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Behavioral Health Integration

What are Behavioral Health Integration (BHI) services?

BHI is a type of care management that makes it easier to deliver behavioral and mental healthcare in a primary care setting. This approach is part of a “whole-person care” practice. BHI is a collaborative approach to healthcare that requires a team to coordinate care to address the physical, psychological and social needs of a patient. BHI is recognized as an effective way to improve outcomes for patients with mental or behavioral health conditions. CMS recognizes two types of BHI services for Traditional Medicare patients: General BHI and Psychiatric Collaborative Care Model (CoCM).

Why provide BHI services to your patients?

There are many benefits to providing BHI services to your patients. Offering BHI services to patients in a primary care setting makes accessing mental healthcare easier for patients who are put off from seeking care because of cultural stigma. In addition, because BHI services take a whole-person care perspective, patients who receive BHI services may have better outcomes for other health conditions. The whole-person care approach helps providers consider how mental and physical conditions are related to one another.

Who provides BHI services?

General BHI services are administered by a physician or non-physician practitioner who typically works in primary care. This practitioner either provides all BHI services or partners with a clinical behavioral health or psychiatric consultant using a team-based approach for treatment.

The CoCM has more strict requirements for the practitioners who provide care. For CoCM the care team must include a Behavioral Health Care Manager, Psychiatric Consultant, and a Treating or Billing Practitioner. The care team works collaboratively to develop an evidence-based, patient-specific plan to improve a patient's health.

The following types of providers may bill BHI codes:

  • Physicians (MD, DO)
  • Nurse Practitioner (NP)
  • Physician Assistant (PA)
  • Certified Nurse Midwife (CNM)
  • Clinical Psychologist (CP) (G0323 service)
  • Clinical Social Worker (CSW) (G0323 service)
  • Mental Health Counselor (MHC) (G0323 service)
  • Marriage and Family Therapist (MFT) (G0323 service)

How do I identify patients who would benefit from BHI services?

There are several strategies to identify patients who would benefit from BHI services. Some practitioners identify patients who qualify and would benefit from BHI services during an AWV or a regular office visit through mental health screening. Measures for mental health screening are available on the Agency for Healthcare Research Quality, including but not limited to the PHQ-9 and GAD-7 tools for depression and anxiety, respectively. Providers can also identify patients through a disease registry that identifies specific mental health conditions. Other providers may analyze patient data, health records, and provider notes to identify patients who may benefit from BHI services.

How can I educate patients about BHI services and what to expect?

Patient education is important when initiative BHI services. Providers should thoughtfully introduce the idea of BHI services while being aware of the stigma some patients may feel around mental health. Patients should be introduced to their care team through a warm handoff, such as have the primary care physician introduce all members of the team during a visit. One approach for introducing the care team is to describe team members skills rather than their discipline. For example, a primary care provider can introduce the behavioral health provider as a “team member who is an expert on managing stress” rather than a “team member who treats depression and anxiety”.

What are the billing codes for BHI services?

BHI codes are split between general BHI codes and CoCM codes. Importantly, practitioner must choose to report the BHI or CoCM codes in a given month. Practitioners cannot bill both codes in a month.

  • 99484: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified healthcare professional time, per calendar month
  • 99492: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral healthcare manager activities, in consultation with a psychiatric consultant, and that the treating physician or other qualified healthcare professional directs
  • 99493: Follow up psychiatric collaborative care management, first 60 minutes in a following month of behavioral healthcare manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional
  • 99494: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral healthcare manager activities, in consultation with a psychiatric consultant, and that the treating physician or other qualified healthcare professional directs
  • G0323: Care management services for behavioral health conditions, at least 20 minutes of clinical psychologist or clinical social worker time, per calendar month

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can only bill HCPCS code G0511 for BHI. RHCs and FQHCs can only bill HCPCS code G0512 for Psychiatric CoCM.

How do I document BHI services in my electronic health record (EHR)?

It is important to ensure that a patient's shared care plan is linked with the EHR. When possible, staff with case management expertise — those trained to assist and support patients in overcoming barriers to physical or behavioral health — can lead the coordination process and ensure that the care plan reflects the input of the patient and other team members in the EHR.

Who in my organization should I engage when designing and implementing BHI services?

General BHI requires a variety of staff to successfully design and implement including a primary care physician, a psychologist/psychiatrist, and a social worker or case manager. Psychiatric CoCM involves treatment by a care team that must have a Behavioral Health Care Manager, Psychiatric Consultant, and Billing Practitioner. The staff you engage will depend on the type of BHI services you practice is implementing.

Clinics should also consider what level of integration they would like to implement. The American Medical Association recognizes six levels of integration for BHI including the following:

  • “Minimal Collaboration
    Care is delivered in separate facilities with separate systems; communication is infrequent and typically initiated only under compelling circumstances driven by physician and other clinician needs; understanding of the others' roles is limited.
  • Basic Collaboration at a Distance
    Behavioral and nonbehavioral health clinicians practice in separate facilities with separate systems; periodic communication about shared patients is driven by patient issues; there is appreciation of other physicians' and other clinicians' roles as resources.
  • Basic Collaboration On-Site
    Physicians and other clinicians practice in the same facility but not necessarily in the same offices. Although they have separate systems, they communicate regularly about shared patients due to the need for each other's services and referrals.
  • Close Collaboration On-Site
    Physicians and other clinicians practice in the same facility with some shared systems, such as scheduling and medical records. They collaborate through consultation, co-create coordinated care plans for patients, and interact face-to-face about shared patients on a regular basis.
  • Close Collaboration
    Physicians and other clinicians are in the same facility with some shared space and identify delivery system challenges and implement system solutions together. They collaborate via frequent in-person team meetings to discuss patient care and specific patient issues and have an in-depth understanding of others' roles and culture.
  • Full Collaboration
    Physicians and other clinicians are in the same facility and share all practice space, functioning as one integrated team. There is consistent communication at the team and individual levels, and collaboration is due to a shared concept of optimal health care. The roles and cultures of care team members blur or blend together.”

How should I schedule staff to provide BHI services?

Scheduling staff to provide BHI services will depend on the clinic size. Practices should consider the average patient load per clinician and the specific needs of the patients that they serve. These considerations will help clinics decide what kind of behavioral health staff are needed such as onsite, on-call or virtual. Some behavioral health clinicians serve multiple primary care providers across an individual practice or multiple practices.

Under CoCM, the care team must include a Behavioral Health Care Manager, Psychiatric Consultant, and a Treating or Billing Practitioner. The Behavioral Health Care Manager can be a nurse, a psychological counselor, or a social worker who oversees the patient's care management services between visits to the Treating or Billing Practitioner. The Treating or Billing Practitioner must be a provider who takes on the responsibility for the patient's care. They can be a physician, NP, or PA. The Psychiatric Consultant must be a practitioner trained in psychiatry and able to prescribe medication, but does not need to see the patient directly. The Psychiatric Consultant may work with the Treating Practitioner to provide input on care and medications.

Are there any special considerations for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) billing for General Care Management services?

CMS allows physicians, non-physician practitioners (physician assistants, nurse practitioners, certified nurse specialists, certified nurse midwives), RHCs, and FQHCs to bill for behavioral health integration (BHI) services they furnish to Medicare patients over a calendar month. This includes both General BHI and the Psychiatric Collaborative Care Model (CoCM).

Resources

Last Updated: 11/26/2024
Last Reviewed: 11/26/2024