Behavioral health treatment requires specific documentation for accurate coding and compliance. Failure to get these systems right can result in denied claims, revenue loss, repayment due to unsupported services, and poor patient experience.
Establishing and reviewing your current internal controls, operational processes, and delivery areas can help mitigate errors, increase efficiency, and improve your revenue cycle.
During the COVID-19 public health emergency (PHE), several of the limitations for providing telehealth services were lifted. Hospital revenue cycle and revenue integrity departments faced multiple challenges not only capturing the right coding but also identifying what behavioral health services were completed using telehealth technologies.
From a documentation and compliance perspective, transitioning to telehealth for behavioral health providers became more complicated.
In 2021 and again in March 2022, the Centers for Medicare & Medicaid Services (CMS) made significant telehealth changes to coverage for mental health services and expanded behavioral health treatment of those services.
New Rule From CMS
Medicare finalized its rule on mental health services in 2021. The rule states that once the PHE ends, mental health service providers will be required to have in-person examinations based on specific time frequencies.
In December 2020, CMS imposed statutory amendments and conditions of payment related to mental health services provided using telehealth. The new requirements would be imposed after the PHE ends. At that time, CMS will require an in-person exam to obtain payment for telehealth mental health services at a patient’s home.
Under the rule, CMS will cover a telehealth service delivered while the patient is at their home if the following conditions are met:
- The practitioner conducted an in-person exam of the patient within the six months before the initial telehealth service
- The telehealth service is furnished for purposes of diagnosis, evaluation, or treatment of a mental health disorder—other than for treatment of a diagnosed substance use disorder (SUD) or co-occurring mental health disorder
- An in-person non-telehealth visit is furnished at least every 12 months for these services
CMS Revised Rule
President Joe Biden signed into law the Consolidate Appropriations Act (CAA) on March 15, 2022. The act revised and updated certain telehealth flexibilities for Medicare patients.
This allows for the telehealth flexibilities to continue for 151 days after the first day after the official end of the PHE which provides an extension related to the in-person requirement for mental health services.
The CMS in-person rule has exceptions. It’s important that hospitals and physicians’ offices, especially those providing telehealth, understand that these exceptions can assist organizations to extend what they consider an originating site, where the patient is located, as well as, expanding the list of telehealth practitioners.
Exceptions to the rule include:
- If the patient is at a qualifying originating site in an eligible geographic area, such as a practitioner office in a rural Health Professional Shortage Area (HPSA), and the arrangement meets the statutory requirements for telehealth service coverage under Medicare, an in-person exam isn’t a prerequisite for reimbursement.
- The in-person exam doesn’t apply to telehealth treatment of a diagnosed SUD or co-occurring mental health disorders—the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act already made the patient’s home an eligible originating site for such services.
- If the patient and practitioner agree benefits of an in-person, non-telehealth service within 12 months of the mental health telehealth service are outweighed by risks and burdens associated with an in-person service, and the basis for that decision is documented in the patient’s medical record, the in-person visit requirement won’t apply for that 12-month period.
Revisions for Rural Providers and FQHCs
The revised statutory language for mental health visits in Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs) was also addressed in CY 2022 Physician Fee Schedule (PFS) Final Rule, enabling RHCs and FQHCS to provide mental health visits using interactive, real-time telecommunications technology effective January 1, 2022. These visits differ from telehealth services provided during PHE and need to be coded as such. On June 6, 2022, CMS delayed the in-person requirements under Medicare for mental health visits that RHCS and FQHCS provide via telecommunications technology. In-person visits won’t be required until the 152nd day after the end of the PHE, as outlined in Section 304 of the Consolidated Appropriations Act (CAA) 2022.
Documentation of Exceptions
When utilizing any of the exceptions, documentation is key. Providers must document the type of exception for each applicable period.
The Code of Federal Regulations (CFR), 125(c) of the CAA amended section 1834(m)(4)(C)(ii) provides the following examples of exceptions:
- Situations in which an in-person service is likely to cause disruption in service delivery or has the potential to worsen the patient’s condition
- The risks and burdens associated with an in-person service could also outweigh the benefit if a patient is in partial or full remission and only requires a maintenance level of care
- The clinician’s professional judgement that the patient is clinically stable or that an in-person visit has the risk of worsening the patient’s condition, creating undue hardship on self or family
- If it’s determined that the patient is at risk for disengagement with care that has been effective in managing the illness
CMS officials emphasized that coverage for audio-only telehealth services is limited to mental health care services furnished by providers to a patient who is in their home, who use two-way audio-visual telehealth platforms—often called video visits—but whose patients either can't or don't want to use that platform and choose to use the audio platform only.
According to the exceptions allowed under the new rule, audio-only telehealth can be reimbursed.
Consequences of Miscoding
The Department of Justice (DOJ) and the Office of Inspector General (OIG) placed telehealth as a focus area in the in 2021 and 2022 work plan items and audit reports.
The OIG has focused on behavioral health services including a study in 2021 stating that states may not have oversight of the extent or quality of the services performed as telehealth and that further expansion without proper delivery provisions may lead to further problems and review.
Consequences of inappropriate reporting may result in identification as an outlier for telehealth services and may include:
- Under or overpayment
- Regulatory audits
- Denial of benefits for professional and telehealth service fees