The Policy Center Submits Feedback on CMS’ Physician Fee Schedule

By the Policy Center for Maternal Mental Health Policy Team

The Policy Center for Maternal Mental Health submitted the following letter in response to the Centers for Medicare and Medicaid Services Proposed Physician Fee Schedule regarding peer support, community health workers, and social determinants of health, gleaning insights from our partners at Mental Health America and the American Association on Health and Disability.

September 11, 2023

The Honorable Chiquita Brooks-LaSure 
Administrator Centers for Medicare & Medicaid Services 
7500 Security Boulevard Baltimore, MD 21244 

Submitted online at https://www.regulations.gov/ 

RE: Medicare Program; CY 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies [CMS-1784-P] 

Dear Administrator Brooks-LaSure: 

Thank you for the opportunity to comment on the CY 2024 proposed Medicare Physician Fee Schedule payment rule. The Policy Center for Maternal Mental Health wishes to share the following recommendations:

Peer Support 

Valuation of Specific Codes: Section IIE

Principal Illness Navigation Services (PIN) – Create a Code that Reflects Core Competencies of Peer Support Specialists.

Comments:

We appreciate the specific discussion of peer support specialists in the preamble of the rule as staff that can provide this newly created principal illness navigation (“PIN”) service. Medicare has not traditionally allowed providers to bill for peer support specialists, so we are very grateful to CMS for recognizing the importance of this key workforce in advancing behavioral health strategy and payment for peer services. Expanding access to peer support services will provide more beneficiaries with critical supportive services, better meet linguistic and cultural needs, and improve outcomes.

However, because Medicare and private insurance do not reimburse peer support specialists and payment in Medicaid is inadequate, many clinicians have not worked with peer support specialists and do not know the history, role, and scope of the services. Congress recognized the need for provider education in the Consolidated Appropriations Act of 2023 when it instructed CMS to “use existing communication mechanisms to provide education and outreach to providers” with respect to the ability of peer support specialists, among others, to participate in crisis psychotherapy services, other services that can be provided during a behavioral health crisis and integrated care services. 

We have several recommendations to ensure that any newly created service does not confuse clinicians as to the role of peer support specialists and does not lead to peer support specialists being asked to do activities that are not within their scope and training, such as case management and administrative tasks. The preamble to the proposed rule indicates that providers billing the PIN code must be trained to provide ALL the services in the code. Based on a review of SAMHSA documents as well as our experience and knowledge of peer support specialist roles, we are concerned that several of the PIN activities are not within the scope of the peer support specialist role.1 We urge CMS to work with SAMHSA and review peer support specialist competencies and the content recommendations for training in the National Model Standards for Peer Certification training to only include activities that are within the scope of peer support specialists.

We further urge CMS to significantly revise this section and create a distinct code for mental health and substance use education and engagement services that better reflects SAMHSA’s core competencies and current training for peer support specialists. Just as CMS notes in the preamble that it created the Community Health Integration (CHI) service to reflect the core competencies of community health workers, it should create a code that reflects the core competencies of peer support specialists. If that is not possible, CMS should clarify PIN for peer support specialists and include only those functions that peer support specialists provide.

Please note that it would not be sufficient for CMS to clarify that peer support specialists are not required to do all PIN services as there is widespread misunderstanding of the role of peer support specialists, including services that are beyond the scope of peer support specialists.

We further recommend CMS include the following services in a newly created Mental Health and Substance Use Education and Engagement code or, if that is not possible, in the newly created PIN for peer support specialists’ code. Changes from the current language are bolded and are designed to better reflect the core principles of empowerment that are fundamental to peer support:

Person-centered assessment, performed to better understand the individual context of the serious, high-risk condition. 

  • Conducting a person-centered assessment to understand the patient’s life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors. 
  • Facilitating patient-driven goal setting and establishing an action plan. 
  • Providing tailored support as needed to accomplish the person-centered goals in the practitioner’s treatment plan. 

Identifying or referring patients (and caregivers or family, if applicable) to appropriate supportive services. 

Practitioner, Home, and Community-Based Care CoordinationCommunication. 

  • Assist the patient in Ccommunicatingon with their practitioners, home-, and community-based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors. 
  • Facilitating access to community-based social services (e.g., housing, utilities, transportation, food assistance) as needed to address SDOH need(s). 

Health education—Helping the patient contextualize health education provided by the patient’s treatment team with the patient’s individual needs, goals, preferences, and SDOH need(s), and educating the patient (and caregiver if applicable) on how to best participate in medical decision-making. 

Building patient self-advocacy skills so that the patient can interact with members of the health care team and related community-based services (as needed) in ways that are more likely to promote personalized and effective treatment of their condition. 

Facilitating behavioral change as necessary for meeting diagnosis and treatment goals, including promoting patient motivation to participate in care and reach person-centered diagnosis or treatment goals. Developing and proposing strategies to help meet person-centered treatment goals and supporting the patient in using chosen strategies to reach person-centered treatment goals. 

Facilitating and providing social and emotional support to help the patient cope with the condition, SDOH need(s), and adjust daily routines to better meet person-centered diagnosis and treatment goals. 

Leverage knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration. 

CMS seeks comments on what training it should require for PIN providers and for how many hours. State peer support certification training requirements must be adequate training for peer support specialists to bill for Medicare services because additional training will be burdensome and make it difficult to scale services delivered by peer support specialists. As a result, it is critical that the code only includes services within the core competencies of peer support specialists that are commonly included in peer support training that has been approved for state certification.

CMS also should clarify that additional providers, who do not bill E&M codes, such as social workers, psychologists, marriage and family therapists, and licensed counselors, can initiate and include the services of a peer support specialist in their treatment plans and contract with community-based organizations that can provide services delivered by peer support specialists. 

Advancing Access to Behavioral Health Services (II J)

Crisis Psychotherapy Services – Add functions to the crisis psychotherapy code that peer support specialists do to help a person effectively engage in the crisis psychotherapy service.

Comments:

We appreciate this new service created in the CAA to reimburse for crisis services in the Medicare program and create sustainable financing for these services. With the implementation of the 988-crisis system, it is particularly important to increase access to behavioral health services that can respond to a crisis in homes and communities and avoid law enforcement involvement. We urge CMS, however, to modify the proposal to clearly create a pathway for peer support specialists to be reimbursed when they work with clinicians on mobile crisis teams. 

This change would be consistent with Congressional intent and SAMHSA’s guidelines which recognize the critical role of a peer support specialist in using their lived experience to support and engage an individual who is experiencing a crisis. SAMHSA’s National Guidelines for Behavioral Health Crisis include mobile crisis teams as an essential component of a crisis system and specify that to fully align with best practice guidelines, teams must “incorporate peers within the mobile crisis team.” 

Psychotherapy is not within the scope of practice for peer support specialists. However, peer support specialists do provide engagement services, including education, support, and sharing of lived experiences to facilitate an individual participation in crisis psychotherapy effectively. Peer support specialists are analogous to emergency medical technicians (EMTs), who are not medical clinicians but are specially trained to respond in emergency situations.

Accordingly, we recommend CMS create a code Crisis Psychotherapy with engagement services and increase the payment by 40% with a 2-person modifier to allow mobile crisis teams. This is similar to other proposals in this rule that add a function to an existing code and increase payment, such as the addition of SDOH risk assessments to annual wellness visits with higher reimbursement. 

Revising the proposal to include peer support activities is critical to achieving Congressional intent in the CAA to expand access to crisis services delivered by peer support specialists. Congress required CMS to educate providers on how to bill auxiliary personnel, including peer support specialists, with respect to crisis psychotherapy services. However, the proposed rule provides no information or pathway for such billing because peer support specialists cannot provide psychotherapy, which is clearly outside the scope of their practice. Accordingly, CMS should adjust the code to include the education, engagement, and support services that peer support specialists provide and adequately reimburse the effective practice of 2-person mobile crisis teams in accordance with SAMHSA guidelines.

Define Peer Support Specialists in regulation – CMS describes SAMHSA’s definition of a peer support specialist and acknowledges that the CAA requires CMS to educate clinicians on how to bill for auxiliary personnel, including peer support specialists, for integrated behavioral health care and crisis care. Yet, CMS does not explain why it did not incorporate a definition of peer support specialists in the regulation defining auxiliary personnel. CMS will be most effective in meeting Congressional goals by using a multi-pronged strategy that includes regulatory language. Many clinicians and health systems read the physician fee schedule rule and pay attention to the regulations because they are tied to reimbursement, so including a definition of peer support specialists in the regulatory text should be a key component of a strategy to educate on the role of this workforce in accordance with the CAA. 

CMS does not have to change the existing language defining auxiliary personnel. We strongly urge CMS to add a sentence saying that Auxiliary personnel include but are not limited to, peer support specialists and define the term using language from SAMHSA’s national model standards. 

Community Health Workers

Integrate verbiage and recommendations from the American Public Health Association (APHA) CHW Section policies in the final rules for Community Health Integration (CHI), Principal Illness Navigation (PIN), and Social Determinants of Health (SDOH) services.

  • Publish guidance and ensure the availability of technical assistance to billing entities and non-billing partner organizations to eliminate administrative and billing barriers to participation in Medicare and Medicaid programs experienced by CBOs and additional CHW employers that may not bill insurance directly, where the majority of the CHW workforce is employed. 
  • Ensure covered CHW services sustain a full range of core CHW roles according to the CHW Core Consensus (C3) Project recommendations and APHA Policy Number 20227 (2022). Include CHW core roles that address community-level priorities and strengths, promote the health and well-being of individuals and families, prevent multiple forms of violence, and promote health equity across all levels of the socio-ecological model. 
  • Assure the quality of CHI, PIN, and SDOH services rendered by a CHW by promoting consistent measurement of beneficiary, community, and CHW workforce wellbeing. Specifically, CMS should promote the use of common process and outcome indicators and constructs developed through an evidence-based, CHW-driven national consensus process, such as those recommended by the CDC-funded National CHW Common Indicators (CI) Project.

Social Determinants of Health Risk Assessment

CMS is proposing a new stand-alone G code GXXX5, Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment. We generally applaud the creation of an HCPCS code to complete an evidence-based SDOH risk assessment. However, the GXXX5 code is limited to a necessary E/M visit. Screening and identifying health-related social needs is integral to the development of a wellness plan during an annual wellness visit. A provider must determine if HRSNs will impair the ability of the beneficiary to complete the required preventive health screening in the wellness plan. We urge CMS to clarify that providers are allowed to bill for the GXXX5 code during an AWN. In addition, screening and addressing health-related social needs should occur during a transitional care management visit as an eligible E/M visit for the provision of GXXX5.

We thank CMS for this important work to appropriately and effectively expand certified peer and community health worker (CHW) workforces through the fee schedule. The time is now.

Sincerely,

Joy Burkhard, MBA
Executive Director
[email protected]

Sarah Johanek, MPH
Policy Project Manager
[email protected]

Our work shaping and reporting on national mental health policy is made possible through a 2020-2024 capacity grant from the Perigee Fund.

Nov. 6, 2023 update: See a summary of what was published in the final rule here.