In this post

• Overview of behavioral health services via telemedicine during the PHE
• Overview of behavioral health services after the PHE
• The Omnibus spending bill passed at the end of Dec. 2022 extended telehealth flexibilities for two years after the end of the PHE.
• This included a two-year delay of the in-person visit required for telehealth services, described below.
• The final MPFS 2025 extends the delay for the -in-person visit requirement yet again through January 1, 2026.
• Detailed review of behavioral health and telemedicine during the PHE

Overview of behavioral health telemedicine services 2020 through 2023: During the public health emergency (PHE)

In March and April 2020, CMS issued numerous waivers affected many medical specialties due to the shelter-in-place requirements. Amongst many of the services, behavioral health service providers were also allowed to bill for initial evaluations, psychotherapy, and crisis psychotherapy encounters when conducted via real-time audio/visual communication, including audio-only for patients in their homes and living anywhere in the U.S., not only in an underserved area. [1] Medication management (office visits 99202—99215) was also included with these waivers when performed using audio/visual technology.

As such, the waivers

• Allowed behavioral health services to be done via real-time, audio/visual communication or phone-only
• Allowed office visits to be done via real-time, audio/visual communication
• Allowed documentation as if the service was in person, via audio/visual technology or audio-only
• Paid for telephone codes 99441—99443 at the same rate as 99212—99215 for medication management
• Required both the patient and clinician to be in the U.S. when the services were undertaken
• Required the reporting of modifier FQ for audio-only behavioral health services
• In an RHC or an FQHC, corresponding HCPCS codes were used to report the services; reporting on a UB claim form does not allow for modifiers (revenue code 780 indicates telehealth can be input onto the form)

Overview of behavioral health services and telemedicine after the PHE, through December 31, 2024, and into 2025

Effective for services performed after the end of the PHE, which occurred on May 23, 2023), behavioral health services continue to be allowed for Medicare patients using real-time audio/visual technology or audio only. This is allowed for behavioral health services because of a provision of the Consolidated Appropriations Act, of 2021 (CAA), passed into law on 12/27/2020, which made telehealth behavioral health a permanent Medicare benefit.

Section 123 of that Act stated that:

• It will allow behavioral health services to be done via real-time, audio/visual communication or phone only for patients in their homes, in all areas of the country
• Both the patient and clinician must be in the U.S. (including U.S. territories) when the services are done
• In an RHC or an FQHC, corresponding HCPCS codes are used to report the services; (reporting on a UB claim form does not allow for modifiers)
• Use modifier FQ for audio-only behavioral health telehealth services
• Starting in 2025 CMS will allow medication management (office visits) for behavioral health services to be done via audio-only if certain conditions are met:
  • It’s a patient-driven choice
  • Based on their technological capabilities and limitations; and
  • Their comfort level with the use of video technology in their home.
• CMS does not require a strict definition of home; they note that patients may not have access to private living space or may, for privacy reasons, prefer to talk from their car or “other private location.”

Note that CPT® codes 99441-99443 are deleted effective 1/1/2025. E/M codes can be reported using 99202-99215 with a 93 or FQ modifier.

Additional requirements for behavioral health and telemedicine

• The practitioner must have the capacity for real/audio-visual technology if the service is performed via audio only [2]
• The patient must have had a face-to-face service with the clinician within 6 months of starting telehealth (except for substance use disorders treatment and patients in a geographically underserved area)
• The face-to-face service may be with a clinician of the same specialty in the same group
• The patient must be seen in person once every 12 months, unless it is determined that would be “inadvisable or impractical” for the beneficiary. Note: the Omnibus bill passed in Dec. 2022 delayed implementation of the in-person visit requirement for two years after the PHE ends.
• If the patient is not seen in person once every 12 months, the reason for the exception must be documented in the medical record

Note: the in-person requirements are now delayed until January 1, 2026, per the 2025 Finalized Medicare Physician Fee Schedule. [3]

Behavioral health services and telemedicine

Behavioral health services have long been on Medicare’s list of services that could be provided via telemedicine. However, Medicare had strict rules about telemedicine, requiring that the patient be at an originating site, such as a hospital or physician’s office–not at home–and in an underserved area.

Performing an initial evaluation or psychotherapy was not allowed if the patient was at home and this was being done for the convenience of the patient. With the declaration of the public health emergency Medicare eased its restrictions, as did most private payers.

Telehealth services that can be provided via audio only

On April 30, 2020 CMS released an updated list of services that could be provided via telehealth, and added a column “Can Audio-only Interaction Meet the Requirements?” During the time of the public health emergency, certain services may be performed audio-only, not audio visual.

Medicare Before March 1, 2020	Medicare After March 1, 2020
Patient must be in a designated rural or underserved area	Patient may be anywhere in the country
Patient must go to an “originating site,” such as a hospital, for most services	Patient may be in any site, whether a healthcare facility or in their home
Patient must be an established patient	Patient may be new or established
Provider must use a HIPAA compliant platform	Requirement for HIPAA compliant platform is waived
Requires two-way, real time audio/visual communication	No Change – Requires two-way, real time audio/visual communication
May only bill services on CMS list	No Change – May only bill services on CMS list

CPT® also has a list of covered telehealth services, and these are found in appendix P of the CPT book. They are also indicated by a star next to the code in the main part of the book.

CMS list of services, during the public health emergency

• 90791, 90792 Psychiatric diagnostic evaluation
• 90832, 90833, 90834, 90836, 90837, 90838 Psychotherapy
• 90839, 90840 Psychotherapy for crisis
• 90785 Interactive complexity
• 90845 Psychoanalysis
• 90846 Family therapy (without the patient present)
• 90847 Family psychotherapy (conjoint psychotherapy) with patient present
• 90853 Group therapy
• E/M services for medication management, 99202—99215 (needed real time, audio and visual, not just audio)
• Inpatient initial and subsequent visits, discharge visits and observation services. (needs real time, audio and visual, not just audio)

There are other behavioral health assessment and intervention codes that may be billed via telemedicine, as well. See CMS list of permanent and temporary telehealth services.

Private payers and behavioral health telemedicine

Most commercial payers have added psychotherapy and behavioral health services to their lists of services that can be performed via telehealth during the public health emergency. As always with commercial carriers, individual practices must check the payer policies.

Place of service and modifiers

Medicare changed its initial guidance and told practices to use the place of service where the patient would have been seen if it had been a face-to-face visit. If the visit would have occurred in person and would have taken place in the physician office, use place of service 11. Providers used place of service 19 or 22 for outpatient department visits and place of service 21 for inpatient visits. Modifier -95 was appended to the CPT® code.

For commercial payers, it was best practice (as it is now) to check each company’s guidance. The most common directions were to use place of service 02, telehealth, and modifier 95.

Two way, interactive, real-time, audio visual required for services not listed as “yes” in the audio only column

Medicare required that these telehealth services be performed via a two-way, interactive, real time, audiovisual platform. Although they have waived some HIPAA compliant platform, they have not waived the requirement.

The Telemedicine in the time of COVID-19 article provides additional information about the changes that were effect during the public health emergency.

[1] This statement does not refer to cross-state licensure requirements.

[2] Final “draft” MPFS publication: https://public-inspection.federalregister.gov/2024-25382.pdf (PDF form), p.144: “§ 410.78(a)(3) to permanently change the regulatory definition of an interactive telecommunications system to include two-way, real-time audio-only communication technology for any telehealth services furnished to beneficiaries in their homes if the distant site physician or practitioner is technically capable of using an interactive telecommunications system that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner, but the patient is not capable of, or does not consent to, the use of video technology.”

[3] Final “draft” MPFS publication: https://public-inspection.federalregister.gov/2024-25382.pdf (PDF form), pp. 879-880.