Billing & Coding
- 2022 Medicare Physician Fee Schedule
- 2021 Medicare Physician Fee Schedule
- 2020 Medicare Physician Fee Schedule
- Interprofessional Telephone/Internet/Electronic Health Record Consultation CPT Codes
On November 2nd, 2021, the Centers for Medicare and Medicaid Services (CMS) issued a Final Rule which revises CY 2022 payment policies under the Medicare Physician Fee Schedule (PFS) and makes other policy changes, including the implementation of certain provisions of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (the SUPPORT Act).
CMS has also published a fact sheet on the 2022 Medicare Physician Fee Schedule Final Rule, available here.
The 3.75% payment increase provided by the Consolidated Appropriations Act of 2021 is set to expire at the end of 2021, absent Congressional action. This along with a decrease in the Medicare conversion factor will mean that several specialties, including Addiction Medicine (ADM), will receive less Medicare dollars as a result during the 2022 payment year.
CMS also finalized changes to other programs. The primary changes are as follows:
Opioid Treatment Programs
CMS finalized rules enabling Opioid Treatment Professionals (OTPs) to furnish counseling and therapy services via audio-only (telephone calls) technologies in cases where two-way audio and video communication is unavailable to the beneficiary, after the conclusion of the public health emergency (PHE) for COVID-19.This includes circumstances where the beneficiary is not capable or denies consent to the use of two-way audio and video interaction.
Electronic Prescribing of Controlled Substances (EPCS)
CMS finalized plans to implement the second phase of the electronic prescribing requirement included in the SUPPORT Act. This revision codifies certain exemptions to the requirement, including when:
- The prescriber and dispensing pharmacy are the same entity;
- The prescriber issues 100 or fewer controlled substance prescriptions for Part D drugs per calendar year;
- The prescriber is located in the same geographic area as a natural disaster or;
- Prescribers are approved for a waiver for extraordinary circumstances (e.g., a sudden influx of patients due to a pandemic). Other extraordinary circumstance exemptions that CMS recently added include technological failures and cybersecurity attacks.
CMS finalized rules enabling prescribers to request a waiver where circumstances beyond their control prevent them from electronically prescribing a controlled substance covered by Part D.
Formal compliance actions will begin on January 1st, 2023. In the interim, CMS will enforce compliance through compliance letters.
CMS announced that it will allow certain services added to the Medicare telehealth list to remain on the list until the end of 2023. The complete list of Medicare telehealth services can be found here. Additionally, CMS finalized proposals to:
- Continue reimbursement for mental health telehealth services without geographic restrictions, provided that the patient has an existing in-person relationship with the provider. CMS requires that an in-person relationship include 1 in-person visit within a 6 month period prior to the telehealth encounter, and at least 1 in-person visit every 6 months thereafter.
- Continue reimbursement for mental health telehealth services in the home, provided that providers and patients complete 1 in-person visit within 6 months of the initial telehealth service, and at least once for every 12 months afterward with exceptions for situations where providers and patients agree that the risk/burden of in-person meetings outweighs the benefit. Requirement for in-person meetings can be satisfied by other physicians within the same specialty and subspecialty group if the existing provider is unavailable.
- Amend current regulatory requirement for interactive telecommunications (multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner) to include audio-only communication technology when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders furnished to established patients in their homes.
- Limit the use of an audio-only interactive telecommunications system to mental health services furnished by practitioners who have the capability to furnish two-way, audio/video communications, but where the beneficiary is not capable of using, or does not consent to, the use of two-way, audio/video technology.
- CMS clarified that substance use disorder (SUD) is included in the revised definition above such that practitioners can use audio-only communication technology to provide treatment for a SUD. CMS also clarified that the in-person requirements described above do not apply to treatment of a patient diagnosed with a SUD for treatment of that disorder or a co-occurring mental health disorder.
- Require the use of a new modifier for services furnished using audio-only communications, which would serve to certify that the practitioner had the capability to provide two-way, audio/video technology, but instead, used audio-only technology due to beneficiary choice or limitations.
CMS confirmed that it will extend its audio-only flexibility for OTPs to the therapy and counseling portions of the bundled payments for SUDs in office-based practices.
CMS finalized coding and payment for a take-home supply of 8 mg naloxone hydrochloride nasal spray.
On December 2, 2020, the Centers for Medicare and Medicaid Services (CMS) released the Final Rule that makes revisions to the CY 2021 payment policies under the Medicare Physician Fee Schedule (PFS) and makes other policy changes, including implementation of certain provisions of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (the SUPPORT Act).
CMS has also published a fact sheet on the PFS final rule, available here
The Consolidated Appropriations Act, 2021, signed into law on December 22, 2020, made several
modifications to the CY2021 PFS:
• Provided a 3.75% increase in MPFS payments for CY 2021.
• Suspended the 2% payment adjustment (sequestration) through March 31, 2021.
• Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023.
• Delayed implementation of the inherent complexity add-on code for evaluation and
management services (G2211) until CY 2024.
The main changes are as follows:
- CMS adopted AMA CPT coding and documentation guidelines to report office and outpatient E/M visits based on either medical decision-making or physician time and reduce unnecessary documentation. These changes will be effective beginning January 1, 2021. Learn more about the changes here.
CMS permanently added several services to the Medicare telehealth services list, including Group Psychotherapy.
Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTP).
CMS finalized its proposal to extend the definition of OUD treatment services to include opioid antagonist medications, specifically naloxone, that are approved by Food and Drug Administration under section 505 of the Federal Food, Drug, and Cosmetic Act for emergency treatment of opioid overdose, and overdose education provided in conjunction with opioid antagonist medication. Read more in the CMS Factsheet.
Bundled Payments under the PFS for Substance Use Disorders (HCPCS codes G2086, G2087, and G2088)
In the CY 2020 PFS final rule (84 FR 62673), CMS finalized the creation of new coding and payment describing a bundled episode of care for the treatment of Opioid Use Disorder (OUD). In response to requests to expand those bundled payments to be inclusive of other SUDs, not just OUD, CMS is revising the code descriptors by replacing “opioid use disorder” with “a substance use disorder.” The payment and billing rules otherwise remain unchanged.
Initiation of Medication Assisted Treatment (MAT) in the Emergency Department (HCPCS code G2213)
In the CY 2020 PFS proposed rule, CMS sought comment on the use of medication assisted treatment (MAT) in the emergency department (ED) setting, including initiation of MAT and the potential for either referral or follow-up care. It was persuaded by the comments received that this work is not currently accounted for in the existing code set. To account for the resource costs involved with initiation of medication for the treatment of opioid use disorder in the ED and referral for follow-up care, CMS is creating one add-on G-code (G2213) to be billed with E/M visit codes used in the ED setting.
Electronic Prescribing of Controlled Substances
Section 2003 of the SUPPORT Act requires that, effective January 1, 2021, the prescribing of a Schedule II, III, IV, or V controlled substance under Medicare Part D be done electronically in accordance with an electronic prescription drug program. CMS finalized the provision with an effective date of January 1, 2021 and a compliance date of January 1, 2022 to encourage prescribers to implement EPCS as soon as possible, while helping ensure that its compliance process is conducted thoughtfully. It noted that physicians who do not implement EPCS “until January 1, 2022 will still be considered compliant with the requirement.
Read the summary here
Read the full rule
On November 1, 2019, the Centers for Medicare and Medicaid Services (CMS) released the Final Rule that makes revisions to the CY 2020 payment policies under the Medicare Physician Fee Schedule (PFS) and other policy changes, including those required to implement certain provisions of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act) related to Medicare Part B payment.
CMS has also published a fact sheet on the PFS Final Rule for 2020.
Three sections of the Final Rule are particularly relevant to ASAM members and are summarized below:
- Section II.G.: Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs
- Section II.H.: Bundled Payments Under the PFS for Substance Use Disorders
- Section III.H.: Medicare Enrollment of Opioid Treatment Programs and Enhancements to Existing General Enrollment Policies Related to Improper Prescribing and Patient Harm
In addition, the Final Rule aligns Medicare E/M coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for new and existing patient office E/M visits. A summary of those changes can be found here. The AMA built an educational website dedicated solely to the E/M changes, available here, which will be updated during the year. CMS also adopted the AMA Specialty Society Relative Value Scale Update Committee (RUC) recommended values for the office E/M visit codes for CY 2021 and the new add-on CPT code for prolonged service time. The AMA RUC-recommended values are anticipated to increase payment for office E/M visits.