As the global pandemic enters its fifth month, we are all feeling the strain. Staying home to slow the spread of the coronavirus may be keeping more people physically healthy, but isolation exacts a toll on mental health. Anxiety over fear of infection and financial loss, frustration and anger about lack of planning and supplies, and other stressors stemming from lengthy quarantines and social distancing have made this pandemic a crisis on all fronts — especially for those with poor mental health and existing mental illness.
Defining the Problem
According to the National Institute of Mental Health, one in five adults in the United States will experience a mental illness in a given year, about half of whom receive mental health services. Mental illnesses include many different conditions that vary in degree of severity, ranging from mild to moderate to severe; and those with existing mental health disorders are at a greater risk of experiencing worsening symptoms as a result of the current public health emergency (PHE). Consequently, the need for telepsychiatry has never been greater.
What is Telepsychiatry?
The American Psychiatric Association defines telemedicine as “the process of providing healthcare from a distance through technology, often using videoconferencing. Telepsychiatry, a subset of telemedicine, can involve providing a range of services including psychiatric evaluations, therapy (individual therapy, group therapy, family therapy), patient education and medication management.” Telepsychiatry can involve direct interaction between a psychiatrist and a patient or involve a psychiatrist providing consultation to healthcare providers.
There are three approaches to telepsychiatry:
- Scheduled services, which are delivered to healthcare facilities typically in an outpatient setting
- On-demand telepsychiatry, which is usually delivered in emergency rooms and inpatient units
- In-home care
As COVID-19 has reached every corner of the United States, telepsychiatry has become crucial. Not only have mental health facilities been limiting services or even closing their doors, cutting off much-needed in-person evaluation and care, but many people with anxiety and fear about the current health climate are also choosing to stay home rather than take the risk of being exposed to the coronavirus in a clinical setting. Quarantine orders and isolation due to illness have also been an obstacle for patients in need of mental healthcare.
Telehealth programs are not a new idea and have been making strides in recent years — especially in rural areas and underserved communities where trained professionals are scare or even completely unavailable — but until 2020, coverage for many telepsychiatry services has been limited. In light of the current crisis, however, the Centers for Medicare & Medicaid Services (CMS) has lifted Medicare restrictions on the use of telehealth services to allow mental healthcare providers to be reimbursed for telehealth visits during the COVID-19 emergency.
In addition to the 1135 waiver set forth on March 6, which allowed Medicare to pay for office, hospital, and other visits furnished via telehealth, CMS has adopted further temporary policy changes on April 30 that go beyond the April 6 Interim Final Rule with the goal being to “increase access to telehealth for Medicare patients so they can get care from their physicians and other clinicians while staying safely at home.”
During the PHE for COVID-19, clinicians can now provide the following additional services by telehealth (including audio-only):
Group psychotherapy (CPT® code 90853)
Psychological and neuropsychological testing (CPT® codes 96130-96133 and 96136-96139)
Using new waiver authority, CMS is allowing many behavioral health and education services to be furnished via telehealth using audio-only communications. The full list of telehealth services can be found here.
For coding and billing guidance, see Medicare Telehealth Coverage as of April 30.
Loosening Limits on Prescribing Through Telemedicine
The Ryan Haight Act was created to regulate online internet prescriptions and imposes rules around the prescription of controlled substances through telepsychiatry. The act requires that a patient receives an in-person medical examination from a doctor before that doctor can prescribe an electronic prescription for a controlled substance. This rule, however, is exempted during the PHE, which was declared by the Secretary of Health and Human Services on Jan. 31, 2020. On March 16, the DEA announced that this requirement is suspended for the duration of the emergency declaration, allowing doctors to prescribe schedule II-V controlled substances to patients for whom they have not conducted an in-person medical evaluation.
According to the U.S. Department of Health and Human Services (HHS), during the COVID-19 national emergency, which is a formally declared PHE, covered healthcare providers subject to the HIPAA rules may seek to communicate with patients remotely to provide telehealth services with the understanding that some of the technologies used and how they are used may not fully comply with the requirements of the HIPAA rules.
Covered healthcare providers may use audio or video communication for telehealth visits as long as they utilize a non-public facing remote communication product. Skype for Business and Microsoft Teams are therefore acceptable platforms, but Facebook Live, TikTok, and other public communication applications should never be used. HHS states that the Office for Civil Rights (OCR) “will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered healthcare providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.”
Managing Mental Health During the PHE
It is important that people with poor mental health receive extra support during this uncertain time. If you or someone you know is struggling, the following resources are available to anyone in crisis:
- Disaster Distress Helpline – Call 1-800-985-5990 or text TalkWithUs to 66746
- National Suicide Prevention Lifeline – Call 800-273-8255
- Crisis Textline – Text TALK to 741741