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    Practice Guidance for COVID-19

    Updated April 13, 2022

    Below is guidance released by the Department of Health and Human Services, FDA and at the state level related to COVID-19 to assist psychiatrists with providing mental health and substance use services.

    No Surprises Act (NSA) Regulations Effective January 1, 2022

    Important information for those providing care in outpatient settings to patients who are uninsured or self-pay or shopping for care.

    As you are aware, regulations have been recently finalized that require certain patient protections to address concerns about surprise bills. These protections not only address emergency care but include disclosure requirements for all uninsured or self-pay services, including services provided in outpatient/office settings, and will, at some point in the future, also include patients with insurance. These regulations formalize some of what you already do when communicating your fees to patients seeking care or for whom you are providing care. View a summary of key requirements along with links to templates here. APA will update this information as we learn more.

    Important information for those providing emergency services and inpatient care in facilities

    The No Surprises Act (NSA) also aims to address situations in which patients receive surprise medical bills when they inadvertently or unknowingly receive care from an out-of-network provider. These new protections ban surprise billing for emergency services and certain non-emergency services provided in patient at facilities. View a summary of key requirements along with links to templates here. APA will update this information as we learn more.

    New for September 2021: 60 Day Grace Period for Post-Payment Reporting Requirements and New Provider Relief Funds Available

    On September 10, 2021, HHS announced a 60-day grace period for providers who previously received payments totaling $10,000 and fail to meet the reporting deadline of September 30, 2021. While the deadlines to use the funds and reporting time period remain unchanged, HHS will not initiate collection activities or similar enforcement during this grace period.

    HHS also announced an additional $25.5 billion in new funding available for health care providers affected by the COVID 19 pandemic. The new funding will be allocated as follows: $17 Billion for “Phase 4” of the Provider Relief Fund General Distribution for providers who can document revenue loss and expenses associated with the pandemic between July 1, 2020, and March 31, 2021; and $8.5 billion in American Rescue Plan resources for providers who serve rural Medicaid, CHIP, or Medicare patients. Providers can apply for both programs in a single application beginning on September 29, 2021.

    More information can be found here: Future Payments | Official web site of the U.S. Health Resources & Services Administration (hrsa.gov).

    New for July 2021: Provider Relief Fund Post-Payment Reporting Requirements

    Recipients of Provider Relief Funds (PRF) are required to report certain data by due dates based on when they received the funds.

    The PRF Reporting Portal is now open for clinicians who need to report on the use of funds in Reporting Period One. If you received one or more PRF payments exceeding, in the aggregate, $10,000 during a Payment Received Period, you must comply with the reporting requirements described in the Terms and Conditions.

    Reports must be submitted electronically through the PRF portal by the due date. Recipients who do not make reports by the due date are out of compliance with the Terms and Conditions and maybe subject to recoupments.

    How to Get Started

    Report Deadlines

    Clinicians who received one or more payments exceeding $10,000, in the aggregate, during a Payment Received Period are required to report in each applicable Reporting Time Period. PRF recipients that do not report within the respective reporting time period are out of compliance with payment Terms and Conditions and may be subject to recoupment.

    Table 2: Reporting Time Periods (From HHS's Provider Relief Fund General and Targeted Distribution: Post-Payment Notice of Reporting Requirements issued June 11, 2021 (.pdf))
    Periods Payment Received Period (Payments Exceeding $10,000 in Aggregate Received) Reporting Time Period
    Period 1 April 10, 2020 to June 30, 2020 July 1, 2021 to September 30, 2021
    Period 2 July 1, 2020 to December 31, 2020 January 1, 2022 to March 31, 2022
    Period 3 January 1, 2021 to June 30, 2021 July 1, 2022 to September 30, 2022
    Period 4 July 1, 2021 to December 31, 2021 January 1, 2023 to March 31, 2023

    Data Required for Reporting

    PRF recipients may use payments for eligible expenses and lost revenues to prevent, prepare for, and respond to coronavirus. A Data Entry Worksheet (.pdf) is available to assist in data gathering prior to entering it in the system.

    Resources

    Guidance on this program continues to be developed and refined. We will continue to update this site as information becomes available. Additionally, CMS is routinely updating their website on Provider Relief Fund.

    Telehealth

    APA has a page dedicated to Telepsychiatry and COVID-19. Key guidance for the duration of the emergency declaration includes:

    • CMS Changes for Audio Only

      • Audio Only services: On April 30, 2020, CMS issued a new ruling permitting audio only telephone care for the following psychiatry codes: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90853. The psychotherapy add-on codes are to be used with the E/M telephone codes, 99441,99442, and 99443. CMS also announced they will increase payments for these E/M codes to match payments for similarly timed office and outpatient visits. Payments for these services have increased from the current range of about $14-$41 to the higher range of about $46-$110, and these payments are retroactive to March 1, 2020.
      • When billing these services in addition to a psychotherapy service (90833, 90836, 90838), divide the time spent between the two codes according to the work performed, taking care not to count the same minute twice. And be sure to document the time spent on each service accordingly.
      • Anyone providing care via audio AND video will continue to bill as they have been using the traditional E/M codes (see below – clarification on billing Medicare telehealth) with the 95 modifier.

    • Clarification on billing Medicare for telehealth: When conducting a telemedicine encounter:

      • By audio and video: use the same CPT codes as if the encounter were in-person, and on the 1500 Claim Form you should add the modifier 95 after each CPT code to indicate that the care was provided as telemedicine. These same directions should be applicable for most commercial payers as well. Please let APA know if your experience is different.
      • By audio only: use any of the psychiatric services identified in the following list: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90853. E/M services should be reported using the telephone E/M codes (99441-99443). As noted above, on the 1500 Claim Form you should add the modifier 95 after each CPT code to indicate that the care was provided as telemedicine, including next to the 99441-99443 codes.
      • For all telehealth services use the Place of Service (POS) that aligns with where your encounter would have occurred
      • For new telepsychiatry encounters (both audio and video as well as audio only) provided to patients under the waiver that would have been office visits, psychiatrists should consider their office as the place of service (POS) and use the place of service code 11, just as you did when you were seeing your patients in person. If you are providing inpatient care, you should use the place of service you would ordinarily use for that place even though you are not actually there.
      • Those psychiatrists who were previously providing telepsychiatry under Medicare's pre-waiver rules should continue to report this care as they always have with POS 02.
      • For more information on telepsychiatry during COVID, see our Telepsychiatry blog.
    • CMS released guidance on March 17, 2020, that allows patients to be seen via live videoconferencing in their homes, without having to travel to a qualifying "originating site" for Medicare telehealth encounters, regardless of geographic location.
    • The Office of Civil Rights (OCR) has indicated they will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through FaceTime or Skype.
    • The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
    • The Ryan Haight Act requires that a provider conduct an initial, in-person examination of a patient—thus establishing a doctor-patient relationship—before electronically prescribing a controlled substance. As of March 17, 2020, the DEA has indicated that this requirement has been suspended.
    • The American Professional Agency, Inc, which provides professional liability malpractice insurance, developed resources to help members, specifically issued an FAQ about Coronavirus and Telehealth and Coronavirus and Telehealth Resources.

    Substance Use Disorders

    • On March 31, SAMHSA and the Drug Enforcement Agency (DEA) released guidance providing flexibility to prescribe buprenorphine to new and existing patients with opioid use disorder via telephone by otherwise authorized practitioners without requiring such practitioners to first conduct an examination of the patient in person or via telemedicine. SAMHSA has separate guidance for patients treated with methadone in an Opioid Treatment Program.
    • The Substance Abuse and Mental Health Services Administration (SAMHSA) is providing guidance and resources for treating patients with mental health and substance use disorders on its COVID-19 webpage.
    • On March 19, the Substance Abuse and Mental Health Services Administration (SAMHSA) released guidance on 42 CFR Part 2 to ensure that substance use disorder treatment services are uninterrupted during this public health emergency.
    • On March 16, SAMHSA posted COVID-19 guidance providing potential flexibility for Opioid Treatment Programs (OTPs). The COVID19 guidance includes approaches for providing pharmacotherapy for opioids use disorder patients exposed to infections and COVID-19, disaster planning, potential flexibility for take-home medication, OTP guidance for patients quarantined at home with the coronavirus, and Frequently Asked Questions. Learn more about SAMHSA's COVID-19 Guidance for Opioid Treatment Programs here.
    • On March 16, the Drug Enforcement Administration’s released guidelines on Use of Telemedicine While Providing Medication Assisted Treatment (MAT).
    • On March 12, National Institute on Drug Abuse alerted the research community that populations with Substance Use Disorders (SUDs) may be impacted particularly hard.

    Inpatient Psychiatric Settings

    • March 18, Centers for Medicare & Medicaid Services (CMS) released recommendations on the delay of adult elective surgeries, and non-essential medical, surgical, and dental procedures during the COVID-19 outbreak. CMS indicates that "as more healthcare providers are increasingly being asked to assist with the COVID-19 response, it is critical that they consider whether non-essential surgeries and procedures can be delayed so they can preserve personal protective equipment (PPE), beds, and ventilators." APA considers ECT an essential procedure.

    Commercial Payers (Note that coverage varies by individual policy)

    APA developed this sample letter to send to the private insurers and Medicaid Directors that provide coverage to your patients. Please let APA know if you receive a response.

    APA has also joined others to request the implementation of consistent telehealth policies across all payers that remove unnecessary barriers to care during the emergency. This includes outreach to America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association.

    State Resources

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