Highlights for Social Workers in the Medicare 2024 Physician Fee Schedule

By NASW Practice Team

February 2024

On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the 2024 Medicare Physician Fee Schedule (PFS) (CMS–1784–P). The PFS is a listing of fees used by Medicare to reimburse Medicare providers. It addresses changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in health care practices. The rule was implemented on January 1, 2024, and applies to Medicare beneficiaries and Medicare providers including clinical social workers (CSWs). In September 2023, NASW submitted detailed comments in response to the proposed rule. This document provides key highlights on the final rule which impact social workers in the areas of telehealth behavioral health, social needs, and many others. NASW is excited to announce that the Health Behavioral Assessment and Intervention services are now reimbursable by clinical social workers. For over 20 years, NASW advocated for clinical social workers to receive payment of these services.Other highlights follow.

Telehealth Services [Section II.D]

Implementation of Provisions of the Consolidated Appropriations Act (CAA), 2023 [Section II.D.1.e]

As mandated by the CAA, 2023 (Pub. L. 117–328), CMS will continue to pay for audio-visual and audio-only services until December 31, 2024. The agency also finalized telehealth services furnished to patients in their homes will be paid at the non-facility rate to protect access to mental health and other telehealth services.

CMS finalized that it would continue to define direct supervision to permit the presence and immediate availability of the supervising practitioner through real-time audio and video interactive telecommunications through December 31, 2024.

In addition, CMS finalized the temporary expansion of telehealth originating sites for services furnished via telehealth to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual’s home. The agency also finalized the continued payment for telehealth services furnished by rural health clinics (RHCs) and federally qualified health centers (FQHCs).

CMS delayed the requirement for an in-person visit with the physician or provider within six months prior to initiating mental health telehealth services, as well as similar requirements for RHCs and FQHCs; and the continued coverage and payment of telehealth services included on the Medicare Telehealth Services List until December 31, 2024.

NASW agrees with the extension of the telehealth services through December 31, 2024, and will continue to advocate for permanency of the telehealth flexibilities.

Caregiver Training Services [Section II.E.4(27)]

CMS finalized its proposal to make Medicare payment available for caregiver training services (CTS). CTS support family caregivers (defined broadly by CMS) to support beneficiaries with certain physical or behavioral health conditions, such as dementia or bipolar disorder, in carrying out a beneficiary’s individualized plan of care. CTS are provided without the beneficiary present, although the beneficiary (or their representative) must provide consent before CTS commence.

In the proposed rule, CMS had stated that treating practitioners eligible to bill Medicare for CTS could include a physician or a qualified health professional such as a nurse practitioner, physician assistant, clinical nurse specialist, clinical psychologist, physical therapist, occupational therapist, or speech–language pathologist. In its comments on the proposal, NASW had urged CMS to add CSWs to that list, offering multiple examples of how CSWs provide CTS as part of a plan of care for beneficiaries living with mental health conditions. (Although CSWs provide CTS related to numerous physical health conditions, as well, the proposed rule had made clear that Medicare would only reimburse for CTS when provided by a practitioner who could diagnose and treat the beneficiary for the condition in question. The diagnosis and treatment of physical health conditions is outside the CSW scope of practice. It is worth noting that AARP also advocated for social workers to be able to provide CTS.)

The final rule does not include NASW’s recommended change; the association will continue its advocacy as opportunities emerge.

Services Addressing Health-Related Social Needs [Section II.E.4(28)]

Community Health Integration (CHI) Services and Principal Illness Navigation (PIN) Services

Beginning January 1, 2024, CMS will pay separately for CHI and PIN services when community health workers, care navigators, and peer support specialists perform medically necessary care. CHI and PIN services are initiated when they are furnished under the general supervision of a billing physician. NASW advocated for inclusion of social workers in CHI and PIN services without success.The association will continue its advocacy in this area.

Social Determinants of Health (SDOH) Risk Assessment [Section II.E.4(28)d]

CMS finalized its proposal to establish SDOH Risk Assessment as a stand-alone G code (HCPCS G0136). Practitioners conducting this assessment may use “any standardized, evidence-based SDOH risk assessment tool that has been tested and validated through research … [and] include[s] the domains of food insecurity, housing insecurity, transportation needs, and utility Difficulties.” CMS declined to add interpersonal safety as a required domain of the standardized SDOH risk assessment tool, as NASW and certain other commenters had suggested:

We agree that interpersonal safety is an important dimension of potential SDOH needs, and we also recognize the potential difficulty of collecting, storing, and acting on such sensitive information in a clinical setting. We note that practitioners may add additional domains if they believe those domains are relevant to their patient population, in which case they could utilize a tool that includes interpersonal safety. (Final Rule, p. 78935)

CMS finalized its proposal to allow any practitioner treating a beneficiary to bill Medicare using the SDOH Risk Assessment G code up to once every six months (per beneficiary), although it acknowledged comments (such as those submitted by NASW) that more frequent use of the code be permitted.

Additionally, CMS stressed that the G code is intended for use primarily in outpatient evaluation and management (E/M) visits conducted by physicians, nurse practitioners (NPs), physician associates (PAs), clinical nurse specialists (CNSs), and certified nurse midwives (CNMs). The code may also be used by these professionals in conjunction with hospital discharge visits. In its comments on the proposed rule, NASW had advocated for CSWs to be able to use the SDOH Risk Assessment G code. The final rule includes this response from CMS:

We agree with commenters that SDOH risk assessment is relevant to the diagnosis and treatment of conditions furnished by practitioners such as clinical psychologists for patients with behavioral health conditions. We do not agree with commenters that all practitioners who can bill for Medicare should qualify to perform the SDOH risk assessment under statute as reasonable and necessary, as we believe that practitioners who can bill E/M or similar behavioral health visits such as CPT code 90791 and HBAI codes are best positioned to provide follow-up and ongoing assessment in a longitudinal way. These codes are used by clinical psychologists to diagnose and treat behavioral health conditions as analogous codes to E/M services given State law and scope of practice. We acknowledge that other practitioners such as clinical social workers may benefit from an understanding of the patient’s SDOH considerations to furnish their services. However, we believe that this information should be shared when possible or applicable with the care team by the furnishing practitioner of the associated E/M or behavioral health visit. (Final Rule, p. 78934)

Based on this information, CSWs would only be able to bill using the SDOH Risk Assessment G code incident to a physician, NP, PA, CNS, CNM, or clinical psychologist. Yet, the final rule states:

Our aim is to allow behavioral health practitioners to furnish the SDOH risk assessment in conjunction with the behavioral health office visits they use to diagnose and treat mental illness and substance use disorders. We are finalizing that in addition to an outpatient E/M visit (other than a level 1 visit by clinical staff) as proposed, SDOH risk assessment can also be furnished with CPT code 90791 (Psychiatric diagnostic evaluation) and the Health Behavior Assessment and Intervention (HBAI) services, described by CPT codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168.

Medicare statute (Social Security Act, 42 U.S.C. § 1395x(hh)(2) (1989)) defines clinical social worker services as the diagnosis and treatment of mental illness. Moreover, the final rule extends to CSWs the ability to bill Medicare using the preceding list of HBAI codes. Given these two factors, one might deduce that CSWs could, in fact, use the SDOH Risk Assessment G code. NASW will seek clarification from CMS regarding this apparent contradiction and will continue to advocate for CSWs in this regard.

The final rule also stresses that the SDOH risk assessment,

when performed in conjunction with an E/M or behavioral health visit[,] is not designed to be a screening, but rather tied to one or more known or suspected SDOH needs that may interfere with the practitioners’ diagnosis or treatment of the patient. (p. 78934)

CMS withdrew its proposal requiring the SDOH risk assessment to be performed on the same date as the associated E/M or behavioral health visit (such as CPT code 90791 or HBAI codes), recognizing that this timing may not be feasible for practitioners. NASW is pleased with this change, which makes team-based care more feasible.

SDOH Risk Assessment in the Annual Wellness Visit (AWV) [Section III.S]

Medicare covers an AWV with a physician, CNS, NP, or PA for each beneficiary. During this visit, the provider conducts a Health Risk Assessment and develops or updates a Personalized Prevention Plan with the beneficiary. Certain areas, such as screening for potential SUDs, are inherent within the AWV. Others, such as advance care planning, are optional (at the discretion of the beneficiary and the provider).

In the final rule, CMS finalized its proposal, consistent with NASW’s recommendation, to add SDOH Risk Assessment (HCPCS G0136) as an optional element within the AWV at no additional cost to the beneficiary. It clarified that CSWs—for whom NASW had advocated in its comments as qualified to conduct SDOH risk assessments—and certain other “medical professionals” (or a team of such medical professionals) may conduct the SDOH Risk Assessment under the direct supervision of a physician.

CMS declined to act on a recommendation from NASW and some other commenters that the SDOH Risk Assessment be a mandatory element of every AWV but stated it may consider the possibility in future rulemaking. However, CMS did clarify that the SDOH Risk Assessment and other elements of the AWV may be completed over multiple visits and days rather than in a single visit on a single day, as NASW and other commenters had recommended. This flexibility will enable primary care practices (including FQHCs and RHCs) to maximize the participation of social workers and other professionals in the AWV, thereby promoting integrated care.

Advancing Access to Behavioral Health Services (Section II.J)

Health Behavior Assessment and Intervention (HBAI) Services

CMS finalized its proposal to allow the HBAI services described by Current Procedural Terminology (CPT) codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168, and any successor codes, to be billed by CSWs, marriage and family therapists (MFTs), and mental health counselors (MHCs) beginning in January 2024. (Clinical psychologists were already allowed to bill Medicare for HBAI services.). HBAI services address psychological, behavioral, emotional, cognitive, and social factors in the treatment of people with diagnosed physical health conditions. Expanding the scope of practitioners who can provide these services will improve the integration of physical and behavioral health care, as many physical health conditions have psychological implications. NASW applauds CMS’s decision to allow CSWs to receive reimbursement for HBAI services.

Mobile Crisis Services [Section II.J.2]

Billing codes under the PFS for psychotherapy services are receiving an increase in payment beginning January 2024. The payment rate for psychotherapy for crisis services will be 150% of the fee schedule amount for non-facility sites of service. Identified by codes 90839 (psychotherapy for crisis; first 60 minutes) and 90840 (psychotherapy for crisis; each additional 30 minutes. NASW supports increased payment for crisis care, substance use disorder treatment, and psychotherapy services.

Payment for Timed Behavioral Health Services [Section II.J.5]

In addition, CMS finalized an increase in the valuation for timed behavioral health services under the PFS. This change will increase the payment for psychotherapy codes over a four-year period and will also apply to HBAI codes. As stated in NASW’s comments on the proposed rule, the association supports the change to increase the valuation for timed behavioral health services under the PFS and believes this is an important step towards providing more equitable payments for all providers of mental health services and increasing patient access to essential mental health services.

Digital Therapies [Section II.J.8]

CMS had requested feedback in the proposed rule on potential advantages and obstacles associated with coverage and payment policies for digital therapies. Specifically, CMS requested concrete examples of digital therapeutics (DTx) being used in practice settings, the safety and privacy criteria set by the industry, and if they could be charged using current codes for remote therapeutic monitoring. CMS inquired about the elements of DTx for mental health that should be considered when determining the need for a new Medicare benefit classification. In its comments on the proposed rule, NASW provided feedback encouraging the continued evaluation of these services to ensure their efficacy in patient care and commended CMS for its consideration of digital services in the workplace. Comments received in the proposed rulewill be considered in future rulemaking beyond 2024.

Mental Health Services Provided by CSWs in Skilled Nursing Facilities (SNFs)

In its comments on the proposed rule, NASW urged CMS to remove the restriction that prohibits beneficiaries who receive SNF services under Medicare Part A from accessing mental health services provided by independent CSWs under Medicare Part B. Noting that CMS had stated more than 26 years ago that it would address the issue in rulemaking, NASW cited the following recommendations from a 2022 study by the National Academies of Sciences, Engineering, and Medicine (NASEM), The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff:

Recommendation 2D: To enhance the available expertise within a nursing home:

• Nursing home administrators, in consultation with their clinical staff, should establish
consulting or employment relationships with qualified licensed clinical social workers at the M.S.W. or Ph.D. level [emphasis added], advanced practice registered nurses (APRNs), clinical psychologists, psychiatrists, pharmacists, and others for clinical consultation, staff training, and the improvement of care systems, as needed.
• The Centers for Medicare & Medicaid Services should create incentives for nursing homes to hire qualified licensed clinical social workers at the M.S.W. or Ph.D. level as well as APRNs for clinical care [emphasis added], including allowing Medicare billing and reimbursement for these services. (NASEM, p. 512)

NASW observed that CMS had implemented regulations enabling MFTs and MHCs to provide independent mental health services to Medicare beneficiaries receiving SNF services (a consequence of the CAA of 2023), concluding: “NASW urges CMS to build on this step by permitting clinical social workers to do the same.”

CMS did not incorporate NASW’s recommended change within the final rule. The association will continue to advocate with CMS on this issue while pursuing a legislative solution, the Improving Access to Mental Health Act (S. 838/H.R. 1638).

Care Management Services

NASW’s comments on the proposed rule acknowledged CMS’s recognition that care management services are integral to effective behavioral health care; that delivery of care management services is often an interdisciplinary effort; and that CSWs are among the professionals who provide care management services within their scope of practice under the general supervision of a physician, NP, PA, or CNS. Explaining that in some circumstances a beneficiary’s needs may align best with care management services provided by a nonmedical team member, NASW encouraged CMS to authorize CSWs to obtain independent reimbursement for care management services. CMS did not respond to this comment within the final rule.NASW will continue to advocate for CSWs to receive reimbursement in this area.

Rural Health Centers and Federal Qualified Health Centers [Section III.B]

CMS established coverage and payment for intensive outpatient (IOP) services provided by RHCs and FQHCs. The finalized proposals for the IOP provisions can be found in the hospital outpatient prospective payment system final rule for calendar year (CY) 2024. CMS also finalized its proposal to change supervision requirements for behavioral health services in RHCs and FQHCs to allow general supervision instead of direct supervision. This change is consistent with policies finalized under the PFS in last year's rulemaking for other settings. Additionally, CMS has approved the inclusion of CHI and PIN services in the general care management code G0511 for RHCs and FQHCs either alone or with other payable services. The payment rate calculation was amended for this code to reflect utilization rates of these services. CMS clarified that obtaining beneficiary consent for chronic care management and virtual communications services is required, but the mode of obtaining consent can vary and direct supervision is not needed.

Opioid Treatment Programs (OTP) [Section III.F]

CMS finalized the proposal to revise paragraph (vii) of the definition of “Opioid use disorder treatment service” at § 410.67(b) of the regulations to state that through the end of 2024, in cases where a beneficiary does not have access to two-way audio-video communications technology, periodic assessments can be furnished using audio-only telephone calls if all other applicable requirements are met.”NASW supported this regulation.

CMS extended telehealth flexibilities another year to allow them time to further consider whether periodic assessments should continue to be furnished using audio-only communication technology following the end of 2024 for patients who are receiving treatment via buprenorphine, methadone, and/or naltrexone at OTPs.”

CMS deferred to the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Agency (DEA) regarding clinical guidance to ensure the use of audio-video modalities maintain program integrity.

Hospice Conditions of Participation [Section III.O]

CMS revised the hospice Conditions of Participation (CoPs) as proposed, to enable MFTs and MHCs to serve in the interdisciplinary group (IDG, also known as “interdisciplinary team”). The final rule states:

The hospice IDG will only be required to include one SW, one MFT, or one MHC. The hospice is not required to include all three of these professions as members of the IDG. We note that the hospice may choose (although is not required) to select more than one of these professions to serve as member(s) of the IDG. (Final Rule, p. 79298)

The final rule simultaneously clarifies that social workers, MFTs, and MHCs may all provide counseling services but that MFTs and MHCs cannot provide medical social services, which remain the domain of the social worker (as defined by CMS regulations):

One significant change from the proposed rule is that CMS did not finalize a proposal mandating that selection of a social worker, MFT, or MHC serve on a particular IDG be based on the preferences and needs of the Medicare beneficiary (hospice patient). In its comments on the proposed rule, NASW acknowledged the addition of MFTs and MHCs to the hospice IDG while upholding the contributions of hospice social workers.

CMS is developing a document addressing frequently asked questions regarding the MFT, MHC, and hospice provisions within the final rule. NASW will notify members when the CMS document is available.

Medicare and Medicaid Provider Supplier Enrollment [Section III.K]

CMS finalized NASW supported proposal intended to confirm that providers and suppliers seeking to bill Medicare for services and items furnished to beneficiaries meet all applicable federal and state requirements to do so. Such proposal concern Medicare enrollment, revocation, and denial.

In contrast, CMS did not finalize proposals enabling it to revoke or deny Medicare enrollment because of misdemeanor convictions that CMS deems detrimental to the best interests of the Medicare program and its beneficiaries.Examples of misdemeanors include fraud or other criminal misconduct involving the provider’s or supplier’s participation in a federal or state health care program or the delivery of services of items thereunder; assault, battery, neglect, or abuse of a beneficiary (including sexual offenses); and any other misdemeanor that places the Medicare program or beneficiaries at immediate risk, such as a malpractice suit that results in a conviction of criminal neglect or misconduct. The decision not to finalize these proposals was based on public comments regarding potential unintentional consequences, such as the criminalization of practice and perpetuation of incarceration-related inequities. NASW believes these points are well taken and concurs with CMS’s decision.

CMS finalized its proposed definition of “indirect ownership interest,” which will be added to § 424.502. NASW supported this proposal, consistent with the association’s spring 2023 comments to CMS regarding a proposed rule addressing nursing home ownership. Comprehensive information about ownership of any Medicare provider organization or supplier promotes quality by enabling CMS and beneficiaries to hold providers and suppliers accountable for services provided.

Dental Services [Section II.K]

CMS finalized its proposal to clarify coverage of dental services that are “inextricably linked to, and substantially related and integral to the clinical success of” (Final Rule, p. 79017) three Medicare-covered cancer treatments: (1) chemotherapy, (2) chimeric antigen receptor (CAR) T-Cell therapy, and (3) high-dose bone-modifying agents (antiresorptive therapy). Moreover, CMS finalized its proposal to permit Medicare payment for a dental or oral examination performed

as part of a comprehensive workup prior to, medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with, and medically necessary diagnostic and treatment services to address dental or oral complications after, radiation, chemotherapy, and/or surgery when used in the treatment of head and neck cancer. (Final Rule, p. 79029).

These NASW-supported changes are specific to traditional (original) Medicare coverage. The association refers social workers to CMS’s Medicare dental coverage page for more information.

During the comment period for the proposed rule, NASW and other members of the Medicare Oral Health Coalition had encouraged CMS to include in the final rule coverage of dental services related to the following circumstances: (1) radiation treatment for cancer, (2) treatment for autoimmune conditions, cardiovascular disease, diabetes, hemophilia, and sickle cell disease; and (3) some treatments for noncancer diagnoses, such as the use of chemotherapy for certain blood disorders and autoimmune conditions. Although the final rule did not include these changes, CMS continues to solicit comments focused on clinical evidence. NASW will continue its advocacy efforts on these changes.

Drugs and Biological Products [Section III.A]

The Inflation Reduction Act (Pub. L. 117–169, 2022) included provisions to reduce out-of-pocket medication costs for Medicare beneficiaries. CMS finalized the following changes to regulatory text, both supported by NASW, to conform with two provisions of the law:

• Section 11101, which requires that beneficiary coinsurance for a Part B rebatable drug is to be based on the inflation-adjusted payment amount if the Medicare payment amount for a calendar quarter exceeds the inflation-adjusted payment amount
• Section 11407, provides that for insulin furnished through a durable medical equipment item, the deductible is waived, and coinsurance is limited to $35 for a month’s supply

Medicare Shared Savings Program [Section III.G]

Participants in the Medicare Shared Savings Program, more commonly known as accountable care organizations (ACOs), must report various quality data to CMS. One such dataset includes responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for Merit-Based Incentive Payment Systems (MIPS) survey. CMS has created official translations of the CAHPS for MIPS survey in seven languages (Cantonese, Korean, Mandarin, Portuguese, Russian, Spanish, and Vietnamese). Yet, aside from a requirement to use the Spanish translation of CAHPS for MIPS in Puerto Rico, use of these translations is voluntary. CMS finalized its proposal to require administration in Spanish of the CAHPS for MIPS survey. This change, which NASW had supported in its comments on the proposed rule, will make the survey more accessible to beneficiaries.

In its comments on the proposed rule, NASW had also encouraged CMS to consider the addition of other CAHPS for MIPS survey languages in future rulemaking. CMS opted not to include such changes in the final rule, citing ACO provider cost as a factor, but expressed its intent to consider requirements related to additional translations in the future.

Vaccine Administration Services [Section III.H]

For the past couple years, CMS has encouraged COVID-19 vaccination by boosting reimbursement for Medicare providers and suppliers who administer COVID-19 vaccines in a beneficiary’s home. Within the current rule, CMS finalized its proposal to continue the additional Medicare Part B payment for in-home administration of COVID-19 vaccines. The final rule also extends the additional in-home payment to the administration of the hepatitis B, influenza, and pneumococcal vaccines. These provisions, which NASW had supported in its comments on the proposed rule, will improve access to vaccines for underserved beneficiaries.

Medicare Diabetes Prevention Program (MDPP) [Section III.I]

The MDPP is an evidence-based, nonpharmalogical, behavioral intervention program to prevent type 2 diabetes. Medicare beneficiaries with certain risk factors may participate in the program, without cost sharing, once during their lifetime. Although the program was designed to be conducted in person, the COVID-19 pandemic prompted CMS to authorize Medicare payment for MDPP delivery in a virtual or hybrid format (among other flexibilities). The final rule includes the following provisions:

• extension of the flexibilities allowed under the COVID-19 public health emergency through December 31, 2027; these flexibilities will apply only to MDPP suppliers that have and maintain CDC certification as a Diabetes Prevention Recognition Program (DPRP)
• addition of definitions for distance learning and online delivery modalities in § 410.79(b) to clarify which virtual modalities can be used in the proposed extended flexibilities period (NASW had not, however, recommended which virtual modalities should be used)
• creation of a new HCPCS G-code specific to distance learning, which will enable CMS to track trends related to this service delivery modality
• enabling MDPP suppliers to deliver the program through both in-person and distance learning

These provisions, which NASW had supported in its comments on the proposed rule, will increase equitable access to diabetes preventive services among rural beneficiaries and beneficiaries at high risk for type 2 diabetes.

Diabetes Screening [Section III.L]

Medicare covers blood glucose laboratory test screenings for beneficiaries at risk for developing diabetes. CMS finalized its proposal to add the Hemoglobin A1C (HbA1c) to the types of diabetes screening tests covered by Medicare. This change is consistent with the recommendations of the U.S. Preventive Services Task Force and input offered by the American Diabetes Association and other diabetes-focused organizations. Additionally, CMS finalized its proposal to simplify frequency limitations for diabetes screening by enabling a beneficiary who was previously diagnosed with prediabetes to obtain up to two diabetes screening tests within a 12-month period rather than within a calendar year. These changes, which NASW had supported in its comments on the proposed rule, will speed detection of and treatment for prediabetes and diabetes.