June 22, 2021:  Masks and other precautions are still necessary in healthcare settings  

Under the latest version of the MIOSHA Emergency Rules, the state’s Workplace Safety Rules are in line with the OSHA Standards. Specifically, MIOSHA’s Emergency Rules are adopted from Subpart U in the OSHA Standards. Subpart U is the COVID-19 Emergency Temporary Standard and provides standards that healthcare settings must follow. Under the latest rules, only healthcare settings have certain protocols and standards to follow. All other sectors and workplaces are encouraged to follow CDC and OSHA guidelines. The updated rules are effective today and are set to expire on December 22, 2021.

To view the latest MIOSHA Emergency Rules, please click here. To view Subpart U from the OSHA Standards, please click here. To view a press release on the new MIOSHA rules, please click here.

View the OHSA requirements here: https://www.osha.gov/coronavirus/ets   APTA additional guidance:  https://www.apta.org/news/2021/06/14/osha-covid-rules

MDHHS updated guidance effective June 22 which states:  Healthcare Facilities, such as hospitals, ambulatory care settings and surgical centers - As of now CDC healthcare guidance remains unchanged. Facilities should continue to follow CDC  guidance. https://www.michigan.gov/documents/coronavirus/MDHHS_Face_Mask_Recommendations_5.20.21_725941_7.pdf

CDC Guidance from February 2021 remains in effect for health care settings: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

CDC Guidance:

Implement Telehealth and Nurse-Directed Triage Protocols

• Continue to use telehealth strategies to reduce the risk of SARS-CoV-2 transmission in healthcare settings while maintaining high quality patient care.
• When scheduling appointments for routine medical care (e.g., annual physical, elective surgery):
  • Advise patients that they should put on their own well-fitting form of source control (see Implement Universal Source Control Measures for more details) before entering the facility.
  • Instruct patients to call ahead and discuss the need to reschedule their appointment if they have symptoms of COVID-19 within the 10 days prior to their appointment, if they have been diagnosed with SARS-CoV-2 infection within the 10 days prior to their appointment, or if they have had close contact with someone with suspected or confirmed SARS-CoV-2 infection within 14 days prior to their scheduled appointment.

• When scheduling appointments for patients requesting evaluation for possible SARS-CoV-2 infection, use nurse-directed triage protocols to determine if an appointment is necessary or if the patient can be managed from home.
  • If the patient must come in for an appointment, instruct them (or their responsible party if they are unable to communicate) to take appropriate preventive actions (e.g., follow triage procedures, put on their own well-fitting form of source control before entry and throughout their visit or, if a well-fitting form of source control cannot be tolerated, hold a tissue against their mouth and nose to contain respiratory secretions) and immediately inform triage personnel upon arrival (e.g., call from car) so they can be placed in an examination room.

Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19

Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.

• Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility
  • Post visual alerts (e.g., signs, posters pdf icon[572 KB, 1 page]) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a well-fitting form of source control and how and when to perform hand hygiene.
  • Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
• Limit and monitor points of entry to the facility.
• Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19,  or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control.
  • Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days.
    • Fever can be either measured temperature ≥100.0°F or subjective fever. People might not notice symptoms of fever at the lower temperature threshold that is used for those entering a healthcare setting, so they should be encouraged to actively take their temperature at home or have their temperature taken upon arrival.
    • Obtaining reliable temperature readings is affected by multiple factors, including:
      • The ambient environment in which the temperature is measured: If the environment is extremely hot or cold, body temperature readings may be affected, regardless of the temperature-taking device that is used.
      • Proper calibration of the thermometers per manufacturer standards: Improper calibration can lead to incorrect temperature readings.
      • Proper usage and reading of the thermometers: Non-contact infrared thermometers frequently used for health screening must be held at an established distance from the temporal artery in the forehead to take the temperature correctly. Holding the device too far from or too close to the temporal artery affects the reading.
• Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who has had contact with someone with suspected or confirmed SARS-CoV-2 infection:
  • Healthcare personnel (HCP) should be excluded from work and should notify occupational health services to arrange for further evaluation.
  • Visitors should be restricted from entering the facility and be referred for proper evaluation.
• Patients should be isolated in an examination room with the door closed.
• If an examination room is not immediately available, such patients should not wait among other patients seeking care.
  • Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies.
  • In some settings, patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
  • Depending on the level of transmission in the community, facilities might also consider designating a separate area at the facility (e.g., an ancillary building or temporary structure) or nearby location as an evaluation area where patients with symptoms of COVID-19 can seek evaluation and care.

Re-evaluate admitted patients for signs and symptoms of COVID-19

Screening for fever and symptoms should also be incorporated into daily assessments of all admitted patients. All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate).

Implement Universal Source Control Measures

Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. In addition to providing source control, these devices also offer varying levels of protection for the wearer against exposure to infectious droplets and particles produced by infected people. Ensuring a proper fit is important to optimize both the source control and protection offered. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.

• Patients and visitors should wear their own well-fitting form of source control upon arrival to and throughout their stay in the facility. If they do not bring their own, they should be offered an option that is equivalent to what is recommended for people in the community
  • Patients may remove their source control when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room.
  • Cloth masks, facemasks and respirators should not be placed on young children under age 2, anyone who cannot wear one safely, such as someone who has a disability or an underlying medical condition that precludes wearing a mask safely, or anyone who is unconscious, incapacitated or otherwise unable to remove their cloth mask, facemask or respirator without assistance.
  • Visitors who are not able to wear source control should be encouraged to use alternatives to on-site visits with patients (e.g., telephone or internet communication), particularly if the patient is at increased risk for severe illness from SARS-CoV-2 infection.
• For guidance on recommended source control for HCP, refer to Implement Universal Use of Personal Protective Equipment below.
  • HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
  • To reduce the number of times HCP must touch their face and potential risk for self-contamination, when used for source control, HCP should consider continuing to wear the same respirator or well-fitting facemask (extended use) throughout their entire work shift.
  • HCP should remove their respirator or facemask, perform hand hygiene, and put on their community source control when leaving the facility at the end of their shift.
• Educate patients, visitors, and HCP about the importance of performing hand hygiene, including immediately before and after any contact with their cloth mask, facemask, or respirator.

Encourage Physical Distancing

Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.

Examples of how physical distancing can be implemented for patients include:

• Limiting visitors to the facility to those essential for the patient’s physical or emotional well-being and care (e.g., care partner, parent).
  • Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets.
• Scheduling appointments to limit the number of patients in waiting rooms, or creating a process so that patients can wait outside or in their vehicle while waiting for their appointment.
• Arranging seating in waiting rooms so patients can sit at least 6 feet apart.
• Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by implementing virtual methods (e.g., video format for group therapy) or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart.
  • In some circumstances, such as higher levels of community transmission or numbers of patients with COVID-19 being cared for at the facility, and when healthcare-associated transmission is occurring, facilities might cancel in-person group activities in favor of an exclusively virtual format.

For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas. Examples of how physical distancing can be implemented for HCP include:

• Reminding HCP that the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions.
• Emphasizing the importance of source control and physical distancing in non-patient care areas.
• Providing family meeting areas where all individuals (e.g., visitors, HCP) can remain at least 6 feet apart from each other.
• Designating areas and staggered schedules for HCP to take breaks, eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked.

Implement Universal Use of Personal Protective Equipment

Transmission from asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection can occur in healthcare settings, particularly in areas with moderate to substantial community transmission.

The fit of the medical device used to cover the wearer’s mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer’s exposure to infectious particles. Respirators offer the highest level of both source control and protection against inhalation of infectious particles in the air.  Facemasks that conform to the wearer’s face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer’s exposure to particles in the air. Improving how a facemask fits can increase the facemask’s effectiveness for decreasing particles emitted from the wearer and to which the wearer is exposed.

PPE recommended for the care of patients with suspected or confirmed SARS-CoV-2 infection is described in Section 2.

HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history):

• HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis; for example, use an N95 respirator or equivalent or higher level respirator if the patient is suspected to have tuberculosis).
• Additionally, HCP should use PPE as described below:
  • N95 respirators or equivalent or higher-level respirators should be used for
    • All aerosol-generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings? ) AND
    • All surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract) (refer to Surgical FAQ During the COVID-19 pandemic, are there special considerations for surgical or other procedural settings, including performance of AGPs?).
  • One of the following should be worn by HCP for source control while in the facility and for protection during patient care encounters:
    • An N95 respirator OR
    • A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators OR
    • A well-fitting facemask (e.g., selection of a facemask with a nose wire to help the facemask conform to the face; selection of a facemask with ties rather than ear loops; use of a mask fitter; tying the facemask’s ear loops and tucking in the side pleats; fastening the facemask’s ear loops behind the wearer’s headexternal icon; use of a cloth mask over the facemask to help it conform to the wearer’s face)
      • Additional information about strategies to improve fit and filtration, are available in Improve the Fit and Increase the Filtration of Your Mask to Help Stop the Spread of COVID-19. CDC has also created an FAQ addressing use of 2 masks at the same time in a healthcare setting.
      • If implementing new strategies or equipment to improve fit, HCP should receive training on how to safely don and doff their facemask and on the facility protocol for cleaning and disinfecting any reusable equipment (e.g., fitter). HCP should also ensure that any new strategies or equipment do not impede their vision or ability to breathe.
  • Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions.

HCP working in areas with minimal to no community transmission, should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other personal protective equipment (PPE). In addition, universal use of a well-fitting facemask for source control is recommended for HCP if not otherwise wearing a respirator.

Consider Performing Targeted SARS-CoV-2 Testing of Patients Without Signs or Symptoms of COVID-19

In addition to the use of universal PPE and source control in healthcare settings, targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19 might be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and further reduce risk for exposures in some healthcare settings. Depending on guidance from local and state health departments, testing availability, and how rapidly results are available, facilities can consider implementing pre-admission or pre-procedure screening testing with authorized nucleic acid or antigen detection assays for SARS-CoV-2.
Testing results might inform decisions about rescheduling elective procedures or about the need for additional Transmission-Based Precautions when caring for the patient. Limitations of using this testing strategy include obtaining negative results in patients during their incubation period who later become infectious and false negative test results, depending on the test method used.

New guidance effective June 1:  https://www.michigan.gov/leo/0,5863,7-336-100207---,00.html

May 15 Gatherings and Face Mask Order:  https://www.michigan.gov/documents/coronavirus/FINAL__-_Masks_and_Gatherings_order_-_5-14-21_signed_725417_7.pdf

This order remains in effect until June 1

Provisions that apply to outpatient settings:

4. Gathering restrictions for other facilities.

1. Gatherings in waiting rooms at outpatient health care facilities, veterinary clinics, and other businesses are prohibited unless the facility implements a system to ensure that persons not of the same group maintain 6 feet of distance. To the extent possible, this system must include a policy that patients wait in their cars for their appointments to be called.

6. Indoor face mask requirement.
   1. Except as specified in section 7, all persons participating in indoor gatherings are required to wear a face mask.
   2. A person responsible for an establishment, or an agent of such person, must prohibit gatherings of any kind at their establishment unless the person makes a good faith effort to ensure that all persons at their establishment (including employees) comply with section 6(a). For purposes of this section, a "good faith effort" may include any of the following: posting a sign notifying people that wearing a mask is required unless a person falls into a specified exception; asking patrons not wearing masks whether they fall into a specified exception; requiring face masks of all patrons and employees; or any other policy designed to ensure compliance with section 6(a).
7. Exceptions to face mask requirement. The requirement to wear a face mask at indoor gatherings does not apply to individuals who:
   1. Are fully vaccinated persons;
   2. Are younger than 2 years old;
   3. Cannot medically tolerate a face mask;
   4. Are eating or drinking while seated in a designated area or at a private residence;
   5. Are swimming;
   6. Are receiving a medical or personal care service for which removal of the face mask is necessary;
   7. Are asked to temporarily remove a face mask for identification purposes;
   8. Are communicating with someone who is deaf, deafblind, or hard of hearing and whose ability to see the mouth is essential to communication;
   1. Are actively engaged in a public safety role, including but not limited to law enforcement, firefighters, or emergency medical personnel, and where wearing a face mask would seriously interfere in the performance of their public safety responsibilities;
   10. Are engaging in a religious service;
   11. Are giving a speech for broadcast or to an audience, provided that the audience is at least 12 feet away from the speaker; or
   12. Are engaging in an activity that requires removal of a mask not listed in another part of this section, and are in a facility that provides ventilation that meets or exceeds 60 ft³/min of outdoor airflow per person.

Continuing Education Requirements  - Waiver is no longer in effect

Under Executive Order 2020-61 (rescinded and replaced by Executive Order 2020-150 the continuing education requirements for renewing the license were waived at the time of renewal, if the renewal was completed while the state of emergency declaration is in effect.  Governor Whitmer issued executive orders declaring a state of emergency - the most recent being Executive Order-186 which extended the state of emergency until October 27.  As the EO is no longer valid, licensees renewing in 2021 are required to earn the full 24 PDR credits.

PDR Credits:  Executive Order 2020-13, issued March 17, included the following:   

5. Effective immediately and continuing through April 14, 2020 at 11:59 pm, LARA may recognize hours worked responding to the COVID-19 emergency as hours toward continuing education courses or programs required for licensure.

Subsequent Executive Orders extended the provision. LARA posted an update for licensees that clarifies licensing issues, including PDR credits for hours worked in response to the COVID emergency.  Hours worked March 17 - June 9, 2020, can be counted as PDR credits for those renewing in 2021.  Unfortunately, LARA has not provided any further clarification as to what specific activities can be counted or how many hours can be counted.  If COVID hours are used for PDR credits, licensees must be able to provide supporting documentation.  The document below provides more detail and outlines what will suffice for documentation. 

BPL Clarification for Licensees  Download file

The Chart found HERE is a complete, up to date listing of payer policies.  Last update: 1/11/21

April 30 Update  - Telehealth Services now covered for Medicare Beneficiaries - see additional information in the Chart. https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf

Additional BCBSM Resources:

• BCBSM Telemedicine Services - note that this policy went into effect before May 1 due to COVID-19
• Telehealth services covered at no cost to the beneficiary
• PTOT benefit extension
• Covid-19:Determining members telehealth benefits
• Telehealth Procedure Codes for services provided at no cost for patients

Legislative Action:

Senate Bill 898 to amend the insurance code (1956 PA 218) requiring that a service provided through telemedicine will provide the same coverage and reimbursement as if the service involved face-to-face contact was introduced by Senator Adam Hollier on April 29, 2020 and was referred to the Health Policy Committee. This bill would also require insurers to continue to provide the same reimbursement for physical therapy provided via telehealth beyond the COVID-19 pandemic.

Information from APTA~

CMS Won't Pay Out on New Code for Additional Pandemic Costs

A code aimed at extra provider costs related to stopping the spread of the coronavirus won't result in more money.

You can lead Medicare to a code, but you can't make it pay.

Back in September, providers were encouraged when the American Medical Association announced it had updated its current procedural terminology code set to include a code for reporting expenses incurred as a result of the necessary public health response to the COVID-19 pandemic. The code — 99072 — was a new practice expense code that describes the additional supplies and clinical staff time required to provide safety measures during a public health emergency. In the current environment, it could be used to denote expenses related to stopping the spread of the coronavirus while still providing safe in-person visits.

Cut to Oct. 27, when the U.S. Centers for Medicare & Medicaid Services put the brakes on any additional payment directly related to the new code under Medicare.

In an MLN Matters update, the agency included 99072 among several codes that were being added to the 2020 Medicare Physician Fee Schedule, but with one important caveat: The code was assigned a "B" procedure status, meaning it is a bundled code and won't be associated with any relative value units and payment policy indicators won't apply.

"Basically, what CMS is saying is that this code doesn't warrant an additional payment on top of what providers are getting paid for the services rendered during that visit, " said Kara Gainer, APTA director of regulatory affairs. "Providers can still include it on the claim, but payment will be considered 'incident to' the treatment being provided that day, meaning that separate payment won't be provided."

According to Gainer, the commercial payment landscape is varied: some payers had already adopted this approach, others were waiting to see where Medicare landed, while still others are in fact paying on the code.

Our advice: Check with your state Medicaid programs and commercial insurers regarding eligibility for payment and coverage of the code.

Another important tip: Should a payer not adopt coverage for 99072, don't bill the cost associated with this code to the patient. And remember that providers must comply with state law, which could restrict the application of surcharges for additional supply expenses associated with the public health emergency.

https://www.apta.org/news/2020/11/04/cms-coding-decision-99072