The Centers for Medicare and Medicaid Services (CMS) proposed CY 2022 Physician Fee Schedule (PFS) issued on July 16 includes a variety of provisions that are relevant to clinical social workers (CSWs) who are participating providers in Medicare. These provisions are outlined below and cover a number of areas, including but not limited to telehealth, the Quality Payment Program (QPP) and reimbursement.
NASW submitted a comment letter to CMS on September 13, 2021. In addition, NASW members were invited to submit their own comments via an action alert. The agency will issue the final rule in late 2021. NASW will provide an update at that time on the contents of the rule and implications for clinical social workers (CSWs).
NASW supports CMS’ proposal to extend several of the telehealth flexibilities which were implemented early in the pandemic. These flexibilities have been transformational in addressing the mental and behavioral health needs of millions of beneficiaries. We also support the removal of geographic restrictions and the proposal to allow beneficiaries’ homes as an originating site for telehealth services for the purpose of diagnosis, evaluation, and treatment of mental health disorders. We welcome the proposed continuation of audio-only services as a telehealth modality. The association requests the following revisions:
- In-Person Requirement: We urge CMS not to impose an in-person requirement for telehealth services, either before or after the first telehealth. Such a requirement would impede access to services for individuals currently receiving treatment and discourage others from seeking treatment. The frequency of any in-person sessions should be determined by clinicians, together with their clients, as has been the case during the public health emergency (PHE). If CMS is forced to institute such a requirement, we would support an in-person visit being required at intervals of no more than once every 12 months.
- Audio-Only Documentation: We urge CMS to refrain from requiring additional documentation for coverage of audio-only. The documentation in the medical record already provides sufficient information needed to justify medical necessity for the service. Additionally, under the proposed rule, providers will already self-certify that they have two-way audio-visual telecommunications devices, but the patient requires or has chosen to receive the service via audio-only. No other documentation should be required.
- Include Behavioral Health Services in Audio-Only. NASW urges CMS to allow use of audio-only services for substance use disorder (SUD) and behavioral health services. Given the prevalence of co-occurring mental health and substance use disorders, this approach would advance CMS’ goal of providing the “right care at the right time” to improve patient and population health outcomes.
- Psychotherapy with Crisis and Higher-Level Codes: NASW urges CMS to allow high-level services such as crisis psychotherapy to be furnished through audio-only. By definition, a mental health crisis is urgent, and help is required as soon as possible. There should be nothing that delays or discourages immediate contact with a provider and audio-only telephones are the easiest telecommunications devices for many beneficiaries to use.
- Payment Parity: A key payment issue not directly addressed in the proposed rule is whether the agency will continue to pay for telehealth services at the same rate as in- person visits once the PHE ends. For mental and behavioral health providers, whose patients rely heavily on telehealth services, it would be a costly reduction if payment for these services returns to pre-pandemic reimbursement. We urge CMS to continue to ensure payment parity for telehealth services.
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
NASW supports CMS’ proposal to expand the definition of RHCs or FQHCs mental health visits to include encounters furnished through interactive, real-time telecommunication technology for mental health disorders, and to allow them to furnish mental health visits using audio-only interactions to beneficiaries when two-way, audio/video communication is not available.
NASW supports CMS’ proposal to revise the current eligible clinician definition to include clinical social workers in the QPP. The association also appreciated CMS’ efforts to simplify the Merit-Based Incentive Payment System (MIPS) by developing the MIPS Value Pathways program (MVP). We support CSW shaving the opportunity to provide meaningful data to promote improved treatment outcomes for beneficiaries and encouraged CMS to consider MVP topics applicable to CSW practice.
NASW opposes CMS’ proposal to reduce the conversion factor by 3.75 percent, which would result in payment cuts for CSWs. The projected 3.89 percent loss for 2022 as a result of this change in conversion factor follows a 3.3 percent budget neutrality-related reduction in 2021. Together, this is a 7+ percent reduction in payment from 2020 to 2022. The proposed cut is particularly harmful to CSWs. CSWs are the largest group of mental health service providers in the nation and among the few mental health professions that provide psychotherapy services for Medicare beneficiaries. Despite possessing extensive education and training and billing the exact same codes, CSWs are reimbursed at only 75 percent of the PFS. This has not changed since CSWs were first added to Medicare in 1989, despite the growing need for our services. Further reduction of already low payments will jeopardize beneficiary access to essential mental health services.
NASW appreciates CMS’ recognition of the need for greater attention to the public health issue of chronic pain and the health and social risks posed by untreated and/or inappropriately treated chronic pain. Further steps are needed to increase Medicare beneficiary access to behavioral and therapeutic management of chronic pain. Social workers can serve in key roles in the delivery of clinical and supportive services to patients who experience chronic pain. Making social workers independently reimbursable for the provision and delivery of pain management-related services (e.g., clinical assessments, consultation, therapeutic care etc.) will expand much needed supportive care to Medicare beneficiaries.
Opioid Treatment Programs
NASW agrees with the proposal to require Opioid Treatment Program (OTP) to use a service-level modifier for audio-only services for counseling and therapy. The association also concurs with the requirement to document in the medical record the rationale for using audio-only services.