ModifiedASAMPolicy N/A

CMS CY 2024 PFS Proposed Rule summary (ASAM)

Summarizes major provisions in the CMS CY 2024 Medicare Physician Fee Schedule Proposed Rule as it affects behavioral health and addiction medicine services, including new/modified codes, RVU adjustments, and practitioner eligibility; intended for payers, providers, and administrators monitoring Medicare payment and coverage changes.

Policy Summary

PayerASAM

PolicyCMS CY 2024 PFS Proposed Rule summary (ASAM)

Policy CodePolicy N/A

Change TypeMultiple added/revised payment, coding, and eligibility provisions

Effective Date

Next Review Date

Key ActionBegin preparing billing and documentation workflows to support new G-codes (e.g., G2211, G0323, GOTP1, GXXX3/4/5) and updated telehealth and IOP/PHP payment rules.

SourceLink

POLICY UPDATE CHANGES

CMS proposes a new add-on code G2211 to recognize visit complexity inherent to E/M visits for complex patients.

CMS proposes enrollment and Medicare payment eligibility for Marriage & Family Therapists (MFTs) and Mental Health Counselors (MHCs), including telehealth and specific billing codes (e.g., G0323).

CMS proposes increases to work RVUs for multiple psychotherapy and crisis codes, using a four-year transition tied to E/M visits with G2211.

Payment rates for the SUD non-drug bundle codes G2086 and G2087 would be increased by crosswalking to CPT 90834 (45-minute) rather than 90832 (30-minute).

CMS proposes new HCPCS codes for mobile crisis psychotherapy services (GPFC1, GPFC2) payable at 150% of analogous CPT crisis codes.

New proposed codes for community health integration (GXXX1/GXXX2), principal illness navigation (GXXX3/GXXX4), and SDOH risk assessment (GXXX5).

New G-codes for Principal Illness Navigation (GXXX3 and GXXX4) are proposed with valuations cross-walked to CCM CPT codes.

SDOH Risk Assessment proposed as an optional, separately payable element of the Annual Wellness Visit, payable at 100% of Medicare fee schedule with no beneficiary cost sharing when furnished same day.

Telehealth originating site rules expanded to allow the beneficiary's home and any U.S. site through Dec 31, 2024, and non-facility payment for home telehealth through 2024.

Proposed definition, coverage criteria, and new HCPCS code (GOTP1) and payment for OTP intensive outpatient services (minimum 9 hours/week).

Remote physiologic monitoring (RPM) limited to established patients post-PHE and reinstates 16-day monitoring requirement; RPM and RTM cannot be billed together.

CMS proposes separate APC/per diem payment structure for PHP and IOP programs and suggests paying IOP equal to PHP in 2024 absent data, with alternative simplified per diem amounts provided.

Audio-only periodic assessment flexibilities for OTPs (HCPCS G2077) extended through end of CY 2024 consistent with CAA 2023, subject to SAMHSA/DEA requirements.

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32.75conversion factor ($)

2.93%Addiction Med adjustment

150%GPFC1/GPFC2 rate

19%psychotherapy RVU adj

21% / 23%G2086 / G2087 RVU gain

$719.67GOTP1 valuation

Coverage Criteria & Eligibility

COVERAGE CRITERIA — Key proposed eligibility and payment conditions reflected in the rule

Key practitioner enrollment, scope, and payment adjustments proposed for 2024 that affect behavioral health and related services.

ALL of the following

MFTs and MHCs eligible to enroll and bill for their services beginning January 1, 2024; HCPCS G0323 clarified to permit MHCs and MFTs to bill (Care management services for behavioral health conditions, at least 20 minutes, per calendar month).
Operational: ensure enrollment effective date and billing privileges are confirmed prior to submitting claims.
CMS proposes allowing MHCs and MFTs to bill health and behavior assessment and intervention CPT codes: 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171.
Billing: verify state scope-of-practice and Medicare enrollment taxonomy to support claims.
Payment increases for office-based SUD treatment HCPCS codes G2086 and G2087 to reflect two individual psychotherapy sessions per month (crosswalk to CPT 90834), increasing RVUs for 2024.
Payment: update charge master and encounter-level coding to reflect revised valuation.
Two new proposed CHI HCPCS codes (GXXX1, GXXX2) describe community health integration services by certified/trained auxiliary personnel (e.g., CHWs) under general supervision; services furnished monthly as medically necessary following an initiating E/M visit that identifies SDOH needs.
Operational: document initiating E/M visit and CHI training/certification of auxiliary personnel.
New proposed SDOH assessment code GXXX5 (5–15 minutes, not more often than every 6 months), cross-walked to G0444, proposed addition to Medicare Telehealth list; required elements include standardized, validated SDOH tool covering food, housing, transportation, utilities. Document findings and consider linking to CHI or community resources.
Clinical: record SDOH Z-code(s) as applicable (Z55–Z65) and limit billing to once every 6 months.

IOP/PHP coverage criteria and billing rules — Proposed IOP/PHP coverage and patient eligibility criteria and scope of benefits under § 410.44

Proposed rules defining Intensive Outpatient Program (IOP) / Partial Hospitalization (PHP) scope, covered services, and patient eligibility under § 410.44.

ALL of the following

Definition: IOP services are distinct organized intensive ambulatory treatment programs furnishing <24-hour care outside of home/inpatient/residential settings and need not be provided in lieu of inpatient hospitalization (proposed § 410.44(a)).
Coverage criteria: services must be reasonable and necessary for diagnosis or active treatment; reasonably expected to improve/maintain condition and functional level and prevent relapse or hospitalization; and furnished in accordance with a physician certification and plan of care per proposed § 424.24(d).
Scope of benefits (§ 410.44(a)(4)) includes: individual and group therapy with physicians/psychologists or other authorized mental health professionals; occupational therapy requiring a qualified OT; services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients; drugs/biologics furnished for therapeutic purposes (non-self-administered when regulation requires); individualized activity therapies that are not primarily recreational/diversionary.

COVERAGE CRITERIA — Remote monitoring and chronic care billing interactions

Clarifications on remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) billing interactions and operational requirements.

ALL of the following

RPM services may only be provided to established patients after the end of the Public Health Emergency (PHE).
Provider action: confirm established-patient status in the medical record before billing RPM after PHE.
The 16-day monitoring requirement for RPM is reinstated post-PHE: monitoring must occur over at least 16 days of a 30-day period.
Billing rule: ensure device-data collection spans >=16 days in the 30-day service month to support claims.
Services associated with multiple devices provided to a patient may be billed only once per patient per 30-day period and only when at least 16 days of data have been collected.
RPM or RTM may be billed, but not concurrently, with the following care management services: Chronic Care Management (CCM), Transitional Care Management (TCM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Chronic Pain Management (CPM). RTM and RPM cannot be billed together.

COVERAGE CRITERIA — Telehealth and originating site rules for 2024

Telehealth, originating site, and in-person visit rules proposed for 2024 and 2025, including additions for SDOH screening.

ALL of the following

Medicare pays for covered telehealth services on the Medicare Telehealth Services List when furnished via interactive telecommunications if the practitioner is a Medicare provider under statute and state-licensed, and the service is furnished at an authorized originating site (examples include physician office, RHC/FQHC, hospital, community mental health center, and patient home for SUD treatment or certain mental health disorder treatment).
Originating site expansion (CAA, 2023 implementation): telehealth originating sites may include any site in the United States where the beneficiary is located at the time of service, including the individual's home, beginning the first day after the end of the COVID-19 PHE through December 31, 2024.
In-person requirements for mental health telehealth: CMS proposes to reinstate the requirement that an in-person visit with the physician/practitioner within 6 months prior to the initial mental health telehealth service (and as determined for subsequent intervals) will be effective January 1, 2025; patients’ homes may serve as originating sites for mental health telehealth through December 31, 2024; extension applies to FQHCs and RHCs.

Codes, Valuations & Billing Parameters

Health and Behavior Codes assignable to MFTs/MHCsCPT | HCPCS | mixedCovered

96156	Health and behavior assessment and intervention
96158	Health and behavior assessment and intervention
96159	Health and behavior assessment and intervention
96164	Health and behavior assessment and intervention
96165	Health and behavior assessment and intervention
96167	Health and behavior assessment and intervention
96168	Health and behavior assessment and intervention
96170	Health and behavior assessment and intervention
96171	Health and behavior assessment and intervention

SUD bundle updatesHCPCSCovered

G2086	Office-based SUD treatment bundle, first month (proposed RVU crosswalk to CPT 90834)
G2087	Office-based SUD treatment bundle, subsequent month (proposed RVU crosswalk to CPT 90834)

Proposed PIN G-codesCPT

GXXX3	Principal Illness Navigation services, 60 minutes per calendar month (proposed)
GXXX4	Principal Illness Navigation services, additional 30 minutes per calendar month (proposed)

Proposed OTP IOP HCPCS codeHCPCSCovered

GOTP1

Intensive outpatient services; minimum of nine services over a 7-contiguous day period (OTP-specific add-on) (proposed)

OTP periodic assessmentHCPCSCovered

G2077

Periodic assessments furnished by OTPs (audio-only flexibilities extended through CY 2024) (existing)

GXXX5 frequency limit

GXXX5 billing frequencyBilled no more often than once every 6 months.

GXXX5 typical durationService described as 5-15 minutes per administration.

Cross-walk valuationValuation proposed to be cross-walked to G0444 (depression screening).

RPM monitoring days

Minimum monitoring daysAt least 16 days of data collected in a 30-day period required to bill RPM.

Patient status requirement

Provider Actions, Billing & Operational Notes

Billing Rule

Visit Complexity Add-on (G2211)

CMS is proposing a new add-on code G2211 to recognize visit complexity for evaluation and management (E/M) visits for primary care and longitudinal care of complex patients. Use G2211 to reflect the additional resource costs inherent in managing a patient's single, serious, or complex chronic condition during an outpatient office visit.

Proposed add-on: G2211 — Visit complexity inherent to evaluation and management
Applicable setting: outpatient office visits for primary/longitudinal care
Purpose: recognize resource costs for treating complex chronic conditions

Billing Rule

Care Management and SDOH-Related Billing (CHI GXXX1/GXXX2 and related proposals)

CMS is proposing new G-codes to support care management and to address social determinants of health (SDOH). Community Health Integration (CHI) services would be furnished by certified or trained auxiliary personnel under general supervision and require an initiating E/M visit that identifies SDOH needs limiting the practitioner's ability to diagnose or treat. CHI codes include a primary 60-minute code and an additional 30-minute add-on. CMS is also proposing Principal Illness Navigation (PIN) services (separate block below) and an SDOH risk assessment code as part of this bundle of new G-codes.

Definitions & Terms

MFT

DefinitionMarriage and Family Therapist (MFT): practitioner meeting CAA definition who furnishes services for diagnosis and treatment of mental illnesses as authorized under State law.

Enrollment/payMFTs may enroll and bill Medicare beginning Jan 1, 2024; payment subject to assignment-only rules and payment calculation described by statute.

Education/licensureMust possess a master's or doctoral degree qualifying for licensure or certification and meet State licensure requirements.

MHC

DefinitionMental Health Counselor (MHC): individual who meets degree, supervised experience, and State licensure/certification requirements to furnish MHC services.

Supervision/experienceAfter degree, must perform at least 2 years of clinical supervised experience in mental health counseling (statutory requirement).

Policy Summary

PayerASAM

PolicyCMS CY 2024 PFS Proposed Rule summary (ASAM)

Policy CodePolicy N/A

Change TypeMultiple added/revised payment, coding, and eligibility provisions

Effective Date

Next Review Date

Key ActionBegin preparing billing and documentation workflows to support new G-codes (e.g., G2211, G0323, GOTP1, GXXX3/4/5) and updated telehealth and IOP/PHP payment rules.

SourceLink

On This Page

Patient eligibility (§ 410.44(c)) requires ALL of the following: at least 9 hours per week of therapeutic services documented in the plan of care; likely to benefit from a coordinated program and require more than isolated outpatient sessions; do not require 24-hour care; have an adequate support system while not engaged in program; have a mental health diagnosis (explicitly includes SUD and behavioral health diagnoses); are not judged dangerous to self or others; have cognitive and emotional ability to participate and tolerate IOP intensity.

Denial risk: concurrent billing of excluded combinations may result in denials — coordinate service selection and document rationale.

Proposed SDOH assessment code GXXX5 to be added to Medicare Telehealth services: Administration of a standardized, evidence-based SDOH Risk Assessment (5–15 minutes), billable no more often than once every 6 months; required documentation of standardized tool covering food, housing, transportation, and utility domains; consider linkage to CHI or community-based organizations for addressing identified needs.

RPM services can only be provided to established patients after the end of the PHE.

Device/billing aggregationServices associated with multiple devices can be billed only once per patient per 30-day period when ≥16 days of data collected.

IOP minimum weekly hours

Minimum weekly hoursMinimum of 9 hours per week of therapeutic services required for IOP eligibility.

Documentation requirementRequirement must be evidenced in the patient's plan of care and supported by physician certification where applicable.

Scope noteIncludes patients likely to benefit from coordinated program and who do not require 24-hour care; term 'mental health diagnosis' includes SUD.

CHI codes: GXXX1 (60 minutes/month) and GXXX2 (each additional 30 minutes/month).
CHI provider rules: Performed by certified/trained auxiliary personnel (may include CHWs), incident to professional services, under general supervision; must be authorized under state law or trained where no licensure exists.
Prerequisite: initiating E/M visit where practitioner identifies SDOH need(s) significantly limiting diagnosis or treatment.
Operational considerations under review: whether non-E/M initiating visits qualify, telehealth vs in-person delivery, and patient consent requirements.
Note: CMS seeks public comment on multiple implementation details.

Prior Authorization

Principal Illness Navigation (PIN) — Provider Prerequisites & Billing

CMS proposes two new G-codes for Principal Illness Navigation (PIN) to be furnished by certified or trained auxiliary personnel under the direction of a physician or other practitioner: GXXX3 (60 minutes per calendar month) and GXXX4 (additional 30 minutes per calendar month). PIN services must follow an initiating E/M visit in which the billing practitioner documents the medical necessity and establishes a treatment plan. Auxiliary personnel provide PIN services incident to the billing practitioner's professional services under general supervision and must be certified/trained and authorized under applicable state law—or trained where no state licensure exists.

Proposed codes: GXXX3 (Principal Illness Navigation, 60 mins/month) and GXXX4 (each additional 30 mins/month).
Valuation crosswalks: GXXX3 → CPT 99490 (first 20 mins CCM) valuation; GXXX4 → CPT 99439 (each additional 20 mins CCM) valuation.
Clinical eligibility: PIN follows an initiating E/M visit addressing a serious, high-risk condition expected ≥3 months that places the patient at significant risk of hospitalization, nursing home placement, acute exacerbation/decompensation, functional decline, or death.
Care plan requirement: Condition requires development/monitoring/revision of a disease-specific care plan and may require frequent medication/treatment adjustments or substantial caregiver assistance.
Provider prerequisites: An initiating E/M visit by the billing practitioner that documents medical necessity and establishes the treatment plan; PIN furnished by auxiliary personnel incident to that practitioner's services under general supervision.
State law: Auxiliary personnel must be authorized by state law to perform PIN service elements or be trained in states without applicable licensure.
CMS request for comment: Whether services other than an E/M visit should qualify as the initiating visit for PIN services.

Payment/assignmentAmounts paid to MHCs are 80% of the lesser of actual charge or 75% of psychologist payment and services are payable on an assignment-only basis.

SDOH Risk Assessment (GXXX5)

PurposeSDOH Risk Assessment (GXXX5): administration of a standardized, evidence-based SDOH risk assessment tool to identify needs across domains.

Required domainsAssessment must include domains such as food insecurity, housing insecurity, transportation needs, and utility difficulties.

Documentation and validationTool must be tested and validated through research and findings must be documented in the medical record (Z codes may be used).

Intensive outpatient services (IOP)

DefinitionIntensive outpatient services (IOP): a distinct, organized intensive ambulatory treatment program offering less than 24-hour daily care outside the home or inpatient/residential settings.

Treatment intentServices must be reasonable and necessary for diagnosis or active treatment, expected to improve or maintain function and prevent relapse or hospitalization.

Program elementsIncludes individual/group therapy and other services listed in § 410.44(a)(4) furnished according to a physician certification and plan of care.

OTP IOP

DefinitionOTP IOP: OTP intensive outpatient services as specified in proposed 42 CFR § 410.44(a)(4) when furnished by an OTP as part of a distinct intensive ambulatory treatment program for OUD.

Physician certificationA physician must certify that the individual needs such services for a minimum of 9 hours per week to qualify as OTP IOP.

Billing noteCMS proposes a new HCPCS add-on (GOTP1) billable in addition to the primary weekly bundle for OTP IOP services (minimum nine services over 7 contiguous days).

SDOH Risk Assessment

AWV optional elementSDOH Risk Assessment proposed as an optional element of the Annual Wellness Visit (AWV).

Payment and cost sharingWhen furnished same day as the AWV, the SDOH Risk Assessment would be separately payable at 100% of the Medicare fee schedule with no beneficiary cost sharing.

Frequency and documentationGXXX5 billed no more often than once every 6 months; assessment findings must be documented in the medical record.