2020 update on Medicare payment for behavioral health care

Medicare began paying for mental and behavioral health services under new billing codes on January 1, 2017. One year later, on January 1, 2018, Medicare began to use new CPT codes to report these types of services. This article highlights how providers can use these new codes to comply with Medicare regulations.

PSYCHIATRIC COLLABORATIVE CARE SERVICES (CoCM)

In an effort to better integrate behavioral health care with primary care, Medicare implemented three new CPT codes (99492, 99493 and 99494) to bill for monthly services furnished using the Psychiatric Collaborative Care Model (CoCM). 

CoCM is a model of behavioral health integration (BHI) that is intended to enhance primary care by integrating two key services to the primary care team, particularly for patients whose conditions have not improved. These services include  care management support for patients receiving behavioral health treatment and regular psychiatric inter-specialty consultation. The model is achieved by utilizing a team of three individuals to promote behavioral health care: the behavioral health care manager, the psychiatric consultant and the treating (billing) practitioner. 

  • Treating (billing) Practitioner – A physician and/or non-physician practitioner; typically primary care but may be of another specialty.
  • Behavioral Health Care Manager – A designated individual with formal education or specialized training in behavioral health, working under the oversight and direction of the treating practitioner.
  • Psychiatric Consultant – A medical professional trained in psychiatry and qualified to prescribe the full range of medications.

 CoCM is broken down into various service components which are billed accordingly –

  • The first step involves an initial assessment by the primary care team which is performed by the billing practitioner and the behavioral health care manager. It may also be necessary to perform an initiating visit which is billed separately.
  • After the initial assessment, the primary care team, jointly with the beneficiary, begins care planning or care plan revision for patients whose conditions has not adequately improved. Various treatments may be considered during care planning including pharmacotherapy, psychotherapy and/or other indicate treatments as applicable.
  • Following the implementation of the care plan, the behavioral health care manager performs proactive, systematic follow-ups using validated rating scales and a registry. The behavioral health care manager should assess treatment adherence, tolerability, and clinical response. Typically, 70 minutes of behavioral health care manager time if scheduled for the first month and 60 minutes for subsequent months. If necessary, the add-on code may be used for 30 additional minutes any month.

  • Finally, the psychiatric consultant will review the case. This involves weekly reviews of the beneficiary’s treatment plan and status with the psychiatric consultant by the primary care team. The primary care team should maintain or adjust treatment as needed.

The CoCM services can be furnished when the beneficiary has one or more psychiatric or behavioral health conditions that, in the treating physician’s judgment, warrant a behavioral health care assessment, a care plan, and brief interventions. Eligible conditions include any mental, behavioral health, or psychiatric condition, including substance use disorders. The diagnosis can be pre-existing or made by the billing practitioner and may be refined over time.

The new CoCM codes describe psychiatric collaborative care management directed by a treating physician in consultation with a behavioral health care manager:

  • Code 99492: Initial psychiatric collaborative care management for the first 70 minutes in the first calendar month satisfying the following elements:
    • Patient outreach and engagement by treating physician or other qualified health care professional (nurse practitioner, physician assistant, etc.)
    • Initial assessment of patient and development of an individualized treatment plan
    • Review by psychiatric consultant and modification of the plan if recommended
    • Entry of the patient in a registry, follow-up tracking and participation in weekly caseload consultation with the psychiatric consultant
    • Brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing and other focus based treatment strategies

       

  • Code 99493: Subsequent psychiatric collaborative care management for the first 60 minutes in a subsequent month satisfying the following elements:
    • Tracking patient follow-up and progress using the registry, with appropriate documentation
    • Weekly caseload consultation with the psychiatric consultant
    • Ongoing collaboration and coordination of patient mental health care by the treating physician and any other treating mental health providers
    • Additional review of progress and recommendations for treatment changes
    • Brief interventions using evidence-based techniques
    • Monitoring of patient outcomes using validated rating scales, along with relapse prevention planning as the patient achieves remission of symptoms or other treatment goals

       

  • Code 99494: Additional 30 minutes of behavioral health care manager activities in a calendar month, in consultation with psychiatric consultant and directed by the treating physician.

NEW CODE 99484 – GENERAL BEHAVIORAL HEALTH INTEGRATION

CPT code 99484 is used to bill monthly services which use BHI models of care other than CoCM but that are similar in service elements such as, systematic assessment and monitoring, care plan revision for patients whose condition is not improving, and a continuous relationship with a designated care team member.

CPT code 99484 may be used to report BHI models of care even if they do not involve a psychiatric consultant or a designated behavioral health care manager. Under this code, BHI services may be provided in full by the billing practitioner or qualified clinical staff may be used to provide certain services using a team-based approach. If clinical staff is utilized, the staff or contractors should meet similar qualifications for the CoCM behavioral health care manager or psychiatric consultant.

General BHI models are broken down into various components which are billed accordingly:

  • Initial assessment – including an initiating visit if required, billed separately
  • Systematic assessment and monitoring
  • Care planning by the primary care team jointly with the beneficiary, with care plan revisions for patients whose condition is not improving
  • Facilitation and coordination of behavioral health treatment
  • Continuous relationship with a designated member of the care team

CARE TEAM MEMBER ROLES

The various BHI codes provide a mechanism to identify and pay for services provided using models of care having well defined roles and relationships among the care team members.

  • Incident to” – BHI services that are not provided personally by the billing practitioner but by the other members of the care team, under the direction of the billing practitioner on an “incident to” basis.The other care team members should either be employees or working under contract for the billing practitioner.
  • Initiating Visit” – An initiating visit is separately billed and is required for all new patients or beneficiaries that have not been seen within one year prior to commencement of BHI services.

The treating (billing) practitioner is charged with directing the behavioral care manager or clinical staff and must oversee the beneficiary’s care, including prescribing medications, providing treatments for medical conditions, and making referrals to specialty care. The billing practitioner should be involved throughout the entire BHI process through ongoing oversight, management, collaboration, and reassessment. In some cases, the billing practitioner may provide the general BHI services in its entirety.

The behavioral health care manager must have formal education or specialized training in behavioral health. CMS recognizes social work, nursing and psychology as acceptable disciplines. The responsibilities of the behavioral health care manager include:

  • Providing the following elements of service in consultation with the psychiatric consultant:
    • Care management services and assessment of needs
    • Behavioral health care planning, including managing treatment plan revisions for patients who are not progressing or whose status changes
    • Brief interventions
    • Ongoing collaboration with the treating physician
    • Registry maintenance
    • Consulting with the psychiatric consultant on a weekly basis
    • Maintaining a collaborative, integrated relationship with the care team members
    • Maintaining the ability to engage the beneficiary during off hours and have a continuous relationship with the beneficiary

The behavioral health care manager does not include administrative or clerical staff and time spent in strictly administrative or clerical duties should not be counted towards the time threshold to bill BHI codes.

The psychiatric consultant must be a medical professional (e.g., a psychiatrist or an advanced practice nurse with psychiatry board-certification) trained in psychiatry and qualified to prescribe the full range of medications. The psychiatric consultant advises and makes psychiatric and other medical care recommendations that are communicated to the treating physician, typically through the behavioral health care manager. The psychiatric consultant does not typically see the beneficiary or prescribe medications, except in rare circumstances, but should facilitate referral for direct psychiatric care when clinically indicated.

In general BHI models, clinical staff may be utilized and are expected to create a continuous relationship with the beneficiary and collaborative, integrated relationship with the rest of the care team.

BHI CODING SUMMARY

Prior to the commencement of any BHI services, the beneficiary must give the billing practitioner permission to consult with relevant specialists. Consent may be verbal but must be documented in the medical record.

If you have any questions regarding the subject matter of this article or any other health care legal matters, please contact one of the attorneys below.

 

 

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