Telehealth Reimbursement Alert: Federal Register Releases Allowed 2022 Telehealth CPT Codes & Services

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HERE IS HOW

UPDATED 11/9/21 Many long-awaited decisions regarding telehealth CPT codes were released earlier this week, signaling a new frontier for telehealth reimbursement. Federal policy changes of this magnitude directly change Medicare and federal Medicaid programs, and more broadly, put direct pressure on third-party carriers to follow suit. In the unpublished version of the 2022 Physician Fee Schedule final rule, the Centers for Medicare and Medicaid Services (CMS) announced landmark changes in support of telehealth, and particularly, telebehavioral health, but only for specified conditions.  The entire document will reportedly be available on November 19, 2021.

CMS Administrator Chiquita Brooks-LaSure announced the changes by stating, “Promoting health equity, ensuring more people have access to comprehensive care, and providing innovative solutions to address our health system challenges are at the core of what we do at CMS,” She continued, “The Physician Fee Schedule final rule advances all these strategic priorities and helps build a better Medicare program for the future.”

Key points for behavioral clinicians include:

• In line with much legislation enacted last year to deliver immediate assistance to millions of U.S. citizens due to the COVID pandemic, CMS eliminated geographic barriers and allows patients at home to access telehealth services for diagnosis, evaluation, and treatment of specified conditions mental health disorders.
• The requirement for a “non-telehealth visit must be furnished at least every 12 months for these services.” They also stipulated that “exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record).”
• Services added to the Medicare telehealth services list will remain on the list through December 31, 2023, to allow additional time for CMS to evaluate whether the services should be permanently added to the Medicare telehealth services list.
• In yet another document, as of September 2021, CME has issued a new set of CPT code modifiers, two of which are relevant to telehealth CPT code billing. Medicare telehealth services practitioners use “02” if the telehealth service is delivered anywhere except for the patient’s home. If the patient is in their home, use “10”. For telehealth, the 95 modifier code is used as well. For details, see the CMS document titled Place of Service Codes for Professional Claims Database (updated September 2021).

In the sections below, direct quotes are taken from the unpublished version of the 2022 Physician Fee Schedule made available for public inspection before the official publication date in the Federal Register.

Audio-Only Telephone Care

The New CMS ruling allows payment for telephone sessions for mental and behavioral health services to treat substance use disorders and services provided through opioid treatment programs. Direct wording from the unpublished version of the 2022 Physician Fee Schedule made available for public inspection is provided below. (Page numbers are not provided in the original document.)

After consideration of public comments, we are finalizing as proposed creation of a service-level modifier for use to identify mental health telehealth services furnished to a beneficiary in their home using audio-only communications technology. We are also amending our regulation at § 410.78(a)(3) to specify that an interactive telecommunications system can include interactive, real-time, two-way audio-only technology for telehealth services furnished for the diagnosis, evaluation, or treatment of a mental health disorder as described under paragraph (b)(4)(iv)(D), under the following conditions: the patient is located in their home at the time of service as described at § 410.78 (b)(3)(xiv); the distant site physician or practitioner has the technical capability at the time of the service to use an interactive telecommunications system that includes video; and the patient is not capable of, or does not consent to, the use of video technology for the service.

We are also clarifying that SUD services are considered mental health services for purposes of the amended definition of “interactive telecommunications system” to include audio-only services under § 410.78(a)(3). We anticipate that this will positively impact access to care for mental health conditions and contribute to overall health equity. [Emphasis added by Telehealth.org]

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) – Telecommunications Technology

Mental health sessions furnished through Rural Health Clinics and Federally Qualified Health Centers via telecommunications technology, including telephone calls, will also be covered. As outlined by CMS, this provision intends to continue expanding access to vulnerable populations, including those in rural areas.

1. Revising the Definition of an RHC and FQHC Mental Health Visit a. Payment Rules for RHC and FQHC Visits and Medicare Telehealth Services Section 1861(aa)(1) of the Act defines RHC services as physicians’ services and such services and supplies that are furnished as an incident to a physician’s professional service, and items and services, as well as certain vaccines and their administration. It also includes services furnished by a PA, NP, clinical psychologist, or clinical social worker and services and supplies furnished as an incident to these services as would otherwise be covered if furnished by a physician or incident to a physician’s service. In the case of an RHC in an area with a home health agency shortage, part-time or intermittent nursing care and related medical supplies may be furnished by a registered professional nurse or licensed practical nurse to a homebound individual under certain conditions. Section 1861(aa)(3) of the Act defines FQHC services to include the specified RHC services and preventive services, as well as required primary preventive health services.

Depression Screening and Referrals from RHCs and FQHCs: Mental Health Counselors Included, Too!

Under section D.18 Preventive Care and Screening: Screening for Depression and Follow-Up Plan in the Physician Fee Schedule, the following section describes the use of non-physicians to offer “follow-up services” after patients are screened by primary care physicians in RHCs & FQHCs. It is worthy of note mental health counselors are included, whereas they have been previously excluded.

Follow-Up Plan: The follow-up plan must be related to a positive depression screening, for example: “Patient referred for psychiatric evaluation due to positive depression screening.” Examples of a follow-up plan include but are not limited to: * Referral to a practitioner or program for further evaluation for depression, for example, referral to a psychiatrist, psychologists, social workers, mental health counselors, or other mental health services such as Family or group therapy, support group, depression management program, or other services for the treatment of depression * [Emphasis added by Telehealth.org]

Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options Should a patient screen positive for depression: * A clinician should only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan. * A clinician should complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. For the CMS Web Interface Measure Specifications collection type: A depression screen is completed on the date of the encounter or up to 14 days before the date of the encounter using an age-appropriate standardized depression screening tool, AND if positive, a follow-up plan must be documented on the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression

Physician Repercussions of New CME Rulings

Dealing a blow to physicians, the conversion factor per relative value unit under the 2022 fee schedule will be reduced to $33.59, down from $34.89 in 2021, a drop of $1.31. The AMA has been quick to respond, stating, The AMA is strongly advocating for Congress to avert this and other looming cuts to Medicare physician payments that, overall, will produce a combined 9.75 percent cut for 2022. 

Why Are the Federal Register Releases & Physician Fee Schedules of Relevance to Telebehavioral Health Professionals?

The Federal Register is the daily journal of the United States government and the official dissemination channel for any changes related to CPT codes by CMS. Working closely with various stakeholders such as the American Medical Association, the American Psychological Association, and other national professional associations, the Centers for Medicare & Medicaid and Services (CMS) proposes new telehealth CPT codes every year. The proposed codes are open for comment from all stakeholders for a few weeks, the comment period is closed, and new codes are published in the Federal Register in November. They take effect on January 1 of the following year. This process is an attempt to update payment policies, payment rates, and other provisions for services. While third-party carriers differ in payment rates by state, Medicare payments for the same code can vary by zip code.

What about Private Payers?

Typically, 3rd party or private insurance carriers in the United States are given the discretion to decide which telehealth CPT codes to reimburse and at which rate. Employers and consumers seeking telehealth reimbursement for 2020 would do well to speak with their carriers before next year to negotiate plans and make informed choices about insurance plans. A third-party carrier can deny procedures reimbursed by Medicare and are, frankly, often are excluded. In most states, private insurers slowly adopted the approved CPT codes, but they are not usually required by state law to follow suit in many states. However, with the tsunami created by COVID, in some states such as California and New York, telehealth laws were recently updated with much more enforcement and penalties for noncompliance imposed by the state insurance commissioner in each state. In short, more states are requiring telehealth reimbursement. Clinicians wishing to continue offering telehealth services then are encouraged to contact their state insurance commissioner’s office as well as their state and national professional associations for more information about local regulations requiring telehealth reimbursement for the future.

Other Telehealth.org Articles of Relevance

For billable CPT codes, see Telehealth.org’s previous articles related to telehealth CPT codes below.

• RPM CPT Codes
• CMS Congressional Report: 85.4% of all Telehealth Providers Used Mental Health CPT Codes
• Future of Telehealth Reimbursement: Offering Medicare Telehealth Services?
• Counselors and marriage and Family Therapists may want to speak with the governmental staff of their national professional associations for updates on the issues discussed in Telehealth.org’s Medicare Telehealth Reimbursement: Act Introduced to Allow Counselors to be Reimbursed by Medicare for updates to the Mental Health Access Improvement Act.