including conditions of participation, program regulations, Emergency Medical Treatment and Labor Act (EMTALA) rules, and Stark regulations.

RACmonitor News asked Dr. Ronald Hirsch, vice president of R1 RCM, to summarize the most pertinent aspects of this waiver during Monitor Mondays live broadcast today.

The most important waiver that was issued relates to the three-day inpatient requirement for access to the Part A skilled nursing facility (SNF) benefit, Hirsch told listeners.

With the waiver, patients covered by traditional Medicare no longer need a three-day inpatient stay to access Part A SNF benefits. Patients can be admitted to a SNF from the hospital with any inpatient stay or any outpatient visit, including an emergency department or physician’s office visit – even from home, as long as they have skilled needs, according to Hirsch.

“I should point out that this applies to patients with any condition, and not only those affected by COVID-19,” Hirsch explained. “The rationale is to free up acute hospital beds for an anticipated influx of COVID-19 patients. Although I don’t suspect this is the case anywhere, if your facility is operating as business as usual, with no change in procedures or planning, you should be careful using this exception.”

Hirsch explained that while removing this requirement will certainly help hospitals prepare for the possible influx of COVID-19 patients, he suspects that the SNFs are going to be very careful throughout the pandemic.

“The outbreak in the nursing home in Seattle, with almost 30 resident deaths and many employee infections, is certain to have every SNF on edge about who they accept,” Hirsch said. “If you are not overwhelmed with patients now, it may be a good time to talk to your SNFs, and plan for use of this waiver if needed. It is important to note that CMS has not waived patient rights at this point, meaning patients will still need to consent to transfer, and of course, the SNF must be able to meet their medical needs.”

Hirsch said CMS has also waived the 100-day limit on Part A coverage, so if a patient has exhausted their 100 days of coverage, they do not need a 60-day period without any Part A care to continue to have SNF days covered. Hirsch explained that in any of these situations, be it an admission without a three-day stay or a patient who has passed 100 days of coverage, the SNF should report Condition Code DR on their claim. An additional requirement for SNF admission is the Preadmission Screening and Resident Review (PASRR).

“I have inquired with CMS about any waiver of the PASRR requirements,” Hirsch said. “Although it is a federal requirement, it is regulated on the state level, so as of now, the PASRR is still required.”

Another provision of the waiver, Hirsch said, is that critical access hospitals (CAHs) are permitted to waive their 25-patient and 96-hour average length of stay limits. If large acute-care hospitals require beds for seriously ill patients, we may see hospitals arrange to transfer non-critically ill patients to these facilities for ongoing care. Once again, Condition Code DR should be placed on the claim by the CAH to inform CMS that the care is being provided as part of the emergency.

“If a hospital has an excluded distinct part or unit, such as inpatient psychiatric hospital, acute inpatient rehabilitation hospital, or a transitional care unit (a SNF within the hospital walls), those beds can be used as acute-care beds and billed as such, if needed,” Hirsch said. “In this case, the ‘DR’ code is not necessary, but the record should clearly indicate that the patient is receiving acute care.”

According to Hirsch, home health agencies and durable medical equipment (DME) suppliers have also been given some flexibility. Home health agencies may complete an abbreviated assessment on admission of a patient, and DME suppliers may provide replacement equipment without a new face-to-face visit or physician order.

“Many hospitals are facing an April 1 deadline for use of the new Important Message from Medicare (IMM) and Detailed Notice of Discharge (DND), along with a new Medicare Outpatient Observation Notice (MOON),” Hirsch said. “Now is not the time to require more face-to-face interaction with patients by non-essential personnel, and to divert IT resources, so a formal request has been submitted to CMS to delay these requirements and to impose a period of non-enforcement of the new discharge planning requirements, many of which require significantly more face-to-face time with patients at a time when time is limited.”

Hirsch also reported that CMS has stated that appeals and documentation submission deadlines will be waived for appeals by both beneficiaries and providers. He said that as with the IMM and DND, a formal request has been submitted to ask CMS to prohibit audits of any care provided during the duration of the national emergency, except in the case of gaming, fraud, or abuse.

Programming Note: Listen to Dr. Hirsch’s live reports every Monday on Monitor Mondays, 10-10:30 a.m. EST.