Medicare Telehealth Mental Health FAQs: CMS and the New In-Person Exam Requirement

The Facilities for Medicare & Medicaid Companies (CMS) has finalized its rule on in-person examination necessities for Medicare protection of telehealth-based psychological well being companies when the affected person is situated at dwelling. The Steadily Requested Questions beneath are based mostly on CMS’ insurance policies in the 2022 Physician Fee Schedule Remaining Rule.

1.  When does the rule take impact?

The rule goes into impact the day after the Public Health Emergency ends.

2.  What does the new rule require?

Beneath the rule, Medicare will cowl a telehealth service delivered whereas the affected person is situated at dwelling if the following circumstances are met:

  1. The practitioner conducts an in-person examination of the affected person inside the 6 months earlier than the preliminary telehealth service;

  2. The telehealth service is furnished for functions of analysis, analysis, or remedy of a psychological well being dysfunction (apart from for remedy of a recognized substance use dysfunction (SUD) or co-occurring psychological well being dysfunction); and

  3. The practitioner conducts at the very least one in-person service each 12 months of every follow-up telehealth service.

If these circumstances are met (in addition to different declare necessities usually), the telehealth service could also be lined by Medicare despite the fact that the affected person’s dwelling is just not a certified originating website below the statutory protection legal guidelines (and subsequently not in any other case eligible for reimbursement). The excellence between the telehealth and non-telehealth companies should be documented in the affected person’s medical report.

3.  Are there any conditions the place the in-person examination requirement doesn’t apply?

Sure. Listed here are three examples supplied by CMS in the Remaining Rule:

  1. If the affected person is situated at a qualifying originating website in an eligible geographic space (e.g., a practitioner workplace in a rural Health Skilled Scarcity Space) and the association meets the statutory necessities for telehealth service protection below Medicare, an in-person examination is just not a prerequisite for reimbursement.

  2. The in-person examination doesn’t apply to telehealth remedy of a recognized SUD or co-occurring psychological well being issues (the SUPPORT Act already made the affected person’s dwelling an eligible originating website for such companies).

  3. If the affected person and practitioner agree the advantages of an in-person, non-telehealth service inside 12 months of the psychological well being telehealth service are outweighed by dangers and burdens related to an in-person service, and the foundation for that call is documented in the affected person’s medical report, the in-person go to requirement won’t apply for that specific 12-month interval.

4.  What situations may help waiving the follow-up in-person examination requirement?

With regard to waiving the in-person examination for follow-up care, there are some conditions through which the dangers and burdens related to an in-person service could outweigh the profit. CMS acknowledged these conditions may embrace, for instance, situations when an in-person service is more likely to trigger disruption in service supply or has the potential to worsen the affected person’s situation(s). The dangers and burdens related to an in-person service may additionally outweigh the profit if a affected person is in partial or full remission and solely requires a upkeep degree of care. Different examples embrace the practitioner’s skilled judgement that the affected person is clinically secure and/or that an in-person go to has the threat of worsening the affected person’s situation, creating undue hardship on self or household, or whether it is decided that the affected person is in danger for disengagement with care that has been efficient in managing the sickness.

If utilizing this exception, practitioners should doc that the affected person has the capability to acquire any wanted level of care testing, together with important signal monitoring and laboratory research. Practitioners should word the exception for every relevant 12-month interval.

There is no such thing as a exception to the requirement for an in-person, non-telehealth service inside 6 months previous to initiation of psychological well being companies by way of telehealth.

5.  What constitutes the affected person’s dwelling for functions of the rule?

CMS’ definition of dwelling, each basically and for this function, is extra than simply the affected person’s major residence, and can embrace short-term lodging, similar to inns and homeless shelters. For circumstances the place the affected person, for privateness or different private causes, chooses to journey a brief distance from the precise dwelling location throughout a telehealth service, the service continues to be thought-about to be furnished “in the home of an individual” for functions of this rule.

6.  What constitutes a telehealth service furnished for the analysis, analysis, or remedy of a psychological well being dysfunction?

The figuring out issue is the Worldwide Classification of Illnesses (ICD-10) analysis codes. CMS acknowledged it can distinguish between psychological well being companies furnished for a recognized SUD or co-occurring psychological well being dysfunction (which don’t require the in-person examination) and these furnished to beneficiaries and not using a SUD analysis (which do require the in-person examination) on the foundation of ICD-10 analysis codes included on claims when the companies are billed.

7.  Who should conduct the in-person examination vs the telehealth companies?

The Remaining Rule suggests the practitioner would conduct each the first in-person examination and the preliminary telehealth service. For the follow-up in-person examination each 12 months, a clinician colleague in the similar subspecialty in the similar group as the practitioner can furnish the in-person, non-telehealth service to the affected person if the unique practitioner is unavailable. This flexibility is per longstanding CMS coverage, which defines a longtime affected person as a person who receives skilled companies from the doctor/NPP or one other doctor of the similar specialty and subspecialty who belongs to the similar group inside the earlier three years, for functions of billing for Analysis and Administration (E/M) companies.

8.  Why did CMS create this in-person examination requirement?

CMS didn’t create it. Congress compelled CMS to implement this regulation, following statutory adjustments in the Consolidated Appropriations Act of 2021 (learn our analysis here). In December 2020, Congress imposed new circumstances on telemental well being protection below Medicare, creating an in-person examination requirement alongside protection of telemental well being companies at the affected person dwelling. These new circumstances, codified as amendments to 42 U.S.C. § 1395m(m)(7), induced confusion in the trade, significantly as a result of it was the first occasion of a federal statute mandating an in-person examination as a prerequisite for Medicare protection of a telehealth-based service. In distinction, the overwhelming majority of federal and state flexibilities throughout the Public Health Emergency had been telemedicine-friendly and promoted the use of digital well being expertise to ship medical care.

9.  Does this have an effect on SUD telehealth companies below the SUPPORT Act?

No. The in-person go to necessities below this CMS rule don’t apply to telehealth remedy of a recognized SUD or co-occurring psychological well being issues, as the SUPPORT Act already requires Medicare cost for such companies. Be taught extra about the SUPPORT Act here.

10.  What telemedicine modality is required for telemental well being companies whereas the affected person is situated at dwelling?

In reference to the current regulation adjustments, CMS acknowledged an interactive telecommunications system can embrace “interactive, real-time, two-way audio-only technology” for telehealth companies furnished for the analysis, analysis, or remedy of a psychological well being dysfunction, below the following circumstances:

  1. The affected person is situated of their dwelling at the time of service as described at 42 C.F.R § 410.78 (b)(3)(xiv);

  2. The distant website doctor or practitioner has the technical functionality at the time of the service to make use of an interactive telecommunications system that features video; and

  3. The affected person is just not able to, or doesn’t consent to, the use of video expertise for the service.

To that finish, CMS created a service-level modifier to be used in these conditions the place psychological well being telehealth companies are furnished to a affected person of their dwelling utilizing audio-only communications expertise. CMS additional acknowledged SUD companies are thought-about psychological well being companies for functions of this amended definition of “interactive telecommunications system” to incorporate audio-only companies below 42 C.F.R § 410.78(a)(3). These adjustments are meant to enhance entry to look after psychological well being circumstances and contribute to total well being fairness.

11.  What was modified in the official regulation?

Listed here are the adjustments to the regulation.

42 C.F.R. § 410.78(b)—Telehealth Companies

(a) * * *

(3) Interactive telecommunications system means, besides as in any other case supplied on this paragraph, multimedia communications tools that features, at a minimal, audio and video tools allowing two-way, real-time interactive communication between the affected person and distant website doctor or practitioner. For companies furnished for functions of analysis, analysis, or remedy of a psychological well being dysfunction to a affected person of their dwelling, interactive telecommunications could embrace two-way, real-time audio-only communication expertise if the distant website doctor or practitioner is technically succesful to make use of an interactive telecommunications system as outlined in the earlier sentence, however the affected person is just not able to or doesn’t consent to, the use of video expertise. A modifier designated by CMS should be appended to the declare for companies described on this paragraph to confirm that these circumstances have been met.

* * * * *

(b) * * *

(3) * * *

(xiv) The house of a beneficiary for the functions of analysis, analysis, and/or remedy of a psychological well being dysfunction for companies furnished on or after the first day after the finish of the PHE as outlined in our regulation at § 400.200 besides as in any other case supplied on this paragraph. Fee won’t be made for a telehealth service furnished below this paragraph except the following circumstances are met:

(A) The doctor or practitioner has furnished an merchandise or service in-person, with out the use of telehealth, for which Medicare cost was made (or would have been made if the affected person had been entitled to, or enrolled for, Medicare advantages at the time the merchandise or service is furnished inside 6 months previous to the preliminary telehealth service;

(B) The doctor or practitioner has furnished an merchandise or service in-person, with out the use of telehealth, at the very least as soon as inside 12 months of every subsequent telehealth service described on this paragraph, except, for a selected 12-month interval, the doctor or practitioner and affected person agree that the dangers and burdens related to an in-person service outweigh the advantages related to furnishing the in-person merchandise or service, and the practitioner paperwork the purpose(s) for this determination in the affected person’s medical report.

(C) The necessities of paragraphs (b)(3)(xiv)(A) and (B) could also be met by one other doctor or practitioner of the similar specialty and subspecialty in the similar group as the doctor or practitioner who furnishes the telehealth service if the doctor or practitioner who furnishes the telehealth service described below this paragraph is just not out there.

(4) * * *

(iv) * * *

(D) Companies furnished on or after the first day after the finish of the PHE as outlined in our regulation at § 400.200 for the functions of analysis, analysis, and/or remedy of a psychological well being dysfunction. Fee won’t be made for a telehealth service furnished below this paragraph except the doctor or practitioner has furnished an merchandise or service in particular person, with out the use of telehealth, for which Medicare cost was made (or would have been made if the affected person had been entitled to, or enrolled for, Medicare advantages at the time the merchandise or service is furnished) inside 6months previous to the preliminary telehealth service and inside 6 months of any subsequent telehealth service.

What’s subsequent?

CMS will monitor claims knowledge relating to the use of telehealth psychological well being companies to establish areas for additional investigation and to tell future rulemaking, together with conditions the place there’s proof beneficiaries are doubtlessly experiencing opposed well being outcomes or elevated problem accessing in-person care, or if inappropriate use or billing of telehealth psychological well being companies is suspected.

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