Behavioral Health Integration Under the 2021 Medicare Physician Fee Schedule Proposed Rule

This article addresses the proposed changes relevant to behavioral health integration services under the 2021 Medicare Physician Fee Schedule Proposed Rule. See our other articles regarding the 2021 Proposed Rule: The Future of Telehealth is Now in Sight; Remote Patient Monitoring in the 2021 Proposed Medicare Physician Fee Schedule

On Monday, August 3, 2020, the Centers for Medicare & Medicaid Services (“CMS”) released the 2021 Medicare Physician Fee Schedule Proposed Rule (the “Proposed Rule”). The 2021 Proposed Rule includes a new code under the Behavioral Health Integration (“BHI”) Collaborative Care Model (“CoCM”) that, if finalized, would offer reimbursement for a shorter increment of time than had previously been available under BHI.

What is BHI?

Behavioral Health Integration (“BHI”) is a reimbursement category under Medicare that reimburses physicians and non-physician practitioners when integrating behavioral health care with primary care delivery. BHI has two separate subcategories: Psychiatric Collaborative Care Services (CoCM) (CPT codes 99492, 99493, and 99494) and General BHI (CPT code 99484). These two subcategories have separate requirements for reimbursement but mainly involve the same services components. This article focuses on the Collaborative Care Model (“CoCM”), which describes a model of BHI that augments the traditional primary care model by adding (i) care management support for patients receiving behavioral health treatment and (ii) regular psychiatric inter-specialty consultation. 

The code descriptors for the current CoCM codes are as follows:

CPT code 99492 ($157): 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, 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.

CPT code 99493 ($126): Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent 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, with the following required elements:

• tracking patient 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.

CPT code 99494 ($64): Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar 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 (list separately in addition to code for primary procedure)

According to the American Medical Association CPT 2020 Professional Edition (the “CPT Codebook”), BHI services must include all of the elements listed in the code descriptors in order to be billable. CoCM services under the above codes are provided by the “behavioral health care manager”, which CMS defines as follows:

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

BHI is often delivered in conjunction with other similar care management services such as Chronic Care Management (“CCM”), Transitional Care Management (“TCM”), and Remote Patient Monitoring (“RPM”). These care management services have fueled the expansion of the digital health industry and have become increasingly important in the wake of the COVID-19 pandemic as a way to keep patients safe at home without sacrificing their access to care. Post-COVID, care management services will continue to be essential for (1) maintaining the health of an ever-aging population and (2) transitioning to a value-based healthcare model. BHI, CCM, and RPM are—and will likely remain—the pillars of those efforts.

BHI in the 2021 Medicare Physician Fee Schedule Proposed Rule

While effective, the existing codes have historically failed to capture the full value of BHI services because the threshold time requirements are so high. For example, the Proposed Rule notes that when a primary care practice sees a patient for BHI services but the patient is in need of hospitalization or more specialized care, the patient is often referred out prior to the practice meeting the 70-minute threshold under CPT code 99492. As such, the practice devotes significant, valuable time to treating the patient but is unable to recoup much of the cost dedicated to delivering the service. 

CMS also notes in the Proposed Rule that in the past, stakeholders have often requested that CMS provide a pathway for reimbursement for shorter increments of time than is currently available under the existing CoCM codes to more accurately capture these situations. In response, CMS is proposing to add a new code to the CoCM list to provide reimbursement for “30 minutes of behavioral health care manager time.” The code would be priced based on one-half of the work and direct PE components of CPT code 99493, and would be described as follows:

GCOL1: 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 Proposed Rule states that if finalized, the required elements under CPT code 99493 would apply under GCOL1 and that the time rules described in the CPT Manual for CPT codes 99492-99494 would apply as well. As is the case with existing BHI codes, GCOL1 would be eligible to be billed during the same month as CCM and TCM services so long as all requirements for the applicable services are met separately, including obtaining independent consent for each separate service. Finally, GCOL1 would be a “designated care management service,” meaning that the services described under the code could be provided under general supervision of the billing practitioner – in other words, the care manager would not need to be located in the same office space as the billing practitioner while delivering services under GCOL1.

How can I provide feedback to CMS regarding the proposed changes?

CMS accepts public comment on the Proposed Rule for 60 days following its publishing in the Federal Register. This year, comments are due on October 5th. Your comments to the Proposed Rule can make a difference in the final rule which will be released in December. We urge you to file comments that reflect your experience with BHI, and we are happy to assist you in doing so.