Integrated care has been recognized as a valuable tool for enhancing the overall health of individuals with serious and persistent mental illness (SPMI) by improving access to care and treatment for co-morbid medical conditions often experienced by individuals with SPMI. Similar benefits are also evident when professionals working in an integrated setting are able to identify and address previously undiagnosed behavioral health issues that impact quality of life and further complicate medical care. Individuals with SPMI are often unable to successfully manage their medical conditions or illnesses and may demonstrate poor judgment in seeking care for serious medical issues. The holistic approach of integrated behavioral and non-behavioral health care is key in breaking down “silos” of care. These traditional “silos” of care can result in reduced quality of care and increased costs associated with more frequent emergency room visits and hospitalizations.
Instead, collaborative care is a powerful tool in improving communication among providers and enhancing access to both behavioral and non-behavioral care and treatment. Integrated services have widely been considered a successful model of care that improves access to overall care, enhances outcomes and reduces health care costs over time.
However, one of the major challenges in implementing this innovative approach to care has been securing adequate reimbursement for those primary care practices engaging in integrated care. According to a 2017 article in the New England Journal of Medicine, “behavioral health integration has remained limited, however, largely because BHI has not been paid for separately, which has left primary care clinicians without a clear business model for incorporating these services into their practice.”1
Over the past several years, the federal Centers for Medicare and Medicaid Services (CMS) has made significant strides in providing a framework for the coding and reimbursement of collaborative care services covered by the Medicare program. The final frontier will be adoption of similar payment systems by the federal Medicaid system and private insurers. This article will address the new Medicare framework and its specific requirements and parameters and highlight one recent success in expansion of the Medicare model on the state and private level.
Psychiatric Collaborative Care Model
In an attempt to remedy some of the payment challenges present in integrated care, starting January 1, 2017, CMS approved payment for psychiatric collaborative care services provided to Medicare beneficiaries during a calendar month. Effective January 1, 2018, CMS then introduced the new Psychiatric Collaborative Care Model (CoCM), utilizing new Current Procedural Terminology® (CPT) codes 99492, 99493 and 99494, which cover treatment by a physician or other qualified health care professional in conjunction with a behavioral health care manager and a psychiatric consultant. CMS describes CoCM as “a model of behavioral health integration that enhances ‘usual’ primary care by adding two key services: care management support for patients receiving behavioral health treatment; and regular psychiatric inter-specialty consultation to the primary care team, particularly regarding patients whose conditions are not improving.” This new CoCM model is different from other behavioral health integration models because it provides for coordination by a designated behavioral health care manager and regular consultation with a psychiatric consultant.
According to CPT: “Patients directed to the behavioral health care manager typically have behavioral health signs and/or symptoms or a newly diagnosed behavioral health condition, may need help in engaging in treatment, have not responded to standard care delivered in a nonpsychiatric setting, or require further assessment and engagement, prior to consideration of referral to a psychiatric care setting.”
Members of the Care Team
As defined in CPT, the treating physician or other qualified health care professional is the billing provider. He or she directs the behavioral health care manager and continues to oversee the patient’s care, including prescribing medications, providing care and treatment for medical conditions and making referrals to specialists as needed. The treating physician or provider may bill for separate evaluation and management or other services during the same calendar month the CoCM services are billed.
The behavioral health care manager is a clinical staff member who must have masters or doctoral level education or specialized training in behavioral health and are often individuals with social work, nursing or psychology backgrounds. In addition to care management services, the behavioral health manager assesses patient needs, develops a care plan, provides brief interventions and maintains the patient registry. The individual must be available to provide face to face services, although face to face services are not always necessary. A behavioral health manager maintains an ongoing relationship with the patient and a collaborative, integrated relationship with the rest of the care team. If the behavioral health care manager is eligible to independently furnish and report services to the Medicare program, then that individual may also provide additional services to the patient, including psychiatric evaluation, psychotherapy and alcohol or substance abuse intervention services.
The psychiatric consultant must be a medical professional who is trained in psychiatry or behavioral health and qualified to prescribe a full range of medications. In most cases, this individual will be a psychiatrist, psychiatric nurse practitioner or physician assistant. The psychiatric consultant is responsible to advise and make recommendations regarding psychiatric and medical care, psychiatric and medical diagnoses, treatment strategies, medication management and medical management of complications associated with treatment of psychiatric disorders. The psychiatric consultant may also provide referrals to specialists which will be communicated to the treating physician through the behavioral health care manager. The psychiatric consultant’s role is typically consultative or advisory and in most cases, the psychiatric consultant will not see the patient face to face or prescribe medications. The psychiatric consultant is not required to be a participating Medicare provider because payment for the CoCM service is made directly to the billing provider (the treating physician or other qualified health care professional).
The behavioral health manager and the psychiatric consultant may or may not be employees of the same practice as the billing provider and may be independent contractors hired by the billing practice. The behavioral health manager must be available to provide face to face services if needed, but the psychiatric consultant is often located remotely.
Code 99492, the code for initial psychiatric collaborative care management, is described as follows:
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 consultation, and directed by the treating physician or other qualified health care professional, with the following required elements:
- outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional;
- initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan’
- review 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, and participation in weekly caseload consultation with the psychiatric consultant; and
- provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.
Code 99493 is used for reporting the first 60 minutes of subsequent psychiatric collaborative care management during a subsequent month of behavioral health care manager activities. This code is generally used for reporting follow up activities, including patient tracking, weekly caseload consultation, and ongoing collaboration, coordination and monitoring. Code 99494 is an add-on code for additional 30-minute periods of either initial or subsequent care management.
CMS has also approved a general care management code (99484), which may be used for integrated services provided without a specific behavioral health care manager. 99484 provides for at least 20 minutes of care management services for behavioral health conditions per calendar month, including assessment, monitoring, behavioral care (including facilitating and coordinating psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation), and continuity of care with a designated member of a care team.
Claims are submitted to the Medicare program by the treating physician or primary care provider. The behavioral health care manager and consulting psychiatrist are then paid by the primary provider through a separate employment or independent contractor relationship. Claims are submitted for a monthly service period and not for a specific date of service.
APA Model Legislation
In response to the increased use of integrated care models and the new CoCM codes introduced by CMS, the American Psychiatric Association (APA) has drafted model legislation seeking to confirm coverage of the collaborative care codes by private insurers and health care plans. The APA has tailored legislation for each of the fifty states and the District of Columbia.
For example, the New York model legislation requires that every health care insurance policy that “provides coverage of mental health and substance use disorder benefits shall provide reimbursement for such benefits that are delivered through the psychiatric Collaborative Care Model, which shall include the following current procedural terminology (CPT) billing codes established by the American Medical Association (AMA): (i) 99492; (ii) 99493; (iii) 99494 . . .” In order to remain budget neutral, the model legislation focuses solely on private carriers. Language applicable to state Medicaid programs may be added for individual states, where feasible.
In exciting breaking news, in late August, 2019, Illinois became the first state to enact the APA’s model collaborative care legislation into law. Illinois bill SB 2085, Psychiatric Collaborative Care, statute requires private insurers in Illinois as well as the Illinois Medicaid program to provide reimbursement for the CoCM CPT codes.
Hopefully, other states will follow suit in the near term, allowing for greater implementation of behavioral health integration among primary care services. In order to fully implement integrated care into our health system, we must have the full support of all third-party payers, including government and private carriers. Without adequate reimbursement, integrated care models cannot be truly successful and the system will fall short in its goals of improved outcomes, enhanced access and lowered costs for all.
Rachel A. Fernbach, Esq. is Deputy Director and Assistant General Counsel of the New York State Psychiatric Association and Vice-Chair of the Mental Health News Education, Inc. Board of Directors.
1. Medicare Payment for Behavioral Health Integration, N ENGL J MED376;5 (citing Schwenk TL. Integrated behavioral and primary care: what is the real cost? JAMA 2016;316:822.3).