Please support Telehealth.org’s ability to deliver helpful news, opinions, and analyses by turning off your ad blocker.
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 In the unpublished version of the 2022 Physician Fee Schedule final rule, the Centers for Medicare and Medicaid Services (CMS) announced landmark changes in support of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.
“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“
02 and 10 are place of service codes, which are entered on the Place of Service field of the claim line to indicate where the service was provided. They are not modifiers (which are placed after a HCPCS/CPT code).
Alec, you are correct. Thank you for taking the time to comment. This change in requirements was announced in one of our earlier articles and will take place in April of this year.
To comment on the retort from the LICSW regarding LMHC’s get your facts straight. I have 24 more credits than any LICSW course of study from any school in the US which I needed to graduate and sit for my licensure exam. We both do the same job. In some States we can work in schools but in no States can we get paid for MEdicare clients. I believe both occupations are excellent with all groups they service.
With regard to Tricare billing, when I called them today (1.4.2022) the rep said to keep using POS 11, not 10 if client is in their home. Does anyone have any info about when this will actually be effective?
Hello Lisa, In another announcement that TBHI Telehealth.org reported on November 23, CMS announced that “The change in the telehealth policy will take effect on January 1, 2022, and be implemented on April 4, 2022.” How that applied to Tricare, we don’t know. See our full announcement summary here:
Can you please suggest who I can contact regarding, “exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record).” I see clients virtually in 3 states where I am licensed. Normally I’m told to submit claims to the BCBS or Medicare jurisdiction in the state where my practice has an address (only one state) regardless of client location. If I fly to go see a client in their state, I’m supposed to bill the BCBS or local Medicare jurisdiction for that state, where I don’t have in-network contracts, nor a practice address, and it would be processed as out of network. I know there are ways to get an address in another state, but if I do not have to spend more money on such a thing, I won’t. There then might be income tax problems when physically providing for and billing a service when I’m physically in another state.
Thank you for your question. I wish I had a better answer but all I can say is to contact the payer in all such specific billing questions. If the payor is Medicare or Medicaid, you may want to consider meditating a bit before jumping on the call. 🙁
Perhaps someone else reading this article has a better answer for William?
Anyone who believes that LMHC’s have a higher education requirement than LCSW’s NEED to do some due diligence before making statements. LICSW’s do have extensive education and it is within our scope of practice to treat substance abuse clients (noting CEU’s) In fact, historically LCSW’s were the only ones to receive reimbursement from insurance companies like psychologists and md’s. To be clear, An LMHC focuses SOLELYon a patient’s mental health (that may be changing in some schools as CARF is demanding some of the changes), whereas an LCSW helps clients with their mental health and other areas of their lives. LCSWs also work on finding ways to change an individual’s environment to adapt to their needs. They take Holistic Approaches when working with clients and try to connect clients with resources to help them reach their goals. LMHCs take a more Individualistic approach to improve development problems interfering with a client’s wellbeing. And we know what the research says… Holistic Approaches are what is efficaticacious over the long term.
Lmhc’s have a higher education requirement than Social Workers. We are not coordinators like LICSW but we do it. We are clinically qualified to tx. Mental Health and substance abuse clients
Is it once per calendar year for in person visits? I also read each telehealth visit had to be within 6 months of an in-person visit which means all patients need to be immediately seen in person before any further psychiatric telehealth is permitted. Since I see patients every 3 months when stabilized for psych meds, I essentially need to see them in person every other visit if that is true. Do you have further information regarding this? Also any rules about the providers working from home for telehealth?
Laura, Thank you for your questions. The Federal Register is the official US federal government dissemination channel for updates. We are consultants, trainers & publishers and not billing specialists. We disseminate the news that we find. However, many people would agree that official policy announcements from the Federal Register supersede previous rulings. You may want to have your billing agent research this to get confirmation from CMS.
As for working from home, traditional telemedicine has been practiced by clinicians working from their homes for decades. In fact, that’s one of the big draws for the industry since day 1. The patient’s location has been the issue, not the practitioner’s. There are a few rules, such as the fact that the clinician working from home must live in an approved jurisdiction. It involves state licensing law and not federal CME reimbursement requirements. As the years wore on, some states such as Alaska started requiring providers to be in Alaska when serving Alaskans, but most states haven’t gone that far.
You may also want to know that there are several other key stipulations that are wise to fully understand. See this 1-hour webinar devoted to this topic: Telehealth Working from Home: Legal & Ethical Compliance
Great, thank you for the clarification. This is not true for me, as I am a psychologist in a FQHC, but are these new rules suggesting that licensed mental health counselors in FQHC’s are not able to bill for telephone services?
Licensed Counselors and Marriage and Family Therapists have the same education requirements as the Licensed Clinical Social Workers so it is not sensible to fund one and not all three.
Social workers have always have a strong lobby so have been funded.
Many people will be deprived of needed services if Licensed Counselors and Marriage and Family Therapists are not also recognized.
If concern is really about helping those that need behavioral health services, this is defeating the goal.
Thank you for your comment. This battle is not new. A political battle has been waging for decades over whether or not counselors and MFTs can be reimbursed for serving Medicare beneficiaries. In this article, we discuss one of the more recent legislative efforts is being waged to reimburse these groups of providers, but we’ve not seen any updates as recently as Friday when we last checked: Medicare Telehealth Reimbursement: Act Introduced to Allow Counselors to be Reimbursed by Medicare
If and when anyone gets news about a change in policy, please take 5 minutes to post it here for us all to see.
I’m not sure I fully understand. Who is being left out of the new rules? And which Medicare clients won’t be able to receive telehealth services? My reading of the rules is that telehealth will be able to continue.
Jeremy, Thank you for commenting. We have revised our comments to make them clearer and also added the November 1, 2021 CMS list of approved CPT codes and associated services. If you download the file, you will see a number of behavioral codes that were approved for the COVID pandemic and several others that have been approved over the years. Let us know if you have any other questions.