The Centers for Medicare & Medicaid Services (CMS) unveiled a proposed rule on July 10 regarding policy changes that will determine reimbursement for services for Medicare providers under the Physician Fee Schedule (PFS). The proposed provisions, if adopted, will go into effect Jan. 1, 2025.
Learn more about the proposed rule and read the CMS fact sheet.
Each year CMS issues a PFS, which is a comprehensive listing of fees used by Medicare to pay physicians and non-physicians, such as mental health providers, on a fee-for-service basis. Beginning in 2024, mental health counselors (MHCs) and marriage and family therapists (MFTs) can bill for services provided to Medicare beneficiaries. Psychiatrists, psychologists, and social workers have been billing for mental health services under Medicare since the inception of the fee schedule. Fees for all providers are based on a formula that includes a provider work/professional component, practice expenses, and professional liability insurance, which is then adjusted for geographic differences. The overall unit based on those costs is then multiplied by a dollar amount known as a “conversion factor” that determines a national average fee for services.
The 2024 PFS Rule that was finalized in November 2023 focused on eligibility requirements for MHCs and MFTs to participate in the Medicare program, provided detailed processes and resources to enroll in the program, and highlighted coding and billing opportunities.
New Efforts to Improve Access to Mental Health Services
Key provisions in the proposed 2025 PFS (see pp.370–392) pertaining to MHCs and MFTs that would increase access to mental health services include:
- Crisis and Safety Planning Interventions: Introducing new, separate billing codes for safety planning for clients in crisis, including those at risk of suicide or overdose. The code would allow providers to code under a new add-on “G code” to bill Medicare alongside an evaluation or management visit (E/M) or psychotherapy visit for a client when interventions are performed by the billing provider.
- Follow-Up Intervention Services: Adding a billing code for post-discharge follow-up intervention services for clients in crisis, which would be essentially a bundled payment for four calls in a month in conjunction to a client discharged from the emergency department or a related setting, or a crisis encounter. The Medicare beneficiary would need to consent.
- Digital Mental Health Tools: Creating three new payment codes for reimbursing digital mental health treatment services—such as “digital CBT”—used in conjunction with ongoing behavioral health treatment. The codes would only apply to technologies and products approved by the Food and Drug Administration (FDA).
- Interprofessional Consultations Via Communications Technology: Allowing MHCs and MFTs to bill for interprofessional consultations. The goal of the expanded codes is to allow for increased integration of mental health treatment into primary care and related settings. The Medicare client would need to consent.
- Telehealth: Allowing audio-only telehealth services when a Medicare client is limited in technology for mental health services when they are at home.
- Timed Services: Increasing the valuation for 2025—for the consecutive second year—for many mental health services billed by MHCs and MFTs (in the 2024 MFPS, CMS finalized a nearly 20% increase for timed mental health services, which will be phased in over 4 years).
- Intensive Outpatient Services: Considering payment for intensive outpatient program services in additional settings such as certified community behavioral health clinics (CCBHCs). CMS is seeking specific comments on this provision.
- Opioid Use Disorder Treatment Services: Proposing new codes for FDA-approved medications for the treatment of opioid use disorder (OUD) and known or suspected opioid overdose, increasing telecommunication flexibilities, and providing more comprehensive services for OUD treatment, including assessing unmet health-related social needs, harm reduction intervention needs, and recovery support services.
The policy changes that CMS has included in the rule are part of a broader CMS strategy to advance behavioral health care.
The 2025 PFS includes a 2.8% reduction in the conversion factor that determines—as part of an overall formula—final payment for medical and mental health services. The proposed rule reduces the conversion factor amount to $32.36 in 2025 from $33.29 in 2024.
The rule is open for comment until Sept. 9, 2024, and NBCC is in the process of developing comments for submission to CMS and will encourage NCCs to submit comments based on our recommendations.
For more information on NBCC’s resources on Medicare implementation of counselors in the Medicare program, visit https://nbcc.org/govtaffairs/medicare.
