Telehealth practice in 2022: CMS expands coverage and access

On November 2, 2021, the Centers for Medicare and Medicaid Services (CMS) issued the final rule on the Medicare physician fee schedule detailing how health care services offered by psychologists and other providers will be delivered and reimbursed in 2022. Below are some of the key issues of interest to psychologists.

Reimbursement for audio-only services for mental health will continue after the public health emergency ends

Following changes made through new federal legislation, CMS will allow audio-only services to be provided for the diagnosis, evaluation, and treatment of mental health conditions and substance use disorders after the public health emergency (PHE) ends. The originating site requirement will not apply when patients receive these services through audio-only devices in their homes, with the definition of home being viewed broadly to include temporary lodging, such as a hotel.

The agency agreed with APA’s request to continue coverage and reimbursement of high-level psychotherapy services furnished via audio-only devices beyond the end of the PHE.

However, Health Behavior Assessment and Intervention services will be excluded from audio-only coverage once the PHE ends. Absent new federal legislation, health behavioral services, feedback sessions for psychological and neuropsychological testing evaluations, and other services will not be allowed via audio-only technology after the PHE ends.

Additional requirements for audio-only services

APA advocated against imposing additional requirements—such as periodic in-person visits or additional documentation other than a modifier—for coverage or reimbursement of mental or behavioral health services furnished via telehealth.

Under the final rule, once the PHE ends, audio-only telehealth services for mental health and substance use disorder (SUD) services will require an in-person visit within six months of the initial telehealth visit and within 12 months of any subsequent telehealth visit. Providers will be able to request exemptions if they believe it would benefit the patient not to meet in-person. CMS will not require additional documentation but providers furnishing audio-only services will need to use a billing modifier on claims to indicate that the patient did not have access to two-way audio-visual communication technology or did not consent to its use.

Psychological and neuropsychological testing remain temporary telehealth services through December 2023.

APA supported CMS’s proposal allowing all psychological and neuropsychological testing services to be provided via telehealth after the PHE ends. CMS adopted this proposal, keeping psychological and neuropsychological testing on the temporary (category 3) telehealth list through the end of 2023.

APA asked CMS to also add the codes for developmental testing and adaptive behavior services to the telehealth list through the end of 2023, but the agency did not adopt this idea.

Multiple family group psychotherapy

APA asked CMS to add multiple family group psychotherapy (90849) to Medicare’s permanent telehealth list but the agency declined, noting that generally the code is not separately payable in Medicare as an in-person service.

A lower conversion factor in 2022

APA urged CMS to work with Congress to avoid a 3.89% cut to the 2022 conversion factor (CF), the figure that is multiplied by each service’s relative value units to determine its reimbursement amount. Under the final rule the 2022 CF will be $33.59 or 3.75% lower than the current CF of $34.89. This reflects the loss of 3.75% in additional funding from Congress for this year that ends on December 31, 2021. 

Federally Qualified Health Centers and Rural Health Clinics

CMS will allow patients in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to receive mental health and SUD services through audio-communications technology. The patient must have received an in-person service within six months of the initial telehealth service, and the telehealth visit must be billed with a modifier. A modifier consists of two characters and is listed on the claim form to provide additional information about the service. 

Behavioral health services in RHCs and FQHCs will not be eligible for reimbursement as a telehealth service unless provided with two-way audio-visual communications technology. 

Remote direct supervision of “incident to” services

In July 2021, CMS announced the flexibility allowing direct supervision to be furnished via two-way audio-visual communications technology would end when the PHE was over or by December 31, 2021, but also invited comments on its decision. APA recommended that CMS continue to allow direct supervision of “incident to” services through audio-visual technology after the PHE ends. 

In the final rule, the agency thanked commenters for their input and said it will consider addressing the issues raised regarding remote direct supervision in future rules or guidance, as appropriate. 

Remote Therapeutic Monitoring

APA advocated that CMS adopt the codes for Remote Therapeutic Monitoring (RTM) and reimburse these services at the same rate as the Remote Physiological Monitoring (RPM) codes they resemble. 

CMS is finalizing its proposed adoption of the RTM codes and the proposed valuations for the services to strike a balance between supporting patient access to care that these services describe and allowing practitioners, such as psychologists, who cannot bill for evaluation and management (E/M) to furnish and bill for these services. CMS acknowledged stakeholders’ concerns about broadening the base of practitioners that could furnish the RTM and RPM services, as well as maximizing the efficiency with which these services could be furnished. The agency will continue engaging with health care societies on how best to refine the coding for the RTM services.

Reimbursement for telehealth will revert to facility rate

APA advocated for CMS to continue to reimburse telehealth services, including audio-only, at the nonfacility rate after the PHE ends. 

CMS rejected this request, stating that it is consistent to use the facility rate, which is lower than the nonfacility rate, when reimbursing for telehealth because direct practice expense costs for telehealth services are generally incurred at the originating site where the patient is located. For more discussion on how this decision impacts payment amounts see the January 15, 2021 issue of Practice Update: Telehealth after the pandemic: CMS outlines proposed changes.

Changes in the Merit-based Incentive Payment System reporting for 2022

Numerous changes will make it more difficult for providers to avoid penalties in 2022 but also increase the potential for incentives.

In 2022, providers will have to achieve a minimum of 75 points (up from 60 in 2021) making it likely that more providers will be penalized; however, because Merit-based Incentive Payment System (MIPS) is a budget neutral program, incentives will also be at the highest levels for top performers with the payment adjustment remaining +/- 9% for 2022.

There will also be some changes to the weighting of MIPS performance categories, decreasing the Quality category to 30% from 40% and increasing the Cost category from 20% to 30% of the combined score. The Improvement Activities and Promoting Interoperability (PI) categories remain the same at 15% and 25% respectively. CMS will continue reweighting the PI category to zero for psychologists and certain other nonphysicians. All small practices (15 or fewer eligible clinicians) that do not report PI data will continue to see reweighting of categories similar to previous years.

The introduction of a minimum for new Quality measures (7 points for first year, 5 points for second year) make 2022 a good time for psychologists, particularly neuropsychologists, to select new specialty measures available in the Mental and Behavioral Health Registry.

Licensed clinical social workers and certified nurse midwives will be added as MIPS eligible clinicians (ECs) in 2022.

Looking ahead: The transition to MIPS Value Pathways

In 2023, CMS will begin to transition away from using traditional MIPS to a new system known as MIPS Value Pathways (MVPs). MVPs are subsets of connected measures and activities for different specialties or conditions. CMS maintains that MVPs will be more meaningful to ECs than the MIPS measures have been and in turn will produce comparative performance data of greater value to patients making decisions about their healthcare.

To date CMS has approved only seven MVPs for 2023, none of which are applicable to mental or behavioral health. APA continues to advocate that CMS retain traditional MIPS for those providers to whom no MVPs are relevant or are not feasibly implementable. CMS anticipates that all providers will transition to MVPs by 2027.