NASW Comment Letter to CMS 2025 Physician Fee Schedule

NASW Practice Team

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September 9, 2024

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS–1807–P
7500 Security Boulevard
Baltimore, MD 21244-1850

Re: Medicare and Medicaid Programs; CY 2025 Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies (CMS–1807–P)

Submitted electronically: https://www.regulations.gov/commenton/CMS-2024-0256-0045

Dear Administrator Brooks-LaSure:

I am writing to you on behalf of the 110,000 members of the National Association of Social Workers (NASW). NASW is the largest and oldest professional social work organization in the United States. The association promotes, develops, and protects the practice of social work and professional social workers. Social workers are the largest provider of mental, behavioral, and social care services in the nation and serve a crucial role in connecting individuals and families to health care services.

NASW appreciates the opportunity to submit comments on CMS–1807–P, Notice of Proposed Rule Making (NPRM) on the revisions of Medicare and Medicaid Programs; CY 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; and Medicare Overpayments. The association supports CMS’s strategy to create an equitable health care system that results in better access to care, quality, affordability, and innovation.

NASW’s comments address the following subjects:

• Payment for Medicare Telehealth Services under Section 1834(m) of the Social Security Act (Section II.D)
  • Frequency Limitations on Medicare Telehealth Subsequent Care Services in Inpatient and Nursing Facility Settings, and Critical Care Consultations (II.D.1.d.)
  • Audio-only Communication Technology to Meet the Definition of “Telecommunications System” (II.D.1.e.)
  • Distant Site Requirements, including Proposal to Extend Definition of “Direct Supervision” to Include Audio–Visual Communications Technology through 2025 (II. D.2.a(1))
• Valuation of Specific Codes (Section II.E)
  • Payment for Caregiving Training Services (II.E.4(39)), including Additions to Medicare Telehealth Services List (II.D.1.b(10))
  • Request for Information on Services Addressing Health-Related Social Needs (II.E.4(40)(b))
• Advanced Primary Care Management (APCM) (Section II.G.2)
• Advancing Access to Behavioral Health Services (Section II.I)
  • Safety Planning Interventions (II.I.1.b)
  • Postdischarge Telephonic Follow-up Contact Intervention (FCI) (II.I.1.c)
  • Payment for Digital Mental Health Treatment (DMHT) Devices (II.I.2.b)
  • Interprofessional Consultation Billed by Practitioners Authorized by Statute to Treat Behavioral Health Conditions (II.I.3.b)
  • Comment Solicitation on Payment for Services Furnished in Additional Settings, Including Freestanding SUD Treatment Facilities, Crisis Stabilization Units, Urgent Care Centers, and Certified Community Behavioral Health Clinics (CCBHCs) (II.I.4)
• Proposals on Medicare Parts A and B Payment for Dental Services Inextricably Linked to Specific Covered Services (Section II.J)
• Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) (Section III.B)
  • Request for Information—Aligning with Services Paid under the PFS (III.B.2.e)
  • In-person Visit Requirements for Remote Mental Health Services Furnished by RHCs and FQHCs (III.B.3.d)
  • Payment for Preventive Vaccine Costs in RHCs and FQHCs (III.B.5)
  • Payment for Dental Services Furnished in FQHCs (III.B.8.a)
  • “Grandfathered” Technical Requirement (III.B.9)
• Proposed Changes to RHC and FQHC Conditions for Certification and Conditions for Coverage (CfCs)—Provision of Services (42 C.F.R. 491.9) (Section III.C.2.a)
• Medicare Diabetes Prevention Program (Section III.C)
• Modifications Related to Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs) (Section III.F)
  • Telecommunication Flexibilities for Periodic Assessments and Initiation of Treatment with Methadone (III.F.2)
  • Proposals Related to Reforms to 42 CFR Part 8 (III.F.3)
  • Clarification to Require an OUD Diagnosis on Claims for OUD Treatment Services (III. F.5)
• Medicare Part B Payment for Preventive Services (§§ 410.10, 410.57, 410.64, 410. 152) (Section III.H)
• Medicare Prescription Drug Inflation Rebate Program (Section III.I)
• Expand Hepatitis B Vaccine Coverage (Section III.M)
• Medicare Parts A and B Overpayment Provisions of the Affordable Care Act (Section III.O)
• Updates to the Quality Payment Program (Section IV)
  • Merit-based Incentive Payment System (MIPS) Clinical Quality Measures (QCMs) for Clinical Social Work
  • CY 2025 Proposed and Modified MIPS Value Pathways (MVPs)
  • Measure/Activity Inventories and Scoring Methodologies
  • Maintaining Stability
  • Request for Information
  • Elder Maltreatment Screen and Follow-Up Plan (Quality # 181)
• Access to Mental Health Services Provided by Independent CSWs to Skilled Nursing Facility (SNF) Residents under Medicare Part B
• CSW Reimbursement Rates

Our comments follow.

Payment for Medicare Telehealth Services under Section 1834(m) of the Social Security Act (Section II.D)

Frequency Limitations on Medicare Telehealth Subsequent Care Services in Inpatient and Nursing Facility Settings, and Critical Care Consultations (II.D.1.d)

NASW respectfully disagrees with CMS’s proposal to remove frequency limitations for subsequent nursing facility visits as reflected in CPT codes 99307 through 99310. Nursing facility residents have acute and complex health conditions that necessitate careful monitoring and treatment. Moreover, some residents are unable to advocate for themselves and lack family caregivers who could engage in such advocacy. In-person, facility-based visits by physicians and nonphysician practitioners (NPPs) are essential to quality of life and quality of care for residents.

Audio-Only Communication Technology to Meet the Definition of “Telecommunications System” (II.D.1.e)

NASW supports the proposed revision to regulation § 410.78(a)(3), which would allow an interactive telecommunications system to also encompass two-way, real-time, audio-only communication technology for any telehealth service provided to a beneficiary in their home. This proposal is a strategic initiative that enhances inclusivity and accessibility in the delivery of telehealth services, attending to patients’ varying technological access, abilities, and comfort levels. It supports patient autonomy in health care and mitigates potential technological barriers, thus promoting both telehealth service utilization and overall health care access.

Distant Site Requirements (II.D.1.f)

NASW supports CMS’s proposal to continue permitting the distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. We appreciate CMS's proactive approach in addressing concerns regarding the privacy and safety of telehealth practitioners. 

Proposal to Extend Definition of “Direct Supervision” to Include Audio–Video Communications Technology through 2025 (II.D.2.a(1))

NASW agrees with CMS's proposal to extend the definition of direct supervision to include the real-time audio and visual presence of the supervising practitioner via interactive telecommunications through December 31, 2025. This proposal addresses the important role of telehealth and providing supervision without geographical constraints. At the same time, we encourage CMS to continue to monitor the effectiveness of supervision through telehealth. Per our comments on the CY 2024 PFS proposed rule (CY 2024 Physician Fee Schedule Rule, 2023) virtual supervision should be treated similarly to in-person supervision, with the same level of oversight to ensure appropriate service provision. (Bedney, B, 2023). NASW encourages CMS to take measures to prevent potential fraud and abuse. Such measures include safeguards to ensure that any virtual supervision is conducted in a secure environment and in accordance with all HIPAA and Medicare requirements. Utilizing appropriate privacy and security protocols is essential to protect patient information within the supervision relationship. The use of videoconferencing on HIPAA-compliant platforms provides an additional layer of safety for both the supervisors and supervisees. Additionally, NASW consideration of the complexity of the service and the skills and training of the personnel performing the service is essential when determining requirements for virtual or in-person supervision.

Valuation of Specific Codes for CY 2025 (Section II.E.4)

Payment for Caregiver Training Services (II.E.4(39))

Caregiver Assessment (II.E.4(39)(b))

NASW supports CMS’s proposal to include assessment of the caregiver’s skills and knowledge in the service described by CPT code 96161 when such assessment is necessary for the purposes of caregiving training. We appreciate the reminder that caregiver-focused health risk assessments can be necessary components of services furnished to Medicare beneficiaries. We agree with CMS that obtaining the consent of the beneficiary (or that individual’s representative) is necessary when such caregiver-focused health risk assessments are furnished outside the beneficiary’s presence. Moreover, we concur with the proposal to apply to caregiver training services (CTS) and the caregiver-focused health risk assessment the definition of “caregiver” specified in the calendar year (CY) 2024 Physician Fee Schedule (PFS) final rule.

Proposals and New Coding (II.E.4(39)(c))

• Direct Care CTS—Coding (II.E.4(39)(c)(A)i)
  NASW supports CMS’s proposals to establish coding (GCTD1, GCTD2, and GCTD3) and payment for direct care CTS and to add these three new codes to the Medicare Telehealth Services List. Innumerable caregivers provide direct care. These caregivers frequently require training to fulfil these tasks and to effectuate desired health outcomes for beneficiaries. An example of a direct care service for which caregivers might need training is the emptying of colostomy, ostomy, or urostomy bags. Direct care CTS may overlap with services provided by home health agencies and hospice programs.
• Individual Behavior Management/Modification CTS (II.E.4.(39)(b)(A)i)
  NASW supports CMS’s proposal to establish coding (GCTB1 and GCTB2) and payment for caregiver behavior management and modification training that could be furnished to the caregiver(s) of an individual beneficiary. We also support the proposal to add these codes to the Medicare Telehealth Services List. Limitations in respite services and transportation may prevent many caregivers from participating in similar training services provided in group settings (CPT codes 96202 and 96203). Moreover, group services may not meet the needs of all caregivers; some may learn more easily in one-on-one situations.
• Patient Consent (II.E.4.(39)(b)(C))
  NASW concurs with CMS that consent can be provided verbally by the beneficiary or representative for services reflected in the current CTS CPT codes, any CTS HCPCS codes finalized in the CY 2025 rule, and any subsequently created CTS codes.
• Addition to Telehealth List (II.E.4.(39)(b)(D) and (II.D.1.b(10))
  NASW supports CMS’s proposal to add CTS, as described by CPT codes 96202 and 96203 and HCPCS codes GCTB1, GCTB2, GCTD1, GCTD2, and GCTD3, to the Medicare Telehealth Services List. We are not offering comment on the proposed addition of CPT codes 97550, 97551, and 97552 to the list.

Moreover, NASW respectfully reiterates its request for clarification regarding the ability of clinical social workers (CSWs) to bill Medicare directly for CTS in the context of a plan of care for mental health conditions. As we noted in our comments on the CY 2024 PFS NPRM, CSWs provide CTS as part of a plan of care for beneficiaries living with mental health conditions that CSWs are qualified to diagnose and treat. Moreover, CSWs provide CTS in both group-based and individual contexts (Bedney, 2023). These CTS not only improve the quality of life for beneficiaries and caregivers, but also facilitate beneficiary participation in and adherence to the mental health treatment plan.

Yet, the information published by CMS to date has been inconsistent. The CY 2024 final rule, like the CY 2024 proposed rule, included clinical psychologists and excluded CSWs in the list of NPPs who could bill Medicare directly for CTS but excluded CSWs. CMS included identical information in the Medicare Learning Network (MLN) booklet Health Equity Services in the 2024 Physician Fee Schedule Final Rule, published in January 2024. In contrast, CMS’s Health-Related Social Needs FAQ, which was included in the MLN news of March 21, 2024, (Centers for Medicare & Medicaid Services, 2024) included CSWs in the list of professionals who could provide CTS (p. 3, question 6a). This discrepancy has created confusion for CSWs. NASW respectfully requests that CMS provide clarification in the CY 2025 PFS final rule that CSWs may furnish, and bill CMS independently for, CTS as reflected in CPT codes 96202 and 96203 and the five proposed HCPCS codes: GCTB1, GCTB2, GCTD1, GCTD2, and GCTD3. Should our understanding be correct, we encourage CMS to update the Health Equity Services booklet for consistency.

Request for Information on Services Addressing Health-Related Social Needs (II.E.4(40)(b))

NASW appreciates CMS’s commitment to advancing health equity through implementation of new services and codes addressing health-related social needs (HRSNs) in CY 2024. These health equity services provide opportunities for innovation, collaboration, and promotion of well-being for underserved populations. The social work profession is committed to reducing health disparities, and social workers serve a key role in addressing social barriers to health care access and engagement. NASW appreciates the chance to provide comments on Community Health Integration (CHI) (HPCCS codes G0019, G0022), Principal Illness Navigation (PIN) (HCPCS codes G0023, G0024), and Social Determinants of Health (SDOH) Risk Assessment (HCPCS code G0136) services.

Provision of CHI and PIN Services by Auxiliary Personnel

NASW thanks CMS for recognizing that CSWs are important members of health care teams and address unmet social needs that interfere with the successful treatment of medical issues. Social workers have expertise in addressing social needs, reducing health disparities, and improving population health outcomes (De Saxe Zerden, L., Cadet, T. J., Galambos, C., & Jones, B., 2020)(National Academies of Sciences, Engineering, and Medicine, 2019). They serve patients with complex and chronic physical, mental, and behavioral health conditions and resolve barriers to care. Social workers also serve as a bridge between health institutions and community support services. To prepare for implementation of the health equity codes in CY 2024, NASW informed its membership that CSWs are auxiliary personnel with the ability to perform incident to services in Medicare and, therefore, may perform CHI and PIN services. NASW appreciates the clarification in this CY 2025 proposed rule that CSWs can serve as auxiliary personnel to deliver CHI and PIN services.

CMS is requesting information on additional auxiliary personnel to perform CHI and PIN services. Social workers at the bachelor’s and master’s levels often work in community-based organizations (CBOs) and have relevant training to support individuals with complex health and social needs. NASW has interpreted the 2024 PFS final rule as permitting social workers at all levels to provide CHI and PIN services, within the scope of practice that is defined by each state, when meeting incident to requirements and conditions of payment outlined by Medicare. Social workers at different educational levels have relevant competency-based training to provide CHI and PIN services. Regarding licensure, social workers practicing in community-based settings may not be required to obtain a state license, while social workers in hospitals and health care settings are typically required to have an active state license. (It is also worth noting that some states only license social workers at the clinical level.) Having received feedback on this proposed rule, NASW asks that CMS provide a comprehensive list of auxiliary personnel that may deliver CHI and PIN services . This clarification will help organizations, particularly CBOs, understand the opportunity to deliver services to Medicare beneficiaries to address HRSNs.

Barriers to Implementation of CHI and PIN Services

Barriers to implementing CHI and PIN services in facility settings persist. Though CMS has offered facility codes for CHI and PIN, NASW has received feedback that health care institutions need more guidance on the eligible settings to provide and bill for CHI and PIN services.

Role of CBOs in Provision of CHI and PIN Services

As the NPRM states, many CBOs provide social services and are well positioned to provide CHI and PIN services. For example, 45 percent of Area Agencies on Aging (AAAs) provide social care services through contracts with health care entities, including Medicaid managed care plans, hospitals, health systems, Veterans Administration medical centers, state Medicaid agencies, Medicare Advantage plans, commercial or employer-sponsored plans, Accountable Care Organizations, and plans for dually eligible beneficiaries (Aging and Disability Institute, 2024). Similarly, 39 percent of AAAs serve as Community Care Hubs and contract through networks (Aging and Disability Institute, 2024). Nearly two-thirds of contracting AAAs provide case management, care coordination, or service coordination through these contracts; other commonly contracted services included assessment for long-term services and supports eligibility (including level of care and functional assessment), transitions from hospital to home (including discharge planning and hospital readmission prevention programs), nutrition programs, person-centered planning, home care, SDOH assessment or screening, and caregiver support, training, or engagementAging and Disability Institute, 2024). Moreover, more than three-quarters of contracting AAAs support people with complex care needs through these contracts; persons served include individuals at high risk for emergency department (ED) use, hospitalization, or hospital readmission, individuals with dementia (Aging and Disability Institute, 2024). Yet, AAAs experience significant challenges in contracting with health care entities, such as negotiation of price or contract terms, time required to establish contracts, and lack of awareness by health care entities of CBO programs and services.Aging and Disability Institute, 2024). Thus, NASW encourages CMS to continue to explore the role of CBOs—many of which include social workers on staff—in addressing HRSNs.

Use of Z Codes to Address Social Risk Factors

NASW appreciates CMS's interest in understanding the challenges and opportunities associated with using Z codes on claims in tandem with CHI, PIN, and SDOH risk assessment codes. For decades, CSWs have used Z codes for social risk factors on the CMS-1500 form for reimbursement. They also document Z codes in the clinical–medical record. Two barriers to reporting Z codes are (1) lack of payment by insurers for Z codes and (2) denied access to performing medically necessary services such as SDOH risk assessments, CHI, PIN, and CTS, even though we have utilized Z codes for decades. NASW requests that CMS allow clinical social workers to perform these services and seek reimbursement for them. Doing so would help provide a true picture of Z code utilization.

Time Structure of HRSN Codes

Currently CHI and PIN services can be billed monthly as medically reasonable and necessary for 60 minutes and then for each additional 30 minutes thereafter. To capture the variation in beneficiary needs, NASW suggests that PIN and CHI services be available to provide initially in a 30-minute visit with 15-minute add-on services so that providers can tailor the length of sessions to meet the needs of patients and families. This coding structure would match the structure of CTS.

Ability of CSWs to Bill Medicare Directly for Services Addressing HRSN

NASW continues to seek clarification on the ability of CSWs to bill Medicare directly for provision of SDOH risk assessment. The CY 2024 PFS final rule stated: 

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. (p. 78934) 

The 2024 PFS final rule granted CSWs the ability to furnish, and bill directly for, HBAI services; therefore, the preceding paragraph implies that CSWs may furnish, and seek direct reimbursement for, SDOH risk assessment. CMS conveyed similar information in the January 2024 MLN booklet, Health Equity Services in the 2024 Physician Fee Schedule Final Rule, stating that SDOH risk assessment may be combined with “behavioral health office visits, such as psychiatric diagnostic evaluation and health behavior assessment and intervention,” among other services (p. 5)(Centers for Medicare & Medicaid Services, 2024, January). 

In contrast, the CY 2024 PFS final rule also stated: 

We received many comments requesting clinical social workers be added explicitly to the list of practitioners able to furnish SDOH risk assessments, citing that assessment of SDOH needs falls within their competencies and training. … 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. (p. 78934) 

Likewise, CMS’s Health-Related Social Needs FAQ, which was included in the MLN news of March 21, 2024,(Centers for Medicare & Medicaid Services, 2024, March) stated: “The SDOH risk assessment can be performed by the treating physician or other practitioner (NPs, CNSs, CNMs, PAs), or by auxiliary personnel under the general supervision of the billing practitioner incident to their professional services” (p. 6, question 6a)(Centers for Medicare & Medicaid Services, 2024, March). CSWs are not on the list of NPPs who may bill for SDOH risk assessment. Given these discrepancies, NASW requests clarification regarding the ability of CSWs to furnish—and bill Medicare directly for—SDOH risk assessment when providing behavioral health office visits or HBAI services. (Likewise, we encourage CMS to update the Health Equity Services booklet and the Health-Related Social Needs FAQ for consistency.) Furthermore, we strongly recommend that CMS enable CSWs to bill Medicare directly for SDOH risk assessment when such assessment is conducted in the context of a behavioral health visit or in combination with HBAI services. Social workers have long possessed the skills and expertise to address challenges posed by the social environment. The social work profession’s understanding of the impact of SDOH and work in this area dates back decades. Social workers were one of the first health care disciplines to demonstrate that improving psychosocial conditions enhanced health outcomes. For these reasons, NASW reiterates it request that CMS allow CSWs to perform SDOH risk assessment and bill for the service. 

Similarly, NASW hopes that CHI and PIN services will be available to use at a range of visit types, including mental and behavioral health visits that CSWs conduct. In the CY 2025 proposed rule CMS indicates: 

CSWs could not directly bill Medicare for CHI and PIN services if they were provided by auxiliary personnel, as they are not authorized to supervise, bill, and be paid directly by Medicare for services that are provided by auxiliary personnel incident to their professional services” (p. 61669). 

NASW recommends that CMS consider enabling CSWs to bill Medicare directly for CHI and PIN services. 

Advanced Primary Care Management (APCM) (Section II.G.2)

NASW supports CMS’s focus on enhancing care management services through primary care. Many Medicare beneficiaries have strong relationships with primary care physicians and primary care providers identify and treat complex medical issues, particularly in underserved areas. With expertise in assessing and delivering social care in health settings, social workers are key partners in interprofessional health care teams (National Academies of Sciences, Engineering, and Medicine, 2019). NASW encourages incentives for primary care practices to include social work practitioners on staff. Research has shown the positive impact of integrated primary care teams that include social workers by reducing hospital admissions and ED use (Rowe et al., 2016)(Cornell et al., 2020).

NASW has expressed support for CMS care management services in primary care settings, including chronic care management, transitional care management, chronic pain management, and behavioral health integration services. In this proposed rule, CMS acknowledges limited uptake of care management services in primary care settings. Primary care clinics may lack staff and resources to deliver care management services to patients; social workers are natural partners to enhance these services in primary care settings (National Academies of Sciences, Engineering, and Medicine, 2019). Social workers in various health care settings lead care coordination services outside of evaluation and management (E/M) visits. However, financial sustainability to provide these services has been a barrier as E/M services do not reflect the time and effort needed to conduct comprehensive care management. In addition, CSWs are not able to furnish and bill for care management services at this time. NASW encourages CMS to explore opportunities for CSWs to independently bill for care management in the future.

Given the current barriers to independent reimbursement for care coordination for CSWs, NASW perceives APCM as a great opportunity to provide a sustainable path to fund care management services in a bundled payment model. We appreciate the clarification that auxiliary personnel, including social workers, can provide these services within a team. NASW supports this new proposed APCM model, which engages an interprofessional team and recognizes the range of complexity of patients that merit varied levels of support with HCPCS codes GPCM1, GPCM2, and GPCM3 (Section II.G.2.b).

Social workers bring expertise in many required areas of the APCM model, including conducting systematic needs assessments of psychosocial factors, developing patient-centered care plans, managing care transitions, leading home and community-based care coordination, and facilitating asynchronous communication with beneficiaries and caregivers. This new approach without time-based billing may encourage flexibility to allow staff to meet the particular needs of the patient population. NASW is interested in additional feedback from providers about the benefits and challenges of services that are not time based.

While APCM provides an opportunity for comprehensive case management, NASW agrees that other existing services can complement APCM, including behavioral health integration and health equity services such as SDOH risk assessment, CHI, and PIN. An area for future analysis would be understanding the prevalence of mental and behavioral health conditions within the population of Medicare beneficiaries that receive care management services.

Regarding beneficiary consent (II.G.2.c(1)), NASW supports mechanisms for patients and families to consent to APCM services, be informed of potential cost-sharing responsibilities, and understand the way in which identified needs will be documented in the electronic medical record.

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

Safety Planning Interventions (SPI) (Section II.I.1.b)

NASW supports CMS’s proposal to establish separate coding and payment for SPI. Social workers are licensed mental health professionals who currently provide SPI in a variety of settings, including hospital Emergency Departments (EDs), mobile crisis units, schools, and private practice. They have the skills, knowledge, and expertise to create and revise appropriate safety plans and perform follow-up services connecting patients to appropriate community resources. Because suicide treatment and safety planning occur most frequently in EDs, this setting seems the most appropriate for conducting safety planning with patients who have physical, mental health, and substance use conditions. Interventions in safety planning should be executed with caution, carefully thought out, and skillfully discussed. NASW recommends the following:

• Establish SPI services as a stand-along service billable by qualified health care professionals
• Allow SPI services to be billed in multiple 20-minute increments based on patient complexity, up to a maximum of 120 minutes to accurately account for the time spent to provide the service. NASW does not believe 20 minutes accurately captures the amount of time spent with a patient on SPI
• Permit up to four telephone calls or telehealth sessions per month in follow-up for at least six months with a typical telephone call or telehealth session being 15-20 minutes. Unbundle the follow-up telephone calls or telehealth sessions to allow for billing of the service when performed.

NASW agrees that safety planning intervention and follow-up contacts are effective interventions that can improve health and mental health outcomes for patients.

Postdischarge Telephonic Follow-up Contact Intervention (FCI) (Section II.I.1.c)

NASW supports CMS’s proposal to create a monthly billing code (HCPCS code GFC11) for postdischarge telephonic FCI in conjunction with a discharge from the ED for a crisis encounter. We recommend that CMS clarify in the final rule which providers may use this FCI code. In requesting this clarification, NASW offers for CMS’s consideration regarding the effectiveness of social workers in FCIs such as the evidence-based Bridge Model of transitional care (www.chasci.org/care-models): 

The Bridge Model uses social workers to provide care management to support adults with complex medical and social needs as they transition from a hospital or skilled rehab stay. Bridge leverages care coordination and therapeutic techniques to increase patient activation and support medical stability after returning home (Center for Health and Social Care Integration. (n.d.).

Research regarding the Bridge Model yielded the following significant outcomes: 

• increased communication with primary care providers (PCP) and attendance at PCP appointments within 30 days of discharge
• decreased number of postintervention ED visits
• decreased number of hospital readmissions at 30-day, 60-day, and 90-day intervals
• decreased average hospital charges per episode
• decreased total hospital charges per person (Altield, et al., 2013)(Alvarez, R., Ginsburg, J., Grabowski, J., Post, S., & Rosenberg, W, 2016)(Xiang, X., Zuverink, A., Rosenberg, W., & Mahmoudi, E., 2019)

Social workers have also served as Transitions Coaches® within the evidence-based Care Transitions Intervention® (CTI) model ( https://caretransitions.health/). CTI has been found to reduce hospital readmissions, decrease high-cost utilization, improve participants’ functional status and quality of life, and enhance the likelihood of achieving self-identified personal goals in the areas of symptom management and functional recovery (Care Transitions Intervention, 2024).

Given this evidence supporting the social work role in transitional care, NASW encourages CMS to enable CSWs to provide FCI and bill Medicare directly for these services.

Additionally, NASW is in favor of getting written consent before providing the services that will be noted in the medical record. It is advisable to also record service refusals in the medical record.

Digital Mental Health Treatment (DMHT) Devices—Payment (Section II.I.2.b)

NASW welcomes CMS's proposal to create three new HCPCS codes for Digital Mental Health Treatment (DMHT) devices. The inclusion of these codes could help to facilitate better tracking of utilization and reimbursement. We believe it seems reasonable to expand payments to DMHT devices cleared under other U.S. Food and Drug Administration (FDA) regulations as long as these devices are demonstrated to be safe and effective in mental health treatment. As noted in our previous comments to CMS, we believe DMHT may be an adjunct to traditional therapies under the guidance of a trained clinician such as a CSW by providing patients with more tailored support, such as 24-hour access to mental health resources. However, there are several factors to consider when utilizing DMHT as a primary or supplemental treatment for mental and behavioral health conditions. For instance, patient technology should not replace the therapeutic relationship between a provider and patient. It is also important to identify what types of patients are best suited for DMHT and which ones require more in-person treatment.

Additionally, some patients may not have access to the technology or equipment for digital therapy. Furthermore, it is important to understand the clinical and technical competencies needed to provide digital therapies safely and any relevant ethical and legal considerations associated with providing digital mental health services. Technology should be user-friendly to accommodate those with various ability levels, literacy, and language proficiency. Lastly, there is a potential for misuse of self-treating tools, which can lead to dangerous outcomes. NASW encourages the continued evaluation of these services to ensure their efficacy in patient care. We commend CMS for its consideration of digital services in the workplace.

NASW thanks CMS for the opportunity to provide feedback on the proposed parameters regarding the services described by GMBT1. The proposed parameters for payment regarding the services described by GMBT1 raise several points for consideration. First it is to ensure that payment is made for digital devices that have been FDA cleared specifically for mental health treatment to guarantee their efficacy and safety for patients. Additionally, extending payment eligibility to devices cleared under other FDA regulations might enhance access but requires careful scrutiny to avoid misuse. Limiting payment if a patient discontinues device use prematurely and setting a cap on the number of devices per month could help manage costs but might also restrict necessary treatments. It is recommended to establish clear guidelines on device usage and ensure robust monitoring to maintain treatment integrity and patient safety.

Interprofessional Consultation Billed by Practitioners Authorized by Statute to Treat Behavioral Health Conditions—Coding (Section II.I.3.b)

NASW strongly supports CMS’s proposed new codes (GIPC1 through GIPC6) that will enable clinical psychologists, CSWs, marriage and family therapists (MFTs), and mental health counselors (MHCs) to bill for interprofessional consultations. CMS has demonstrated its support and understanding of the significance of all providers’ involvement in treatment by proposing these new codes and allowing for a variety of communication channels.
NASW also concurs with CMS’s proposal to enable various time-based billing options that include verbal and written reports. While working with populations that face complex issues and concerns, it can be challenging to set definitive time frames. Nevertheless, CMS once again highlights the significance of holistic care and supports by offering the option to bill for these services. Additionally, we are in favor of getting written consent before providing the services that will be noted in the notes. It is advisable to also record service refusals in the notes.

Comment Solicitation on Payment for Services Furnished in Additional Settings, including Freestanding SUD Treatment Facilities, Crisis Stabilization Units, Urgent Care Centers, and Certified Community Behavioral Health Clinics (CCBHCs) (Section II.I.4)

Crisis stabilization units serve a necessary role in mental health care by offering immediate access to both voluntary and involuntary care, often providing services that can be compared to those described by psychotherapy for crisis codes (CPT codes 90839 and 90840). The definition of crisis stabilization units can indeed vary by state, reflecting differing regulations, service models, and community needs. While some units are stand-alone facilities, some states incorporate them within hospital or outpatient clinic structures. If CMS provided guidance on how crisis stabilization units could bill Medicare under the PFS, NASW believes it could encourage more widespread adoption of these services, particularly in underserved areas. This could, in turn, lead to improvements in access to urgent mental health care and potentially reduce the strain on EDs.

The proportion of patients enrolled in Medicare or who are dually eligible for Medicare and Medicaid that these units serve can vary depending on factors such as regional demographics, and availability of other health care resources in the area. This population tends to have greater racial and ethnic diversity and is often in poorer health compared to those who only receive Medicare. There are also ongoing issues regarding the lack of integration between the two programs. This fragmentation can result in inadequate care, undesirable outcomes, and elevated costs (Peña, M. T., Mohamed, M., Fugelsten Biniek, J., Cubanski, J., & Neuman, T, 2023). By providing timely intervention during mental health crises, these units can help prevent costly hospitalizations and ED visits. Crisis stabilization units are typically staffed by a multidisciplinary team of professionals to provide comprehensive mental health care. This team may include but are not limited to social workers, psychiatrists, psychologists, and nurses. However, the exact composition of these teams can vary based on factors such as resources and the specific needs of the served population. The resource Roadmap to the Ideal Crisis System(Community for the Group for the Advancement of Psychiatry, 2021) Committee on Psychiatry and the Community for the Group for the Advancement of Psychiatry, 2021) has been included as it provides best practices for behavioral health crisis response.

NASW appreciates the broad request for information issued by CMS for CY 2025 aimed at engaging interested parties on additional policy refinements for future rulemaking. We recognize and commend CMS’s efforts to better address the social needs of beneficiaries and the commitment to work within the current coding framework to explore additional opportunities. Practitioners serving underserved communities often face unique challenges, such as those listed below:

• Limited resources: Facilities like community health clinics, including FQHCs and RHCs, often operate with limited resources which can affect their ability to attract, train and retain qualified auxiliary personnel.
• Cultural sensitivity: Tribal health centers and migrant farmworker clinics often serve diverse populations. Auxiliary personnel in these settings need to be culturally competent, which may require additional training and resources.
• Language barriers: In communities with high levels of non-English speakers, auxiliary personnel must be proficient in other languages or have access to reliable translation services, which can add additional complexity to their roles.

Proposals on Medicare Parts A and B Payment for Dental Services Inextricably Linked to Specific Covered Services (Section II.J)

NASW applauds CMS’s continued efforts to address oral health in the context of certain conditions and services. We support CMS’s proposal, outlined in II.J.2., to amend the regulation at § 411.15(i)(3)(i)(A) to include the following provisions:

• dental or oral examination performed as part of a comprehensive work-up in either the inpatient our outpatient setting before Medicare-covered dialysis services for end-stage renal disease (ESRD)
• medically necessary diagnostic and treatment services to eliminate an oral or dental infection before, or concurrent with, Medicare-covered dialysis services for ESRD

NASW supports CMS’s commitment to continue seeking clinical evidence demonstrating the integral connection between dental services not only for diabetes (II.J.3), but also sickle cell anemia (II.J.1.b.1), hemophilia (II.J.1.b.2). Likewise, we encourage CMS to continue exploring the connection between systemic autoimmune disease requiring immunosuppressive therapies and dental services (II.J.1.b.4). We also affirm CMS’s consideration of the relationship between dental services and the use of oral appliances to treat obstructive sleep apnea (II.J.1.b.6).

Moreover, NASW notes new language related to the coverage standard for "medically necessary" Medicare dental coverage. The CY 2025 proposed rule notes: 

In the CY 2023 PFS final rule (87 FR 69663 through 69688), we clarified and codified at § 411.15(i)(3) that Medicare payment under Parts A and B could be made when dental services are furnished in either the inpatient or outpatient setting when the dental services are inextricably linked to, and substantially related and integral to the clinical success of, other covered services. (CY 2025 NPRM, p. 61747) 

In contrast, the CY 2025 proposed rule includes additional clarifying language specifying criteria for submissions of clinical scenarios that could be considered to meet the CY 2023 criteria:  

Submissions should focus on the inextricably linked relationship between dental services and other services necessary to diagnose and treat the individual’s underlying medical condition and clinical status,  and whether it would not be clinically advisable to move forward with the other covered services without performing certain dental services. (p. 61751; emphasis added) 

NASW is concerned that the added criterion, "would not be clinically advisable to move forward with other covered services," might be applied as a more restrictive definition of the coverage standard than what has already been codified. Although this criterion would provide excellent evidence to prove that dental services are "inextricably linked" to a medical service, deeming something "clinically advisable" could be subjective and limiting beyond the original intent of the standard. We request that CMS clarify its intent, and we recommend that the medical necessity of dental services not be limited to the “clinically advisable” criterion.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) (Section III.B)

Request for Information—Aligning with Services Paid Under the PFS (III.B.2.e)

To improve the transparency and predictability of which HCPCS codes are considered care coordination services, NASW believes CMS can establish a clear classification system on the PFS. This system should automatically translate the impact of these codes to RHCs and FQHCs. By distinguishing services that are separately payable from those included in visit payments, CMS can provide greater clarity. We agree that establishing a streamlined policy regarding which services are separately paid for RHCs and FQHCs versus included as part of the visit is more transparent. Also, we agree that a policy where codes are communicated and updated through subregulatory guidance may be more efficient.

In-person Visit Requirements for Remote Mental Health Services Furnished by RHCs and FQHCs (III.B.3.d)

NASW supports CMS's proposal to extend the delay of the in-person visit requirement for mental health services provided via communication technology by RHCs and FQHCs until January 1, 2026. This extension would be helpful for maintaining the quality of care and ensuring continued access to mental health services for beneficiaries in their homes. By leveraging communication technology, providers such as CSWs can provide timely and effective mental health support, especially for those in remote or underserved areas.

Payment for Preventive Vaccine Costs in RHCs and FQHCs (III.B.5)

NASW supports CMS’s proposal to allow RHCs and FQHCs to bill for the administration of Part B–covered preventive vaccines (COVID-19, hepatitis B, influenza, and pneumococcal) at the time of service. Likewise, we support the additional payment for in-home administration of these vaccines, provided that the home visit meets the requirements both for Part B preventive vaccine administration and for RHC and FQHC services in the home. We concur with CMS that such reimbursements will improve access to preventive vaccines for Medicare beneficiaries.

Payment for Dental Services Furnished in FQHCs (III.B.8.a)

NASW affirms CMS’s clarification that dental services as described in Section II.J., which are furnished in an RHC or FQHC constitute RHC and FQHC visits, may be paid by Medicare.

“Grandfathered” Technical Refinement (III.B.9)

NASW appreciates CMS’s effort to remove stigmatizing language from regulations. Accordingly, we support CMS’s proposal to replace the term “grandfathered” with “historically excepted” in §§ 405.2452, 405.2463, 405.2464, and 405.2469.

Proposed Changes to RHC and FQHC Conditions for Certification and Conditions for Coverage (CfCs)—Provision of Services (42 C.F.R. 491.9) (Section III.C.2.a)

NASW appreciates CMS’s continued focus on improving access to care for rural communities served by RHCs. Currently RHCs providing behavioral health services may employ a range of professionals, including CSWs, physicians, psychologists, and (most recently) MFTs and MHCs. It is essential to assess each clinic's capacity for accepting new behavioral health patients and the impact of expanding these services. Enhanced behavioral health services could significantly improve community access, potentially reduce ED visits, and foster integrated care models. Addressing these impacts will require bolstering workforce capabilities and exploring collaborative partnerships. Clinics might have specialized expertise in treating conditions such as depression or anxiety, based on their staff’s qualifications and experience. For RHCs not currently providing behavioral health services, challenges such as geographic isolation, limited transportation options, service area size, staffing constraints, stigma, and regulatory hurdles may be prevalent. Surveyors should use clear criteria to evaluate whether an RHC operates primarily for mental health care, including assessing the proportion of mental health services offered, the qualifications of the staff, and patient outcomes to ensure alignment with the intended focus of the facility.

Medicare Diabetes Prevention Program (MDPP) (Section III.E)

NASW appreciates CMS’s efforts to align MDPP requirements with those of the Diabetes Prevention Recognition Program’s 2024 standards, as established by the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention Diabetes Prevention Recognition Program, 2024). We particularly support three provisions within this section:

• clarification that chat bots and artificial intelligence forums do not constitute live interaction for the purpose of online MDPP sessions (III.E.1)
• proposal to allow self-reported weights to be obtained either via observation by the MDPP Coach or submission by the beneficiary of two date-stamped photos or a video recording, as specified on pages 61814–61815 of the NPRM (III.E.2)
• proposal to specify in-person and distance learning delivery for MDPP core and core maintenance sessions, as detailed on page 61817 (III.E.4)

Modifications Related to Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs) (Section III.F)

Telecommunication Flexibilities for Periodic Assessments and Initiation of Treatment with Methadone (III.F.2)

Proposal to Allow Periodic Assessments to Be Furnished via Audio-only Telecommunications on a Permanent Basis (III.F.2.a)

NASW supports CMS’s proposal to make audio-only communications permanent starting on January 1, 2025, to include patients who are receiving buprenorphine, methadone, and/or naltrexone at OTPs. CMS has demonstrated their support for and consideration of provider and patient concerns with this proposal. Flexibility in telemedicine offers treatment options, access to care, limited disruptions in care and demonstrates the importance of patient and provider voices.

Proposals Related to Reforms to 42 CFR Part 8 (III.F.3)

Proposal to Establish Payment for SDOH Risk Assessments (III.F.3.a)

NASW appreciates CMS’s proposal to update payment for intake activities furnished by OTPs to include payment for SDOH risk assessments. Implementation of this change would support the efforts of OTPs to identify a patient’s unmet HRSNs. Given that patient circumstances and situations vary over time, NASW recommends modifying the frequency at which the codes can be used. We also remind CMS that social workers are experts in determining the social needs of patients and request that CMS consider paying CSWs directly for SDOH assessment.

Request for Information on Payment for Coordinated Care and Referrals to Community Based Organizations that Address Unmet Health-Related Social Needs, Provide Harm Reduction Services, and/or Provide Recovery Support Services (III.F.3.b)

Having several safety needs to prioritize can be difficult, making getting treatment a secondary concern. By offering extra assistance and assisting in reducing the stressors that may hinder the healing process, referrals and connections to resources can support OTPs in addressing the diagnosis or treatment of OUDs. According to Maslow's Hierarchy of Needs, the higher-level needs of, belonging, esteem, and self-actualization can only be experienced after the lower-level basic needs of physiological and safety have been satisfied. It is challenging for people to concentrate on their recovery efforts when they are facing obstacles that limit their capacity to thrive.

Clarification to Require an OUD Diagnosis on Claims for OUD Treatment Services (III.F.5)

NASW is pleased that CMS has clarified the OTP billing requirements, stating that in order to submit claims, OTPs must have a diagnosis code that corresponds to an OUD. CMS has demonstrated their desire to ensure OTPs are held responsible for delivering services in accordance with statutory requirements. Permitting providers to deliver services that are inconsistent with diagnosis could have an effect on the course of treatment as well as the progress made during recovery.

Medicare Part B Payment for Preventive Services (§§ 410.10, 410.57, 410.64, 410.152) (Section III.H)

NASW appreciates CMS’s continued efforts to increase access to preventive vaccines under Part B. In particular, we support three provisions within this section of the NPRM:

• continued in-home additional payment for COVID-19, influenza, hepatitis B, and pneumococcal vaccines (III.H.1.d); this payment increases access to vaccination for beneficiaries who cannot leave their homes without great difficulty
• aligning payment for hepatitis B vaccines and their administration in RHCs and FQHCs with rates for COVID-19, influenza, and pneumococcal vaccines in those settings, as described on page 61930 (III.H.2.c); finalization of this proposed change would reduce hepatitis B infections in beneficiaries
• waiving of beneficiary cost-sharing for the administration or supplying of drugs covered as additional preventive services (DCAPS) (III.H.3.c), including in RHCs and FQHCs (III.H.3.d); this proposal is congruent with Medicare coverage of other preventive services

Medicare Prescription Drug Inflation Program (Section III.I)

NASW applauds CMS’s work to implement the Inflation Reduction Act (IRA) of 2022 (Inflation Reduction Act of 2022, Pub. L. 117–169, 2022). The IRA has already begun decreasing prescription drug costs for beneficiaries by decreasing the coinsurance for certain Part B drugs if the drug’s price increases more quickly than the inflation rate in a given benchmark quarter. We support CMS’s proposals to adopt new provisions at §§ 427.00 and 427.201 that would codify the policies regarding the computation of that inflation-adjusted beneficiary coinsurance (Section III.I.2.c).

Furthermore, the IRA saves money for the Medicare program by requiring prescription drug manufacturers to pay a rebate if they increase their prices for certain drugs more quickly than the rate of inflation. We concur with CMS that “the ability to assess civil money penalties [CMPs] is necessary in all circumstances where a payment is due for a rebate amount to CMS to ensure compliance with the rebate program’s requirements” (CY 2025 NPRM, p. 61959). Consequently, we support the use of CMPs for manufacturers’ failure to pay specified rebate amounts for applicable drugs under Part B (III.I.2.g) and Part D (III.I.2.g). We are not offering comments, however, on the details of CMP calculation and enforcement.

Expand Hepatitis B Vaccine Coverage (Section III.M)

NASW supports CMS’s proposal to extend Medicare coverage of hepatitis B vaccination to beneficiaries who have not previously received a completed hepatitis B vaccination series or whose vaccination history is unknown. We agree that finalization of this proposal would help protect beneficiaries from acquiring hepatitis B.

Medicare Parts A and B Overpayment Provisions of the Affordable Care Act (Section III.O)

NASW appreciates the proposed amendments described in Section III.O.2.c., which provide clarity and flexibility in the reporting and returning of overpayments. The proposed modifications to § 401.305(b)(2) and the introduction of § 401.305(b)(3) could offer additional time to conduct thorough, good-faith investigations into potential overpayments before the obligation to report and return them is triggered. This approach could prevent providers from being unfairly penalized for prematurely reporting overpayments that have not been fully investigated or quantified. To further support providers, NASW encourages CMS to consider an option for an extension for complex situations such as providers who have large overpayment amount. Additionally, it is helpful to offer educational resources on new regulations. Lastly, we ask CMS to consider requiring Medicare Advantage companies to issue overpayment notices in a specified timeframe. This would allow providers to address potential overpayments in a timely manner. Prompt notification also helps providers ensure compliance with regulatory requirements, as well as reduce the risk of financial hardship from accruing large overpayment amounts, interest, or other penalties.

Updates to the Quality Payment Program (Section IV)

New Specialty Measure Sets Proposed for Addition and Modifications to Previously Finalized Specialty Measure Sets Proposed for the CY 2025 Performance Periods/2027 MIPS Payment Year and Future Years—Merit-based Incentive Payment System (MIPS) Clinical Quality Measures (QCMs) for Clinical Social Work

Quality # 503, Gains in Patient Activation Measure (PAM) Scores at 12 Months—proposed addition

NASW supports the inclusion of the Gains in Patient Activation Measure (PAM) Scores at 12 Months into the clinical social work quality measure set. This measure assesses patients' knowledge, skills, and confidence, which are central to effective clinical social work practice. However, challenges may arise in terms of the resources required to administer and score the PAM questionnaire consistently across different settings. To address these challenges, NASW encourages CMS to provide training and support for social workers to effectively implement and interpret the measure. For example, integrating this measure into existing electronic health record systems could streamline data collection and enhance feasibility.

Quality # 504, Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide Risk—proposed change to a previously finalized measure

NASW supports the proposed change to include patients 12 years and older as part of data collection for Quality # 504. However, NASW recommends lowering the age to 10 years and older to capture the quality of care for a broader population of patients that are impacted by suicide. Per CMS, “Suicide is the second leading cause of death for 10- to 24-year-olds in the United States and is a global public health issue, with a recent declaration of a National State of Emergency in Children’s Mental Health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association.” NASW recognizes current challenges facing youth and agrees with CMS’s rationale for updating the age range. Standardized suicide assessments and evidence-based safety planning are critical to mental health treatment. Social workers assess patients for suicidal ideations/risks and develop safety plans as part of care for both adolescent and adult patients. Quality # 504 is a high priority CQM that should include patients 10 years and older.

CY 2025 Proposed and Modified MIPS Value Pathways (MVPs)

NASW supports the proposed modification to add IA_ERP_6: COVID-19 Vaccine Achievement for Practice Staff to the Quality Care in Mental Health and Substance Use Disorders MVP. It enhances public health by protecting both health care workers and patients, particularly in vulnerable settings. Promoting staff vaccination reduces COVID-19 transmission risk, ensuring a safer environment for patients. This activity aligns with public health goals, incentivizes best practices, and is operationally feasible, addressing ongoing COVID-19 mitigation needs. By endorsing this addition, stakeholders can help advance the quality and safety of care in mental health and SUD settings.

Measure/Activity Inventories and Scoring Methodologies

NASW supports the following proposals in the NPRM:

• We agree with the proposed changes to revise the cost measure scoring methodology to assess clinician cost of care more appropriately in relation to national averages. This revision ensures a fairer comparison, allowing for more accurate and equitable performance assessments across diverse health care settings.
• We support revising the methodology for scoring topped-out quality measures in specialty sets with limited measures as it could help to provide a fairer and more accurate performance assessments, encouraging continuous improvement even in specialties with fewer available measures. This change addresses the challenges posed by high-performing measures, preventing skewed evaluations, and supporting consistent high-quality care.
• We support the proposed changes to CMS's policy on the treatment of multiple data submissions for the Promoting Interoperability performance category should be supported for several reasons. Firstly, the new policy aims to calculate a score for each data submission received and assign the highest score, ensuring that inadvertent errors or incomplete submissions do not unfairly penalize clinicians. Secondly, this approach aligns with existing policies for other performance categories, promoting consistency and reducing complexity for participants. However, it is important to consider the potential administrative burden of managing multiple submissions and ensuring that the policy is implemented in a way that minimizes confusion and maximizes clarity for all stakeholders.
• We support the proposed changes to remove improvement activity weighting and streamline reporting requirements are beneficial as they reduce administrative burden and complexity for clinicians, allowing them to focus more on patient care. By treating all improvement activities equally, the changes promote fairness across different practice settings and align with CMS's efforts to make the Quality Payment Program (QPP) more accessible. Additionally, simplification encourages clinicians to engage in high-impact activities, improving the relevance and benefit of reported activities. However, careful implementation and monitoring are needed to address potential transition challenges and ensure the continued effectiveness of the QPP.

NASW appreciates CMS’s efforts to improve the QPP. The proposed adoption of minimum criteria for a qualifying data submission for MIPS performance categories aims to ensure comprehensive and consistent data collection across quality, improvement activities, and Promoting Interoperability categories. From a clinical social work perspective, this change can help standardize reporting, making performance comparisons more accurate and equitable. However, the requirement to provide detailed performance data and attestation statements could increase the administrative burden, particularly for smaller practices with limited resources.

Maintaining Stability

NASW supports CMS’s proposal to leave the performance threshold set at 75 points for the CY 2025 performance period/2027. We also appreciate the proposal to maintain the 75% data completeness criteria through the 2028 performance period. Maintaining the performance threshold at 75 points for the CY 2025 performance period/2027 MIPS payment year is beneficial as it alleviates concerns about increasing cost performance weight, supports small practices by avoiding additional burdens, and allows CMS time to analyze the impact of new policies. Continuing the 75% data completeness criteria through the 2028 performance period ensures data reliability and consistency, making the reporting process smoother for clinicians. NASW believes it is important to provide ongoing support for small practices and gather regular feedback to ensure the program remains fair and effective.

Request for Information

MVP Adoption and Subgroup Participation

NASW supports CMS’s efforts to streamline and enhance the relevance of performance measures, potentially improving the quality of care. We also note that the proposed transition to MVPs by the 2029 performance period may present several challenges. Clinician readiness is a significant concern, particularly for those in smaller or less resourced practices, who may face difficulties adapting to new reporting requirements and technologies. Ensuring that applicable MVPs are available for all clinicians, including those with limited quality and cost measures would be important. Attention should also be given to reducing administrative burden for clinicians. Additionally, establishing clear criteria for subgroup composition and addressing the unique needs of multispecialty small practices will be essential for a smooth transition. Throughout this transitional process, NASW encourages CMS to provide ample training and support with continuous opportunities for feedback from stakeholders.

Public Health and Clinical Data Exchange Objective

NASW believes that leveraging the Public Health and Clinical Data Exchange Objective requirements under the Promoting Interoperability performance category presents both opportunities and challenges. The focus on improving timely reporting, data quality, and completeness could be beneficial for enhancing public health reporting and patient outcomes. However, challenges may include limited access to advanced electronic health record (EHR) systems and insufficient resources or staff to manage and report these measures. Additionally, the technical requirements and data privacy concerns can add complexity to the reporting process. We are also concerned that this could also create an unintended administrative and/or financial burden, as they may have to apply for a Promoting Interoperability Hardship Exception if they do not qualify for an automatic reweighting. Failure to report correctly increases the risk of a negative payment adjustment, exacerbating the strain on already resource-limited practices. NASW recognizes that the option for continued reweighting for clinicians, including CSWs, is not part of this proposed rule but believes it is important to highlight as a potential challenge and reporting burden. To balance reporting needs and clinician burden, CMS can streamline measures by focusing on essential data points and reducing redundancy, thereby simplifying reporting requirements and providing clear guidelines. Incentivizing the adoption of advanced information exchange standards can be achieved by offering bonus points. Other recommendations include providing comprehensive training and resources for clinicians, simplifying reporting requirements, encouraging advanced standards through financial incentives, and reconsidering reweighting for CSWs to ensure equitable participation and reduced administrative burden.

Principles for Patient-Reported Outcome Measures in Federal Models and Quality Reporting and Payment Programs

Incorporating Patient-Reported Outcome Measures (PROMs) and Patient-Reported Outcome Performance Measures (PRO-PMs) into CMS quality reporting payment programs could be beneficial in enhancing patient-centered care by capturing the patient's voice and improving care outcomes. However, NASW also wishes to bring attention to potential challenges such as the possibility for increased administrative burden and the need for data infrastructure to integrate into daily workflows and support seamless data integration across different health care settings. We encourage CMS to consider including accessible and user-friendly reporting tools and provide training and resources to clinicians, especially in smaller practices to mitigate the administrative impact.

Survey Modes for the Administration of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey

The proposed expansion of the CAHPS for MIPS Survey to include a web-based mode, followed by mail and phone, is a promising approach to increase response rates, as evidenced by the 13% increase observed in the field test. However, challenges include the feasibility of collecting and managing email addresses, particularly for smaller practices or those serving older populations less familiar with digital communication. If implemented, NASW recommends CMS consider providing technical assistance and resources to help practices transition to the new protocol and consider phased implementation to allow time for adjustment. Additionally, CMS should ensure that increased survey administration costs do not disproportionately impact smaller practices. An example of support could include funding for technology upgrades necessary for managing digital survey distribution.

Elder Maltreatment Screen and Follow-Up Plan (Quality # 181)

NASW strongly supports the proposal to add encounter codes for ED visits to the denominator for this measure. We concur that the ED is a prime setting for elder maltreatment identification and follow-up planning. Additionally, NASW strongly supports retention of this CQM within the clinical social work and skilled nursing facility specialty sets.

Access to Mental Health Services Provided by Independent CSWs to Skilled Nursing Facility (SNF) Residents under Medicare Part B

NASW has been working for years 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. This restriction limits beneficiary access to mental health services in a couple ways:

• A beneficiary who resides in a nursing home (paid for by sources other than Medicare) and receives mental health services from an independent CSW is unable to continue working with that CSW when they transfer to a SNF. As CMS is aware, beneficiaries can transition from nursing home to SNF services both quickly and unexpectedly, even without having moved into a different building, room, or bed. Similarly, a beneficiary residing in a community-based setting (such as assisted living) or at home is unable to continue mental health treatment with their CSW of choice when they transfer to a SNF. In either situation, services must stop abruptly, depriving the beneficiary of mental health services with a familiar provider. Consequently, the beneficiary feels abandoned during a time when continuity of mental health treatment is critical.
• A beneficiary who is not receiving mental health services before SNF admission may require such assessment and treatment during the SNF stay. When this occurs, the pool of practitioners to which the beneficiary has access is limited because of the restriction on CSW billing.

The importance of these access barriers has been underscored by a recommendation published in a 2022 nursing home study published by the National Academies of Sciences, Engineering, and Medicine: 

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. (p. 512) (National Academies of Sciences, Engineering, and Medicine, 2022).

Moreover, NASW respectfully reminds CMS of its commitment to reconsidering the restriction on independent CSW services provided to beneficiaries receiving SNF services. In 2001, the Health Care Financing Administration (HCFA) released a proposed rule that “would permit separate Medicare Part B payment for certain psychotherapy services of clinical social workers furnished to a skilled nursing facility resident whose stay is not covered by Medicare” (Medicare Program; Clinical Social Worker Services, 65 Fed. Reg. 62681 (proposed Oct. 19, 2000). NASW submitted comments supporting this proposal. The proposal was not finalized; instead, CMS indicated in the proposed Medicare PFS rule for CY 2003 (Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2003, 67 Fed. Reg. 43861, proposed Jun. 28, 2002) that it would address, within the final PFS rule for CY 2003, comments received on the 2000 CSW proposed rule. Yet, the CY 2003 PFS final rule stated: “Upon further review, we have determined that we will not include this issue in this final rule, but will address it in future rulemaking” (CY 2003 Physician Fee Schedule Rule, 67 Fed. Reg. 79987, Dec. 31, 2002).

This future rulemaking has not occurred. In the meantime, CMS has implemented regulations permitting MFTs and MHCs to provide Part B–reimbursed independent mental health services to Medicare beneficiaries simultaneously receiving SNF services under Part A. NASW urges CMS to build on this step in the CY 2025 PFS final rule by permitting CSWs to do the same.

CSW Reimbursement Rates

The need for mental health services has increased greatly since the beginning of the COVID-19 pandemic. As CMS is aware, CSWs are reimbursed at only 75 percent of the PFS. This CSW rate is even lower than the 85 percent rate at which some NPPs—specifically, NPs, PAs, clinical nurse specialists, occupational therapists, physical therapists, speech–language pathologists, and registered dieticians—are reimbursed. Mitigating this reimbursement inequity by increasing the CSW rate to 85 percent of the PFS would increase recruitment and retention of CSWs in the Medicare workforce, thereby expanding beneficiary access to mental health practitioners. NASW again invites CMS to collaborate in exploring policy changes to increase reimbursement rates and increase reduce access barriers for beneficiaries.

Thank you for your consideration of NASW’s comments on the NPRM. Please do not hesitate to contact me at bbedney.nasw@socialworkers.org if you have questions. 

Sincerely,
Barbara Bedney, PhD, MSW
NASW Chief of Programs