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.
• The final MPFS 2025 extends the delay for the -in-person visit requirement yet again through January 1, 2026.

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
• Use modifier FQ for audio-only behavioral health telehealth services (check with your MAC; modifier 93 is also audio only)
• 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.”

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. This is delayed, again.
• The 2025 PFS Final Rule delayed the in person requirement until Jan. 1, 2026.
• If the patient is not seen in person once every 12 months, the reason for the exception must be documented in the medical record.

CMS list of services on the telehealth list for 2025

• 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
• Inpatient initial and subsequent visits, discharge visits and observation services

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

Use place of service 02 telehealth provided other than patient’s home or POS 10 telehealth provided in patient’s home.

• Modifier 93 Telemedicine audio only real-time interaction (abbreviated description)
• Modifier 95 Telemedicine audio-visual real-time communication (abbreviated description)
• Modifier FQ Telemedicine audio-only for behavioral health

For commercial payers, check each company’s guidance.

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.”

Display copy MFS publication: https://public-inspection.federalregister.gov/2024-25382.pdf (PDF form), pp. 879-880.