Understanding the role of each team member is vital to proper billing of CoCM services

CoCM is provided by a primary care team that includes a primary care physician, BHM, and psychiatric consultant. The care manager—typically a social worker or licensed therapist—is responsible for working with the psychiatric consultant. The psychiatric consultant can be a psychiatrist or a nurse practitioner with a psychiatric specialty.

Team members’ roles and responsibilities:

• The PCP or another medical provider (billing provider) – “A physician or non-physician practitioner (physician assistant or nurse practitioner); typically primary care, but may be of another specialty (for example, cardiology, oncology)

• “Behavioral Health Care Manager – A designated individual with formal education or specialized training in behavioral health (including social work, nursing, or psychology), working under the oversight and direction of the billing practitioner.

• “Psychiatric Consultant – A medical provider trained in psychiatry and qualified to prescribe the full range of medications”^[2]

The PCP is responsible for screening and initiating CoCM services for patients who could benefit from these behavioral health services. Additionally, the PCP is responsible for engaging/contracting with a BHM and psychiatric consultant to bill for CoCM services. Lastly, as the billing provider, the medical physician must have the documentation from all team members and make sure all documentation is complete prior to billing for CoCM services.

The role of the BHM is to assess the patient, create a treatment plan, and set measurable goals. During sessions with the patient, the BHM supports the patient in meeting the goals set in the treatment plan. The BHM also educates and helps coordinate community resources to ensure ongoing success for the patient. The BHM is responsible for meeting with the psychiatric consultant and PCP to ensure that progress is made and goals are met. Additionally, the BHM maintains the “registry” (a tool to manage the patient caseload to track patient treatment activities and progress).

The psychiatric consultant is responsible for regularly reviewing the clinical status of the practice’s patients receiving CoCM services. Psychiatric consultants are responsible for advising the PCP and BHM concerning the patient’s psychiatric diagnoses and resolving any issues that may arise related to adherence or tolerance to the treatment plan. They are not expected to meet directly with patients receiving CoCM but serve as a resource to the PCP and the BHM. Finally, they can give referrals for direct higher-level care facilities when clinically indicated.

To bill for CoCM services, each team member must fulfill their role to adhere to CoCM guidelines. The key distinction of the psychiatric CoCM is the team approach; therefore, all three individuals of the clinical team must be involved in the patient’s care.

Understanding the CoCM CPT^® codes is important to billing compliance

In 2018, the CPT codes for CoCM billing were changed. The CPT code 99492 is for billing the initial CoCM services, and CPT code 99493 is for billing the subsequent monthly visits. Three CPT codes can be used for billing CoCM services:

• 99492 is used for the first 70 minutes of the initial psychiatric collaborative care management in the first calendar month of BHM activities.

• CPT code 99493 is used for billing the first 60 minutes of subsequent psychiatric collaborative care management services in a subsequent month of BHM activities.

• CPT code 99494 is an add-on code used for the initial or subsequent psychiatric collaborative care management for each additional 30 minutes in a calendar month of BHM activities.

All three of the CoCM CPT codes are timed codes, so documentation of the time spent with the patient is required to bill for these codes. The medical record should have the exact amount of time spent with the patient documented. This can best be done by recording the in and out time in the medical record. Since the CPT codes for CoCM are billed based on time, the CPT time rule applies. The CPT time rule states that the billing of the CPT service code is allowed if at least 50% of the time required in the code description is met, plus one minute. For example, to bill for CPT code 99492, the time spent and documented in the record must be a minimum of 36 minutes since the CPT code description for CPT code 99492 states the code is for the first 70 minutes in the first calendar month for the initial psychiatric CoCM services. The same rules would apply for CPT code 99493; the time spent and documented in the record must be a minimum of 31 minutes since the CPT code description for CPT code 99492 states the code is for the subsequent 60 minutes in the subsequent calendar month for the subsequence psychiatric CoCM services. Additionally, there is an add-on CPT code for instances where additional time was spent providing CoCM services in a month. The CPT code 99494 can be used when the time required for the primary code has been fully met—either 70 minutes for CPT code 99492 or 60 minutes for CPT code 99493.

Documentation guidelines to watch out for

CoCM CPT codes can be billed once per calendar month. There are several elements that must be documented in the medical records to ensure that the CPT codes billed for CoCM are supported and meet medical necessity requirements. The documentation by the BHM, psychiatric consultant, and PCP should include the following 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 qualified health care professional 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.”^[3]

CoCM services can be done via telehealth or face-to-face visits with the BHM. Telehealth visits can be done using a video call or telephone. How the visit is conducted is essential and should be documented in the medical record.

Consent, registry, and treatment plan

As with other Medicare services, the PCP or other medical provider must refer the patient for CoCM services. Additionally, the physician is required to obtain consent from the patient before billing for CoCM services. Beneficiaries must understand and agree to receive CoCM services since cost sharing is involved, such as copays and coinsurance, depending on the beneficiary’s coverage. Consent can be written or verbal and should be clearly documented in the medical record to validate the patient agreement to avoid denials during an audit.

“The consent will include permission to consult with relevant specialists, including a psychiatric consultant, and inform the beneficiary that cost sharing will apply to in-person and non-face-to-face services provided. Consent may be verbal (written consent is not required) but must be documented in the medical record.”^[4]

Another critical component of CoCM service documentation is entering patients receiving CoCM services into a registry to track the patient’s progress and clinical outcomes. The other purpose of the registry is to summarize patients’ improvements and identify barriers to treatment. Treatment adjustments can be made and tracked based on the information gathered through the registry. Lastly, it serves as a tool to facilitate effective psychiatric consultant case reviews each week with the BHM and to monitor the patient’s progress.

Finally, all providers involved in patient care must document all encounters with the patient so it can be counted towards the CoCM activities for the monthly billing. It is vital that the core components are documented to support the CoCM services billed. There should be an active treatment plan and care management for each individual patient. Documentation should use an evidence-based patient tracking tool, such as the patient health questionnaire–9, for consistent, proactive outcome monitoring and regular—usually weekly—planned psychiatric caseload reviews with the care team.^[5]

Billing provider issues

The PCP is the billing provider responsible for contracting with a BHM and a psychiatric consultant. As the billing provider, the PCP does the initial referral and bills for CoCM services. Another important role of the PCP is to prescribe medications and treatment based on the psychiatric consultant’s recommendations. Managing a caseload of patients, maintaining regular contact and communication, and gathering all necessary documentation can be tricky.

Before billing CoCM services, the PCP needs to ensure that all documentation has been reviewed to ensure that the CoCM services are fully supported in the medical record and that the correct codes are billed. If this process is not streamlined and closely monitored, it could cause billing delays and/or errors. Finally, in the event of a government audit, the documentation needs to be readily available and easily and efficiently gathered. Since the billing provider is ultimately responsible for the billing, it is in their best interest to ensure the CoCM documentation is complete and easily accessed.

Conclusion

The CoCM has proven effective for treating patients with chronic mental health disorders. Physicians, other healthcare providers, compliance officers, and billing staff should have a good understanding of the coding, billing, and documentation guidelines for CoCM services to avoid denials and compliance headaches. Practices should take the time to research and find appropriate and qualified contractors (BHM and psychiatric consultant), ensuring a good fit to confirm a successful partnership. Ongoing monitoring is imperative to identify risk areas and weaknesses in the CoCM program and ensure success by preventing errors and possible denials.

Takeaways

• Collaborative Care Management (CoCM) uses a team-based approach to treat mental health disorders.

• A psychiatric consultant must be on the team.

• Patient consent is required before billing for CoCM services.

• Maintaining a patient registry is a requirement of CoCM services.

• Good communication with your CoCM team and solid documentation are essential.