A closer look at the behavioral health changes proposed in the physician fee schedule rule released in July reveals more reimbursement opportunities for orginizations that are willing to expand their mental and behavioral health offerings but have not yet been able to figure out how to make it pay.
A closer look at the behavioral health changes proposed in the physician fee schedule rule released in July reveals more reimbursement opportunities for orginizations that are willing to expand their mental and behavioral health offerings but have not yet been able to figure out how to make it pay.
CMS called these updates “some of the most important changes to improve access to behavioral health in Medicare in the program’s history." Among the highlights:
- Enrollment and expansion of eligible services for new types of providers — not only including licensed professional counselors (LPC), licensed marriage and family therapists (LMFT) and licensed mental health counselors (MHC), but also addiction counsellors who would be considered MHCs.
- 150% reimbursement for therapy services done “in crisis.”
- Higher reimbursement for several therapy and substance use disorder (SUD) codes.
The changes show that CMS is serious about mental and behavioral health and are part of the agency’s larger “behavioral health strategy."
For example, during the pandemic CMS has been generous with telehealth flexibilities for psychotherapy codes — resulting in 40% of such visits being virtual in 2021. And in its most recent benefits and payment parameters for ACA plans, parent agency HHS has stipulated that the maximum wait time for behavioral health appointments under such plans can’t exceed 10 days — versus 15 days for routine primary care and 30 days for non-urgent specialty care.
In the 2024 proposed rule there are several smaller changes that reflect this focus. For example, the Medicare Diabetes Prevention Program (MDPP) would add three G-codes for “behavioral counseling for diabetes prevention." And CMS makes clear its proposal to have claims billed with POS 10 (Telehealth provided in patient’s home) paid at the higher non-facility rate starting in 2024 is inspired by changes in behavioral health practice: “Practice patterns for many mental health practitioners have evolved, and they are now seeing patients in office settings, as well as via telehealth.”
Also, among the E/M codes slated for reimbursement growth in the rule, the care management service for behavioral health code 99484 is getting the biggest boost, which would raise the fee 26% to $54. And some “corollary telehealth provisions” will add opportunities for the new providers to use telehealth, says Allison Cohen of the Baker Donelson law firm in Washington, D.C. For example, these would allow “MFTs [marriage and family therapists] and MHCs [mental health counselors] to serve as telehealth distant site providers” in some circumstances, Cohen says.
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