On July 7, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year 2023 Physician Fee Schedule (PFS) proposed rule, which would significantly expand access to behavioral health and other services. These proposed changes play a vital role in the Biden Administration’s Unity Agenda, which includes making sizeable investments in mental health, especially in expanding the reimbursable behavioral health workforce, improving care coordination, and dealing with nation’s opioid epidemic.
Regarding the proposed 2023 CMS changes, CMS Administrator Chiquita Brooks-LaSure stated:
At CMS, we are constantly striving to expand access to high quality, comprehensive health care for people served by the Medicare program….Today’s proposals expand access to vital medical services like behavioral health care, dental care, and cancer treatment options, all while promoting access, innovation, and cost savings in the Medicare program.
Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare, added:
Integrated, coordinated, whole-person care — which addresses physical health, behavioral health, and social determinants of health — is crucial for people with Medicare, especially those with complex needs. Dr. Seshamani also stated: If finalized, the proposals in this rule will advance equity, lead to better care, support healthier populations, and drive smarter spending of the Medicare dollar.
MFTs, LPCs, and Addiction Counselors to Receive Medicare Reimbursement?
In the 2022 CMS Behavioral Health Strategy, CMS set goals to remove barriers to care and improve access to mental health and substance use care. To help address the acute shortage of behavioral health practitioners, the agency proposes allowing marriage and family therapists, licensed professional counselors, addiction counselors, certified peer recovery specialists, and others to provide behavioral health services and other behavioral health practitioners to provide behavioral health services. Additionally, CMS proposes paying for clinical psychologists and licensed clinical social workers to provide integrated behavioral health services as part of a patient’s primary care team. Therefore, CMS is proposing to make an exception to the direct supervision requirement under our “incident to” regulation at 42 CFR 410.26 to allow behavioral health services to be provided under the general supervision of a physician or NPP rather than under direct supervision when these services or supplies are provided by auxiliary personnel incident to the services of a physician (or non-physician practitioner). They believe that this proposed change will facilitate utilization and extend the reach of behavioral health services.
See TBHI’s article for specifics: Medicare Telehealth Reimbursement for LMFTs, LPCs, Addiction Counselors & Certified Peer Recovery Specialists? CMS also proposes covering opioid treatment and recovery services when delivered from mobile units, such as vans, to improve access.
Increased Roles for Psychologists, Social Workers & Psychiatrists
Given the increased need for mental health services and the feedback CMS has received over the years, they propose creating a new General BHI service delivered by clinical psychologists (CPs) or clinical social workers (CSWs). The new service would be responsible for monthly care integration where the mental health services furnished by a CP or CSW serve to focus the care integration. The new CMS proposal includes a psychiatric diagnostic evaluation to serve as the initial visit for the new general BHI service.
Additionally, in the 2022 CMS Behavioral Health Strategy, CMS aims to improve access to by reduce existing barriers and make greater use of the services of behavioral health professionals, such as licensed professional counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs).
Telehealth Service CPT Codes
CMS is proposing to extend key flexibilities in place during the PHE for 151 days after the PHE ends, such as allowing telehealth services to be furnished in any geographic area and any originating site setting, including the beneficiary’s home, allowing certain services to be furnished via audio-only telecommunications systems. They also propose delaying the in-person visit requirements for mental health services furnished via telehealth until 152 days after the end of the PHE. CMS is proposing that telehealth claims will require the appropriate place of service (POS) indicator to be included on the claim, rather than modifier “95,” after 151 days following the end of the PHE and that modifier “93” be used to indicate that a Medicare telehealth service was furnished via audio-only technology, where appropriate. Please note that CMS is proposing these changes. They have not yet been approved.
Opioid Treatment Programs (OTPs)
CMS is proposing to revise its methodology for pricing the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone. Under this proposal, CMS would base the payment amount for the drug component of HCPCS codes G2067 and G2078 for CY 2023 and subsequent years on the payment amount for methadone in CY 2021 and update this amount annually to account for inflation using the PPI for Pharmaceuticals for Human Use (Prescription). Additionally, based on the severity of needs of the patient population diagnosed with opioid use disorder (OUD) and receiving services in the OTP setting, CMS is proposing to modify the payment rate for the non-drug component of the bundled payments for episodes of care to base the rate for individual therapy on a crosswalk code describing a 45-minute session, rather than the current crosswalk to a code describing a 30-minute session. This would increase overall payments for medication-assisted treatment and other treatments for OUD, recognizing the longer therapy sessions that are usually required.
CMS is also proposing to allow the OTP intake add-on code 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 the Drug Enforcement Administration (DEA) and Substance Abuse and Mental Health Services Administration (SAMHSA) at the time the service is furnished. CMS also proposes to permit the use of audio-only communication technology to initiate treatment with buprenorphine in cases where audio-video technology is unavailable to the beneficiary and all other applicable requirements are met.
Additionally, CMS clarifies that OTPs can bill Medicare for medically reasonable and necessary services furnished via mobile units per SAMHSA and DEA guidance. CMS 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.
Medicare Fee Cuts
In confusing jargon, medicare fee cuts or physician payment cuts are also being proposed by CMS:
With the budget neutrality adjustments, as required by law to ensure payment rates for individual services don’t result in changes to estimated Medicare spending, the required statutory update to the conversion factor for CY 2023 of 0%, and the expiration of the 3% increase in PFS payments for CY 2022, the proposed CY 2023 PFS conversion factor is $33.08, a decrease of $1.53 to the CY 2022 PFS conversion factor of $34.61.
The significance of these medicare fee cuts for behavioral health professionals is challenging. While most behavioral national association websites are silent on these issues as of the date of this blog article’s publishing, Jack Resneck Jr., MD, president of the American Medical Association, responded on July 7:
It is immediately apparent that the rule not only fails to account for inflation in practice costs and COVID-related challenges to practice sustainability but also includes a significant and damaging across-the-board reduction in payment rates. Such a move would create long-term financial instability in the Medicare physician payment system and threaten patient access to Medicare-participating physicians. We will be working with Congress to prevent this harmful outcome.
See TBHI’s previous articles for more information below.
- For a fact sheet on the CY 2023 Quality Payment Program proposed changes, please visit (clicking link downloads zip file): https://qpp-cm-prod-content.s3.amazonaws.com/uploads/1972/2023%20Quality%20Payment%20Program%20Proposed%20Rule%20Resources.zip
- Fact sheet on the proposed Medicare Shared Savings Program changes.