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2023 Medicare Physician Fee Schedule Final Rule: What Clinical Social Workers Should Know

By Denise Johnson, LCSW-C, Senior Practice Associate, Clinical Social Work; and Makeba Royall, LCSW, Senior Practice Associate, Behavioral Health


Effective January 1, 2023, the Centers for Medicare and Medicaid Services (CMS), implemented the 2023 Medicare Physician Fee Schedule (PFS). The 2953 page rule includes updates to policies and payments that are applicable to clinical social workers (CSWs) and other Medicare providers. The following is a summary of the provisions and their implications for CSWs.

Reimbursement

The conversion factor for 2023 decreased to $33.8872. The conversion factor is a variable that is multiplied by the relative value unit assigned to CSWs to determine payment for a psychiatric service. A decrease in the conversion factor results in an overall average decrease in reimbursement for CSWs. Factors such as the economic index and geographic location will also impact CSWs. The reduction will help to achieve Medicare budget neutrality required by law to ensure payment rates for individual services don’t result in changes to estimated Medicare spending. Congress took action as part of Consolidated Appropriations Act of 2023 to help mitigate the cuts. Specifically, the cuts will be reduced by 2.5% in 2023 and 1.25 % in 2024.

Telehealth

Medicare has historically authorized telehealth services, however, coverage was limited prior to the COVID-19 public health emergency (PHE). The PHE created concerns related to health equity and access of care. In response to these concerns, CMS temporarily expanded telehealth flexibilities to include the addition of covered services, removal of the geographic restrictions, and coverage of services provided via smartphones and audio-only devices.

In accordance with the2022 Consolidated Appropriations Act, CMS has extended the duration of certain telehealth flexibilities for CSWs to continue for 151 days following the end of the PHE. Currently, all psychiatric codes used by CSWs can also be used for telehealth services. Telehealth claims will continue to use the 95 modifier (a telehealth identifier) and the place of service (POS) code that would have been reported had the service been furnished in-person.

In person requirement

The in-person visit requirements for mental health services furnished by CSWs via telehealth will also be delayed until 152 days after the end of the PHE. Once the in-person requirement goes into effect, CMS will require all established patients to be seen by CSWs in-person within 12 months. An established patient is one who received treatment during the PHE or during the 152-day extension. New patients should be seen in-person by a CSW before receiving telehealth services and once a year going forward. A 12-month in-person visit will be required thereafter.

Behavioral Health Services

CMS finalized policies to reimburse CSWs and clinical psychologists (CP) who provide behavioral health integration (BHI) services as part of a primary care team. A new Healthcare Common Procedure Coding System (HCPCS) code (G0323) was developed that allows CSWs and CPs to furnish general BHI services to account for monthly care integration when mental health serves as the focal point of care.

The restricted procedure status indicator for family psychotherapy services was also removed. Currently the CPT codes for family psychotherapy are reimbursable under Medicare but are assigned a restricted status indicator in the Medicare Physician Fee Schedule payment files. CMS has finalized updates to the procedure status indicators for CPT codes 90847 and 90849. Effective January 2023, both codes will be assigned an “A” for active status. CMS may consider changes to the procedure status for CPT code 90846 in the future.

In response to the increased demand for mental health services, CMS has also made an exception to the direct supervision requirement under the “incident to” regulation. Behavioral health services will be permitted by CSWs under the general supervision of a physician or non-physician practitioner (NPP), instead of under direct supervision.

Payment to CSWs for new codes that describe caregiver behavioral management training (CPT Codes 96202 and 96203) will be addressed more thoroughly in the CY 2024 ruling.

Chronic Pain Management (CPM) and Treatment Services

CMS has finalized the definition of chronic pain as “persistent or recurrent pain lasting longer than 3 months.” Beneficiaries who were previously diagnosed with chronic pain, as well as those who are newly diagnosed would both be eligible.

Two new HCPCS (G3002 and G3003) codes have been also created for chronic pain management and treatment services and would include a monthly bundle of services provided by CSWs and other providers.

Code Descriptor Changes for Annual Alcohol Misuse and Annual Depression Screenings

CMS is finalizing their descriptor changes to “Annual alcohol misuse screening, 5 to 15 minutes” for HCPCS code G0442 and to “Annual depression screening, 5 to 15 minutes.” for HCPCS code G0444.

Opioid Treatment Programs (OTPs)

Medicare will reimburse Opioid Treatment Programs (OTP) that use telecommunications with patients to initiate treatment with buprenorphine. CMS has modified the payment rate for the non-drug component of bundled services. The base rate for individual therapy will increase from 30 to 45 minutes for CSWs who provide services in OPTs.

CMS is also allowing periodic assessments to be provided via audio-only when video is not available until the end of CY 2023.

OTPs may bill Medicare for medically reasonable and necessary services provided by mobile units. Locality adjustments for services provided by mobile units will be applied as if the service were provided at the OTP’s physical location.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

Reimbursement for BHI and CPM services will continue in RHCs and FQHCs. The addition of chronic pain management and behavioral health integration services was finalized to the RHC and FQHC specific general care management HCPCS code, G0511. The payment rate for this code will remain as the average of the national non-facility PFS payment rates for the RHC and FQHC care management and general behavioral health codes.

Mental health visits in FQHCs and RHCs can be furnished virtually on a permanent basis by CSWs. However, the in-person requirements for mental health visits furnished by RHCs and FQHCs through telecommunication technology are delayed until the 152nd day after the COVID-19 PHE ends.

Lastly, CMS states that a 12-consecutive month cost report should be used to determine a specified provider-based payment limit per visit for RHCs. CMS believes this will allow for a more accurate base that payments can be made moving forward. NASW will continue to monitor Medicare regulations and inform members of any further updates from CMS. The association advocates continuously for CSWs and their patients, including efforts to increase CSWs’ reimbursement rates.