CMS expands Medicare payment for behavioral health services


Commencing Jan. 1, 2017, Medicare will pay for mental and behavioral health services under new billing codes set forth in the 2017 Medicare Physician Fee Schedule Final Rule issued by the Centers for Medicare & Medicaid Services (CMS) on Nov. 2, 2016.  

Psychiatric Collaborative Care Model (3 New Codes: G0502, G0503, and G0504)

CMS is establishing four new behavioral health integration (BHI) billing codes, three of which apply to care provided under the psychiatric Collaborative Care Model (CoCM) by a primary care team consisting of a treating physician or other qualified health care professional (e.g., a nurse practitioner (NP) or physician assistant)[1] and a behavioral health care manager working in collaboration with a psychiatric consultant. The three CoCM G codes[2] describe psychiatric collaborative care management directed by the treating physician in consultation with a behavioral health care manager:

  • G0502: Initial psychiatric collaborative care management for the first 70 minutes in the first calendar month satisfying the following elements:
    • Patient outreach and engagement by the treating physician
    • Initial assessment of the patient and development of an individualized treatment plan
    • Review of the treatment plan by a psychiatric consultant and modification of the plan if recommended
    • Entry of the patient in a registry, follow-up tracking, and participation in weekly caseload consultation with the psychiatric consultant
    • Brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies
  • G0503: Subsequent psychiatric collaborative care management for the first 60 minutes in a subsequent month satisfying the following elements:
    • Tracking patient follow-up and progress using the registry, with appropriate documentation
    • Weekly caseload consultation with the psychiatric consultant
    • Ongoing collaboration and coordination of patient mental health care by the treating physician and any other treating mental health providers
    • Additional review of progress and recommendations for treatment changes
    • Brief interventions using evidence-based techniques
    • Monitoring of patient outcomes using validated rating scales, along with relapse prevention planning as the patient achieves remission of symptoms or other treatment goals
  • G0504: Additional 30 minutes of behavioral health care manager activities in a calendar month, in consultation with a psychiatric consultant and directed by the treating physician.

The CoCM services can be furnished when the beneficiary has one or more psychiatric or behavioral health conditions (including substance abuse disorders) that, in the treating physician’s judgment, warrant a behavioral health care assessment, a care plan, and brief interventions. In its commentary, CMS elaborated on several key points:

  1. The patient must present with a psychiatric or behavioral health condition that, in the clinical judgment of the treating physician, warrants referral to the behavioral health care manager for further assessment and treatment through CoCM services.
  2. The diagnosis may be pre-existing or established by the treating physician.
  3. The CoCM codes are not limited to a particular set of behavioral health conditions.

The CoCM codes can only be reported by a treating physician who directs the behavioral health care manager and oversees the beneficiary’s care. The physician must remain involved in ongoing oversight, management, collaboration, and assessment for the duration of the time that he or she is reporting it. CMS expects most CoCM services to be performed by primary care practitioners, but recognizes that the CoCM codes can also be billed in other medical specialty settings when the physician manages the beneficiary’s behavioral health and other conditions. CMS generally does not expect psychiatrists to bill the CoCM codes, because psychiatric work is defined as a sub-component of the CoCM codes.

The MPFS final rule also describes the roles and qualifications of the behavioral health care manager and the psychiatric consultant, both of whom are subject to the “incident to” rules and regulations as well as state law, licensure, and scope of practice. The MPFS final rule revises the “incident to” regulation to allow general supervision (rather than the more stringent direct supervision standard in place for most “incident to” services) for the CoCM and general BHI codes as well as the non-face-to-face portion of other designated care management services such as complex chronic care management.[3]

The behavioral health care manager must have formal education or specialized training in behavioral health. CMS recognizes social work, nursing and psychology as acceptable disciplines. The responsibilities of the behavioral health care manager include:

  • Providing the following elements of service in consultation with the psychiatric consultant:
    • Care management services and assessment of needs
    • Behavioral health care planning, including managing treatment plan revisions for patients who are not progressing or whose status changes
    • Brief interventions
    • Ongoing collaboration with the treating physician
    • Registry maintenance
    • Consulting with the psychiatric consultant on a weekly basis
    • Maintaining a collaborative, integrated relationship with the care team members
    • Maintaining the ability to engage the beneficiary during off hours and have a continuous relationship with the beneficiary

The proposed rule would have required the behavioral health care manager to be a member of the treating physician’s clinical staff and to be located on site. CMS now recognizes that some CoCM services can be contracted out to third parties and that a behavioral health care manager may provide his or her services from remote locations. The behavioral health care manager must be available to provide services on a face-to-face basis, but CMS does not require face-to-face services.

The psychiatric consultant must be a medical professional (e.g., a psychiatrist or an NP with psychiatry board-certification) trained in psychiatry and qualified to prescribe the full range of medications. The psychiatric consultant advises and makes psychiatric and other medical care recommendations that are communicated to the treating physician, typically through the behavioral health care manager. The psychiatric consultant does not typically see the beneficiary or prescribe medications, except in rare circumstances, but should facilitate referral for direct psychiatric care when clinically indicated.

General Care Management for Behavioral Health Conditions (One New General Code: G0507)

CMS is also adding a new general BHI code (G0507) covering care management services of behavioral health conditions for at least 20 minutes of clinical staff time per month. The following elements must be satisfied:

  • Initial assessment or follow-up monitoring, including validated rating scales
  • Behavioral health care planning relating to behavioral/psychiatric problems
  • Facilitating and coordinating care
  • Continuity of care with a designated member of the care team

Like the three CoCM codes, G0507 is reported by the treating physician[4] for services furnished when the beneficiary has one or more psychiatric or behavioral health conditions that, in the treating physician’s clinical judgment, require a behavioral health care assessment, behavioral health care planning, and interventions.

Services under G0507 may be provided by the treating physician or by clinical staff under his or her direction. Clinical staff members providing services under G0507 are not required to satisfy specific qualifications such as those set forth in the CoCM standards for a behavioral health care manager or psychiatric consultant.

All of the CoCM and general BHI codes require an initiating visit that is separately billable, as well as prior beneficiary consent.

Assessment and Care Planning for Patients with Cognitive Impairment (One New Code: G0505)

New code G0505 will cover assessment and care planning for patients with cognitive impairment, such as Alzheimer’s disease or dementia, if the following elements are satisfied:

  • Cognition-focused evaluation including history and examination
  • Moderate or high complexity medical decision-making
  • Functional assessment, including decision-making capacity
  • Use of standardized instruments to stage dementia
  • Medication reconciliation and review for high-risk medications (if applicable)
  • Evaluation for neuropsychiatric and behavioral symptoms, including depression
  • Evaluation of safety, including motor vehicle operation
  • Identification of caregiver(s), caregiver’s knowledge, caregiver’s needs, social support, and caregiver’s willingness to give care
  • Advance care planning and palliative care needs
  • Creation and sharing of a care plan with the patient and/or caregiver with initial education and support

All of the specified elements under G0505 must be performed by the billing physician.

The new codes for CoCM, general BHI, and cognitive impairment assessment offer new sources of revenue for care management services relating to mental health. Physician practices and other providers, however, need to take care to establish appropriate policies and procedures to ensure that all requirements are satisfied and documented for billing and compliance purposes. To learn more about the MPFS final rule or the new mental and behavioral health care codes, contact one of the health care attorneys listed below.

[1] In the interest of simplicity, this alert generally refers to the treating physician or other qualifying health care professional as the “physician” even though the new codes are not limited to physicians and apply to other health care providers such as NPs and physicians assistants.

[2] G codes (rather than CPT codes) will initially be used because the new CPT codes that have been approved by the CPT Editorial Panel will not be ready until 2018.  

[3] The “incident to” regulation already applies the general supervision standard to chronic care management and transitional care management.

[4] Or other qualified health care professional.

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