Billing & Coding
- 2023 Medicare Physician Fee Schedule
- 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 July 7, 2022 the Centers for Medicare and Medicaid Services (CMS) issued a Proposed Rule which revises CY 2023 payment policies under the Medicare Physician Fee Schedule (PFS) and makes other policy changes.
CMS has also published a fact sheet on the 2023 Medicare Physician Fee Schedule Proposed Rule, available here.
A summary of the major proposed changes is listed below:
CMS proposes a CY 2023 Medicare conversion factor (CF) of $33.0775, a decrease of $1.53 or 4.42 percent from the 2022 CF rate of $34.6062. The proposed CF is largely a result of an expiring 3 percent increase funded to the CF at the end of CY 2022 as required by law. The additional approximate 1.5 percent decrease to the CF is a result of a budget neutrality adjustment primarily from increases to payment for hospital, nursing facility, home health and emergency medicine visits.
During the COVID-19 Public Health Emergency (PHE), CMS significantly expanded the Medicare Telehealth List through the addition of about 150 services that can now be provided via telehealth, including emergency department visits, critical care, home visits, and telephone visits. It also created two new categories of interim telehealth services. Codes in Category 3 of the Medicare Telehealth List are covered on an interim basis until data can be gathered to help determine whether they should become Category 1 or 2 services or be removed from telehealth coverage. Category 3 services will be covered through the end of 2023. Interim services that are not in Category 3 were only slated to be covered until the end of the PHE. In March 2022, the Consolidated Appropriations Act included a provision that extended payment for Medicare telehealth services to all communities in the country, not just rural areas, and allowed patients to continue to receive telehealth services in their homes or wherever they are located without going to a medical facility for an additional 151 days after the end of PHE, which is five months. In this proposed rule, CMS proposes to similarly extend Medicare telehealth coverage for the codes that were only going to be on the telehealth list through the end of the PHE for an additional five months after the PHE ends.
Additionally, CMS received requests to add the telephone evaluation and management (E/M) codes to the list of covered telehealth services on a category three basis. CMS notes in the proposed rule that the agency is declining to add these services on a category 3 basis, noting that while audio-only services will remain appropriate to bill for delivery of mental health services given the change in the telehealth definition made by regulation last year, statute requires that telehealth services be so analogous to in-person care such that the telehealth service is essentially a substitute for a face-to-face encounter.
CMS counters that the audio-only telephone E/M services are inherently non-face-to-face services, since they are furnished exclusively through remote, audio-only communications. CMS reiterated that outside the circumstances of the PHE, the telephone E/M services would not be analogous to in-person care; nor would they be a substitute for a face-to-face encounter. Therefore, the agency believes that it would not be appropriate for these codes to remain on the Medicare Telehealth Services List after the end of the PHE and the 151-day post-PHE extension period.
CMS is also proposing certain changes in coding and payment policies that would take effect five months after the PHE ends. Most importantly, Medicare telehealth services would revert to being paid at the “facility” rate instead of the “non-facility” rate, as CMS believes that the facility payment amount “best reflects the practice expenses, both direct and indirect, involved in furnishing services via telehealth.”
Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs)
CMS is proposing that beginning in calendar year (CY) 2023 and for subsequent years, the payment amount for methadone will be based on the payment amount for methadone in CY 2021 as determined under § 410.67(d)(2)(i)(B)(1) and updated by the Produce Price Index (PPI) for Pharmaceuticals for Human Use (Prescription). For example, the 2023 price for the drug component of the OTP bundle for methadone would be $39.29, a roughly $2 increase from the current rate.
OTP Bundle - Therapy
Currently, the individual therapy component of the OTP bundles is priced based on a crosswalk to CPT code 90832 (Psychotherapy, 30 minutes with patient). CMS has received feedback that patients with OUD are often utilizing more individual therapy than the current 30 minute crosswalk suggests.
Therefore, CMS is proposing to modify the payment rate for the non-drug component of the bundled payment for an episode of care to base the rate for individual therapy on a crosswalk to CPT code 90834 (Psychotherapy, 45 minutes with patient).
Beginning with CY 2023, CMS would apply the Medicare Economic Index (MEI) from 2021-23 to update the 2023 payment rate for the non-drug components of the bundle.
G2076 – OTP Intake Activities
CMS is proposing to allow G2076 to be furnished via two-way audio-video communications technology when billed for the initiation of treatment with buprenorphine, to the extent that the use of audio-video telecommunications technology to initiate treatment with buprenorphine is authorized by DEA and SAMHSA at the time the service is furnished. CMS is also proposing to permit the use of audio-only communication technology to initiate treatment with buprenorphine in cases where audio-video technology is not available to the beneficiary. CMS interprets the requirement that audio/video technology is “not available to the beneficiary” to include circumstances in which the beneficiary is not capable of or has not consented to the use of devices that permit a two-way, audio/video interaction.
CMS is seeking comment on whether allow periodic assessments (G2077) to continue to be furnished using audio-only communication technology following the end of the PHE for COVID-19 for patients who are receiving treatment via buprenorphine, and if this flexibility should also continue to apply to patients receiving methadone or naltrexone. Prior to the declaration of the PHE, the CY 2021 PFS Final Rule amended the definition of periodic assessment in Section 410.67(b)(7) to say that the definition is limited to a face-to-face encounter, and that a clinician must perform a face-to-face medical exam or biopsychosocial assessment to bill G2077.
CMS is clarifying that OTPs can bill Medicare for medically reasonable and necessary services furnished via mobile units in accordance with SAMHSA and DEA guidance. The agency is proposing that locality adjustments for services furnished via mobile units would be applied as if the service were furnished at the physical location of the OTP registered with DEA and certified by SAMHSA.
Requirement for Electronic Prescribing for Controlled Substances (EPCS)
CMS is proposing to extend the existing non-compliance action of sending letters to non-compliant prescribers for the EPCS program from 2023 into 2024. These letters would consist of a notification to prescribers that they are violating the EPCS requirement, information about how they can come into compliance, the benefits of EPCS, an information solicitation as to why they are not conducting EPCS, and a link to the CMS portal to request a waiver.
CMS notes that the agency plans to increase the severity of penalties beginning in CY 2025. CMS is considering the following non-exhaustive list of penalties for non-compliant prescribers beginning in CY 2025:
- Requiring a non-compliant prescriber to enter into a corrective action plan, which would require the non-compliant prescriber to comply with the EPCS requirement within 2 years prior to applying other potential actions outlined below;
- Posting a non-compliant prescriber’s name on the CMS website and identifying the prescriber as non-compliant;
- Public reporting of EPCS compliance status, including that a prescriber is noncompliant, on the Care Compare website;
- Referral of non-compliant prescribers to the DEA to support potential investigations;
- Sharing the list of EPCS non-compliant prescribers with the States; and/or
- Referral for potential fraud, waste and abuse review.
CMS is interested in comments on whether these proposed penalties would be appropriate/effective, whether the penalties should be phased-in, and compliance enforcement among Medicare participating and non-participating providers.
Annual Alcohol Misuse and Depression Screenings
CMS notes in the proposed rule that the agency has received feedback that the 15 minute threshold in the code descriptors for G0442 and G0444 is too high and limit providers ability to bill the codes. As a result, CMS is proposing to revise the code descriptors for each code from 15 min to 5-15 minutes in hopes that more providers can bill for the services.
Chronic Pain Management (CPM) Services
CMS is proposing to create two bundled codes to describe chronic pain management and treatment. The agency is proposing to define chronic pain as “persistent or recurrent pain lasting longer than three months” and is seeking comment on whether this is the right definition and how it should be documented in the medical record. The code descriptors would read as follows:
- GYYY1: Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care (e.g. physical therapy and occupational therapy, and community based care), as appropriate. Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (When using GYYY1, 30 minutes must be met or exceeded.)
- GYYY2: Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month (List separately in addition to code for GYYY1). (When using GYYY2, 15 minutes must be met or exceeded.)
CMS is seeking comments on several aspects of this proposal, including whether the code descriptors make sense, code valuations, supervision requirements, and care settings.
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
CMS proposed to add the CPM and behavioral health integration services to the all-inclusive RHC/FQHC payment for general care management (G0511)
CMS maintains that since requirements for the new chronic pain management and behavioral health integration services are similar to the requirements for the general care management services furnished by RHCs and FQHCs, 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 codes (CPT codes 99484, 99487, 99490, and 99491) and PCM codes (CPT codes 99424 and 99425).
CMS is proposing to implement the telehealth provisions in the Consolidated Appropriations Act, 2022 (CAA, 2022) via program instruction or other sub-regulatory guidance to ensure a smooth transition after the end of the PHE. These policies extend certain flexibilities in place during the PHE for 151 days after the PHE ends, including allowing payment for RHCs and FQHCs for furnishing telehealth services (other than mental health visits that can be furnished virtually on a permanent basis) under the payment methodology established for the PHE. The CAA, 2022 also delays the in-person visit requirements for mental health visits furnished by RHCs and FQHCs via telecommunications technology until 152 days after the end of the PHE.
Supervision Requirements for Behavioral Health Services
CMS is proposing to amend the direct supervision requirement under the agency’s “incident to” regulation at § 410.26 to allow behavioral health services to be furnished under the general supervision of a physician or non-physician practitioner (NPP) when these services or supplies are provided by auxiliary personnel incident to the services of a physician or NPP.
Comment Solicitation on Intensive Outpatient Mental Health Treatment, including Substance Use Disorder (SUD) Treatment, Furnished by Intensive Outpatient Programs (IOPs)
As part of the agency’s Behavioral Health Strategy, CMS is seeking comments on whether the current coding and payment mechanisms under the PFS adequately account for intensive outpatient services that are part of a continuum of care in the treatment of substance use disorder. Specifically, CMS is seeking comment on the following questions:
- “Whether there is a gap in coding under the PFS or other Medicare payment systems that may be limiting access to needed levels of care for treatment of mental health or substance use disorder treatment, including and especially SUDs, for Medicare beneficiaries;
- The extent to which any potential gaps would best be addressed by the creation of new codes, revision of particular billing rules for some kinds of care in specific settings, or whether the valuation of particular codes (existing or new) needs to be addressed in order to better reflect the relative resource costs involved in furnishing intensive outpatient mental health services; and
- The settings of care in which these programs typically furnish services, the range of services typically offered, the range of practitioner types that typically furnish those services, and any other relevant information, especially to the extent it would inform our ability to ensure that Medicare beneficiaries have access to this care.”
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.