Primary Care Coding Alert

Many communities within the United States lack access to high-quality, specialty-specific mental health services. This puts the responsibility on primary care practitioners (PCPs) to provide comprehensive care (www.aafp.org/about/policies/all/mental-health-services.html). A team-based approach in one location allows patients easy access to mental health services, and building a behavioral health integration (BHI) program also makes good business sense, as the resulting higher complexity visits often translate to increased revenue.

These facts seem like a win-win, but a successful BHI program, whether general or a collaborative care model (CoCM), relies on accurate coding, which continues to befuddle coders and practitioners alike. If you find yourself on shaky ground when it comes to BHI coding, here’s a comprehensive breakdown that should help.

Recall the Addition of HCPCS G2214

Medicare refined CoCM service coding by adding G2214 (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) to the mix, which took effect at the start of 2021 (www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1751-f). Be sure to check with your state Medicaid program and private payers for details on their policies for G2214.

This code addition came from a need to document shorter amounts of time than the CPT^® CoCM codes allow.

Understand the Difference Between CoCM and General BHI

Know who’s who in CoCM: If your practice has a psychiatric CoCM program, the care team should have three distinct members: the behavioral health care manager, a psychiatric consultant, and the treating practitioner. This model is essentially an enhancement of the general BHI primary care model that provides additional support for patients receiving behavioral health treatment through their primary care practitioner (PCP).

Know the CoCM codes: To bill for monthly services using the CoCM approach, use the following codes based on time and whether the service is initial or subsequent:

• First 30 minutes, initial or subsequent: G2214
• First 70 minutes, initial: 99492 (Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant …)
• First 60 minutes, subsequent: 99493 (Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant …)
• Additional 30 minutes, initial or subsequent: +99494 (Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month …)

Coding alert: Even though a consultant is part of the care team, the 2023 CPT® evaluation and management (E/M) updates to consultation codes should not affect coding. “The CoCM model includes regular psychiatric interspecialty consultation that is covered by the CoCM codes and does not necessitate separate reporting,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Know who’s who in general BHI: If your practice has a general BHI model, the care team will have two distinct member types: the treating practitioner and other qualified clinical staff to round out the team-based approach. The clinical staff might include contractors who also meet the qualifications for CoCM, but it’s not required.

Know the general BHI code: Report BHI code 99484 (Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month …) in situations that do not involve a psychiatric consultant or an appointed behavioral health care manager. Essentially, you may use this code for behavioral health services that aren’t part of a formal CoCM, if they include the service elements outlined in the long descriptor explained in the following section.

Remember All Required Documentation

CoCM: The full code descriptors for 99492, 99493, and G2214 include the scope of services and, therefore, tell you what documentation is required. Here is what the combined requirements look like for CoCM:

• A primary care team (billing practitioner and behavioral health care manager) initial assessment with the development of an individualized treatment plan:
  • Initial assessment, including administration of validated rating scale(s)
  • Review of the plan by the psychiatric consultant with modifications of the plan if recommended
• Entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation
• Proactive behavioral health care manager follows up systematically using validated rating scales and a registry:
  • Assesses treatment adherence, tolerability, and clinical response using validated rating scales; delivers brief evidence-based psychosocial interventions such as behavioral activation or motivational interviewing
  • 70 minutes of behavioral health care manager time in the first month of behavioral health care manager activities (99492)
  • 60 minutes in following months (99493)
  • Add-on code for each additional 30 minutes in any month (initial or subsequent) (+99494)
• Regular case load review with psychiatric consultant:
  • The primary care team regularly (at least weekly) reviews the patient’s treatment plan and status with the psychiatric consultant.
  • The primary care team continues or adjusts treatment, including referral to behavioral health specialty care, as needed.
• Relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment

Note: Psychiatric consultants and other members of the care team are allowed to provide certain services remotely under the BHI codes. For CoCM, the behavioral health care manager must be available to provide face-to-face services in person, but provision of those services is not required. You should consult the individual payer’s guidelines for details on which telehealth or non-face-to-face services they allow in these circumstances.

Account for time spent: The CoCM codes are time-based, which means in addition to documenting the scope of service, each clinician is also required to document their time to coincide with each initial or follow-up code you report. Although the CoCM code descriptors refer to the behavioral health care manager’s time, you may also count other clinicians’ time if not used to meet the criteria for separately reportable codes. Per CPT^®, if the treating physician or other qualified healthcare professional personally performs behavioral healthcare manager activities and doesn’t use those activities to meet criteria for a separately reported code, they may count their time toward the required behavioral healthcare manager time for 99492, 99493, and +99494. Similar to outpatient E/M coding, you may need to remind practitioners of the importance of clearly indicating total time spent during behavioral healthcare manager activities so you can report the proper code.

General BHI: If your office is using the model that revolves around 99484, the documentation must show the following, according to the code descriptor:

• An initial assessment or follow-up monitoring, including the use of applicable validated rating scales;
• Behavioral health care planning in relation to behavioral/ psychiatric health problems, including revision for patients who are not progressing or whose status changes;
• Facilitation and coordination of treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and
• Continuity of care with a designated member of the care team.

Establish a Workflow to Streamline Communication

Because these codes are all reported monthly, it can be challenging to keep track of everything. In fact, this is one of the biggest challenges with BHI programs because “each clinician must write his or her own note. Clinicians don’t always document in the same place around the same time for a service that is collaborative,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. It’s important that each member of the team, including coders, understands the elements required to report each code to ensure seamless reporting each month.

This means it’s a good idea to establish a workflow for the team, and be sure to communicate regularly regarding updates or other changes. Specifics on what that workflow looks like will depend on “practice size, patient population, current staff capabilities, technology, and resources, etc.,” according to the AMA. See www.ama-assn.org/system/files/bhi-workflow-how-to-guide.pdf for more information on how to set up a BHI documentation workflow in your practice.

For more information on how to establish a BHI program in your office, check out www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf.