United States: Medicare Telehealth And Substance Use Disorder Treatment FAQs: New CMS Reimbursement Requirements

In the 12-month period starting in April 2021, over 100,000 people have died from drug overdoses, a 28.5% increase from the same period the year before. While the opioid crisis has been a declared public health emergency (PHE) since October 26, 2017, overdose deaths remain at an all-time high and have only been exacerbated by the COVID-19 pandemic. To combat this epidemic, physicians and other health professionals have called for additional telehealth flexibilities to allow for increased access to care for patients with substance use disorders (SUD), including opioid use disorder (OUD).

The Centers for Medicare & Medicaid Services (CMS) has responded to these calls by continuing its efforts to address this epidemic and expand access to mental/behavioral health in its new 2022 Physician Fee Schedule Final Rule.

The New Rule and the SUPPORT Act

Under the new rule, Medicare extended the time increments between in-person visits for patients receiving telehealth-based mental health services when the patient is located at home, among other requirements. (Please review our recent FAQs for more information on this change.) While this change impacts telehealth service furnished for purposes of diagnosis, evaluation, or treatment of a mental health disorder, it carves out telehealth treatment of a patient with a diagnosed SUD or co-occurring mental health disorder, which is separately addressed in the SUPPORT Act.

Effective on July 1, 2019, the SUPPORT Act statutorily removed the geographic limitations for telehealth services furnished to patients who with a diagnosed SUD or co-occurring mental health disorder, if the telehealth service is used to treat the SUD or co-occurring mental health disorder. The Act also removed telehealth originating site restrictions, which enabled patients to receive SUD treatment at any location, including the patient's home. However, these flexibilities only apply to SUD treatment for patients with an already diagnosed SUD—it does not apply to the initial diagnosis of the underlying condition. For the initial SUD diagnosis, the provider would likely need to bill an evaluation and management (E/M) code, which is subject to Medicare's usual statutory restrictions (e.g., geographic location, originating site, etc.).

Audio-Only Counseling and Therapy Services at OTPs

Under the new rule, Medicare will extended the ability of Opioid Treatment Programs (OTPs) to provide therapy and counseling services via audio-only telephone calls in certain instances. An OTP is a federally-certified program or practitioner who treats OUD with an "opioid agonist treatment medication," such as methadone or buprenorphine, and is commonly referred to as a "narcotic treatment program" or "methadone clinic." Unlike office-based opioid treatment (OBOT), OTPs can prescribe, dispense, and administer methadone on site. CMS added audio-only interaction to promote access, improve beneficiary choice, and provide effective and sustainable treatment for the particularly vulnerable OUD patient population.

Provided all other applicable requirements are met, OTPs can utilize audio-only telephone calls for counseling and therapy services when audio-video technology is "not available to the beneficiary," which is defined to include the following instances:

1. Circumstances in which the beneficiary is not capable of using audio-video communication, or
2. When the beneficiary has not consented to the use of devices that permit a two-way, audio-video interaction.

While CMS will reimburse certain audio-only telephone calls, providers still need to adhere to state law, which may be more restrictive on the use of the audio-only telephone modality. For example, Florida's telehealth statute does not allow audio-only telephone calls, so a provider delivering telehealth services to Florida patients will need to adhere to this more restrictive modality requirement.

What's next?

The CMS policy changes will take effect for Medicare beneficiaries on January 1, 2022 through the end of CY 2023, or when the public health emergency ends.