SGIM Letter on Primary Care Exception Issue

 , March 26, 2020

Seema Verma, Administrator
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
Room 445–G, Hubert H. Humphrey Building
200 Independence Avenue SW
Washington, DC 20201

Dear Administrator Verma:

Members of the Society of General Internal Medicine (SGIM), a national medical society of 3,500 general internists, are on the front lines of providing care to patients suffering with COVID-19. We are grateful the Centers for Medicare and Medicaid Services (CMS) has expanded the opportunities for Medicare beneficiaries to receive needed care for chronic conditions in their homes via telehealth during this public health emergency.

Primary care practice throughout the county have been rapidly adapting to the environment demanded by the highly infective SARS Cov-2 virus. Patients with conditions such as diabetes and hypertension can be monitored and managed at home via telephone and/or video links. This has proven enormously valuable to Medicare beneficiaries who run the risk of feeling that their ongoing health issues are ignored in the context of the national COVID-19 emergency.

As a professional society comprised of clinician educators, under normal circumstances, we are actively engaged in the supervision and guidance of residents in hospital based and affiliated training sites during practice sessions. The physician trainees under our direct in-person guidance provide care to many chronically ill Medicare beneficiaries. Patients choose to receive outpatient primary care at academic sites do so because they simultaneously receive hospital level care or feel they need such access.

Currently, these traditional modes of resident supervision are not possible not only because of the social and travel limitations placed by various states but because of the very nature of the COVID-19 pandemic. Until SARS Cov-2 virus protection is provided by vaccination or effective and safe treatments are widely available, there will need to be new forms of practice. Patients may be better served at home for an extended time. In addition, personnel requirements at academic medical centers needed to provide inpatient coverage result in shifting schedules and demand innovations in patient contact.

The limited scope of the primary care exception is a significant barrier to rapid telehealth implementation for the care of patients normally seen in the residency clinics under faculty supervision, as it does not apply to telehealth visit categories identified by CMS. When applicable, this exception allows a teaching physician to bill E/M services provided by residents in primary care centers when the teaching physician is not physically present. Without a change to this exception, telehealth E/M services provided by residents will not be billable limiting the capacity of teaching clinics to provide the telehealth access patients need.

SGIM requests that CMS expand the scope of the primary care exception at least for the duration of the COVID 19 Public Health Emergency by allowing the following services to be billed by residents by telehealth:

• All in-person outpatient established patient E/M services currently covered by the primary care exception;
• The level 4 and 5 new and established patient E/M codes and the initial and subsequent Annual Wellness Visit codes (G0438 and G0439); and
• The 7- and 14-day Transitional Care Management codes (99495 and 99496) codes.

Additionally, SGIM is asking that remote precepting be permitted for residents providing services under the primary care exception.

Thank you for your prompt attention to this issue to ensure Medicare beneficiaries continue to receive appropriate care during this public health emergency. Please contact Erika Miller at emiller@dc-crd.com with any questions.

Sincerely,

Eric B. Bass, MD, MPH, FACP
Chief Executive Officer