The 2023 Medicare Physician Fee Schedule (PFS) Final Rule (Final Rule), was issued on November 2 and published in the Federal Register on November 18, 2022. The Final Rule includes several rules relating to coverage and payment for Medicare telehealth services, changes to behavioral health services, and remote therapeutic monitoring. The Final Rule also addresses changes to expect after the COVID-19 public health epidemic (PHE) expires, which was recently extended through January 11, 2023. The Final Rule did not include any changes to remote patient monitoring or chronic care management services. Unless otherwise noted in the Final Rule, the Centers for Medicare and Medicaid Services’ (CMS) Final Rule will become effective January 1, 2023.
CMS Declines to Add New Telehealth Services to Categories 1 & 2 of the Medicare Telehealth Services List
The regulatory process for adding or deleting services from the Medicare telehealth services list was established under the 2003 PFS Final Rule. The public submits requests for adding services and, upon CMS’ review and approval, CMS then assigns the service to a category. A requested service is added to Category 1 if it is similar to professional consultations, office visits, and office psychiatry services that are currently on the Medicare telehealth services list. A requested service is added under Category 2 if there is evidence of clinical benefit if provided using telehealth.
CMS received several requests to permanently add a wide variety of services to the Medicare telehealth services list effective for CY 2023. However, CMS found that none of the requests met the Category 1 or Category 2 criteria for permanent addition to the Medicare telehealth services list. Denied services include several therapy services, electronic analysis of implanted neurostimulator pulse generator/transmitter, adaptive behavior treatment and behavior identification assessment, and certain services that are not separately payable under the PFS.
Although CMS denied all stakeholder-requested services, CMS finalized on its own initiative three new HCPCS G codes (temporary codes that are assigned to services and procedures that are under review before being included in the CPT coding system) to add to the Medicare telehealth services list on a permanent, Category 1 basis.
- G0316 (Proposed as GXXX1) – Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services).
- G0317 (Proposed as GXXX2) – Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management services).
- G0318 (Proposed as GXXX3) – Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99345, 99350 for home or residence evaluation and management services).
CMS stated that the codes are intended to describe prolonged services associated with certain types of evaluation and monitoring (E/M) services and will replace existing codes that describe prolonged services and will also replace CPT codes 99356 and 99357 for prolonged inpatient services.
Category 3 of the Medicare Telehealth Services List
Under the 2021 PFS Final Rule, CMS created a new Category 3 for telehealth services that would allow coverage and payment for such services through December 31, 2023 (CMS denied extending this date any further under the 2023 Proposed Rule). Category 3 services represent those services that CMS believed were likely to have clinical benefit when furnished via telehealth, but for which there was not sufficient evidence available to consider the services as permanent under Category 1 or 2 (as defined above).
In the 2023 Proposed Rule, CMS proposed adding a handful of additional services on a Category 3 basis through the end of 2023. Under the Final Rule, CMS finalized several services on a Category 3 basis. These include therapy services that are currently on the Medicare telehealth services list on a temporary basis for the PHE (CPT codes 90901, 97150, 97530, 97537, 97542, 97763, and 98960-98962), general brain nerve neurostimulation services (CPT codes 95970, 95983, and 95984), emotion/behavioral assessment services that were denied Category 2 status (CPT codes 97151- 97158, 0362T, and 0373T), ophthalmologic services (CPT Codes 92012 and 92014), and audiology services (CPT codes 92550, 92552, 92553, 92555-92557, 92563, 92565, 92567, 92568, 92570, 92587, 92588, 92601, 92625-92627). The full list of services added on a Category 3 basis can be found in Table 12 of the Final Rule (page 69,458).
CMS received requests to add certain telephone E/M services (CPT codes 99441, 99442, and 99443) to the Medicare telehealth services list on a Category 3 basis after the end of the PHE. However, because audio-only telephone E/M services are “inherently non-face-to-face services” and are not analogous to in-person care, CMS will not permanently add these services to the Medicare telehealth services list. CMS acknowledged that audio-only technology can continue to be used to furnish mental health telehealth services to patients in their homes after the PHE ends (this policy was made permanent under the 2022 PFS), but that after the PHE, two-way, audio-video communications technology is the appropriate standard that will apply for Medicare telehealth services that are not mental health services.
Telehealth Services After the PHE
Many of the telehealth services CMS implemented during the COVID-19 PHE were only implemented on a temporary basis and will expire 1) at the end of the PHE, or 2) on the 152nd day after the PHE ends (as discussed below). Following the expiration of the PHE, the statutory and regulatory restrictions on payment for Medicare telehealth services under section 1834(m) of the Social Security Act and 42 C.F.R §§ 410.78 and 414.65 will apply once again. This means that, in most cases, payment will only be made for the previously approved Medicare telehealth services furnished by certain types of physicians and practitioners to patients located in specified types of medical settings (originating sites) located in mostly rural areas, and only when the service is furnished using audio and video equipment permitting two-way, real-time interactive communication between the patient and furnishing practitioner.
However, CMS finalized its proposal to extend certain flexibilities for an additional 151 days after the end of the PHE. Flexibilities that will be extended include: allowing Medicare telehealth services to be furnished to patients located anywhere within the U.S.; allowing the extended scope of eligible telehealth practitioners to include occupational therapists, physical therapists, speech-language pathologists, and audiologists; extending payment for telehealth services furnished by FQHCs and RHCs; and delaying the requirement that there be an in-person visit with the physician or practitioner within 6 months before an initial mental health telehealth service. Additionally, instead of reducing payments for telehealth visits to the facility rates, CMS agreed to continue paying the same rates for office visits provided in-person or via telehealth through the latter of the end of the of CY 2023 or the end of the calendar year in which the PHE ends.
There are also some “place of service” (POS) code changes. Since 2017, physicians and practitioners have used the place of service code “02” to indicate a Medicare telehealth service paid at the facility payment rate. During the PHE, CMS instructed physicians and practitioners who bill for Medicare telehealth services to report the POS code that would have been reported had the service been furnished in person. In the Final Rule, CMS states that on or after the 152nd day after the end of the PHE, physicians and practitioners should use the following POS codes:
- POS “02” – which will be redefined as Telehealth Provided Other than in Patient’s Home (Descriptor: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.); and
- POS “10” – Telehealth Provided in Patient’s Home (Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.).
CMS is aligning telehealth services taking place in the beneficiary’s home, using POS “10” for Medicare telehealth, and those services not provided in a patient’s home, using POS “02” for Medicare telehealth, to be made at the same facility payment amount.
Behavioral Health Integration Services
In 2017, CMS established codes to describe monthly services furnished using the Psychiatric Collaborative Care Model (CoCM), an evidence-based approach to behavioral health integration (BHI) that enhances “usual” primary care by adding care management support and regular psychiatric inter-specialty consultation (99492 – 99494). CMS also created a fourth code to describe services furnished using other models of BHI in the primary care setting (99484).
In the Proposed Rule, CMS acknowledged that COVID-19 has likely contributed to an increase in the demand for behavioral health services and also strained barriers to accessing such services that were already prevalent before the PHE. CMS finalized the creation of a new G code describing general BHI performed by clinical psychologists or clinical social workers to account for monthly care integration where the mental health services furnished by a clinical psychologist or clinical social worker are serving as the focal point of care integration.
- G0323 (Proposed as GBHI1) – Care management services for behavioral health conditions, at least 20 minutes of clinical psychologist or clinical social worker time, per calendar month (These services include the following required elements: Initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, coordination with and/or referral to physicians and practitioners who are authorized by Medicare law to prescribe medications and furnish E/M services, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team.
Medicare requires an initiating visit for new patients or patients not seen within one year of commencement of BHI services. CMS also finalized its proposal to allow CPT code 90791 (psychiatric diagnostic evaluation) to serve as the initiating visit for G0323. Recognizing that clinical psychologists and clinical social workers can bill the 90791 code, CMS noted that allowing 90791 as an initial visit would offer greater access and opportunity to furnish integrated care management services. Additionally, CMS finalized that G0323 can be billed concurrently for a patient receiving chronic care management services and transitional care management. CMS finalized valuing the new code based on a direct crosswalk to the work values and direct practice expense inputs for CPT code 99484.
CMS is also amending the direct supervision requirement under the “incident to” regulation at 42 C.F.R. § 410.26 to allow behavioral health services to be furnished under the general supervision of a physician or NPP when these services or supplies are provided by auxiliary personnel (clinical staff) incident to the services of a physician or non-physician practitioner. This rule is in response to the increased needs for behavioral health treatment and workforce shortages in the field.
Chronic Pain Management
In the 2022 PFS, CMS sought comments on how best to approach coding and valuation for chronic pain management (CPM) services. CMS stated that it received over 2,000 comments from all types of stakeholders, many of which were supportive of CMS creating separate coding and payment for CPM under the PFS. CMS acknowledged that there is currently no existing CPT code that specifically describes the work of the clinician who performs comprehensive, holistic CPM, and the resources involved in furnishing CPM services to beneficiaries with chronic pain are not appropriately recognized under current coding and payment mechanisms. Thus, CMS proposed to create separate coding and payment for CPM services beginning January 1, 2023.
Commenters were supportive of CMS’ proposal to create coding and payment codes for CPM services. For CY 2023, CMS finalized the following two HCPCS codes to describe bundled services that are provided monthly.
- G3002 (Proposed as GYYY1) – Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate. Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (When using G3002, 30 minutes must be met or exceeded.)
- G3003 (Proposed as GYYY2) – Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month. (List separately in addition to code for G3002. When using G3003, 15 minutes must be met or exceeded.)
CMS clarified that any of the CPM in-person components included in HCPCS codes G3002 and G3003 may be furnished via telehealth, as clinically appropriate, in order to increase access to care for beneficiaries. Based on feedback received from comments, CMS added a flexibility in the Final Rule to allow providers to bill G3003, for each additional 15 minutes of care, an unlimited number of times, as medically necessary, per month, after HCPCS code G3002 has been billed.
CMS received comments asking the agency to clarify if the proposed CPM services would be available for billing/reporting in conjunction with RPM and RTM codes. CMS clarified that the RTM, RPM, and CPM are distinct services and that the CPM codes could be billed for the same patient in the same month as the RPM and RTM codes.
CMS also finalized its proposal to define “chronic pain” as “persistent or recurrent pain lasting longer than three months.”
Medicare requires certain types of services to be furnished under specific levels of supervision of a physician or practitioner, including diagnostic tests, services incident to physician services, and other services. During the PHE, CMS changed the definition of “direct supervision” as it pertains to supervision of diagnostic tests, physicians’ services, and some hospital outpatient services, to allow the supervising professional to be immediately available through virtual presence using real-time audio/video technology, instead of requiring their physical presence. The PHE flexibility for direct supervision is set to expire at the end of the calendar year in which the PHE is declared over, which at this point is expected to be the end of 2023.
CMS did not propose to make the exception to the direct supervision requirement permanent but did solicit comments on whether remote supervision should be made permanent and, if so, whether it should be limited to a certain sub-set of services. In the Final Rule, CMS reminded stakeholders that the temporary change in policy was adopted to address the circumstances of the PHE. CMS believes that additional time is necessary to collect information and evidence for direct supervision through virtual presence to better understand the potential circumstances for making this flexibility permanent.
Remote Therapeutic Monitoring
Under the 2022 PFS, CMS created five new CPT codes that describe remote therapeutic monitoring (RTM) – three PE-only codes and two professional work, treatment management codes. When the codes were first created, the American Medical Association CPT Editorial Panel intended RTM primary billers to be non-physician practitioners such as psychologists, nurse practitioners (NPs), and physical therapists (PTs). However, the codes are classified under the “General Medicine” category of the CPT book which prevented the RTM codes from being used by qualified health care professionals that are not authorized to furnish and bill “incident to” services.
Under the Proposed Rule, CMS proposed to replace two of the current RTM codes (CPTs 98980 and 98981) with four HCPCS G codes that would allow certain qualified non-physician healthcare professionals to bill Medicare Part B for services. CMS chose not to finalize the four new G-codes. Instead, in the Final Rule CMS announced that any RTM service (CPT codes 98975, 98976, 98977, 98980, and 98981) can be furnished under general supervision requirements. CMS also noted that it will continue to weigh the possible tradeoffs that would be necessary to further reduce coding and billing complexity for RTM and increase care delivery flexibility and retain appropriate beneficiary access to RTM services.
CMS also finalized its proposal to accept the RVS Update Committee’s (RUC) recommendation to contractor price CPT code 989X6 (RTM Cognitive Behavioral Therapy Monitoring). CMS reiterated that that it will continue to work with Medicare contractors to gain a better understanding of the devices and device costs they are encountering as they review claims for payment for the 989X6 code.