Behavioral Health Integration Services

Behavioral health integration is widely believed to be effective for improving the health outcomes of millions of Americans who have mental or behavioral health conditions. Medicare makes a separate payment to physicians and non-physician practitioners for the BHI services they supply to beneficiaries over a calendar month service period. Keep reading to learn how to deliver and bill for the service!

Introduction

Behavioral health integration (BHI) is the practice of integrating behavioral health care with primary health care. This strategy is now widely believed to be effective for improving the health outcomes of millions of Americans who have mental or behavioral health issues. Since BHI is a type of care management service, Medicare makes a separate payment to physicians and non-physician practitioners for the BHI services they supply to beneficiaries over a calendar month service period.

Medicare has, in recent years, modified the policies to improve payment for care management services by expanding the suite of codes used to report care management services. The new codes describe the following services:

• Services that represent a single encounter, a monthly service, or both
• Services that involve direct patient contact (in-person, face-to-face services) or do not involve direct patient contact
• Services that are timed
• Services that address specific conditions
• Services that represent the work of the billing practitioner, auxiliary personnel (specifically, clinical staff), or both

Background

On January 1, 2017, Medicare had started offering a separate payment to physicians and non-physician practitioners for providing BHI services to patients during a calendar month. The following year (CY 2018) they expanded covered services and started making payment for BHI using CPT codes 99492, 99493, and 99494.

CMS introduced a new BHI service by refining coding for psychiatric collaborative care model (CoCM) services in the CY 2021 MPFS Final Rule (CMS-1734-F). So, on January 1, 2021, it began to offer payment for the services of HCPCS code G2214 — described  as  “initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant and directed by the treating physician or other qualified health care professional.”

The HCPCS code G2214 was created in response to requests from stakeholders who reported the need for additional coding to capture shorter increments of time spent with a patient. An example of this type of situation is when a patient is seen for services but later has to be hospitalized or referred for specialized care. In such a scenario, the number of minutes required to bill for services using the current coding is not met. So, CMS had to create HCPCS code G2214 to precisely account for such services.

Psychiatric Collaborative Care Services (CoCM)

To bill for monthly services rendered under the Psychiatric Collaborative Care Model (CoCM), you can use CPT codes 99492, 99493, and 99494, and HCPCS code. The CoCM approach to BHI has been shown to improve outcomes in multiple studies.

What Is CoCM?

The figure below shows a BHI model that improves the usual primary care outcomes by adding two key services to the primary care team, specifically for patients whose conditions are not improving. The two extra services are behavioral care management support for patients receiving behavioral health treatment and regular psychiatric inter-specialty consultation.

So, a team of three individuals is needed to deliver CoCM, and they include:

• The Behavioral Health Care Manager
• The Psychiatric Consultant
• The Treating (Billing) Practitioner 

The Care Team Members

Here are the details of the CoCM care team:

• Treating (Billing) Practitioner: This is the physician and/or a non-physician practitioner, such as physician assistant or nurse practitioner. They are usually primary care providers but may be a specialist, such as a cardiologist or an oncologist.
• Behavioral Health Care Manager: This is a designated individual with formal education or specialized training in behavioral health care, such as social work, nursing, or psychology. They work under the supervision of the billing practitioner.
• Psychiatric Consultant: This is a trained psychiatrist who is qualified to prescribe the full range of medications.

The Components Of the CoCM Services

Initial assessment by the primary care team: This often involves the billing practitioner and behavioral health care manager. The service here includes:

• Initiating visit, which can be billed separately if required.
• Administration of validated rating scale(s)

Systematic follow-up: The behavioral health care manager uses validated rating scales to perform proactive, systematic follow-up and keeps a registry of what is done. Services here include:

• Assessing treatment adherence, tolerability, and clinical response using validated rating scales and delivering brief evidence-based psychosocial interventions, such as behavioral activation or motivational interviewing
• For the first month, 70 minutes of behavioral health care manager time
• For subsequent months, 60 minutes of behavioral care
• On any month, add-on code for 30 additional minutes

Regular caseload review with a psychiatric consultant:

• The primary care team engages the psychiatric consultant to review the patient’s treatment plan and status every week
• The primary care team implements the recommended treatment, including referring the patient to behavioral health specialty care when needed

General BHI

Monthly services delivered using BHI models of care other than CoCM are billed with the CPT code 99484. These services include service elements like care plan revision for patients whose condition is not improving adequately, systematic assessment and monitoring, and a continuous relationship with a designated care team member.

CPT code 99484 can also be used to bill models of care that do not require the services of a psychiatric consultant or a designated behavioral health care manager. However, this set of practitioners can also render General BHI services.

The Members of the Care Team

Members of the general BHI care team include:

• Treating (Billing) Practitioner: This is a physician and/ or non-physician practitioner, such as PA, NP, CNS, CNM). They are usually primary care providers but may be a specialist, such as a cardiologist, oncologist, or psychiatrist.
• Potential Clinical Staff: While the billing practitioner can deliver the service alone, he or she may work with qualified clinical staff to render the services using a team-based approach. Clinical staff can be a contractor who meets the qualifications for the CoCM behavioral health care manager or psychiatric consultant.

The Components Of the Services

• Initial assessment: An initiating visit, which is separately billable, is required for new patients or old patients not seen within one year before the start of BHI services. This is also the time for the administration of applicable validated rating scale(s).
• Systematic assessment and monitoring: This is done using applicable validated clinical rating scales.
• Care planning: The primary care team jointly with the patient plans what the care would entail. For a patient whose condition is not improving, the team can review the care plan.
• Facilitation and coordination of behavioral health treatment: The beneficiary is referred for behavioral care as needed
• Continuous relationship with a designated member of the care team

The BHI Codes also allow for a remote provision of certain services by the psychiatric consultant and other members of the care team

Key things to note

Incident To BHI services that are not rendered personally by the billing practitioner but, instead, delivered by other members of the care team (not including the patient), under the supervision of the billing practitioner on an incident to basis (as an integral part of services rendered by the billing practitioner), subject to applicable state law, licensure, and scope of practice:

• the other care team members could either be employees or working under contract to the billing practitioner that Medicare pays directly for BHI
• BHI services that are not personally performed by the billing practitioner are assigned general supervision under the Medicare
• General supervision is defined as the service rendered under the overall direction and control of the billing practitioner, and during service provision, their physical presence is not required

Advance Consent

Before receiving BHI services, the beneficiary must permit the billing practitioner to consult with relevant specialists, which include conferring with a psychiatric consultant. Even if supplemental insurers cover cost-sharing, the billing practitioner must inform the beneficiary that cost-sharing applies for both face-to-face and non-face-to-face services. The beneficiary may give verbal consent, as written consent is not required, but the consent must be documented in the medical record.

Table 1: The Summary of BHI Coding

**CoCM is considered rendered monthly for any session of care that ends when targeted treatment goals are met, when there is failure to attain targeted treatment goals, leading to the beneficiary’s referral for direct psychiatric care, or when there is a break in a session (no CoCM for 6 consecutive months).

†Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), Transitional Care Management services (TCM).

(Fee is based on the locality, coinsurance and deductible would apply)

Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf