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 In the unpublished version of the 2022 Physician Fee Schedule final rule, the Centers for Medicare and Medicaid Services (CMS) announced landmark changes in support of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.