EM Coding Alert

Clinical responsibilities key to successful integration.

The introduction of three new behavioral health CPT^® codes at the beginning of 2018 marked the continuation of a growing movement to integrate behavioral health (BHI) into healthcare. The American Medical Association (AMA) added them specifically to address the call for “quality healthcare that includes coverage for mental health and substance use disorder services” that was a centerpiece of the 2014 Affordable Care Act (ACA) (Source: aspe.hhs.gov/report/affordable-care-act-expands-mental-health-and-substance-use-disorder-benefits-and-federal-parity-protections-62-million-americans).

Since their introduction, there has been some confusion among coders as to what they mean and how they should be implemented. So, we took a deeper look at the codes to see what the services entail and some of the issues they present.

What is BHI?

Models of BHI differ. When a pediatric practice alone offers the services, you would code them using 99484 (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 …). Per the CPT^® descriptor, the clinical responsibilities for the provider include the following:

• “Initial assessment or follow-up monitoring, including the use of applicable validated rating scales;
• Behavioral healthcare 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 consultation; and
• Continuity of care with a designated member of the care team.”

However, “these codes involve working hand in hand with psychiatry, which is not the norm in pediatrics,” Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, points out. Because of that, some practices that wish to implement BHI have turned to the collaborative care model (CoCM), where the billing pediatrician collaborates with child and adolescent psychiatrists, psychologists, and behavioral therapists to streamline care and ensure better outcomes.

Often, that care is coordinated by a care manager working for the billing provider. This presents another problem for practices, “mainly because they have to have a healthcare manager who has a degree or a behavioral healthcare provider,” says Holle. “Many offices won’t have this type of person,” Holle notes, and those that want to implement CoCM will have to incur the expense of hiring another staff member to fulfill the role.

How Do You Code CoCM?

If your pediatrician adopts CoCM, three different codes come into play. CPT^® 99492 (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 …) describes the initial encounter with the patient, while 99493 (Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month …) details the patient’s ongoing care. And you can add +99494 (Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month … (List separately in addition to code for primary procedure) …) on to either code for additional care beyond the time parameters for 99492 and 99493.

Like 99484, 99492 requires the provider to administer validated rating scales and establish a care plan. But the addition of the psychiatric consultant adds the following clinical responsibilities:

• “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.”

For subsequent monthly patient care described by 99493, you will continue to document the collaboration between pediatrician and psychiatric consultant, patient tracking and outcomes monitoring, use of validated rating scales, and any care plan revisions. But CPT^® adds a further, critical component to the service: “relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.”

The BHI Bottom Line

As beneficial as these models may be for complex patient outcomes, “the problem is, who documents? Where is the documentation?” asks Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. “Keep in mind each clinician must write his or her own note. Clinicians don’t always document in the same place around the same time for a service that is collaborative,” Hauptman adds.

But this should not deter practices from adopting BHI or CoCM models to improve patient outcomes. Nor should it give coders a headache when it comes time to report the services. Instead, coders should be proactive and “work with the clinicians to come up with a template or process for documenting these services so that they can be reported compliantly,” concludes Hauptman.