Expanding access to mental and behavioral health services in Medicare

Covid–19 contributed to an increase in the demand for behavioral health services. The Centers for Medicare and Medicaid Services (CMS) acknowledges that workforce shortages already exist for behavioral health practitioners, including clinical psychologists, psychiatrists, counseling and school psychologists, mental health and substance use social workers, school counselors, and marriage and family therapists, and the impact of these shortages are expected to increase in years to come.

In response, CMS is taking steps to reduce barriers to mental and behavioral health treatment, partly by including two changes in the 2023 Medicare Physician Fee Schedule Final Rule that directly impact psychologists.

The first change is the agency’s approval to allow “incident to” services for behavioral health care to be furnished under general rather than direct supervision, meaning that the psychologist does not have to be physically present to oversee service delivery. The second change was the creation of a 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.

In surveys conducted in 2020 and 2021, APA set out to better understand how Covid-19 impacted mental health treatment and the work of practicing psychologists. The results showed that many psychologists were experiencing increases in workload and the demand for anxiety, depression, and trauma-related treatment, longer waitlists, and a low capacity for new patients. CMS cited these findings in their 2023 proposed and final rule, in their discussion regarding their goal to improve access to and quality of mental health care services.

In previous years, when behavioral health services were billed “incident to” a physician’s or nonphysician practitioner’s (NPP) services, direct supervision was required, which meant the physician or NPP must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. However, recognizing increased needs for behavioral health services and workforce shortages, effective for 2023, CMS created an exception to the direct supervision requirement under “incident to” regulation (42 CFR 410.26), and now allows mental and behavioral health services to be furnished by mental health professionals not recognized in Medicare, such as licensed professional counselors and licensed marriage and family therapists, under general supervision.

Under the new implemented general supervision requirements, behavioral health services can be performed under the direction and control of the physician or NPP, but they do not need to be physically present.

While CMS did not provide a specific definition for what they consider to be behavioral health services, they did state in the 2023 final rule that they generally understand a behavioral health service “to be any service for the diagnosis, evaluation, or treatment of a mental health disorder, including a substance use disorder (SUD).” The agency also provided examples, stating “behavioral health services could include, but are not limited to, psychotherapy; screening, brief intervention, and referral to treatment services; and psychiatric diagnostic evaluations.”

CMS indicates that any clinician who meets the definition of “auxiliary personnel” may serve as auxiliary personnel under the exception. “Auxiliary personnel” is defined as any individual who meets the following criteria:

• Is acting under the supervision of a physician (or another practitioner), regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or another practitioner) or of the same entity that employs or contracts with the physician (or another practitioner).
• Has not been excluded from Medicare, Medicaid, and all other federally funded health care programs by the Office of Inspector General or had their Medicare enrollment revoked.
• Meets any applicable requirements to provide incident-to services, including licensure requirements, imposed by the state in which the services are being furnished.

Psychologists can now receive reimbursement from Medicare for providing behavioral health integration (BHI) services. In the 2023 Medicare Physician Fee Schedule Final Rule, CMS finalized their proposal to create the 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, which describes services performed by a clinical psychologist (CP) or clinical social workers (CSWs) to account for monthly care integration where the mental health services furnished by a CP or CSW are serving as the focal point of care integration. The psychiatric diagnostic evaluation (CPT^® code 90791) can serve as the initiating visit for the new general BHI service.

HCPCS code G0323 is care management services for behavioral health conditions and is used to account for monthly care integration where mental health services are provided by a clinical psychologist or clinical social worker serving as the focal point of care integration. This service requires the CP or the CSW to perform at least 20 minutes of care management services over the course of a calendar month.

When psychologists and clinical social workers perform general BHI services, the following elements of care are required in order to report HCPCS code G0323:

• 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.

There is an unprecedented growing mental health crisis among all ages across the country. One in five adults experience a diagnosable mental health disorder and two out of five report symptoms of anxiety and depression. It is critical that those who struggle with mental health problems receive care; however, less than half of those who need care are receiving the help they need. Timely access to mental health care is often limited by resources, especially in rural and under/uninsured and ethnically diverse patient populations. BHI services increase access to mental and behavioral health care.

APA is dedicated to improving population health, along with advocating for financial incentives that support psychologists’ involvement in these efforts. A population health approach, or preventive health approach, focuses on improving the health, health equity, safety, and well-being of entire populations, including individuals within those populations. Providing general BHI services is an important part of addressing population health.

Behavioral health concerns

A psychologist in a primary care setting is referred a patient from the primary care provider for behavioral health concerns. The psychologist sees the patient for an initial diagnostic evaluation. The psychologist diagnoses the patient with generalized anxiety disorder (GAD) and depressive disorder. The psychologist would bill code 90791; Psychiatric diagnostic evaluation, as an initiating visit for an established patient. The psychologist assigns the case manager in the clinic to administrator the GAD and PHQ-9, facilitate and coordinate psychotherapy treatment, and coordinate outside referral for medication management. The case manager documents the time for each task and then completes all the required components of the service across a month and the time totals 30 minutes. The case manager would bill the general BHI HCPCS code G0323, incident to the psychologist.

Management of diabetes

A psychologist in a primary care setting is referred a patient from the primary care provider for difficulties adhering to management of diabetes. The psychologist sees the patient for an initial diagnostic assessment and determines that the patient’s primary diagnosis is diabetes. The psychologist would bill CPT^® code 96156; Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making). The psychologist then schedules a follow-up appointment to address difficulties with adhering to medication recommendations. The psychologist would bill code 96158; health behavior intervention, individual, face-to-face; initial 30 minutes for the intervention service, along with the primary physical health condition as the patient’s primary diagnosis. In this scenario, general BHI cannot be reported, because the primary diagnosis is not a mental health condition.

Reimbursement for HCPCS code G0323 will be based on the payment rate for CPT code 99484, the medical procedure code billed for at least 20 minutes of BHI care management services performed over the course of a calendar month.

Psychologists can also report G0323 when services are furnished by auxiliary staff, such as, but not limited to, licensed professional counselors and licensed marriage and family therapists, under their general supervision.

A psychiatric diagnostic interview (code 90791) can serve as the initiating visit, but not a health behavior assessment or reassessment (code 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.

APA recommends that, in order to reduce the risk of your claim(s) being denied for reporting noncovered/noncontracted codes, you should check each commercial payer policy, as well as the list of codes included in your contract with each payer, to determine which codes are covered/reimbursed.

• 2022 CMS Behavioral Health Strategyopens in new window
• APA’s 2022 Covid-19 Practitioner Impact Survey: Psychologists struggle to meet demand amid mental health crisis
• Mental health crisis: CMS finalizes proposals to help psychologists meet the need
• Centers for Medicare and Medicaid Services CY 2023 Medicare Physician Fee Schedule Final Ruleopens in new window, Revisions to the “Incident to” Physicians’ Services Regulation for Behavioral Health Services and New Coding and Payment for General Behavioral Health Integration (BHI) Billed by Clinical Psychologists (CPs) and Clinical Social Workers (CSWs), pages 69545-69551