Coding for Behavioral Health Services in Primary Care
New Opportunities for Payment
In the 2017 final rule for the Medicare Physician Fee Schedule (MPFS), CMS finalized new coding and payment mechanisms for behavioral health integration (BHI) services as part of the evidence-based psychiatric collaborative care model (CoCM). This model was developed at the Advancing Integrated Mental Health Solutions (AIMS) Center of the University of Washington and is an evidence-based model that has been proven effective in more than 80 randomized, controlled trials. The AIMS Center has been an invaluable ally in advocating for reimbursement coding for collaborative care. While these codes will most often be used by the primary care physician, they can also be used by physician specialists. CMS points out that cardiologists, for example, may use the codes for patients who suffer from depression following a heart attack while oncologists may offer these services to patients going through cancer treatment.
Psychiatric Collaborative Care Model (CoCM) Codes:
Psychiatric CoCM is typically provided by a primary care team consisting of a primary care provider, a care manager and a psychiatric consultant. The psychiatric consultant does not necessarily have to be an employee of the treating physician. Care is directed by this primary care team and includes structured care management with regular assessments of clinical status and regular consultations with the psychiatric consultant to review and/or make recommendations.
CMS created separate payment for services under the psychiatric CoCM using three new G-codes: G0502, G0503 and G0504. These codes will parallel the Current Procedural Terminology (CPT) codes that are under development and are expected to be effective January 1, 2018.
The services provided under these codes will be furnished when a patient has a diagnosed psychiatric disorder that requires a behavioral health care assessment; establishing, implementing, revising, or monitoring a care plan; and provision of brief interventions. The codes may be used to treat patients with any behavioral health condition that is being treated by the billing physician, including substance use disorders. The diagnosis could be either pre-existing or made by the billing physician.
The codes are described as follows:
- G0502: 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 information into 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.
- G0503: 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 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; and
- 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.
- G0504: Initial or subsequent psychiatric CoCM, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultations with a psychiatric consultant and directed by the treating physician or other qualified health care professional.
Three important takeaways to remember when billing these new G-codes:
1. Three professionals are involved:
- Primary Care Physician: Supervises and oversees the care/plan;
- Psychiatrist: He/she does not have to be an employee, but should have an established contract with the physician or group; and
- Behavioral Care Manager: The care manager should be selected based on the clinical skills needed; there are currently no defined credentials for this.
2. The time counted is the time of the care manager.
3. Services are billed once per calendar month by one individual (the primary care physician).
Nearly every family medicine practice will have patients who can benefit from these services. This CoCM can be used to treat patients with common psychiatric conditions such as depression, anxiety, alcohol or substance abuse, in the primary care setting through the provision of a defined set of services which operationalize the following core concepts:
- Patient-Centered Team Care / Collaborative Care;
- Population-Based Care;
- Measurement-Based Treatment to Target; and
- Evidence-Based Care.
Before providing and then billing for these services, each practice should plan how these services will be delivered as a team. The AIMS Center offers the following five-step guidance to implementing the core model:
The full implementation plan and resource library may be accessed at: https://aims.uw.edu/collaborative-care
General Behavioral Health Integration (BHI) Code:
There are a variety of other care models ranging from embedding a behavioral health professional within a primary care office for same-day treatment, to remote consultations, to assessment-and-referral. To recognize the resource costs associated with furnishing such BHI services to Medicare beneficiaries, CMS makes payment using a new G-code that describes care management for beneficiaries with behavioral health conditions under other models of care.
Beneficiaries should have an identified psychiatric or behavioral health condition that requires a behavioral health care assessment, behavioral health care planning, and provision of interventions. Similar to the CoCM codes, the BHI code may be used to treat patients with any behavioral health condition and could be either pre-existing or made by the billing physician. Evaluation and management services, such as face-to-face E/M visits, may be separately billed during the service period or on the same day as this new code (G0507), provided time is not counted twice towards the same code.
The code is described as follows:
- G0507: 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, with the following required elements:
- 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;
- Facilitating and coordinating treatment such as psychotherapy pharmacotherapy counseling and/or psychiatric consultations; and
- Continuity of care with a designated member of the care team.
- Time is counted by clinical staff time;
- You can only bill this code once a month; and
- The services furnished must involve assessment, planning and provision of interventions.
Three important takeaways to remember when billing these new G-codes:
If you are planning to provide and bill for these services, now is the time to look ahead and understand how these models lead to better patient outcomes, better patient and provider satisfaction, improved functioning and reductions in health care costs while achieving the Triple Aim of health care reform.
About the Author
Mary Jean Sage is the Founding Principal and Senior Consultant of The Sage Associates. She has
extensive experience as a health care management specialist and is a coding and practice management
The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create at attorney-client relationship. Consult your attorney or other professional for advice in your particular situation.