Collaborative Care Management Services

Reimbursement Policy:
Collaborative Care Management Services

Effective Date:
December 1, 2021

Purpose:
To provide guidelines for the proper use and reimbursement of certain collaborative codes relating to behavioral health care in the context of primary and specialty care.

Scope:
All products are included, except

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
• Horizon NJ Health
• Flex Link
• ITS Home Par
• ITS Host Medicare Advantage (PPO OON)
• MPL
• COB

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

Collaborative Care Management is a model of behavioral health integration that enhances “usual” primary or specialty care by adding two key services to the primary care team, particularly regarding patients whose conditions are not improving:

1. Care management support for patients receiving behavioral health treatment.
2. Regular psychiatric inter-specialty consultation.

Collaborative Care Management Procedure Codes

Policy:

Psychiatric Collaborative Care Services are provided under the direction of a treating physician or other qualified health care professional. The following codes are deemed properly billed when the conditions set forth below are met.

CPT Code 99492: Initial psychiatric collaborative care management:

• Total duration of collaborative care management over the calendar month is 36 to 85 minutes. Time less than 36 minutes will not be reimbursed.
• This code can be billed one time per month for all the work done in that month
• Time spent on activities for services reported separately are not included in the time applied to 99492

CPT Code 99493: Subsequent psychiatric collaborative care management:

• Total duration of collaborative care management over the calendar months is 31-75 minutes. Time less than 31 minutes will not be reimbursed.
• This code can be billed one time per month for all the work done in that month.
• Do not report 99492 and 99493 in the same month.
• Time spent on activities for services reported separately are not included in the time applied to 99493

CPT Code 99494: Each additional 30 minutes in a calendar month of behavioral health care manager activities:

• This code can be billed one time per month with units reflecting the number of additional 30-minute increments of work done in that month.
• This is an add-on code to 99492 and 99493
• Time spent on activities for services reported separately are not included in the time applied to 99493

CPT Code 99484: Care management services for behavioral health conditions:

• Total duration at least 20 minutes
• General behavioral health integration care management services (99484) are reported by the supervising physician or other qualified healthcare professional.
• Behavioral Health Care Integration care management (99484) and psychiatric collaborative care management (99492, 99493, 99494) may not be reported by the same professional in the same month.

CPT Code G2214:

• Total duration at least 30 minutes
• This code can be billed once a month, as an alternative code to 99492 or 99493
• It cannot be billed in same month in addition to 99492 or 99493
• Time spent on activities for services reported separately are not included in the time applied to G2214.
• If billed more than one time per month, the additional claims will deny.

The procedure section below also includes requirements for the proper submission and billing of the above collaborative care management codes; in the absence of those requirements, claims for collaborative care management codes 99492, 99493, 99494 and 99484 will be denied.

Please note that the CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Applicable ICD-10 codes

• Mental Health Codes F10 – F99
• Codes F01 – 09 and F17 are excluded.

Collaborative care management procedure codes may be billed by a member’s primary care provider. Covered specialties include

• Family Medicine
• Internal Medicine and subspecialties
• Pediatrics and subspecialties
• Obstetrics and Gynecology
• Hospice, Palliative Care

Procedure:

In addition to the requirements set forth in the Policy: section above, Horizon BCBSNJ will not provide reimbursement and shall deny submitted collaborative care management procedure codes 99492, 99493, 99494, 99484, and G2214 if:

• There is not an appropriate psychiatric indication:
  • Requires active psychiatric diagnosis, and documentation of meeting DSM 5 criteria.
  • Most commonly major depression, general anxiety disorder, somatoform disorder.
  • Often post-traumatic stress disorder, bipolar disorder.
  • Occasionally schizophrenia, schizoaffective disorder, cognitive disorder, obsessive compulsive disorder, substance use disorder.
  • Documentation of how diagnosis affects medical/surgical treatment.

• Documentation does not include the following:
  • Documentation of communication with primary caregiver for mental health.
  • Documentation of measurable treatment goals and interventions.
  • Use of standardized rating scales relevant to patient’s condition.
  • Documentation of progress and changes to treatment plan.
  • Frequency of care consistent with severity of symptoms.
  • Involvement of family when needed.

• Rating scales do not meet the following criteria:
  • Performed annually, unless there is a diagnosis requiring more frequent testing (Rating scales may not be performed more than once per month).
  • Are used to measure progress for individuals receiving collaborative care management.
  • Significantly abnormal rating scale results should include a patient specific plan of care.

• There is not:
  • A patient-specific review of symptoms/signs/progress.
  • A patient-specific diagnosis code(s).
  • A patient-specific intervention and treatment plan.
  • Documentation of coordination of care when member is also seen by a psychiatrist or other provider of mental health care.
  • Use of validated rating scale(s).
  • Use of an appropriate specialty.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

Resources:

• CMS Medicare Learning Network Booklet: Behavioral Health Integration Services, MLN909432, March 2021,
• American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

History:

06/09/2021: Policy approved

Policy145_v1.0_06092021

CPT® is a registered trademark of the American Medical Association.