2025 Medicare Physician Fee Schedule

On November 1, 2024 the Centers for Medicare and Medicaid Services (CMS) released the unpublished version of the final rule which revises calendar year (CY) 2025 payment policies under the Medicare Physician Fee Schedule (PFS) and makes other policy changes. The rule is set to be published in the Federal Register on December 9, 2024.

CMS has also published a fact sheet on the 2024 Medicare PFS proposed rule, available here.

CMS separately released the CY 2025 Medicare Hospital Outpatient Prospective Payment System final rule and a separate fact sheet here.

A summary of the major finalized changes that impact addiction medicine are listed below.

Conversion Factor

CMS finalized a CY 2025 Medicare conversion factor (CF) of $32.35, a decrease of $0.94 or 2.83 percent from the current 2024 CF rate of $33.29. This conversion factor multiplied by the total relative value units applied to a service totals the payment amount for a given service.

Telehealth Services

Changes to the list of telehealth services

CMS received a request to add General Behavioral Health Integration (CPT code 99484) and Principal Care Management (CPT codes 99424 – 99427) services to the list of telehealth services but are declining as they note that the codes do not meet federal regulatory definitions of telehealth services.

Inclusion of Audio-only Under the Definition of Telehealth

During the COVID-19 public health emergency (PHE), CMS used its statutory waiver authority to allow the use of audio-only technology to furnish evaluation and management (E/M) services, as well as behavioral health counseling and education services. Further, the Consolidated Appropriations Act (CAA) of 2021 removed the geographic restrictions for Medicare telehealth services for the diagnosis, evaluation, or treatment of a mental health disorder and the addition of the patient’s home as a permissible originating site for these services. Following this change, CMS changed the regulatory definition of “interactive telecommunications system” to allow for audio-only to be used to furnish services to established patients in their homes for purposes of diagnosis, evaluation, or treatment of a mental health disorder (including substance use disorder) if the distant site physician or practitioner is technically capable of using an interactive telecommunications system as defined previously, but the patient is not capable of, or does not consent to, the use of video technology.

Section 4113 of the CAA, 2023 further extended the availability of telehealth services that can be furnished using audio-only technology and provided for the extension of other PHE-related flexibilities including removal of the geographic and location limitations under section 1834(m) of the Social Security Act through December 31, 2024.

In response to these evolving regulatory flexibilities, CMS has finalized that for CY 2025, audio-only technology can be used to furnish any service on the Medicare telehealth list. Note that the list does not include services furnished in opioid treatment programs (OTPs) as these services described by those codes do not meet Medicare’s definition of a telehealth service.

The full list of finalized services on the telehealth list can be found here. CMS has finalized policies to maintain most of the services already on the list of telehealth services, including codes for psychotherapy, outpatient evaluation and management (E/M) services, smoking cessation, social determinants of health risk assessments, SBIRT, unhealthy alcohol use screenings, office-based treatment of OUD, complex E/M visits, and chronic pain treatment. However, CMS has finalized policy to remove telephone E/M services from the list of Medicare telehealth services. Notably, since CPT codes 99202-05 and 99211-15 are now permanently on the list of Medicare telehealth services, CMS’ change in the definition of “interactive telecommunications system” to encompass audio-only for any service on the telehealth list, these services may be provided via audio-only.

Telehealth Codes Proposed by AMA CPT Editorial Panel

CMS is finalizing its proposal not to recognize a broad swatch of new telehealth evaluation and management codes authored by the AMA’s CPT Editorial Panel. CMS notes that the agency already pays for analogous evaluation and management (E/M) services for telehealth and thus, these new codes are unnecessary. Further, the statute would require CMS to pay for these services at equivalent rates to the services that CMS already covers, duplicating payments. Hence, CMS has finalized proposals for clinicians to continue to bill existing E/M codes with a telehealth indicator in 2025.

However, CMS is finalizing its proposal to adopt CPT code 98016 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion) and delete code G2012. The national payment rate for this code will be approximately $15.85.

Distant Site Requirements

CMS will continue to allow practitioners to use their practice address on enrollment forms, rather than their home address in response to safety and privacy concerns from practitioners.

Direct Supervision

Currently, CMS allows certain services, including most incident-to services to be performed under direct supervision, meaning that the supervising physician or other supervising practitioner must be present in the office suite and “immediately available” to furnish assistance and direction throughout the performance of the procedure. Through December 31, 2024, the presence of the physician (or other practitioner) includes virtual presence through audio/video real-time communications technology (excluding audio-only). CMS will continue this status quo through 2025.

After 2025, CMS will permanently redefine direct supervision for certain services to note that the presence of the physician (or other practitioner) includes virtual presence through audio/video real-time communications technology (excluding audio-only). The services that would be included under this definition include services furnished incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision and for which the underlying HCPCS code has been assigned a PC/TC indicator of ‘5’ (meaning that it’s an incident-to service); and office and other outpatient visits for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional, such as CPT code 99211.

Services that do not fall in this category after 2025 would require direct supervision without the ability to provide this supervision via audio/video real-time communications technology.

Teaching Physician Services

CMS will continue to require through 2025 the requirement that teaching physicians have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings, but only when the service is furnished virtually. This cannot be provided via audio-only.

Visit Complexity (G2211)

CMS will allow payment of the office/outpatient O/O E/M visit complexity add-on code when the O/O E/M base code is reported by the same practitioner on the same day as an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventive service furnished in the office or outpatient setting.

Advancing Access to Behavioral Health Services

Safety Planning Interventions

CMS has finalized a new G code to describe safety planning interventions: G0560 (Safety planning interventions, each 20 minutes personally performed by the billing practitioner, including assisting the patient in the identification of the following personalized elements of a safety plan: recognizing warning signs of an impending suicidal or substance use-related crisis; employing internal coping strategies; utilizing social contacts and social settings as a means of distraction from suicidal thoughts or risky substance use; utilizing family members, significant others, caregivers, and/or friends to help resolve the crisis; contacting mental health or substance use disorder professionals or agencies; and making the environment safe.)

In response to concerns from ASAM and others, CMS has modified the code descriptor to include references to substance use and SUD clinicians.

The code will be valued based on the valuation of CPT code 90839 (Psychotherapy for crisis), which describes 60 minutes of service. CMS is assuming a typical time of 20 minutes for G0560 and is valuing the code at a work RVU of 1.09, based on one-third of the value assigned to 90839. The finalized national payment rate for this code will be approximately $41.41. Additionally, CMS will allow this code to be billed as a stand-alone service that can be billed in 20-minute increments.

CMS has also placed this code on the list of eligible telehealth services.

Post-Discharge Telephonic Follow-up Contacts Intervention

CMS finalized a new G code to describe post-discharge telephonic follow-up contacts interventions. These services would be used to describe the specific protocols involved in furnishing post-discharge follow-up contacts that are performed in conjunction with a discharge from the emergency department for a crisis encounter. The code can be billed monthly, describing four calls in a month, 10-20 minutes each. The new code is HCPCS code G0544: Post discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or other crisis encounter, per calendar month. As finalized, the national payment rate for this code will be approximately $61.79.

Clinicians need to have at least one phone call per month to bill for G0544 and unsuccessful attempts to reach the patient cannot be billed. Since patient cost sharing would apply, CMS will require that patient consent be obtained either before or during the furnishing of the service.

This is not an eligible Medicare telehealth service.

Digital Mental Health Treatment (DMHT)

CMS finalized three new G codes to describe digital mental health treatment. Specifically, CMS has established the following codes to allow clinicians authorized to furnish services for the diagnosis and treatment of mental illness:

• G0552 (Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan) – billable only if the device is FDA-cleared and the billing practitioner is incurring the cost of furnishing the DMHT device to the beneficiary.
• G0553 (First 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month).)
• G0554 (Each additional 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing information related to the use of the DMHT device, including patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month. (List separately in addition to HCPCS code G0553)).

G0522 will be based on carrier pricing. As finalized under the 2025 conversion factor, the national payment rate for G0553 will be approximately $51.76, and the national payment rate for G0554 will be approximately $39.79.

In response to concerns by ASAM and others that it is unclear whether these codes could be used to furnish services for the diagnosis and treatment of a SUD, consistent with other related changes that CMS has made in regulations to permit SUD to be included in the definition of mental health, CMS responded that the agency understands a behavioral health service to be any service furnished for the diagnosis, evaluation, or treatment of a mental health disorder, including substance use disorders (SUD). In all cases, DMHT devices under this payment policy must be cleared under section 510(k) of the FD&C Act or granted De Novo authorization by FDA and in each case must be classified under 21 CFR 882.5801 for mental or behavioral health treatment to be eligible for billing.

Interprofessional Consultation Billed by Practitioners Authorized by Statute to Treat Behavioral Health Conditions

Currently, there are six CPT codes that can be used to bill for interprofessional consultations (99451, 99452, 99446, 99447, 99448, 99449). However, these codes are limited to clinicians that can independently bill E/M services. This means that these codes cannot be billed by clinical psychologists, clinical social workers, marriage and family therapists, or mental health counselors because these practitioners cannot independently bill Medicare for E/M visits.

In response, CMS is proposing to create six new HCPCS codes to allow these mental health professionals to independently bill for consultative services with other clinicians. These services would be described by the following codes:

• G0546 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient’s treating/requesting practitioner; 5-10 minutes of medical consultative discussion and review),
• G0547 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient’s treating/requesting practitioner; 11-20 minutes of medical consultative discussion and review),
• G0548 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient’s treating/requesting practitioner; 21-30 minutes of medical consultative discussion and review),
• G0549 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a verbal and written report to the patient’s treating/requesting practitioner; 31 or more minutes of medical consultative discussion and review),
• G0550 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, including a written report to the patient’s treating/requesting practitioner, 5 minutes or more of medical consultative time), and
• G0551 (Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting practitioner in a specialty whose covered services are limited by statute to services for the diagnosis and treatment of mental illness, 30 minutes)

CMS will require the treating practitioner to obtain patient consent before the provision of these services, noting that cost-sharing applies, potentially for two services (the treating and the consultative practitioner). CMS is valuing these services based on a direct crosswalk to the existing CPT codes that describe these services for clinicians that can directly bill E/M services.

Here are the finalized national Medicare payment rates:

G0546: $17.15
G0547: $34.62
G0548: $52.41
G0549: $70.20
G0550: $32.35
G0551: $33.97

Opioid Treatment Program Services

Audio-only for Periodic Assessments and Initiation of Treatment with Methadone

CMS is permitting OTPs to furnish periodic assessments using audio-only communications technology when video is not available on a permanent basis beginning January 1, 2025, so long as these services meet SAMHSA and DEA requirements.

Telehealth for Initiation of Methadone Treatment

Consistent with regulatory changes finalized by SAMHSA under 42 CFR Part 8 for methadone, and to be consistent with regulatory changes made to allow initiation of buprenorphine via telehealth in OTPs, CMS will for the first time in 2025 allow OTPs to bill G2076 (intake activities) via telehealth (excluding audio-only). This flexibility would remain in place so long as DEA and SAMHSA permit it.

Payment for Social Determinants of Health (SDOH) Risk Assessments

Consistent with regulatory changes made by SAMHSA under the 42 CFR Part 8 revisions and to sync payment with revised standards for assessing various SDOHs in OTPs, CMS is updating the payment rate for G2076 (intake activities) by adding HCPCS code G0136: Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5–15 minutes, not more often than every 6 months to the value of G0136. The new payment rate for G2076 will be $228.42.

Payment for Brixadi and Opvee

In line with FDA approvals of Brixadi and Opvee, CMS has finalized payment for these medications under the OTP Medicare benefit. Specifically, CMS has finalized G0532 [Take-home supply of nasal nalmefene hydrochloride; one carton of two, 2.7 mg per 0.1 mL nasal sprays (provision of the services by a Medicare-enrolled Opioid Treatment Program); (List separately in addition to each primary code)]. The payment for this code would consist of the drug component and non-drug component of the code, consistent with the payment methodology adopted by CMS under previous rulemaking. The drug component would be priced at $75.44 while payment for the non-drug component of the code would cross-walked to CPT code 96161 (Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument), which is currently valued at ~$3.00. Hence, the payment total for Opvee would be about $78. CMS is further proposing to limit payment for the drug to once every 30 days with an exception for a beneficiary who has an overdose and uses the initial supply of Opvee.

Furthermore, CMS finalized a revision to G2069 (Medication-assisted treatment, buprenorphine (injectable)) to include payment for the monthly formulation of Brixadi. Specifically, the volume-weighted average sales price of Sublocade and Brixadi has been averaged to calculate the payment amount for the drug component of the revised code. Additionally, the code descriptor has been updated to reflect that G2069 is to be billed monthly.

CMS also finalzied a new code G0533 (Medication assisted treatment, buprenorphine (injectable) administered on a weekly basis; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed) to bill for the weekly formulation of Brixadi. The payment would be cross-walked to the payment amount described by HCPCS code J0577 (Injection, buprenorphine extended release (brixadi), less than or equal to 7 days of therapy).

Require OUD Diagnosis on Claims for OUD Treatment Services

CMS has finalized a requirement that OTP claims contain an OUD diagnosis to permit payment.

Finally, CMS is finalizing three new codes for use in OTPs:

• G0534 (Coordinated care and/or referral services, such as to adequate and accessible community resources to address unmet health-related social needs, including harm reduction interventions and recovery support services a patient needs and wishes to pursue, which significantly limit the ability to diagnose or treat an opioid use disorder; each additional 30 minutes of services (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to each primary code).
• G0535 (Patient navigational services, provided directly or by referral; including helping the patient to navigate health systems and identify care providers and supportive services, to build patient self-advocacy and communication skills with care providers, and to promote patient-driven action plans and goals; each additional 30 minutes of services (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to each primary code).
• G0536 (Peer recovery support services, provided directly or by referral; including leveraging knowledge of the condition or lived experience to provide support, mentorship, or inspiration to meet OUD treatment and recovery goals; conducting a person-centered interview to understand the patient’s life story, strengths, needs, goals, preferences, and desired outcomes; developing and proposing strategies to help meet person-centered treatment goals; assisting the patient in locating or navigating recovery support services; each additional 30 minutes of services (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to each primary code).

The value for all these new add-on codes will be $41.69.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

General Care Management

CMS finalized that beginning in CY 2025, rather than pay a weighted average of the compilation of individual CPT and HCPCS codes that bundled by HCPCS code G0511 (care management), Medicare will pay RHCs and FQHCs for billing the individual codes that make up G0511. Under this proposal, HCPCS code G0511 would no longer be payable when billed by RHCs and FQHCs. CMS will give RHCs/FQHCs 6 months to transition to this new policy.

Direct Supervision

Like the temporary policy that CMS is proposing for services that require direct supervision under the MPFS, CMS is finalizing that until December 2025, FQHCs and RHCs may continue to provide direct supervision via virtual presence (audio/video real-time communications technology, excluding audio-only).

Telehealth for Mental Health Services

Currently, regulatory flexibilities are set to expire in December 2024 for mental health services provided by FQHCs and RHCs. Afterwards, individuals visiting FQHCs/RHCs for mental health reasons would need to have an in-person visit at least 6 months prior to a telehealth visit. Furthermore, a subsequent visit within a year following the telehealth visit must occur. CMS will delay this requirement until January 2026. While CMS is allowed to make this change for FQHCs and RHCs, allowing the same flexibility for mental health visits outside of these facilities would require action from Congress.

Intensive Outpatient Program (IOP) Services

In 2024 MPFS, CMS established payment for IOP services provided in FQHCs/RHCs, hospital outpatient departments, and community mental health centers. CMS established payment based on 3 and 4 or more services provided per day for hospital outpatient departments and community mental health centers. However, CMS only established a three service per day payment for FQHCs/RHCs. CMS has now established four or more services per day payment for FQHCs/RHCs in addition to the current three services per day payment.

Other Proposals of Interest in the Medicare Hospital Outpatient Prospective Payment System Proposed Rule

Medicaid Clinic Services Four Walls Exceptions

CMS will amend the Medicaid clinic services regulation to authorize federal reimbursement (at the state’s request) for services provided by behavioral health clinics and services provided by clinics located in rural areas. CMS is finalizing an approach to defining “rural area” where states will select either a definition used by a federal agency for programmatic purposes, or a definition adopted by a state agency with a role in setting state rural health policy.

Individuals Formerly in the Custody of Penal Authorities

CMS is finalizing its proposal to narrow the definition of “custody” to no longer include individuals who are on parole, probation, and home detention. This change will remove the presumption that Medicare is prohibited from paying for health care items or services furnished to individuals on parole, probation, or home detention, thus facilitating access to Medicare payment. To facilitate access to Medicare coverage, CMS has also revised the eligibility criteria for the special enrollment period for formerly incarcerated individuals to include individuals who have been released from incarceration or on parole, probation, or home detention.

2024 Medicare Physician Fee Schedule

On November 2, 2023 the Centers for Medicare and Medicaid Services (CMS) issued a final rule which revises CY 2024 payment policies under the Medicare Physician Fee Schedule (PFS) and makes other policy changes.

CMS has also published a fact sheet on the 2024 Medicare Physician Fee Schedule Proposed Rule, available here.

A summary of the major proposed changes is listed below:

Conversion Factor & Impact on Addiction Medicine Specialty

CMS finalized a CY 2024 Medicare conversion factor (CF) of $32.74, a decrease of $1.15 or 3.4 percent from the current 2023 CF rate of $33.89.

Per an analysis from the American Medical Association (AMA), the Addiction Medicine specialty is expected to see a 3% positive adjustment in allowed Medicare charges in 2024.

Visit complexity inherent to evaluation and management (G2211)

CMS finalized a proposal to implement a new add-on code (G2211) designed to better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care of complex patients. CMS noted that this code should be used in outpatient office visits, recognizing the inherent costs practitioners may incur when longitudinally treating a patient’s single, serious, or complex chronic condition.

Medicare Coverage of Marriage & Family Therapists, and Mental Health Counselors

The Consolidated Appropriations Act of 2023 defines Marriage and Family Therapist (MFT) services as services furnished by an MFT for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital), which the MFT is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are furnished, as would otherwise be covered if furnished by a physician or as an incident to a physician’s professional service.

The CAA also defines a as a person who:

• Possesses a master’s or doctor’s degree which qualifies for licensure or certification as a MFT pursuant to State law of the State in which such individual furnishes marriage and family therapist services;
• Is licensed or certified as a MFT by the State in which such individual furnishes such services;
• After obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; and 
• Meets such other requirements as specified by the Secretary.

The CAA defines mental health counseling (MHC) services as for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital), which the MHC is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are furnished, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service.

The CAA also defines a MFT as an individual who:

• Possesses a master’s or doctor’s degree which qualifies for licensure or certification as law of the State in which such individual furnishes MHC services;
• Is licensed or certified as a mental health counselor, clinical professional counselor, or professional counselor by the State in which the services are furnished;
• After obtaining such degree has performed at least 2 years of clinical supervised experience in mental health counseling; and
• Meets such other requirements as specified by the Secretary.

The CAA also specified that amounts paid to MFT and MHC shall be 80 percent of the lesser of either (1) the actual charge for the services or (2) 75 percent of the amount determined for payment of a psychologist.

MFTs and MHCs were also added to the list of practitioners whose services can only be paid by Medicare on an assignment basis, meaning that MFTs and MHCs agree to charge beneficiaries no more than the amount Medicare has approved for that service.

CMS finalized a proposal to add MFTs and MHCs to the list of practitioners who are eligible to furnish Medicare telehealth services at the distant site. CMS also finalized a proposal to allow Addiction Counselors who meet all of the applicable requirements (possess a master’s or doctor’s degree which qualifies for licensure or certification as a mental health counselor; after obtaining such degree have performed at least 2 years (or, as proposed, 3,000 hours) of clinical supervised experience in mental health counseling; and licensed or certified as a MHC, clinical professional counselor, or professional counselor by the State in which the services are furnished) to enroll in Medicare as MHCs.

These practitioners will be eligible to enroll and bill for their services beginning January 1, 2024. Additionally, HCPCS code G0323 is being modified to clarify that MHCs and MFTs can bill for this code (Care management services for behavioral health conditions, at least 20 minutes, per calendar month.)

MFT and MHC services furnished in RHCs and FQHCs are also now eligible for Medicare payment beginning in 2024.

Mobile crisis services

Consistent with the CAA, CMS is establishing two new psychotherapy for crisis services:

G0017 (Psychotherapy for crisis furnished in an applicable site of service (any place of service at which the non-facility rate for psychotherapy for crisis services applies, other than the office setting); first 60 minutes)

G0018 (Psychotherapy for crisis furnished in an applicable site of service (any place of service at which the non-facility rate for psychotherapy for crisis services applies, other than the office setting);; each additional 30 minutes (List separately in addition to code for primary service)).

Consistent with the CAA, 2023, CMS will pay for these services when provided in non-facility settings, other than the office setting. Additionally and further consistent with the CAA, 2023, CMS finalized a  proposal to pay for G0017 and G0018 at 150% of the RVUs for CPT codes 90839 (Psychotherapy for crisis; first 60 minutes) and 90840 (Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)), respectively.

CMS will also be required to use existing communication mechanisms to provide education and outreach to providers of services, physicians, and practitioners with respect to the ability of auxiliary personnel, including peer support specialists, to participate, consistent with applicable requirements for auxiliary personnel, in the furnishing of psychotherapy for crisis services billed under the PFS, behavioral health integration services, as well as other services that can be furnished to a Medicare beneficiary experiencing a mental or behavioral crisis.

Health and Behavior Assessment and Intervention

CMS finalized a proposal to allow MHCs and MFTs to bill CPT codes 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, and 96171 which describe health and behavior assessment and intervention. These codes apply to services that address psychological, behavioral, emotional, cognitive, and interpersonal factors in the treatment/management of people diagnosed with physical health issues.

Adjustments to Payment for Timed Behavioral Health Services

CMS finalized a proposal to adjust the work RVUs for the following services over a four-year transition period as part of the agency’s effort to address distortions that may occur within the valuation process that may otherwise result in understated estimates of the relative resources involved in furnishing psychotherapy services. The work RVUs will be adjusted for the following services:

• CPT code 90832 (Psychotherapy, 30 minutes with patient)
• CPT code 90834 (Psychotherapy, 45 minutes with patient); CPT code 90837 (Psychotherapy, 60 minutes with patient)
• 90839 (Psychotherapy for crisis; first 60 minutes)
• CPT code 90840 (Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)
• CPT code 90845 (Psychoanalysis)
• 90846 (Family psychotherapy (without the patient present), 50 minutes)
• CPT code 90847 (Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes)
• CPT code 90849 (Multiple-family group psychotherapy)
• CPT code 90853 (Group psychotherapy (other than of a multiple-family group)
• HCPCS codes G0017 and G0018 ((Psychotherapy for crisis furnished in an applicable site of service (any place of service at which the non-facility rate for psychotherapy for crisis services applies, other than the office setting)
• CPT codes 90833, 90836, and 90838 (psychotherapy codes that are billed as an add-on to an E/M visit)

CMS proposes to adjust the work RVUs for these services by calculating the difference between the total RVUs for evaluation and management office visits (99202-99205 & 99211-99215) billed with the visit complexity code (G2211) and evaluation and management office visits billed without the visit complexity code. If finalized, this would represent a nearly 19% upward adjustment, notwithstanding the impact of the decrease in the Medicare Conversion Factor.

Updates to the Payment Rate for the PFS Substance Use Disorder (SUD) bundle (HCPCS codes G2086-G2088)

In the FY 2023 MPFS, CMS finalized a change to the payment rate for the non-drug component of the bundled payment for episodes of care under the Opioid Treatment Program (OTP) benefit to base the rate for individual therapy on a crosswalk to CPT code 90834 (Psychotherapy, 45 minutes with patient), which reflects a 45-minute psychotherapy session, instead of a crosswalk to CPT code 90832 (Psychotherapy, 30 minutes with patient), as was the policy at the time.

CMS notes in the final rule that they are persuaded by comments in previous rulemaking that noted that patients who are prescribed buprenorphine in non-OTP settings will have similarly complex care needs requiring more intensive therapeutic care, and that CMS should recognize the appropriate complexity and intensity of the services in those settings.

In response, CMS finalized a proposal to increase the payment made for HCPCS codes G2086 (Office-based treatment for a substance use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month) and G2087 (Office-based treatment for a substance use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month) to reflect two individual psychotherapy sessions per month, based on a crosswalk to the work RVUs assigned to CPT code 90834 (Psychotherapy, 45 minutes with patient), rather than CPT code 90832 (Psychotherapy, 30 minutes with patient).

Accordingly, the total non-facility RVUs for G2086 and G2087 will be 13.9 and 12.84, respectively for the 2024 payment year. That represents a 21% increase in total RVUs for G2086 and a 23% increase in total RVUs for G2087.

Behavioral Health Request for Information

CMS sought feedback on the following topics earlier in the proposed rule:

• Ways to increase access to behavioral health integration (BHI) services, including the psychiatric collaborative care model;
• Whether CMS could consider new coding to allow interprofessional consultation to be billed by practitioners who are authorized by statute for the diagnosis and treatment of mental illness;
• Intensive outpatient (IOP) services furnished in settings other than those addressed in the CY 2024 OPPS proposed rule;
• How to increase psychiatrist participation in Medicare given their low rate of participation relative to other physician specialties;
• Whether there is a need for potential separate coding and payment for interventions initiated or furnished in the emergency department or other crisis setting for patients with suicidality or at risk of suicide, such as safety planning interventions and/or telephonic post-discharge follow-up contacts after an emergency department visit or crisis encounter, or whether existing payment mechanisms are sufficient to support furnishing such interventions when indicated; and
• Other ways CMS might consider expanding access to behavioral health services for Medicare beneficiaries.

CMS thanked commenters for weighing in and noted that the agency would consider the comments in future rulemaking.

Digital Therapies

CMS sought a wide variety of information on digital therapeutics. CMS thanked commenters for weighing in and noted that the agency would consider the comments in future rulemaking.

Community Health Integration Services

CMS finalized the creation of two new HCPCS codes to describe community health integration (CHI) services. Specifically, these services can be performed by certified or trained auxiliary personnel, which may include a Community Health Worker (CHW), incident to the professional services and under the general supervision of the billing practitioner. CMS finalized that CHI services could be furnished monthly, as medically necessary, following an initiating E/M visit (CHI initiating visit) in which the practitioner identifies the presence of a social determinants of health (SDOH) need(s) that significantly limit the practitioner’s ability to diagnose or treat the problem(s) addressed in the visit. Under the proposal, CHI services could be furnished under general supervision of the billing practitioner. Auxiliary personnel who provide CHI services must be certified or trained to perform all included service elements, and authorized to perform them under applicable State laws and regulations. In states where there are no applicable licensure or other laws or regulations relating to providing CHI services to be trained to provide them.

CMS sought comment on several items related to the provision of CHI services, and finalized that:

1. Other professional services other than an E/M visit performed by the billing practitioner can serve as the prerequisite initiating visit for CHI services:
2. These services can be provided via telehealth or solely in-person; and
3. Patient consent is required as with other care management services.

The specific code descriptors are:

G0019 Community health integration services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month, in the following activities to address social determinants of health (SDOH) need(s) that are significantly limiting ability to diagnose or treat problem(s) addressed in an initiating visit.

G0022 – Community health integration services, each additional 30 minutes per calendar month (List separately in addition to GXXX1).

CMS finalized a proposal to assign the RVUs of CPT code 99490 (Chronic care management services, first 20 minutes of clinical staff time per calendar month) to G0019 and the RVUs of CPT code 99439 (Chronic care management services, each addition 20 minutes of clinical staff time per calendar month) to code G0022, noting their belief that these values reflect the resource costs incurred when the billing practitioner furnishes CHI services.

Social Determinants of Health

CMS finalized a proposal to create a new G code described by G0136, Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.

The valuation for G0136 would be directly cross-walked to G0444 (Screening for depression in adults, 5-15 minutes). CMS finalized the proposal to add this service to the list of Medicare Telehealth services.

CMS did not finalize the proposal that a SDOH risk assessment be furnished by the practitioner on the same date they furnish an E/M visit. Required elements would include the administration of a standardized, evidence-based SDOH risk assessment tool that has been tested and validated through research, and includes the domains of food insecurity, housing insecurity, transportation needs, and utility difficulties.

CM sought comment on whether the agency should require as a condition of payment for SDOH risk assessment that the billing practitioner also have the capacity to furnish CHI, PIN, or other care management services, or have partnerships with community-based organizations (CBO) to address identified SDOH needs. After public comment, CMS has decided not to finalize this proposal.

The SDOH needs identified through the risk assessment must be documented in the medical record, and may be documented using a set of ICD-10-CM codes known as “Z codes”22 (Z55-Z65) which are used to document SDOH data to facilitate high-quality communication between providers. CMS finalized a proposal that G0136 be billed no more often than once every 6 months, noting the belief that there are generally not significant, measurable changes to health outcomes impacted by a patient’s SDOH in intervals shorter than 6 months.

Annual Wellness Visit (AWV)

CMS finalized a proposal to add the new SDOH Risk Assessment service as an optional element within the AWV. CMS finalized the proposal that the SDOH Risk Assessment service be paid at 100 percent of the Medicare fee schedule amount. Additionally, finalized as proposed, the SDOH Risk Assessment service will be separately payable with no beneficiary cost sharing when furnished as part of the same visit with the same date of service as the AWV.

Principal Illness Navigation (PIN) Services

CMS finalized a proposal to create two new G codes described by G0023 Principal Illness Navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator or certified peer specialist; 60 minutes per calendar month and G0024 – Principal Illness Navigation services, additional 30 minutes per calendar month (List separately in addition to G0023).

In response to feedback from stakeholders, CMS is also finalized two additional PIN codes:

G0140—Principal Illness Navigation—Peer Support by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a certified peer specialist; 60 minutes per calendar month.

G0146—Principal Illness Navigation—Peer Support, additional 30 minutes per calendar month (List separately in addition to G0140).

For codes G0140 and G0146, if no applicable State training requirements exist, CMS finalized that training must be consistent with the National Model Standards for Peer Support Certification published by SAMHSA.

The valuation for G0023 and G0140 will be directly cross-walked to CPT code 99490 (Chronic care management services, first 20 mins of clinical staff time directed by a physician or other qualified health care professional, per calendar month) and the valuation for G0024 and G0146 will be directly cross-walked to CPT code 99439 (Chronic care management service ; each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month).

CMS finalized the proposal that PIN services could be furnished following an initiating E/M visit addressing a serious high-risk condition/illness/disease, with the following characteristics:

• One serious, high-risk condition expected to last at least 3 months and that places the patient at significant risk of hospitalization, nursing home placement, acute exacerbation/decompensation, functional decline, or death; and
• The condition requires development, monitoring, or revision of a disease-specific care plan, and may require frequent adjustment in the medication or treatment regimen, or substantial assistance from a caregiver.

Similar to the proposal for CHI services, CMS finalized the proposal that in order to bill for PIN services, there must first be an E/M initiating visit in which the billing practitioner would identify the medical necessity of PIN services and establish an appropriate treatment plan. The subsequent PIN services would be performed by auxiliary personnel incident to the professional services of the practitioner who bills the PIN initiating visit under the general supervision of the billing practitioner. Auxiliary personnel who provide PIN services must be certified or trained to perform all included service elements and authorized to perform them under applicable State laws and regulations. In states where there are no applicable licensure or other laws or regulations relating to providing PIN services, auxiliary personnel must be trained to provide them. Patient consent will be required to receive these services.

CMS sought comment on whether they should consider any professional services other than an E/M visit performed by the billing practitioner as the prerequisite for the initiating visit for PIN services. After public comment, CMS finalized that CPT code 90791 (Psychiatric diagnostic evaluation) and the Health Behavior Assessment and Intervention (HBAI) services described by CPT codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168 can serve as initiating visits for PIN services.

CMS also finalized that the AWV may serve as an initiating visit for PIN services when the AWV is furnished by a practitioner who has identified in the AWV a high-risk condition(s) that would qualify for PIN services.

CMS decided not to make these services available on the Medicare telehealth list.

Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs)

Audio-only flexibilities for periodic assessments

CMS finalized the proposal to extend the audio-only flexibilities for periodic assessments (HCPCS code G2077) furnished by OTPs through the end of CY 2024, consistent with flexibilities allowed under the CAA, 2023. CMS will allow periodic assessments to be furnished via audio-only when video is not available to the extent that use of audio-only communications technology is permitted under the applicable SAMHSA and DEA requirements at the time the service is furnished and all other applicable requirements are met.

Direct Supervision

CMS finalized the proposal to continue to allow the presence and “immediate availability” of the supervising practitioner to be through “real-time audio and visual interactive telecommunications” through the end of 2024.

In the case of the supervision of teaching residents, teaching physician can continue to have a virtual presence in all teaching settings but only in clinical instances when the service is furnished virtually. This may continue through to December 31, 2024. Audio-only is not permitted.

Telehealth

As a reminder, Medicare pays for covered telehealth services included on the Medicare telehealth list when furnished by an interactive telecommunications system if the following conditions are met:

• The practitioner is a Medicare provider under statute and licensed under state law to provide the service
• The service is furnished at an originating site as defined in statute, which includes, but not limited to a:
  • Physician office
  • RHC or FQHC
  • Hospital
  • Community Mental Health Center
  • Home of a patient (for the purposes of the treatment of a SU)
  • Home of a patient (for the purposes of the treatment of a mental health disorder under certain circumstances)
• Provided under certain geographic requirements, except that the requirements do not apply to services to treat a SUD or mental health condition

Payment

For the duration of 2024, for telehealth services provided to patients in their homes, CMS will continue to pay the non-facility rate for these claims. Telehealth services provided in locations other than a patients home will be paid at the facility rate.

Implementation of Provisions of the CAA, 2023

In-person Requirements for Mental Health Telehealth

CMS implemented through regulatory revision the requirements under CAA, 2023 that delays the requirement for an in-person visit with the physician or practitioner within 6 months prior to the initial mental health telehealth service, and again at subsequent intervals as the Secretary determines appropriate. Therefore, the in-person requirements for telehealth services furnished for purposes of diagnosis, evaluation, or treatment of a mental health disorder will again be effective on January 1, 2025. Specifically, the implementing regulations will allow a patient’s home to serve as an originating site for mental health telehealth services until December 31, 2024. Beginning in 2025, for Medicare mental health telehealth services, patients must have an in-person visit at least 6 months prior to the telehealth visit and within 6 months after any subsequent telehealth visit. This extension also applies to FQHCs and RHCs.

Originating Site Requirements

CMS implemented additional sections of the CAA, 2023 which expands the telehealth originating sites for any service on the Medicare Telehealth Services List to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual's home, beginning on the first day after the end of the PHE for COVID-19 through December 31, 2024.

Adding Services to the Telehealth List

CMS finalized a proposal to revise the process of adding, revising, and removing codes from the approved list of Medicare telehealth services. CMS will now approve services as approved, provisional, or rejected, under a revised process.

Remote Monitoring Services

CMS finalized the following clarifications in the final rule:

• Remote physiologic monitoring (RPM) services can only be provided to established patients after the end of PHE.
• The 16-day monitoring requirement is reinstated after the PHE. Monitoring must occur over at least 16 days of a 30-day period. This requirement applies to CPT codes 99457, 99458, 98980, and 98981.
• CMS notes that although multiple devices can be provided to a patient, “the services associated with all of the medical devices can be billed only once per patient per 30-day period and only when at least 16 days of data have been collected.”
• Practitioners may bill RPM or RTM, but not both, concurrently with the following services:
  • Chronic Care Management (CCM)
  • Transitional Care Management (TCM)
  • Behavioral Health Integration (BHI)
  • Principle Care Management (PCM)
  • Chronic Pain Management (CPM)
• RTM and RPM cannot be billed together.

Implementation of Intensive Outpatient Services Benefit

CMS finalized the proposed definition of IOP Services

“Intensive outpatient services means a distinct and organized intensive ambulatory treatment program that offers less than 24-hour daily care other than in an individual's home or in an inpatient or residential setting and furnishes the services as described in § 410.44. Intensive outpatient services are not required to be provided in lieu of inpatient hospitalization.”

CMS finalized the proposed new regulations at § 410.44(a) and added reference to SUD treatment professionals that defines that IOP services are services that:

(1) are reasonable and necessary for the diagnosis or active treatment of the individual's condition; (2) are reasonably expected to improve or maintain the individual's condition and functional level and to prevent relapse or hospitalization; (3) are furnished in accordance with a physician certification and plan of care as specified under new regulations at § 424.24(d); and include any of the services listed in § 410.44(a)(4).

Scope of Benefits (410.44(a)(4))

• Individual and group therapy with physicians or psychologists or other mental health professionals (including substance use disorder professionals) to the extent authorized under State law;
• Occupational therapy requiring the skills of a qualified occupational therapist;
• Services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients (including patients with substance use disorder);
• Drugs and biologicals furnished for therapeutic purposes (which cannot, as determined in accordance with regulations, be self-administered);
• Individualized activity therapies that are not primarily recreational or diversionary;
• Family counseling (the primary purpose of which is treatment of the individual’s
• condition);
• Patient training and education (to the extent that training and educational activities are closely and clearly related to individual’s care and treatment);
• Diagnostic services; and
• such other items and services as the Secretary may provide (excluding meals and transportation) that are reasonable and necessary for the diagnosis or active treatment of the individual’s condition, reasonably expected to improve or maintain the individual’s condition and functional level and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the Secretary shall by regulation establish, taking into account accepted norms of medical practice and the reasonable expectation of patient improvement

CMS also finalized in the OPPS rule that it is clarifying that partial hospitalization (PHP) services can be provided to patients with a SUD, in response to concerns from stakeholders.

CMS also finalized the proposal under § 410.44(b) that the following services are separately covered and not paid as intensive outpatient services: (1) physician services; (2) physician assistant services; (3) nurse practitioner and clinical nurse specialist services; (4) qualified psychologist services; and (5) services furnished to residents of a skilled nursing facility (SNF).

Patient Eligibility for Services (§ 410.44(c))

CMS finalized the proposal, with modifications to establish that intensive outpatient services are intended for patients who: (1) require a minimum of 9 hours per week of therapeutic services as evidenced in their plan of care; (2) are likely to benefit from a coordinated program of services and require more than isolated sessions of outpatient treatment; (3) do not require 24-hour care; (4) have an adequate support system while not actively engaged in the program; (5) have a mental health or substance use disorder diagnosis; (6) are not judged to be dangerous to self or others; and (7) have the cognitive and emotional ability to participate in the active treatment process and can tolerate the intensity of the intensive outpatient program.

CMS also explicitly notes that the term “mental health diagnosis” would include SUD and behavioral health diagnoses generally.

Coding and Billing

Currently, CMS makes payment on a per diem base to hospital-based and Community Mental Health Centers (CMHC)-based PHP programs based on those programs offering at least 3 services from an approved list of procedures per day.

CMS finalized a proposal that beginning in 2024, to qualify for payment, PHP and IOP programs (hospital or CMHC-based) would be required to provide at least 3 services from an approved list of services to bill for a per diem. Specifically, CMS proposes to establish 4 separate codes and payment rates for PHP and IOP programs beginning in 2024. Those are described and valued as follows:

OTPs

CMS finalized the proposal to define OTP intensive outpatient services as those services specified in proposed 42 CFR § 410.44(a)(4) when furnished by an OTP as part of a distinct and organized intensive ambulatory treatment program for the treatment of Opioid Use Disorder and that offers less than 24-hour daily care other than in an individual's home or in an inpatient or residential setting.

OTP intensive outpatient services are services that are reasonable and necessary for the diagnosis or active treatment of the individual's condition; are reasonably expected to improve or maintain the individual's condition and functional level and to prevent relapse or hospitalization; and are furnished in accordance with a physician certification and plan of care. In order to qualify as “OTP intensive outpatient services,” a physician must certify that the individual has a need for such services for a minimum of 9 hours per week and requires a higher level of care intensity compared to existing OTP services.

CMS finalized a proposal to establish a new HCPCS add-code that could be billed in addition to the HCPCS code for the primary weekly bundle. The code would be G0137 (Intensive outpatient services; minimum of nine services over a 7-contiguous day period, which can include individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under State law); occupational therapy requiring the skills of a qualified occupational therapist; services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients; individualized activity therapies that are not primarily recreational or diversionary; family counseling (the primary purpose of which is treatment of the individual’s condition); patient training and education (to the extent that training and educational activities are closely and clearly related to individual’s care and treatment); diagnostic services; List separately in addition to code for primary procedure.

CMS will value HCPCS code G0137 based on an assumption of a typical case of three IOP services furnished per day for approximately 3 days per week. After adjustments, the valuation for this code in 2024 would be $778.20.

Additionally, CMS modified the original proposal such that non=-physician practitioners may certify that a patient requires IOP services, including: nurse practitioners, physician assistants, clinical psychologists, clinical social workers, mental health counselors, marriage and family therapists, and any other non-physician practitioners as defined in section 1842(b)(18)(C) of the Act, as permitted by state law and consistent with scope of practice requirements.

FQHCs/RHCs

CMS finalized a proposal to maintain the same patient eligibility, physician certification, and scope of benefits related to IOP services that are provided under the IOP benefit established by the CAA, 2023.

The CAA, 2023 required that IOP services provided in FQHCs/RHCs be the same rate as if they had been covered outpatient department services furnished by a hospital. Therefore, CMS proposes that the rate determined for APC 5861 (Intensive Outpatient (3 services per day) for hospital-based IOPs): $266.35 would be the payment rate for IOP services furnished in an RHC. For IOP services furnished in FQHCs, CMS proposes that that payment is based on the lesser of a FQHC’s actual charges or the rate determined for APC 5861.

2023 Medicare Physician Fee Schedule

On November 1, 2022 the Centers for Medicare and Medicaid Services (CMS) issued a final 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 Final Rule, available here.

A summary of the major changes is listed below:

Conversion Factor

CMS finalized a CY 2023 Medicare conversion factor (CF) of $33.06, a decrease of $1.55 from the 2022 CF rate of $34.6062. The final 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.

Telehealth

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 an earlier proposal, CMS proposed 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. CMS adopted this proposal in its final rule and services included temporarily on the list of telehealth services on an interim basis will now be covered for 151 days after the end of the PHE. CMS also finalized a delay of the in-person visit requirements for mental health services (including substance use disorder) furnished via telehealth until 152 days after the end of the PHE, inline with the Consolidated Appropriations Act of 2022.

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 noted in the final rule that the agency was 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. In the final rule, CMS again stated that it would not add telephone E/M codes to the list of telehealth services. CMS provided that due to a change in the definition of “telecommunications system” during 2022 rulemaking allowing telehealth services for the diagnosis, evaluation, and treatment of mental health conditions (including substance use disorder) to be furnished through audio-only technology in certain circumstances, the agency did not believe it was appropriate or necessary to add these codes to the list of telehealth services.

CMS also finalized certain changes in coding and payment policies that would take effect five months after the PHE ends. Most importantly, Medicare telehealth services will 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.” CMS finalized this proposal.

Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs)

Methadone Price

CMS is finalizing an earlier proposal 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). The 2023 price for the drug component of the OTP bundle for methadone will 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 finalized a proposal 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.

CMS also clarified that practitioners can bill for OTP bundled services even if the duration of a therapy session is less than 45 minutes, noting that “This crosswalk code is being used for the purposes of valuation, but we do not intend it to be a requirement regarding the number of minutes spent in an individual therapy session in order for the service to qualify as an OUD treatment service.”

G2076 – OTP Intake Activities

CMS finalized a proposal 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 also finalized its proposal 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.

G2077

CMS sought comment on whether to 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. In 2023, CMS has finalized regulations that will allow G2077 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. CMS notes in the final rule that it will continue to evaluate whether to extend this flexibility to patients treated with naltrexone and methadone.

Mobile Units

CMS finalized policy 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 also finalized a proposal allowing locality adjustments for services furnished via mobile units to 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 finalizing a proposal 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 will utilize email addresses as the primary method of contacting prescribers.

While CMS noted in it proposed rule that the agency plans to increase the severity of penalties beginning in CY 2025, CMS added in the final rule that it continues to consider potential penalties and therefore does not intend to finalize any additional penalties at this time. Below is a list of potential penalties that CMS included in the earlier proposed rule 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.

Annual Alcohol Misuse and Depression Screenings

CMS finalized a proposal to revise the code descriptors for G0442 and G0444 from 15 min to 5-15 minutes following feedback that the 15-minute threshold in the code descriptors for G0442 and G0444 is too high and limits providers ability to bill the codes. CMS did not respond to ASAM’s request that the agency reexamine the payment and coverage policy for these services to ensure that qualified practitioners are eligible to bill for these services and to ensure that the policy was consistent with the latest guidance from the US Preventive Services Task Force (USPSTF).

Chronic Pain Management (CPM) Services

CMS is finalized a proposal to create two bundled codes to describe chronic pain management and treatment. The agency is finalizing its proposal to define chronic pain as “persistent or recurrent pain lasting longer than three months.” The code descriptors will read as follows:

• G3002: 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/or 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, complementary and integrative approaches, 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 G3002, 30 minutes must be met or exceeded.)
• G3003: (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 G3002. When using G3003, 15 minutes must be met or exceeded.)

  After seeking comment from interested parties, CMS also finalizing other provisions related to this bundle, including that:

• These codes will not be used to report acute pain;
• The practitioner must see the patient in-person the first time G3002 is billed;
• A physician or other qualified health practitioner may bill HCPCS code G3003, for each additional 15 minutes of care, an unlimited number of times, as medically necessary, per month, after HCPCS code G3002 has been billed;
• CMS is not limiting the types of physician specialties, or the types of qualified health professionals, who can furnish CPM services, as long as they can furnish all of the service elements of HCPCS code G3002, including prescribing medication as needed, within their scope of practice in the State in which the services are furnished;
• These codes will not be limited to specific places of service, other than that G3003 must be provided in person for the first visit; and
• Any of the CPM in-person components included in HCPCS codes G3002 and G3003 may be furnished via telehealth, as clinically appropriate.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

CMS finalized its proposal to add the CPM and behavioral health integration services to the all inclusive RHC/FQHC payment for general care management (G0511).

CMS also finalized its proposals 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 finalized its proposal 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 sought comments on whether or not 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. CMS thanked commenters for their responses and indicated that the agency will consider the comments for future rulemaking.

On November 2^nd, 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 1^st, 2023. In the interim, CMS will enforce compliance through compliance letters.

Telehealth

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.

Other Provisions

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.