Mental health crisis: CMS finalizes proposals to help psychologists meet the need

In 2023, psychologists’ Medicare patients will continue to have broad access to tele-mental health services, regardless of where they are located, and increased access to behavioral health treatments.

Changes to reimbursement for mental and behavioral health services are included in the final rule on the 2023 Medicare Physician Fee Schedule, released on November 1, 2022 by the Centers for Medicare and Medicaid Services (CMS). Psychologists—who submitted 12,000 comments to CMS on the proposed rule issued in July 2022—can now see how their efforts to advocate for the profession impacted the agency’s decision making. Your feedback to CMS helped secure expanded access to telehealth, behavioral health services, and screenings for alcohol and depression.

For the past two years APA advocated for CMS to continue paying for psychologists’ telehealth services at the nonfacility rate, which is higher than the facility rate applied to telehealth services furnished before the covid-19 public health emergency (PHE). In a change to the agency’s previous position, CMS agreed to continue reimbursing telehealth services based on the place of service that would apply if the service had been furnished in person.

For psychologists working in outpatient settings, such as their private offices, reimbursement for telehealth will be at the nonfacility rate through the end of 2023 or the end of the calendar year in which the PHE expires, whichever comes later.

APA asked CMS to institute a coding modifier to identify audio-only telehealth services. Starting in January 2023, providers will append modifier 93 - Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System, to allowable mental health services furnished via audio-only technology. Claims for audio-only services rendered in Rural Health Clinics or Federally Qualified Health Centers should append modifier FQ - Medicare telehealth service was furnished using audio-only communication technology.

Per APA’s request, beginning on January 1, 2023, CMS has agreed to add the following services to the Medicare Telehealth Services List on a temporary (category 3) basis:

• 90875 Psychophysiological therapy
• 90901 Biofeedback train, any method
• 96110–96113 Developmental screen; developmental testing
• 96127 Brief emotional assessment
• 96170–96171 Health behavior intervention, family without patient
• 97150–97158 Adaptive behavior assessment and treatment services

As projected, the conversion factor (CF), the figure used to convert relative values to payment amounts, will be lower in 2023. The current (2022) CF of $34.61 will drop to $33.06, a loss of 4.48%. The reduction is largely due to the year-end expiration of a 3% increase made to the 2022 CF added through federal legislation, adjustments for budget neutrality, and changes in malpractice expense. APA Services is working with the broader health care community to address the impending payment cuts to all Medicare providers before the December 31, 2022 deadline.

Update: On December 29, 2022, the Consolidated Appropriations Act 2023 containing important increases in funding for federal programs became law. Several key changes will impact psychologists who treat Medicare patients including:

• Reducing the 4.5% cut projected for the 2023 Medicare fee schedule CF. Congress provided additional funding so that the CF is being reduced by just 2.0% in 2023 and by 3.25% in 2024. The CF is a critical part of the Medicare payment formula and is used to convert relative value units into payment amounts. Changes to the CF impact payments to all Medicare providers billing for professional services under Medicare Part B.
• Medicare’s current telehealth waivers will be extended through December 31, 2024. This includes allowing for audio-only telehealth services and continuing the delay of the in-person visit requirement for behavioral health services. This extension to December 31, 2024 will remain in effect even if the COVID-19 public health emergency ends in 2023.

General Behavioral Health Integration (BHI) Services

CMS finalized their proposal to create the new HCPCS code G0323:

Care management services for behavioral health conditions, at least 20 minutes of clinical psychologist or clinical social worker time, per calendar month.

This service describes general BHI services provided by psychologists and clinical social workers, and includes the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, coordination with and/or referral to physicians and practitioners who are authorized by Medicare law to prescribe medications and furnish E/M services, counseling, and/or psychiatric consultation; and continuity of care with a designated member of the care team.

Reimbursement for G0323 will be based on the payment rate for code 99484, the medical procedure code billed for at least 20 minutes of BHI services in a month. Currently the nationwide rates for 99484 are $44.64 (nonfacility) and $30.45 (facility).

Psychologists can also report G0323 when services are furnished by auxiliary staff, such as, but not limited to, licensed professional counselors and marriage and family therapists, under their general supervision. A psychiatric diagnostic interview (90791) can serve as the initiating visit but not a health behavior assessment or reassessment (96156).

Psychologists and clinical social workers will bill for BHI services furnished in a Rural Health Clinic or Federally Qualified Health Center using HCPCS code G0511, either alone or with other payable services.

Allowing “incident to” services to be furnished under general rather than direct supervision

CMS is finalizing the proposal to add an exception to the direct supervision requirement under “incident to” regulation at 42 CFR 410.26. This will allow mental and behavioral health services to be furnished by mental health professionals not recognized in Medicare (such as licensed professional counselors and marriage and family therapists) under general, rather than direct supervision when provided “incident to” the services of a physician or nonphysician practitioner (NPP). Psychologists are one of the NPP provider types. So, in Medicare, providers such as licensed professional counselors and marriage and family therapists will be able to provide services when provided “incident to” a psychologist. Direct supervision requires that the physician or NPP be physically present in the office suite while the service is being performed by auxiliary staff. Under general supervision, the service is performed under the direction and control of the physician or NPP, but they do not need to be physically present. There will be no changes to the “incident to” definition of auxiliary personnel (APA will provide more information about this change in 2023).

Amending requirements for annual alcohol misuse and depression screenings

In response to concerns raised regarding the code descriptors that require 15 minutes of time to bill for annual alcohol misuse and depression screenings (HCPCS codes G0442 and G0444 respectively), CMS is revising the code descriptors to specify screening times of 5 to 15 minutes, which represents a typical range of time to furnish these services. The following revised HCPCS code descriptors and times required to report these services will be implemented on January 1, 2023:

• G0442: Annual alcohol misuse screening, 5 to 15 minutes
• G0444: Annual depression screening, 5 to 15 minutes

Upgrading the status of the family psychotherapy codes

The codes used to report family psychotherapy services—CPT codes 90847; Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes and 90849; Multiple-family group psychotherapy—will be assigned an active (“A”) procedure status indicator in 2023. CMS said it may consider changes to the status of code 90846 (family without the patient) in the future.

Acknowledging time needed for psychotherapy services within opioid treatment programs (OTPs)

CMS is changing the payment for the nondrug component of the OTP services bundle to reflect 45 minutes of psychotherapy, an increase over the current standard of 30 minutes. This means the individual psychotherapy component will be paid based on a crosswalk to code 90834; Psychotherapy, 45 minutes with patient, rather than 90832; Psychotherapy, 30 minutes with patient, even when the length of the therapy service is less than 45 minutes.

Cognitive behavioral therapy monitoring device

The code for a cognitive behavioral therapy monitoring device, 989X6; Remote therapeutic monitoring (e.g., therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor cognitive behavior therapy, each 30 days), is a practice expense code that has no professional work. CMS will have 989X6 contractor priced as the agency learns more about the different devices and their related costs.

Additionally, CMS agreed to allow for general supervision when physicians and other qualified health care professionals use the Remote Therapeutic Monitoring treatment management services (98980, 98981).

Chronic pain management and treatment services

While the agency finalized new HCPCS codes and valuation for chronic pain management and treatment services for 2023, they did not agree to remove medication management from the descriptors for codes G3002 and G3003. CMS believes that medication management is an essential element of pain care, which customarily includes a review of prescription drugs, over-the-counter medications, supplements, natural treatments, and/or any other substances the person with chronic pain might be using for any purpose. CMS noted that psychologists treating patients with chronic pain can already bill for their services using health behavior assessment and intervention (HBAI) codes. HBAI codes capture services related to physical health, such as adherence to medical treatment, symptom management, health-promoting behaviors, health-related risky behaviors, and adjustment to physical illness, and are intended to be used for psychological assessment and treatment, when the primary diagnosis is a medical condition, such as chronic pain.

Outstanding policy and reimbursement resolutions

While the actions described above will benefit psychologists in 2023, CMS said it is still considering the following issues which may be addressed in future rulemaking:

• Revised methodologies to improve payment for mental and behavioral health
• Coverage and reimbursement for Caregiver Behavior Management Training services (96202, 96203)
• Adoption of new codes for Cognitive Assessment and Care services provided without medication reconciliation
• Allowing psychologists to bill for Intensive Behavior Therapy for Obesity services
• New codes for assessing for social determinants of health affecting patient well-being
• Increasing reimbursement rates and developing new codes to support Intensive Outpatient Programs for Mental Health and Substance Use Disorder Treatment
• Institute payment for services provided by community health workers

APA will closely monitor future notices from CMS and continue to advocate for these proposals.