Starting January 2017, the Centers for Medicare and Medicaid Services (CMS) approved payment for services provided to patients with behavioral health disorders who are participating in psychiatric collaborative care programs or are receiving behavioral health integration services. Medical coding companies utilized the three CMS approved HCPCS codes – G0502, G0503 and G0504 – for billing these services. In 2018, new CPT codes replace the 2017 HCPCS codes for Collaborative Care Management-Behavioral Health Integration (CoCM-BHI). The three new CPT codes to report psychiatric collaborative care management (PCCM) in starting January 1, 2018 are: 99492, 99493 and 99494.
Reporting CPT Codes 99492-99494
Psychiatric collaborative care management (PCCM) as described by Current Procedural Terminology (CPT) 2018 reflects behavioral health services delivered via a specific evidence-based model. The American Academy of Pediatrics (AAP) provides the following guidelines for the use of the new PCCM codes
- In a PCCM model, care is managed by a behavioral health care manager (BHCM), who has master’s/doctoral-level education or specialized training in behavioral health, under direction of a treating physician or qualified health care professional (QHP) in consultation with a medical professional trained in psychiatry or behavioral health and qualified to prescribe the full range of medications. Therefore, in collaborative care, patients expect that they are getting a separate service from a specialist, who collaborates closely with their physician.
- PCCM codes 99492-99494 are reported only by the treating physician or QHP, as the psychiatric consultant’s services are included in these codes. The treating physician pays the psychiatric consultant through a contractual arrangement.
- PCCM codes are time-based with the CPT midpoint rule applying. Time is met when the midpoint is passed. Any PCCM service for which time is not documented cannot be counted toward the minutes of service reported.
- PCCM is reported for an initial calendar month when at least 36 minutes are spent in provision of PCCM services and for at least 31 minutes of service in a subsequent calendar month.
- Time spent in PCCM activities while the patient is in observation or inpatient hospital status should not be included while reporting these services. PCCM activities to coordinate care with the emergency department may be included in the time of service reported.
- 99492 Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of BHCM activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHP, with the following required elements:
- outreach to and engagement in treatment of a patient directed by the treating physician or other QHP;
- 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.
- 99493 Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of BHCM activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHP, with the following required elements:
- tracking patient follow-up and progress using the registry, with appropriate documentation;
- participation in weekly caseload consultation with the psychiatric consultant;
- ongoing collaboration with and coordination of the patient’s mental health care with the treating physician or other QHP and any other treating mental health providers;
- additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant;
- provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing and other focused treatment strategies;
- monitoring of patient outcomes using validated rating scales; and
- relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.
- +99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of BHCM activities, in consultation with a psychiatric consultant, and directed by the treating physician or other QHP (List separately in addition to code for primary procedure) (Use 99494 in conjunction with 99492, 99493).
Critical Role of Primary Care Clinicians in PCCM
According to the National Alliance on Mental Illness (NAMI), approximately 1 in 5 adults in the U.S.-43.8 million, or 18.5%-experiences mental illness in a given year. Mental illness begins very early in life and it is estimated that 50 percent of all lifetime cases begin by age fourteen, and three-quarters have begun by age twenty-four.
The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) stress the role of primary care clinicians in delivering mental health services to children and adolescents in the primary care setting. With the appropriate training and collaborative relationships, primary care clinicians can initiate services to children with emerging developmental and behavioral problems and common mental health disorders such as attention-deficit/hyperactivity disorder (ADHD), depression, anxiety disorders, and substance use. The primary care setting is ideal for early identification and intervention, counseling, guidance, care coordination, and chronic illness management.
The introduction of the new PCCM codes indicate that CMS is recognizing and reimbursing non-face-to-face care collaboration services for patients with behavioral health conditions as part of their support for primary care physicians. According to the AAP, rough calculation of practice expense reveals that the treating physician or QHP could realize about $75 net revenue per PCCM service. This will differ based on practice location, health plan fee schedule, salaries of BHCMs, and actual times of service. As these new codes come into effect in 2018, providers can partner with a family practice medical billing service provider to report PCCM correctly and take advantage of these new revenue opportunities.