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Jul 14, 2021

Proposed Medicare Physician Fee Schedule Rule Addresses Mental Telehealth, Diabetes Improvement Program, Coinsurance for Colorectal Exams

On July 13, 2021, the Centers for Medicare and Medicaid Services (CMS) released the annual proposed rule for updating the physician fee schedule and other Medicare Part B services.

Proposed Telehealth Changes Focus on Mental Health Services: In addition to updating the fee schedule, the proposed CY2022 rule would allow certain services added to the Medicare telehealth list to remain on the list until the end of December 2023. This allows CMS to continue to evaluate the temporary expansion of telehealth services that were added during the public health emergency (PHE) to determine whether the services should be permanently added to the telehealth list after the PHE ends.

Because of the public health emergency, Congress added the home of the beneficiary as a permissible originating site for telehealth services for the purposes of diagnosis, evaluation or treatment of a mental health disorder. In addition, it required an in-person, non-telehealth service with the physician or practitioner within six months prior to the initial telehealth service and at subsequent intervals specified by the Secretary of Health and Human Services. 

CMS proposes to do the following:

  • Require an in-person, non-telehealth service be provided by the physician or practitioner furnishing mental health telehealth services within six months prior to the initial telehealth service and at least once every six months thereafter. CMS is seeking comment on whether a different interval is appropriate for mental health services furnished through audio-only communication technology.
  • Amend the current regulatory requirement for interactive telecommunications systems (communication equipment that includes at a minimum audio and video equipment permitting two-way real-time interactive communication between the patient and distant site physician or practitioner), to allow audio-only communication technology when used for telehealth services for the diagnosis, evaluation or treatment of mental health disorders of established patients in their homes. The proposal would limit the use of an audio-only interactive telecommunications system to mental health services furnished by practitioners who have the capability to furnish two-way, audio/video communications, but where the beneficiary is not capable of using or does not consent to the use of two-way audio/video technology.
  • Include a new modifier for services furnished using audio-only communications, which would serve to certify that the practitioner had the capability to provide two-way audio/video communication but the beneficiary was not capable of using or did not consent to use of that technology.
  • Include a new modifier for services furnished through audio-only technology due to beneficiary choice or limitations.
  • Allow Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) to report and receive payment for mental health visits furnished via real-time telecommunication technology in the same way they do now when visits take place in-person, including audio-only visits when the beneficiary is not capable of or does not consent to the use of video technology.

CMS seeks comments specifically on the following:

  • How to address scenarios where a physician or practitioner of the same specialty/subspecialty in the same group may need to furnish a mental health service due to unavailability of the beneficiary’s regular practitioner.
  • Whether to require additional documentation in the patient’s medical record to support the clinical appropriateness of audio-only telehealth.
  • Whether CMS should or should not preclude audio-only telehealth for some high-level services, such as level 4 or 5 E/M visit codes or psychotherapy with crisis.
  • Whether CMS should consider putting in place any additional guardrails to address program integrity and patient safety concerns.

Proposed Changes to Medicare Diabetes Prevention Program (MDPP): The proposed rule would make changes to the MDPP to increase supplier enrollment and increase beneficiary participation and access to services that can help them develop and maintain healthy behaviors to prevent the onset of type 2 diabetes.

CMS proposes to do the following:

  • Utilize CMS Innovation Center’s waiver authority to waive the provider enrollment Medicare application fee on or after Jan. 1, 2022, and beyond the PHE. This is consistent with changes CMS made during the PHE.
  • Shorten the MDPP services period to one year by removing the ongoing maintenance sessions phase (months 13-24) of the MDPP set of services for beneficiaries starting on or after Jan. 1, 2022. This would make the MDPP services time frame consistent with the Centers for Disease Control and Prevention’s Diabetes Prevention Program. CMS believes this would relieve supplier cost and burden.
  • Redistribute a portion of the ongoing maintenance sessions phase performance payments to certain core and core maintenance section performance payments, in conjunction with removing the maintenance sessions phase from the MDPP services. This includes payments for the beneficiary’s 5 percent weight loss goal and continued attendance in the core maintenance interval.

If finalized, the changes would apply to beneficiaries who start the MDPP set of services on or after Jan. 1, 2022. Beneficiaries who began participating before Dec. 31, 2021, would continue with the maintenance phase if they maintain their 5 percent weight loss and other requirements.

Phaseout of Coinsurance for Colorectal Screening Additional Services: The proposed rule would implement a long-fought-for change in relation to the requirement of coinsurance should a practitioner remove polyps in the course of a colorectal cancer screening test. The removal of polyps changes the screening test to a diagnostic test. Currently, any procedure beyond the planned colorectal screening (for which there is no coinsurance) results in a patient paying coinsurance. Under the proposal, beginning Jan. 1, 2022, the amount of coinsurance patients will pay for “additional services” (the removal of polyps) would be reduced over time, so that by Jan. 2, 2030, the coinsurance would be zero.

To read the rule in its entirety, visit the Office of the Federal Register’s online collection of documents currently on file for public inspection.