Psychiatrists Win Important Gains in 2024 Fee Schedule

APA’s advocacy efforts scored important victories for psychiatrists and patients in the 2024 Medicare Physician Fee Schedule, released by the Centers for Medicare and Medicaid Services (CMS) on November 2. These include policies regarding reimbursement for psychotherapy conducted in addition to evaluation and management (E/M) services, outpatient telepsychiatry, the Merit-Based Incentive Payment System (MIPS) reporting, and virtual supervision of trainees. The new policies will go into effect January 1, 2024.

Those gains will offset an expected decrease in physician payment overall. Unless Congress acts to reverse it, the Medicare “conversion factor”—a component of the equation that determines physician payment—will be reduced by 3.4% in 2024.

The impact of that overall reduction for individual psychiatrists will depend on what kinds of services they provide. Importantly, CMS accepted APA’s recommendation to increase the relative value units (RVUs) for psychotherapy codes used alongside codes for an evaluation and management (E/M) service by approximately 19.1%, phased in over four years. For 2024, this will result in an increase in payment for psychotherapy visits of between $3 and $6.

Jeremy Musher, M.D., chair of APA’s Committee on RBRVS, Codes, and Reimbursement, explained that the increase in payment for psychotherapy added on to an evaluation and management (E/M) service improves compensation for psychiatrists who are doing at least 16 minutes of psychotherapy along with other services—typically, medication management.

“CMS has been interested in increasing the value of the psychotherapy stand-alone codes that are used by psychologists, social workers, and other therapists,” Musher said in comments to Psychiatric News. “What we were able to do is convince CMS that if the administration wanted to appropriately increase the value of psychotherapy, it should also do so for psychiatrists who are providing psychotherapy add-on services combined with evaluation and management. Without this increase included in the final rule, psychiatrists would have fallen further behind our nonmedical colleagues in reimbursement for psychotherapy services.”

(RBRVS refers to the Resource-Based Relative Value Scale, the equation used to determine physician payment. The RBRVS combines “relative value units” for a physician’s work, practice expenses, and malpractice into a total relative value unit, or RVU, adjusted for geographic variation. 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.)

As part of the 2024 fee schedule, CMS also approved a new E/M add-on code (G2211), which can be used in addition to codes for outpatient E/M services to recognize the resource costs associated with care of patients with chronic or complex conditions.

Musher explained that the “G” code is a new one designed for primary care and some specialty physicians—including psychiatrists—who see patients over time. “This code recognizes that there are additional costs associated with the care of chronic or complex patients,” he said.

MIPS Reporting Threshold to Remain at 2022 Level

Over the past two decades, Medicare has moved toward paying physicians for the value of the services they provide, as opposed to simply paying for volume of services. MIPS is a value-based payment system that adjusts Medicare Part B payments according to physician performance in four differently weighted categories: quality (30%), cost (30%), promoting interoperability (25%), and improvement activities (15%). The annual fee schedule now includes updates to MIPS and other Medicare quality initiatives.

For 2024, the reporting threshold for physicians participating in MIPS will remain at last year’s level of 75 points, spread over the four MIPS reporting categories. In previous years, the reporting threshold has consistently increased, from three points in 2016 to 75 in 2022 (a 15-point increase from 2021).

Maintaining the threshold at 75 is good news for physicians who may have fallen short of the threshold last year and want to avoid the 9% penalty this year. Members who have questions about MIPS or their reporting status can contact Caryn Davidson, APA deputy director of quality, at [email protected].

Good News for Telepsychiatry

The 2024 fee schedule also includes good news for psychiatrists in the area of telehealth services. Especially important is the fact that CMS extended through 2024 the current temporary policy to reimburse outpatient telepsychiatry in the patient’s home (code POS 10) at the same rate as in-person care. The patient’s home can include temporary lodgings or other community-based settings. Medicare practitioners may continue to report their practice location instead of home address when providing telehealth services from their homes.

“CMS should consider allowing this on a permanent basis,” said Shabana Khan, M.D., chair of APA’s Committee on Telepsychiatry. “Many psychiatrists have a hybrid practice in which they provide care both in person and virtually into patients’ homes. There are significant practice expenses associated with maintaining an office setting, even if a portion of visits are conducted virtually. Practitioners are providing the same care to patients, whether the service is in person or virtual, and these services should be reimbursed at the same rate permanently.”

She added that CMS should permanently allow practitioners to report their practice location instead of their home address when providing telehealth services from their home. “If this flexibility expires, there may be significant privacy and safety concerns with practitioners having to report their home address,” Khan said.

CMS also extended through 2024 payment for telehealth services delivered by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) without a prior in-person visit. “This is so important given that over half of U.S. counties don’t have practicing psychiatrists. The need for an in-person visit should be left to the clinical discretion of the practitioner rather than a federal mandate,” Khan said.

Virtual Resident Supervision Extended

Virtual supervision of residents delivering telehealth has been a high priority for APA, and CMS extended reimbursement for virtual supervision through 2024. However, in-person care delivered by residents must still be supervised in person, and resident training sites should be prepared to provide in-person supervision beginning in January. An exception to this is when the resident and patient are in rural areas, in which case virtual supervision is permitted.

Khan said APA will continue to advocate for making the provision for virtual supervision permanent. “Many sites have difficulty recruiting and retaining teaching physicians,” she said. “Permanently allowing the virtual supervision of virtual and in-person care provided by residents in both rural and urban areas allows patients to receive timely and effective care under the supervision of the highest-quality teaching faculty.”

Finally, CMS payment for audio-only periodic assessments in opioid treatment programs is extended through 2024. Also, services in intensive outpatient programs will be covered when delivered by hospital outpatient departments, community mental health centers, RHCs, and FQHCs. ■