2021 Physician Fee Schedule for Behavioral Health & Telebehavioral Health

In the most significant telehealth reimbursement advance to date, the Centers for Medicare & Medicaid Services (CMS) have released an early version of the 2021 Physician Fee Schedule. While the current document is still missing information at this point, the pre-published document foretells a significant shift in reimbursement policy for telehealth, and particularly for telebehavioral health.

• The telehealth boom is directly attributable to the increased awareness and adoption of a ready-and-waiting telehealth industry in response to the worldwide coronavirus pandemic. Urgency surfaced everywhere.
• US practitioners had no choice but to learn how to use telehealth software and reimbursement practices if they wished to continue delivering services. Most of them set up their virtual offices within a week.
• An estimated decade of legal reform took shape and was enacted within months.
• And now, with the 2021 Physician Fee Schedule, CMS has announced 60 new telehealth services to be reimbursed starting 2021.

Medicare Telehealth Services 

A partial list of telehealth services that can be reimbursed under Medicare are as follows:

• Group Psychotherapy (CPT code 90853)
• Psychological and Neuropsychological Testing (CPT code 96121)
• Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99334-99335)
• Home Visits, Established Patient (CPT codes 99347-99348)
• Cognitive Assessment and Care Planning Services (CPT code 99483)
• Visit Complexity Inherent to Certain Office/Outpatient Evaluation and Management (E/M) (HCPCS code G2211) and
• Prolonged Services (HCPCS code G2212)

The services under Category 1 have permanent coverage a separate group, called Category 3, includes the services that were issued during the past year to improve telehealth service and ease the adoption during the public health emergency (PHE). CMS has decided these services will continue to be reimbursed until the end of PHE.

• Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99336-99337)
• Home Visits, Established Patient (CPT codes 99349-99350)
• Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285)
• Nursing facilities discharge day management (CPT codes 99315-99316)
• Psychological and Neuropsychological Testing (CPT codes 96130-96133; CPT codes 96136-96139)
• Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507)
• Hospital discharge day management (CPT codes 99238-99239)
• Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT codes 99469, 99472, 99476)
• Continuing Neonatal Intensive Care Services (CPT codes 99478-99480)
• Critical Care Services (CPT codes 99291-99292)
• End-Stage Renal Disease Monthly Capitation Payment codes (CPT codes 90952, 90953, 90956, 90959, 90962) and
• Subsequent Observation and Observation Discharge Day Management (CPT codes 99217; CPT codes 99224-99226).

For yet more information, see CMS Announces Expanding List of New Telehealth Services Covered by Medicare

Nursing Facility Visit via Telehealth

Moreover, according to the 2021 Physician Fee Schedule, CMS will now cover one nursing facility visit via telehealth every 14 days, which was once every 30 days before. Telehealth advocates had suggested the frequency limit to be reduced to once every three days or remove the limitation altogether. But after re-considering that these patients require longer care than hospital inpatients, CMS finalized a frequency limitation for NF telehealth visits to every 14 days. CMS has also expanded the list of care providers able to be reimbursed for using telehealth in the 2021 Physician Fee Schedule.

The current list includes medical professionals, clinical social workers, clinical psychologists, physical and occupational therapists, and speech-language pathologists.

Virtual Check-Ins, Remote Evaluation

Two new billing codes will be introduced so that these providers can bill for virtual check-ins and remote evaluation of patient-submitted video or images.

If the provider and patient are in the same location, telehealth rules will not be applicable even if the provider is using telecommunications equipment to monitor a patient to avoid the risk of exposure to COVID-19. CMS is creating a new code with regards to coverage for audio-only phone check-ins. 11-20 minutes should be spent on the phone to ascertain the necessity of in-person care. This reimbursement would be about half as much as equivalent in-person care.

Remote Patient Monitoring Coverage

With more healthcare providers looking to extend care into the home, CMS has been gradually expanding coverage for remote physiologic monitoring services. It was previously discussed in Increased Reimbursement for Remote Patient Monitoring (RPM). The following RPM rules are included in the final document of the 2021 Physician Fee Schedule: 

• Once the public health emergency ends, a care provider must have an established patient-physician relationship for RPM services to be furnished.
• Consent to receive RPM services may be obtained at the time that RPM services are furnished.
• Auxiliary personnel (including contracted employees) may provide services described by CPT codes 99453 and 99454 incident to the billing practitioner’s assistance and under their supervision.
• The mHealth technology supplied to a patient in an RPM program must be defined as a medical device under Section 201(h) of the Federal Food, Drug, and Cosmetic Act and must be reliable and valid. In addition, the data coming from these platforms must be electronically (i.e., automatically) collected and transmitted rather than self-reported.
• After the PHE ends, 16 days of data must be collected and transmitted every 30 days to meet the requirements to bill CPT codes 99453 and 99454.
• Only physicians and NPPs who are eligible to furnish E/M services may bill RPM services.
• RPM services may be medically necessary for patients with acute conditions as well as patients with chronic conditions.
• Via CPT codes 99457 and 99458, an “interactive communication” takes place in real-time and includes synchronous, two-way interactions that can be enhanced with video or other kinds of data as described by HCPCS code G2012.  In addition, the 20-minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication.

Telehealth Expansion 

Furthermore, according to the 2021 Physician Fee Schedule, CMS is expanding coverage for direct supervision through interactive communications technology to reduce infection exposure risk by the use of telehealth. CMS will allow coverage for direct supervision through real-time interactive audio-visual technology until the end of the PHE or 2021.

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