CMS’ Behavioral Health Strategy: Expanded Incident-to Billing and new BHI code in the proposed 2023 Medicare Physician Fee Schedule
In the Spring of 2022, the Centers for Medicare and Medicaid Services (“CMS”) released its 2022 Behavioral Health Strategy (the “BH Strategy”) to increase access to care and improve patient outcomes. The BH Strategy has 5 primary goals: (a) strengthen equity and quality, (b) improve access to substance abuse prevention, care, and treatment, (c) ensure effective pain treatment and management, (d) improve access and quality of mental health care services, and (e) increase utilization of healthcare data to effectuate more impactful behavioral health policies and services.
As part of implementing the BH Strategy, the 2023 Medicare Physician Fee Schedule Proposed Rule (the “2023 Proposed Rule”):
creates a new G-code to allow clinical psychologists (“CPs”) and clinical social workers (“CSWs”) to bill for general behavioral health integration (“GBHI”); and
amends the direct supervision requirement under CMS’ “incident to” regulation at 42 CFR § 410.26 to allow behavioral health services to be furnished by clinical staff under the general supervision of a physician or non-physician practitioner (“NPP”), so long as CMS’ “incident to” requirements and state licensure requirements are met.
Behavioral Health Integration Background
Effective January 1, 2017, CMS established G-codes to allow physicians and non-physician practitioners (e.g., nurse practitioners, physician assistants, clinical nurse specialists) (“NPPs”) to provide behavioral health integration (“BHI”) services using the psychiatric collaborative care model (“CoCM”), which enhances traditional primary care services by adding care management support and psychiatric specialty care.
The following year, effective January 1, 2018, CMS replaced the G-codes with CPT codes 99492, 99493, and 99494, and created CPT code 99484 to cover other BHI models of care in the primary care setting that do not involve or require psychiatric specialty care. CMS expected that BHI services would evolve based on new behavioral health standards of care.
For example, in response to stakeholder feedback and clinical evidentiary support, effective January 1, 2021, CMS created HCPCS code G2214 (i.e., 30-minute service requirement) to allow for the reimbursement of CoCM services that do not require a prolonged period of service (e.g., CPT code 99492, the prior sole first-month CoCM code, requires 70 minutes of service).
We now see this evolution continuing in the 2023 Proposed Rule.
New Behavioral Health Integration Opportunity: G-code Clinical Psychologists and Clinical Social Workers
CMS notes several times throughout the 2023 Proposed Rule that the COVID-19 public health emergency (“PHE”) has increased the demand for behavioral health services and created new barriers to accessing these services.
In response to stakeholder feedback, clinical data, scientific evidence, and the increased need for mental health services, CMS is creating a new G-code for 2023 to allow CPs and CSWs to furnish and bill for BHI when they are the patient’s primary treating clinician for covered behavioral health services.
G8HI1 Proposed Descriptor and Potential Payment Amount
GBHI1, the proposed code, is described as:
Care management services for behavioral health conditions, at least 20 minutes of clinical psychologist or clinical social worker time, per calendar month, with 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.
CMS currently intends to value GBHI1 the same as for CPT code 99484 because the services closely mirror each other.
The proposed 2023 non-facility national payment amount for both CPT code 99484 and HCPCS code GBHI1 is $41.35.
Clinical Considerations and Allowable Services under GBHI1
“Incident To” Billing: Yes for CPs, No for CSWs
Per the CP and CSW statutory benefit categories (Sections 1861(ii) and 1861(hh)(2) of the Social Security Act, respectively):
CPs will be allowed to bill for GBHI1 when services are provided by clinical staff incident to their services (so long as the “incident to” requirements under 42 CFR § 410.26 are met), while
CSWs will only be able to bill for GBHI1 when they personally furnish the services.
Initiating Visit Required
CMS intends to require an initiating visit for new patients or patients not seen within one year of commencement of BHI services. Because the scopes of practice for CPs and CSWs differ significantly from those of physicians and NPPs, CMS plans to allow CPT code 90791, an integrated biopsychosocial assessment, to serve as the initiating visit for GBHI1.
CMS is accepting comments as to whether it should add additional codes to qualify as the initiating visit.
GBHI1 Will Be a Designated Care Management Service – CP General Supervision of Clinical Staff Permitted
CMS intends to add GBHI1 to the designated care management services list to allow CPs to bill for services furnished by clinical staff incident to their services under general supervision.
CMS reiterated its position dating back to January 1, 2017, that it is not clinically necessary for the BHI billing practitioner to be immediately available to the clinical staff at all times based on the nature, scope, and clinical risk of BHI services. This is an important designation, as it will allow CPs to outsource staff to a third-party vendor similar to the ways in which other care management services such as chronic care management (“CCM”) and remote physiologic monitoring (“RPM”) are delivered.
GBHI1 Can Be Billed Concurrently With Other Care Management Services
Subject to impermissible “double-dipping,” whereby billing practitioners are prohibited from billing twice for the same time and effort, CMS intends to allow GBHI1 to be billed concurrently for a patient receiving other care management services such as CCM and transitional care management (“TCM”).
While CMS does not list RPM in the 2023 Proposed Rule as a permissible concurrent service, this appears to be an unintentional rule-writing oversight as RPM is a designated care management service like CCM and TCM.
Patient consent for GBHI1 is independently required when it is provided concurrently with other care management services.
Clinical Staff May Now Provide Behavioral Health Services Under General Supervision of Physicians and Non-Physician Practitioners
CMS recognizes the COVID-19 PHE has increased the demand for behavioral health services and increased the barriers to care access.
Per the Department of Health and Human Services’ (“DHHS”) Health Resources and Services Administration, by 2025 behavioral health clinician staffing shortages are projected nationally, particularly in the areas of psychiatry, psychology, mental health and substance use social workers, school counselors, and marriage and family therapists.
In response to these challenges and realities, CMS will amend the direct supervision requirement under its “incident to” regulation at 42 CFR § 410.26 to allow behavioral health services to be furnished under the general supervision of a physician or NPP when they are provided by auxiliary personnel (i.e., clinical staff) incident to services of a physician or NPP.
This is a significant expansion of permissible reimbursable behavioral health clinical workflows and clinical pathways as the change applies generally to all behavioral health services.
Clinical and compliance risk under this regulatory change should be reduced because auxiliary personnel must still satisfy all applicable: (a) “incident to” requirements, and (b) state licensure requirements by the state where the services are being furnished.
Steps You Can Take Now to Prepare for the New Behavioral Health Opportunities
Software platforms should be reviewed and updated, if necessary, to allow for the electronic transmission of validated clinical rating scales, which would allow CPs and CSWs to provide the code-required follow-up monitoring.
Vendors of outsourced care management services should consider augmenting their clinical workforce with CSWs and other types of therapists to support an outsourced offering to physicians and NPPs.
CSW practices/practitioners may be a new customer base for vendors of software platforms that facilitate two-way audio-visual communications between CSWs and their patients, allowing CSWs to conduct the initial assessment and follow-up monitoring via the platform. Consider conducting market research and preparing to educate this new customer base on the value of GBHI1 and the support you can provide them in implementing and delivering the covered service.
Please remember that certain substantive changes to your software platform may require a new FDA regulatory marketing assessment. We’re happy to help with this!
Conclusion
Behavioral health services will continue to expand in 2023 and beyond as CMS recognizes that these services have been undervalued and under-resourced for far too long.
For example, CMS is also proposing new chronic pain management codes for 2023. Implementation of the BH Strategy will continue at least throughout the remaining years of the Biden Administration, so we will stay attuned to new developments at the Department of Health and Human Services and will continue to advise our clients on new opportunities in the behavioral health space.