New CMS rule, coding, and compliance for behavioral health and telehealth

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.

Background

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