CMS Proposes Pricing for CPT Codes, Updates to Telehealth Coverage in 2022 Medicare Physician Fee Schedule

July 29, 2021

The Centers for Medicare & Medicaid Services (CMS) released the proposed 2022 Medicare Physician Fee Schedule (MPFS) and other proposed rule changes on July 13. The document can be found here. Addendum B, which contains all assigned relative value units (RVUs) for services within the MPFS, clearly indicates that the CPT codes for adaptive behavior/ABA services (97151 – 97158, 0362T, 0373T) are proposed to remain carrier-priced in 2022 (denoted by “C” in the status column in Addendum B). That means those codes would not have assigned RVUs.

Additionally, CMS proposes changes in the Medicare list of services/codes for which payment for telehealth delivery is approved. The agency assigns services to one of the following telehealth categories (not to be confused with CPT code categories):

• Category 1 – Services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the Medicare telehealth services list
• Category 2 – Services that are not similar to those on the current Medicare telehealth services list
• Category 3 – A new category for services that were added to the Medicare telehealth list during the COVID-19 public health emergency (PHE) for which there is likely to be clinical benefit when furnished via telehealth, but there is not yet sufficient evidence available to consider the services for permanent addition under Category 1 or Category 2. To be added to the Medicare telehealth list permanently, services in this category would have to meet criteria that can be found here.

The CPT codes for adaptive behavior/ABA services were among a number of codes that were added to the Medicare telehealth list temporarily on an interim basis in response to the COVID-19 PHE (see Table 11 in the MPFS document). Those services were not added to Category 3, so payment for telehealth delivery would not continue after the end of the PHE. However, citing uncertainties about when the PHE might end, in the MPFS document CMS announced that it is soliciting comments on whether those services should now be added to telehealth Category 3 to allow for additional data to be collected for a submission for approval under telehealth Category 1 or 2. Placement in Category 3 would also extend telehealth coverage of the services through the end of 2023. The Coalition is in the process of drafting such comments. We had previously submitted a request for CMS to add several of the ABA CPT codes to the Medicare telehealth list permanently, based on an extensive review and analysis of published research. We will keep our constituents apprised of the status of our submissions and any changes in CMS policies regarding coverage of ABA services delivered by telehealth.

One other note: The MPFS rule published on July 13 is PROPOSED. The final MPFS rule will be released on or around November 1, 2021.