On January 1, 2022, the Centers for Medicare & Medicaid Services (CMS) implemented permanent changes in the Medicare Physician Fee Schedule that offer new possibilities to expand the scope of telehealth for mental health (MH) and substance use disorders (SUD) for Medicare patients. These changes are a direct response to recent increases in MH and SUDs over the last two years, which have been especially deadly in combination with the tsunami of synthetic opioids (namely fentanyl) that has cascaded across the United States.1
Amid the shelter-in-place regulations of the COVID-19 pandemic, telehealth emerged as a powerful tool. Telehealth can improve access to care, particularly among vulnerable populations who may lack funds for travel and care of dependents. For patients with SUDs, stigma may present further barriers to in-person care, which telehealth may help to alleviate.2 Not only do primary care clinics present an entryway into care for MH disorders, they increasingly receive a greater proportion and volume of visits for MH disorders than psychiatry offices.3
Those of us in general medicine have long been hampered in our efforts to expand access for our patients SUD and MH conditions by insufficient resources. With the new service code options provided by CMS, we can explore innovative ways of care delivery that leverage the expertise of a multi-disciplinary team. In the table, we lay out relevant Medicare telehealth service codes with the respective payments in relative value units (RVUs). RVUs translate to dollars by multiplying times the Medicare conversion factor, roughly $35.
Here Are the CMS Changes You Need to Know About
The patient can be located anywhere—whereas telehealth services were previously confined to dedicated spaces, telehealth services for MH and substance use care can be provided to patients who are home, or at another location including a shelter, car, or their place of work. State licensing restrictions still apply. Encounters should be clearly focused on MH/SUD but other conditions can and should be addressed.
In-person visits are sometimes required—CMS has required an in-person visit no more than six months before the telehealth visit, and at no greater than every 12 months after. However, the 12-month periodic in-person visit can be waived if a provider documents that the burdens of an in-person visit outweigh the benefits; and how vital signs, patient monitoring data, and lab testing are available as needed. Finally, all in-person requirements can be waived for SUD telehealth visits.
Audio-visual technology preferred but audio-only allowed—CMS’ preference remains for audio-visual telehealth visits, but audio-only may be delivered if the patient does not have the capabilities or does not consent to participate in a video telehealth visit, and this is appropriately documented.
Examples of How the New Medicare Codes May Be Used
Scenario 1: Depression Follow-up
Mr. J, a 54-year-old man with depression and emphysema, is an established patient in the clinic. He is scheduled for an audio-video visit, during which his PCP addresses his depression, including medication titration and re-referral to counseling. His inhalers are refilled; an outpatient established patient service code, such as 99214, code is used for billing purposes.
Scenario 2: Bundled Opioid Use Disorder Treatment
Ms. Y, a 43-year-old woman without past medical history, is referred to the clinic from her rural ER, where she presented for treatment of an abscess related to injection opioid use. The ER diagnoses her with opioid use disorder and provides her with a telehealth appointment with a primary care doctor. A doctor spends 30 minutes on the phone with her discussing her initial treatment plan and induction with buprenorphine. A follow-up telehealth check-in is scheduled for later in the week with a Physician Assistant. An appointment is made for later that month with the clinic’s therapist via telehealth. The month of multidisciplinary care is coded with the Medicare service code, G2086, for billing purposes.
Pitfalls and Cautions
CMS has been hesitant to permanently add telehealth billing codes for medical conditions, as there is a concern that fraud may be rampant, despite little evidence of this. Additional concerns, none clearly demonstrated in previous research, include the potential for difficulty in rapport-building, and possibility of decreased understanding of medical recommendations, particularly in audio-only encounters.3, 4 We caution providers to use standardized documentation tools when available to prevent fraud and bias and involve a multi-disciplinary team to ensure high-quality, coordinated care. We encourage providers to always verify the patient’s name, date of birth, as and location (as providing care across state lines may have legal implications); and to query any unexpected pauses in the conversation or changes in tone, as to maintain two-way understanding despite being physically distant.
Next Steps: A Call to Action within Your Practice or Enterprise
Many colleagues are pivoting to telehealth due to necessity during the pandemic, and finding not only that it is effective but also that it enhances equity and retention particularly with the treatment of SUDs.5 The current Medicare telehealth flexibilities, which have expanded telehealth’s reach greatly and increased revenue for audio-only visits via the 99441-99443 codes, are set to expire, unless Congress takes action. The CY 2022 Medicare Physician Fee Schedule final rule lays out a framework for an expanded role for telehealth in the care of MH conditions and SUDs. We believe these changes represent a call to action for the primary care community to bring its expertise in MH and SUD treatment to the telehealth arena and lay claim to a revenue support model that pays for the work done.
Primary care, as a cognitive specialty, has long been subject to under-reimbursement, a phenomenon that has recently begun to be addressed, though thus far inadequately. If primary care physicians do not work to claim the reimbursement they deserve based on their knowledge, patient care skills, and collaborative capabilities, we risk not seizing an opportunity to enhance the care we aspire to deliver.
These regulations and codes listed above are only applicable to Medicare, but in many cases, other public and private insurers will reimburse similarly to Medicare. And if health systems and clinicians continue to use these codes to provide important services to their patients, further legislation and regulations will follow to continue to support this expansion to include virtual care, and even audio-only care, for those with one or more chronic medical conditions.