Although the COVID-19 Public Health Emergency (PHE) ended six months ago, some regulatory flexibilities initially enacted during the crisis have been extended and other changes were recently finalized by the release of the 2024 Medicare Physician Fee Schedule.

This updated overview, developed by the ACC Advocacy team, summarizes which flexibilities ended on May 11, 2023, and which will continue into 2024. Clinicians, administrators and compliance teams should review the Centers for Medicare and Medicaid Services (CMS) Current Emergencies page and other available agency resources as rules change in the coming months and years following the end of the PHE.

Telehealth Flexibilities

The Consolidated Appropriations Act of 2023 extended key telehealth flexibilities through Dec. 31, 2024. The 2024 Medicare PFS final rule solidified these changes, including:

• The ability for beneficiaries to receive Medicare telehealth and other communications technology-based services wherever they are located, such as their home or other setting, as allowed by state law.
• The use of audio-only equipment to furnish telehealth services for appropriate services on the list of Medicare telehealth services. Payment for telephone E/M visits reported with CPT® codes 99441-99443 is equivalent to established office/outpatient visits.

In the final rule, CMS also extended the flexibility for clinicians to provide telehealth services from their home without updating their enrollment to include their home address. Now through Dec. 31, 2024, CMS will permit a site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. The agency will consider this issue further in future rulemaking.

Telehealth Across State Lines

During the PHE, CMS waived the requirement that a clinician be licensed in the state where the patient is located. Now that the PHE has expired, clinicians should keep in mind that each state has its own rules for telehealth across state lines. To ensure compliance, clinicians should check with their state medical board or resources developed by the Federation of State Medical Boards.

Cardiac Rehabilitation Flexibilities

Cardiac rehabilitation services have been provided using several related, sometimes overlapping, but different telehealth flexibilities. With the end of the PHE, here are several key items to note:

• Under Hospitals without Walls flexibilities, a beneficiary's home was allowed to serve as a provider-based department of the hospital for cardiac rehabilitation services. Now that the PHE has ended, hospitals are required to provide services to beneficiaries within hospital departments.
• Some clinics have used flexibilities allowing direct supervision by a clinician who is "immediately available" via "virtual presence" utilizing real-time audio and video technology. That flexibility was set to return to pre-PHE rules at the end of 2023. However, in response to concerns from the ACC and others regarding an abrupt transition at the end of 2023, CMS extended this flexibility through Dec. 31, 2024, allowing direct supervision to include the presence and immediate availability of the supervising practitioner through real-time audio and video interactive telecommunications.
• As mentioned above, CPT codes for cardiac rehabilitation were added to the list of Medicare PFS telehealth services on a provisional basis, with flexibilities extended through Dec. 31, 2024.

Virtual Direct Supervision

CMS modified the definition of direct supervision during the PHE to allow a supervising clinician to be "immediately available" to furnish assistance and direction during a service to include "virtual presence" of the clinician using real-time audio and video technology. ACC Members may have relied upon this flexibility to provide cardiac rehabilitation services or to supervise rhythm device management clinics. This flexibility was extended through 2024 after previously being set to return to pre-PHE rules at the end of 2023.

Expired Flexibilities

The following flexibilities have expired:

• HIPAA and Telehealth: The 90-day transition period for telehealth flexibilities and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) expired Aug. 9. Clinicians should refer to the following U.S. Department of Health and Human Services webpages for more on this topic:
  • Resource for Health Care Providers on Educating Patients about Privacy and Security Risks to Protected Health Information when Using Remote Communication Technologies for Telehealth
  • Telehealth Privacy and Security Tips for Patients
  • Additional guidance on HIPAA, telehealth and end of the PHE
• In-Person Evaluation Visit Required For Coverage: During the PHE, to the extent that a National Coverage Determination (NCD) or Local Coverage Determination (LCD) required an in-person, face-to-face visit for evaluation and assessment before a beneficiary progressed to a procedure such as TAVR, these services could be furnished via telehealth. This flexibility expired at the end of the PHE on May 11.
• NCD Procedural Volume Requirements: Procedural volume requirements for NCDs for Percutaneous Left Atrial Appendage Closure, TAVR, Transcatheter Mitral Valve Replacement, and Ventricular Assist Devices were not enforced for facilities and providers that met volume requirements prior to the PHE. NCD enforcement discretion expired at the end of the PHE on May 11.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Mechanical Circulatory Support

Keywords: ACC Advocacy, Centers for Medicare and Medicaid Services, U.S., Health Insurance Portability and Accountability Act, Cardiac Rehabilitation, Heart-Assist Devices, Outpatients, Current Procedural Terminology, Privacy, Public Health, Transcatheter Aortic Valve Replacement, Medicare, COVID-19, Telemedicine, Fee Schedules

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