On July 7, 2022, the Centers for Medicare and Medicaid Services (CMS) released its proposed rule of the Physician Fee Schedule (PFS) that announced proposed policy and practice changes for Medicare Part B payments beginning January 1, 2023. The proposed changes may impact social workers and other Medicare providers in various settings.
The proposed rule also looks to solicit comments from stakeholders on ways to identify and improve access to high value, potentially underutilized services by Medicare beneficiaries. Such services include but are not limited to preventative services, behavioral health integration services, and chronic care management. The following provides key takeaways for clinical social workers:
CMS is proposing several policy changes to Medicare telehealth services. This includes extending coverage for telehealth services that have been temporarily authorized during the COVID-19 public health emergency (PHE). The proposed rule would also implement policies under the Consolidated Appropriations Act of 2022 (P.L. 117-103), which would allow for the continuation of certain flexibilities until 151 days after the end of the PHE.
This would extend the waiver of the geographic location requirement, delay the in-person requirement for mental health services, and continue to allow the use of audio-only and audio-video technology. CMS is proposing telehealth claims use the appropriate place of service (POS) indicator on the claim, in lieu of the modifier “95,” after 151 days following the end of the PHE. Beginning January 2023, services provided using audio-only communications technology would use modifier 93.
In an effort to meet growing mental health needs, CMS is proposing to develop a new code (GBHI1) for behavioral health integration services performed by clinical social workers (CSWs) or clinical psychologists. This code would account for the monthly integration care where mental health is the focal point with the psychiatric diagnostic evaluation code 90791 serving as the initiating visit. Services can be billed “incident to” under general supervision, during the same month as transitional care services and chronic care management providing all requirements are met.
CMS proposes to make an exception to the direct supervision requirement under the “incident to” regulation. Behavioral health services would be provided under the general supervision of a physician or non-physician practitioner (NPP) instead of under direct supervision when these services are provided by auxiliary personnel incident to the services of a physician or NPP.
Lastly, CMS is soliciting comments on whether present payment policies sufficiently cover intensive outpatient mental health services, to include services for substance use disorders and indirect costs for mental health services in non-facility settings.
Chronic Pain Management Services
CMS proposes to revise the definition of chronic pain as persistent or recurrent pain lasting longer than three months. Beneficiaries who are newly diagnosed, as well as those who were previously diagnosed with chronic pain would both be eligible.
Two new HCPCS (GYYY1 and GYYY2) codes have been also created for chronic pain management and treatment services. The proposed codes would include a monthly bundle of services.
Opioid Treatment Programs (OTPs)
CMS proposes a payment increase for the non-drug component of bundled services. The base rate for individual therapy would be increase from 30 to 45 minutes.
CMS seeks to clarify that services delivered via OTP mobile units will be considered for reimbursement under Medicare OTP bundled payment codes and/or add-on codes and would be treated as though they were provided at the OTP’s physical location. CMS notes that the prohibition on billing OTP services for the same beneficiary more than once within a contiguous seven-day period would apply regardless of location.
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
CMS is proposing to implement policies under the Consolidated Appropriations Act of 2022 which includes delaying the in-person requirements for mental health visits furnished by RHCs and FQHCs through telecommunication technology under Medicare until the 152nd day after the COVID-19 PHE ends.
The agency is also proposing to add the new chronic pain management and behavioral health integration services to the RHC and FQHC (HCPCS G0511). the payment rate for HCPCS code G0511 would continue to be the average of the national non-facility PFS payment rates for the RHC and FQHC care management and general behavioral health CPT codes and PCM CPT codes.
Per the request of interested parties, CMS clarifies that 12-consecutive months of cost report data should be used to establish a specified provider-based RHC’s payment limit per visit. They believe the report accurately reflects the costs of providing RHC services and will establish a more accurate base to update payment limits moving forward.
Prepared by Denise Johnson, LCSW-C, NASW Senior Practice Associate for Clinical Social Work