Advocacy

Billing & Coding

On July 23rd, 2021, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule change that makes revisions to the CY 2022 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 Medicare Physician Fee Schedule proposed rule changes, available here

The 3.75% payment increase provided by the Consolidated Appropriations Act of 2021 is set to expire in 2022, absent Congressional action.

  • If this expires, the Medicare conversion factor is set to decrease for the 2022 payment year.
  • Several specialties, including Addiction Medicine (ADM), are scheduled to receive less Medicare dollars as a result.
  • ADM is scheduled to experience a 2.5% cut in reimbursements in 2022.

 

The primary changes are as follows:

Opioid Treatment Programs

  • CMS is proposing to allow Opioid Treatment Professionals (OTPs) to furnish counseling and therapy services via audio-only technologies in cases where two-way audio and video communication is unavailable to the beneficiary, even 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 proposal implements the second phase of the electronic prescribing requirement included in the SUPPORT Act. This proposal would codify 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 circumstance (e.g., a sudden influx of patients due to a pandemic).

CMS is also proposing to enable prescribers to request a waiver where circumstances beyond their control prevent them from electronically prescribing a controlled substance covered by Part D.

Telehealth

  • CMS is proposing to allow certain services to be included on the Medicare telehealth list until the end of 2023. Additionally, CMS is proposing to:

Require an in-person, non-telehealth service be provided by the physician or practitioner furnishing mental health telehealth services within six months prior to the initial telehealth service, and at least once every six months thereafter.

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.

Require 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 is also soliciting comment on:

Whether additional documentation should be required in the patient’s medical record to support the clinical appropriateness of audio-only telehealth

Whether or not CMS should preclude audio-only telehealth for some high-level services, such as level 4 or 5 E/M visit codes or psychotherapy with crisis

Any additional guardrails they should consider putting in place in order to minimize program integrity and patient safety concerns

 

Other provisions:

CMS is also proposing new OTP coding and payment options for a take-home supply of the new, 8 mg naloxone hydrochloride nasal spray product.

The Agency is proposing to implement permanent coverage and payment for HCPCS code G2252 (Brief communication technology-based service, e.g., virtual check-in service).

 

CMS is setting the start date for compliance actions to January 1st, 2023.

 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: 

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.

There are now separately reimbursable “Interprofessional Telephone/Internet/Electronic Health Record Consultation” CPT codes that describe assessment and management services furnished when a patient’s treating physician or other qualified health care professional (OQHCP) requests the opinion and/or treatment advice of a physician (or OQHCP, if eligible) with specialty expertise (the consultant) to assist in the diagnosis and/or management of the patient’s problem without the patient’s face-to-face contact with the consultant.  The American Psychiatric Association (APA) has created resources for psychiatrists about these codes. Read more here on the APA's website. (See APA’s first bullet point under “Codes to Know”.)