Behavioral health and telemedicine during the PHE

In this post

• Overview of behavioral health services via telemedicine during the PHE
• Overview of behavioral health services after the PHI
• Detailed review of behavioral health and telemedicine during the PHE

Overview of behavioral health services via telemedicine during the PHE

In March and April 2020, CMS issued numerous waivers that are still in effect. They allow behavioral health services (initial evaluations, psychotherapy, crisis psychotherapy) to be billed via real-time audio/visual communication and phone only for patients in their homes, and living anywhere in the U.S., not only in an underserved area. Medication management (office visits 99202–99215) must still use real-time audio/visual technology.

• Allows behavioral health services to be done via real time, audio/visual communication or phone only
• Allows office visits to be done via real time, audio/visual communication
• Document if the service was in person, via audio/visual technology or audio only
• Pays for telephone codes 99441-99443 at the same rate as 99212—99215 for medication management
• Both the patient and clinician must be in the U.S. when the services are done
• Beginning 1-1-2022, report modifier FQ for behavioral health audio-only services
• 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

Overview of behavioral health services and telemedicine after the PHE ends

Effective for services performed on or after the first day after the end of the PHE, behavioral health services will 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, passed 12/27/2020. After the PHE ends, office visits for non-behavioral health services will only be allowed for patients in geographically underserved areas, and home will no longer be allowed as an originating site unless Congress changes the law.

• 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
• Will allow medication management (office visits) for behavioral health services to be done via real time, audio/visual communication
• Document if the service was in person, via audio/visual technology or audio only
• Both the patient and clinician must be in the U.S. 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
• The patient may be in their home, but CMS is not requiring 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”

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
• 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
• If the patient is not seen in person once every 12 months, the reason for the exception must be documented in the medical record

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 though Medicare has eased its restrictions, as have 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 with audio-only, not audio visual.

CPT list of behavioral health services that can be reported via telehealth as of 4/30/2020

• 90791, 90792 Psychiatric diagnostic evaluation
• 90832, 90833, 90834, 90836, 90837, 90838 Psychotherapy
• 90785 Interactive complexity
• 90839, 90840 Psychotherapy for patients in crisis
• 90845 Psychoanalysis
• 90846 Family therapy (without the patient present)
• 90847 Family psychotherapy (conjoint psychotherapy) (with patient present)
• 90853 Group psychotherapy

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, 99201—99215 (needs 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 now is telling 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. Use place of service 19 or 22 for outpatient department visits and place of service 21 for inpatient visits. Append modifier -95 to the CPT® code.

For commercial payers, check their guidance. The most common directions are 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 is still requiring 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 in effect during the public health emergency.

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