Telehealth for Mental Health Conditions in the Primary Care Clinic: Opportunities and a Way Forward

On January 1, 2022, the Centers for Medicare & Medicaid Services (CMS) implemented permanent changes in the Medicare Physician Fee Schedule that offer new possibilities to expand the scope of telehealth for mental health (MH) and substance use disorders (SUD) for Medicare patients. These changes are a direct response to recent increases in MH and SUDs over the last two years, which have been especially deadly in combination with the tsunami of synthetic opioids (namely fentanyl) that has cascaded across the United States.¹

Amid the shelter-in-place regulations of the COVID-19 pandemic, telehealth emerged as a powerful tool. Telehealth can improve access to care, particularly among vulnerable populations who may lack funds for travel and care of dependents. For patients with SUDs, stigma may present further barriers to in-person care, which telehealth may help to alleviate.² Not only do primary care clinics present an entryway into care for MH disorders, they increasingly receive a greater proportion and volume of visits for MH disorders than psychiatry offices.³

Those of us in general medicine have long been hampered in our efforts to expand access for our patients SUD and MH conditions by insufficient resources. With the new service code options provided by CMS, we can explore innovative ways of care delivery that leverage the expertise of a multi-disciplinary team. In the table, we lay out relevant Medicare telehealth service codes with the respective payments in relative value units (RVUs). RVUs translate to dollars by multiplying times the Medicare conversion factor, roughly $35.

Here Are the CMS Changes You Need to Know About

The patient can be located anywhere—whereas telehealth services were previously confined to dedicated spaces, telehealth services for MH and substance use care can be provided to patients who are home, or at another location including a shelter, car, or their place of work. State licensing restrictions still apply. Encounters should be clearly focused on MH/SUD but other conditions can and should be addressed.

In-person visits are sometimes required—CMS has required an in-person visit no more than six months before the telehealth visit, and at no greater than every 12 months after. However, the 12-month periodic in-person visit can be waived if a provider documents that the burdens of an in-person visit outweigh the benefits; and how vital signs, patient monitoring data, and lab testing are available as needed. Finally, all in-person requirements can be waived for SUD telehealth visits.

Audio-visual technology preferred but audio-only allowed—CMS’ preference remains for audio-visual telehealth visits, but audio-only may be delivered if the patient does not have the capabilities or does not consent to participate in a video telehealth visit, and this is appropriately documented.