Audio-Only Telehealth Now Approved Permanently for Mental Health/Substance Use Services

The Centers for Medicare and Medicaid Services (CMS) has expanded the definition of telehealth services that are permanently eligible for reimbursement under the Medicare program to include audio-only services for established patients with mental illness/substance use disorders (SUDs) who are unable or unwilling to use video technology.

The final rule on telehealth services for mental illness/SUDs is part of the 2022 Medicare Physician Fee Schedule, which covers updates to physician payment and other regulations regarding Medicare’s Merit-Based Incentive Payment System (MIPS) each year. It was published in the Federal Register on November 19, 2021, and went into effect on January 1.

The expansion of telehealth to include audio-only services applies only to mental illness/SUDs. These services had been temporarily reimbursed as part of the government’s response to the COVID-19 public health emergency, beginning with the presidential emergency declaration in March 2020 (Psychiatric News). In December 2020, Congress approved the Consolidated Appropriations Act (CAA) of 2021, a $1.4 trillion dollar package that—among many other provisions—permanently expanded mental health services provided via telehealth by easing geographic and site-of-service restrictions under the Medicare program (Psychiatric News).

The rule is an enormous victory for patients and psychiatrists for which APA had advocated unceasingly for months.

“I am delighted at the inclusion of audio-only telehealth reimbursement,” said Peter Yellowlees, M.D., a member of the APA Committee on Telepsychiatry and a past president of the American Telemedicine Association. “This is likely to be especially important for patients who are already underserved, homeless, and from racial and ethnic minorities and may be one approach to reducing the inherent longstanding institutional racism and bias that we now acknowledge has existed in our health systems for many years.”

Grayson Norquist, M.D., a member of the APA Council on Quality Care, also underscored the importance of audio-only services for advancing equitable access to care. “The ability to use audio-only is critical for providing access to mental health services for people who lack resources or the skills to use video technology,” he said. “This increases our capacity to engage and treat those who have been underserved in the past in both rural and urban environments.”

Norquist is also vice chair of psychiatry and behavioral sciences at Emory University and chief of the Grady Behavioral Health Service in Atlanta.

In July 2021, CMS proposed that in-person visits take place every six months for all patients—whether new or established patients—after the initial telehealth encounter; in the final rule, the administration extended this provision to every 12 months for established patients, with exceptions at the discretion of the treating psychiatrist. As mandated by the CAA, there is no exception for new patients. They must be seen by physicians or other practitioners in an in-person visit within six months prior to initiation of mental health services via telehealth.

Additionally, CMS expanded the definition of the patient’s home residence to include locations beyond the home, such as a homeless shelter or places a patient may need to go for privacy.

Importantly, clinicians need to document in the patient record the reason for audio-only telehealth, which includes patient refusal to use audio-video, inability to use audio-video, or lack of access. Practitioners must also document that the patient has the ability to obtain any needed point-of-care testing, including vital sign monitoring and laboratory studies.

“This is a real win for our patients,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “The expansion of telehealth services under the public health emergency has transformed the medical landscape and dramatically expanded access to mental health services during an extremely difficult period. APA advocated for permanent payment for audio-only telehealth services and argued successfully that the treating psychiatrist, together with the patient, should decide whether an in-person visit is required.

“We are grateful to CMS for this rule, which will prove invaluable to our patients well beyond the public health emergency,” Levin said.

Physician Fees Increased

CMS had also approved a reduction to the conversion factor (the dollar figure used in the physician payment formula to determine overall payment) of $1.30 to $33.59 in 2022. This would have resulted in an overall decrease in payment for many physicians and—according to an AMA analysis—an overall reduction in payment to psychiatrists of 3.1%.

But last December, after vigorous advocacy from the AMA and other medical groups including APA, Congress acted to avert the payment cuts to physicians and instead approved a one-year increase in the Medicare Physician Fee Schedule of 3%.

Physician payment under the Medicare program is made according to a complex formula known as the Resource-Based Relative Value Scale (RBRVS). For every service or procedure that a physician provides, the formula includes values for physician work, practice expense (a measure of costs involved in a clinical encounter), and malpractice insurance costs.

The sum of these components is a total relative value unit (or RVU) adjusted for geographic variation. The AMA/Specialty Society RVS Update Committee, which includes representatives from APA, makes RVU recommendations to CMS, which ultimately reviews and finalizes the values.

This RVU is then multiplied by the “conversion factor”—a variable derived by Congress through its Office of Management and Budget—to arrive at a fee for each reimbursement code.

Finally, the CMS fee schedule also includes updates to the Merit-Based Incentive Payment System, which is designed to incentivize clinicians and practices to deliver quality services, according to measurable outcomes, over volume of services. No new measures were added to the MIPS Mental/Behavioral Health Specialty Set for 2022. One measure was removed from the set—Closing the Referral Loop: Receipt of Specialist Report.

CMS also adjusted the weighting of MIPS performance categories, fulfilling a statutory mandate to bring the cost and quality dimensions into equal weighting. The new weightings are as follows:

• Quality: 30% (previously 40%)

• Cost: 30% (previously 20%)

• Improvement Activities: 15% (no change)

• Promoting Interoperability: 25% (no change)

Due to the ongoing COVID-19 public health emergency, CMS is automatically applying the small practice hardship exception to individual physicians and small practices (15 or fewer operating under the same tax identification number) for the 2022 reporting year, assigning a weight of zero percent to each performance category, and applying a neutral payment adjustment for the 2023 payment year. ■