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Medicare Telemental Health Care Beyond the Public Health Emergency: Changes APA Advocated for in the Physician Fee Schedule

  • December 05, 2022

On November 1, 2022, the Centers for Medicare & Medicaid Services (CMS) released the final CY 2023 Physician Fee Schedule (.pdf), effective January 1, 2023. With the COVID-19 Public Health Emergency (PHE) expected to come to an end in 2023, this fee schedule provides some clarity around the telemental health practice and reimbursement landscape post-PHE.

The COVID-19 PHE was last renewed on October 13, 2022 for 90 days, and it appears that the administration will extend the PHE beyond January 11, 2023. While we still do not have an end date for the PHE, it will likely continue until at least April 2023. Further, earlier this year, Congress passed the Consolidated Appropriations Act, 2022, requiring a 151-day extension beyond the end date of the PHE of many, but not all, of the telehealth flexibilities authorized as part of Medicare’s pandemic response. Most importantly for psychiatry, some flexibilities – like the waiver of in-person visit requirements for the prescription of controlled substances – are not eligible for the 151-day extension, and will resume the day the PHE ends barring further rulemaking.

Here are some highlights around telemental health:

  • Audio-only services: Mental health telehealth services, including SUD, are the only category of services that will be eligible for audio-only delivery on a permanent basis after the expiration of the PHE and the 151-day extension period. CMS has confirmed that you will use the same billing codes for approved audio-only services as if you were seeing the patient in person.
  • In-person visit requirements: Once the 151-day extension period ends, you should plan to see all your established patients in person within 12 months. For new patients (initiating after the extension period), an in-person visit will be required within the six months prior to the first telehealth mental health visit and then once a year thereafter. Patients who established care via telehealth during the PHE, or during the 151-day extension period, will be considered established patients. Therefore, start now planning how to incorporate in-person visits into your practice if you are not already.
    • There can be exceptions to the required subsequent 12 month in-person visits based on hardship, which must be documented in the patient’s medical record noting a clear reason for the exception (e.g., significant travel time, mobility challenges, scheduling unavailability for either patient or provider).
    • Pending DEA and SAMHSA action, CMS is authorizing buprenorphine prescription to be billed when initiated via two-way interactive audio-video technology, as clinically appropriate, rather than requiring an in-person visit, and in instances where the patient does not have access to or does not consent to a video visit, audio-only modalities may be used to initiate buprenorphine treatment. Note that this flexibility does not apply to methadone treatment.
  • Place of service and modifiers: Through the end of CY2023, continue to bill the POS code as you have been, reporting the POS that would have been reported had the services been in-person. Then, effective at the end of the 151-day flexibilities following the PHE, we confirmed that appropriate E/M codes should be used for live video and audio-only telehealth visits. CPT modifier “95” should be appended to video telehealth visits, while modifiers “93” and “FQ” should be appended to claim lines for audio-only services. Billing both modifiers (FQ and 93) to Medicare for audio-only services accommodates differences between Medicare and commercial payers. After CY2023, stay tuned for additional changes to POS and modifiers.
  • Geographic restrictions and originating sites: Mental health conditions are not subject to geographic restrictions. For telemental health specifically, the patient’s home will continue to be an acceptable originating site (with POS “10”) post-PHE.

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