Proposed Medicare Physician Fee Schedule Would Extend Telehealth Flexibilities and Add New Coverage

General Telehealth-Related Provisions

Medicare Telehealth Services List

CMS is proposing to add the following services to the Medicare Telehealth Services List:

• On a provisional basis: Anticoagulation management monitoring (i.e., Home International Normalized Ratio monitoring) and related caregiver training; and,
• On a permanent basis: Individual counseling for pre-exposure prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV).

CMS decided not to recategorize any existing provisional codes as permanent until they can complete a comprehensive review of all provisional codes. This is expected to be addressed in future rulemaking.

New CPT Codes for Audio-Visual and Audio-Only Telehealth Services

In February 2023, the American Medical Association’s CPT Editorial Panel added seventeen new CPT codes for reporting telehealth office visits, eight synchronous audio video services, eight synchronous audio-only services and one code for an asynchronous virtual check-in service.

CMS is proposing not to recognize the new synchronous audio-video or audio-only CPT codes for telehealth services provided to Medicare patients at this time, citing similarity to existing codes and its interpretation of section 1834(m) of the Social Security Act requiring payment parity for a telehealth delivered service that is equivalent to an in-person delivered service. Thus, providers would continue to report the same codes for in-person office visits and use modifiers to indicate if the patient was home and/or if the visit was audio-only. CMS proposed accepting the CPT Panel’s recommendation related to adopting the asynchronous virtual check-in code as a replacement for an existing code.

The CPT Panel also proposed deleting three codes (99441–99443) for reporting telephone evaluation and management (E/M) services. These codes are assigned provisional status on the Medicare Telehealth Services List and would return to bundled status when current telehealth flexibilities expire on December 31, 2024.

Audio-Only Communication Technology

CMS’ previous definition of “interactive communication system” excluded audio-only technologies. CMS is proposing that the definition of an interactive telecommunications system will be expanded to include audio-only technology only in cases where the patient is unable or does not want to use video.

CMS would require providers to append a modifier (“93” or “FQ,”) to claims for services that meet these criteria to verify that the conditions have been met.

Interprofessional Consultation

CMS is proposing six new codes for interprofessional consultation that can be billed by providers who cannot independently bill Medicare for E/M visits (e.g., clinical psychologists, clinical social workers, marriage and family therapists, and mental health counselors). Providers would need to obtain patient consent in advance of these services. The new codes would facilitate interprofessional consultations between treating/requesting practitioners and consultant practitioners. This proposed payment is consistent with CMS’ efforts to recognize and reflect behavioral health care within the Physician Fee Schedule and allows for compensation for consulting practitioners.

Extending Temporary Policies Through CY 2025.

• Distant Site Requirements: Would continue to allow practitioners to bill using their currently enrolled practice site instead of their home address when the practitioner’s home is the distant site for a telehealth visit.
• Direct Supervision via Use of Two-way Audio/Video Communications Technology: Would continue defining “direct supervision,” for purposes of Medicare billing by supervising practitioners, to include supervision via audio-video communications technology (excluding audio-only).
• Frequency Limitations on Medicare Telehealth Subsequent Care Services in Inpatient and Nursing Facility Settings, and Critical Care Consultations: Would continue the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing visits, and critical care consultations.  
• Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs).In alignment with the virtual supervision proposed rules described above, CMS is proposing to continue defining “direct supervision” to include audio-video communications technology (excluding audio-only) for FQHCs and RHCs. CMS also proposes to temporarily allow payment for non-behavioral health visits furnished via telehealth through the end of 2025 using HCPCS code G2025. Lastly, CMS proposes to continue delaying the in-person visit requirement for mental health services delivered via communication technology by FQHCs and RHCs to beneficiaries in their homes until January 1, 2026; the requirement is currently slated to go back into effect on January 1, 2025.
• Teaching Physician Billing for Services Involving Residents with Virtual Presence:Would continue allowing teaching physicians to have a virtual presence (via real-time audio-visual observation, excluding audio-only) in all teaching settings but only in clinical instances when the service is furnished virtually (for example, a three-way telehealth visit with all parties in separate locations).

Telehealth Originating Site Facility Fee Payment Amount Update

CMS is proposing to increase the telehealth originating site facility fee payment from $26.96 in 2024 to $31.04 for 2025.

Mental Health-Related Provisions

Digital Mental Health Treatment Devices

CMS is proposing new policies to cover digital mental health treatment (DMHT) devices used in conjunction with ongoing behavioral health care treatment.

CMS previously indicated that digital therapeutics did not have a Medicare benefit category. Now, CMS is proposing to adopt three new codes that would give Medicare beneficiaries access to the service. CMS notes that DMHT can “offer innovative means to access certain behavioral health care services,” particularly in light of behavioral health workforce shortages and increased demand. The proposal applies only to the use of DMHT devices that have been cleared by the FDA.

To effectuate coverage, CMS is proposing to create a three-code series of CPT codes, modeled on codes currently in use for remote therapeutic monitoring (RTM).

• The first, GMBT1, would be used for “supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan.” Noting “pricing variability” of various devices, CMS does not propose a price for the code, but suggests instead that GMBT1 be local contractor priced and seeks comment on potential national pricing.
• Two other codes will support the follow-on use of DMHT: GMBT2 for the first 20 minutes of treatment management services related to the use of the DMHT, and GMBT3 for subsequent additional 20 minutes. These two codes would support billing for professional time spent reviewing data generated from the DMHT device from patient observations and patient specific inputs in a calendar month. They require at least one interactive communication with the patient, or the patient’s caregiver, during the calendar month. Pricing for the codes is based on pricing for the comparable treatment management services for RTM.

Telecommunication Flexibilities for Treatment with Methadone

In an effort to address significant barriers many patients face in initiating and participating in opioid use disorder (OUD) treatment services, CMS is proposing new flexibilities for OUD treatment services furnished via telecommunications by opioid treatment programs (OTPs), as long as the technologies being used are permitted under applicable requirements from the Substance Abuse and Mental Health Services Administration and the Drug Enforcement Administration at the time of service provision and all other applicable requirements are met. Specifically, CMS is proposing to allow periodic assessments to be furnished via audio-only starting January 1, 2025, as long as all other applicable requirements are met. The agency is also proposing to allow the OTP intake add-on code (HCPCS code G2076) to be furnished via two-way audio-video communications technology when billed for the initiation of treatment.

Safety Planning Interventions (SPI) and Post-Discharge Telephonic Follow-up Contacts Intervention (FCI)

CMS is proposing payment mechanisms and coding for SPI and post-discharge FCI for interventions initiated or provided to patients with risk of suicide. The coding is being proposed due to a lack of adequate payment mechanisms and billing codes for these interventions, which contributes to inadequate compensation and inconsistency of service.

Post-discharge telephonic FCI is a protocol for individuals with suicide risk where providers make a series of telephone contacts in the weeks or months following discharge from the emergency department or other care settings. They are currently not within the scope of Medicare telehealth services and are under-utilized. The proposed code for FCI is for a bundled service with four calls per month lasting 10–20 minutes and would require patient consent. The RVU value is based on the CPT code for principal care management. CMS is seeking comment as to the appropriate duration of service and the actual contact threshold for billing.

Next Steps

CMS is seeking comments to the CY 2025 MPFS by September 9, 2024. The final rule will be released in early November, and the majority of provisions (if adopted as final) will take effect on Jan. 1, 2025. Stay tuned later this Fall, when Manatt on Health will publish a summary of the final rule.