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Behavioral Health Integration: CMS Requirements & Expectations

In 2017, the Centers for Medicare & Medicaid Services (CMS) began reimbursing practitioners supplying Behavioral Health Integration (BHI) services in a primary care setting to Medicare patients with mental, behavioral health or psychiatric conditions. The following year, CMS and the American Medical Association (AMA) introduced Current Procedural Terminology (CPT) codes to more specifically identify reimbursable services.* 

Behavioral Health Integration, as CMS has defined it, comes with specific requirements for what services can be provided under which billing codes, by which members of the care team, and for a given duration and frequency. Though these expectations may sound daunting, they shouldn’t prevent primary care practices from pursuing integrated mental health service to improve outcomes and support a transition to value-based care.

Download the eBook The Guide to Behavioral Health Assessment Software:  Improving Assessments & Patient Outcomes here.

Unpacking the Intricacies of the BHI Program 

CMS will reimburse practitioners for two types of Behavioral Health Integration services. One is general services, billed to CPT code 99484, which consist of assessment and monitoring, care plan revision and ongoing engagement with a care team member, such as an integrated behavioral health clinician. This code requires 20 minutes of provider time per month per patient participating in BHI services, and services may be offered remotely. 

The other types of services fall under the Psychiatric Collaborative Care Model (CoCM), a framework established more than three decades ago to promote integrated mental health services in a primary care setting. Research from the Center for Health Care Strategies indicates the model has had positive impacts on multiple populations, from adolescents to patients with cancer, and has the potential to generate up to $6.50 in savings for every $1 spent. 

As summarized by the American Academy of Family Physicians, there are three applicable CPT codes as well as two Healthcare Common Procedure Coding System (HCPCS) codes, which themselves are based on CPT.  

  • CPT code 99492: 

    Initial consult under the CoCM model for a duration of 70 minutes, to be performed in one calendar month. 
  • CPT code 99493: 

    Subsequent consult for a duration of 60 minutes, performed in following months.
  • CPT code 99494: 

    Additional consult for a duration of 30 minutes, to be reported in conjunction with codes 99492 or 99423.
  • HCPCS code G2214: 

    Initial or subsequent consult for a duration of 30 minutes.
  • HCPCS code G0323: 

    Additional consult for a duration of at least 20 minutes, performed by a clinical psychologist or clinical social worker. This code was introduced in 2023.

Under Behavioral Health Integration, CMS defines eligible conditions as:

“any mental, behavioral health, or psychiatric condition that the billing practitioner treats, including substance use disorders.”

Patients with pre-existing conditions qualify, and those conditions don’t necessarily need to be managed by the billing practitioner; that may be the case if, say, the billing practitioner is a primary care physician and the patient is also routinely seen by an endocrinologist.

Supporting BHI: The Role of the Integrated Behavioral Health Clinician

The cornerstone of integrated behavioral health is an interdisciplinary care team positioned to care for patients in a familiar and trusted setting. This relieves patients of the hassle, stigma and potential long wait associated with seeking care from a standalone behavioral health provider.  

In addition to patients themselves, CMS identifies the following care team members under the Collaborative Care Model.

  • Treating or billing practitioner.

      This is typically a primary care physician, or a physician assistant or nurse practitioner in the PCP office. In some cases, though, the billing practitioner may be an oncologist, cardiologist or other specialist – reflecting that many providers may have a hand in supporting patients’ behavioral health.
  • Behavioral healthcare manager.

    This is a provider with formal training in behavioral health, which CMS defines as including social work, nursing or psychology. These individuals work under the direction of the billing practitioner.
  • Psychiatric consultant.

    This is a medical provider both trained in psychiatry and qualified to prescribe medications if necessary. 

For practices billing under general Behavioral Health Integration, CMS indicates the care team should consist of the patient, the billing practitioner and additional clinical staff. These providers typically include contractors who meet the qualifications of the behavioral healthcare manager or psychiatric consultant, as outlined above. 

Aligning with CMS Guidelines for Integrated Mental Health Services

The American Psychological Association points out that recent regulatory changes should make it easier for practices to provide the care that patients need. 

Under the 2023 Medicare Physician Fee Schedule Final Rule, services for behavioral health are now allowed under general rather than direct supervision. Given this subtle change, the APA notes:

Behavioral health services can be performed under the direction and control of the physician or [non-physician practitioner], but they do not need to be physically present.” 

The second important change is HCPCS code G0323, which CMS introduced to account for behavioral healthcare management services provided monthly. This helps ensure continuity of care and recognizes that managing behavioral health, especially in conjunction with chronic conditions, requires ongoing engagement with patients and refinement of care plans. 

CMS has clear expectations for practices that aim to bill for providing Behavioral Health Integration services. At the same time, the requirements offer practices a blueprint for building a multidisciplinary care team under the Collaborative Care Model and establishing workflows that meet the needs of patients and practitioners. 

Here, practices benefit from clinical workflow software purpose-built to identify patients who would benefit from integrated mental health services, help develop evidence-based treatment plans and monitor patients’ progress against clinical and quality metrics. To find out more about how the Proem workflow solution can support the delivery of BHI, book a meeting. 

*  CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose.  No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with Proem and no endorsement by the AMA is intended or implied. 

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