Behavioral Health’s Importance
Behavioral health is an area of healthcare that treats mental health and substance use disorders.
Mental health commonly refers to disorders such as depression and anxiety that leads to the worsening of emotional, psychological and social well being. Substance use disorders refers to the dependence on drugs which affects a person’s brain and leads to harmful behavior.
With mental health and substance use disorders, one can lead to the other, and there is a high co-occurrence rate for both. Multiple national population surveys in USA have found that over half of those suffering a mental health condition will also abuse substances in their lives, and vice versa.
Approximately 20 million Americans have a substance use disorder, with alcohol, cannabis and cocaine topping the charts. 51 million Americans live with a mental health disorder according to the National Survey on Drug Use and Health.
That 51 million population is greater than any one chronic care population such as diabetes or heart failure. It is also greater than any acute care procedure. But it gets brushed under the rug perhaps because it is not thought to be as fatal as chronic care, or as necessary as acute care. But such logic is flawed for the following reasons.
Mortality is not the only factor that determines quality of life. Mobility and functionality are absolutely crucial as well, that can suck the joy out of existence if impaired. As we are dealing with behavioral health, a lack of mental wellness could lead to adverse behavior leading to a lack of physical wellness.
Even if we are strictly talking about mortality, the presence of a mental illness or substance abuse disorder can contribute to comorbidity, which is linked to higher mortality. Depression, drug abuse, alcohol abuse and schizophrenia are all listed as chronic conditions by Centers for Medicare & Medicaid Services (CMS), and so having any one of these things along with another chronic condition can be fatal.
While operations and other procedures are prioritized immediately because they deal with the physical body, therapy does not receive the same respect. In USA, it was estimated that 9 out of 10 people with substance use disorders were left untreated.
What is deemed necessary is a matter of short term versus long term orientation. Dealing with the physical body only may keep a person mobile and functional for the short term, but ignoring the mental aspects of health can lead to bad choices which may deteriorate the physical condition, thus going back to square one.
Treating mental health and substance use problems as an afterthought to chronic and acute care, could be ignoring the root of the problem. One-fifth of adults in USA live with mental illnesses, and physicians report the exacerbation of mental health during the COVID-19 era.
It is mental illnesses and substance use disorders that can prevent a person from healing completely or complicate their course of treatment. For example depression complicates the course of care for heart disease, hypertension and post-surgical care. So ignoring mental health could be an invitation for other issues to remerge.
The truth of the matter is, there is no getting around behavioral health. People who need the care should be able to access it. In the same style how chronic care was adopted by primary care models, something similar was done for behavioral health via Behavioral health Integration.
Why Behavioral Health Integration?
While recognizing the need for behavioral health has been established, one may still ask, what is the impetus to integrate it with primary care? The reason is very practical. Individuals dealing with behavioral health issues turn to their primary care physicians for advice.
Only 5% of the patients actually seek support from behavioral health professionals. Either because of perceived stigma or because they don’t know any better, the majority of patients will first disclose any mental health or behavioral symptoms to their primary care doctors. Indeed, 70% of antidepressants are prescribed by primary physicians and not psychiatrists.
This allots to a lot of time spent by primary care physicians, hearing their patient’s case and consulting with behavioral health specialists. In order to truly provide value based patient centric care, such a process is necessary. But it helps to recognize the value of spending this time with the patients. So many things need to be factored in when designing the patient’s care plan, and a primary care physician is in an ideal situation to get this holistic picture of the patient.
We can thus see how behavioral health is forcibly integrated with primary care. Noticing this, just as CMS had introduced chronic care codes to enable chronic care management at a primary care level, it did the same for behavioral health. Just as it introduced the chronic care reimbursement codes in 2015, it introduced the behavioral health integration codes in 2018.
How is Remote Care Helping?
Remote care via telehealth reduces overhead costs for physicians and out of pocket costs for the beneficiary. Talking to each other via two-way video conferencing simulates a real life visitation or therapy session, while providing all the convenience of being connected instantaneously without the need for travel. A lot of the components of the treatment course such as coaching on coping techniques or destressing can be delivered remotely as well.
Telehealth also facilitates consultations between primary care physicians and psychiatrists. They can exchange messages with each other synchronously, which increases communication efficiency when it comes to setting or revising a patient’s care plan.
Using mobile phones where applicable also simplifies the patient experience where they are able to look at a virtual copy of their care plan and also communicate with providers, therapists and pharmacists, all in one place.
If there is an mHealth app that is used to coordinate care, that app can also host information on social resources, health insurance, and other important information. The World Health Organization acknowledges the role of social determinants in affecting mental health, and so providing accurate information is one way to level the playing field when it comes to achieving social equity.
Employing remote patient monitoring can offer additional data which helps improve the quality of behavioral care. Measurement based care, consisting of rating scales to measure psychiatric symptoms can be greatly facilitated by use of telehealth technology. Additionally remote sensors can pick up information such as sleep patterns, pulse rate and blood pressure, all which are linked to assessing a person’s behavioral state.
The Similarities Between Chronic Care Management and Behavioral Health Integration
As with chronic care services, an initiating visit is also required for behavioral health integration (BHI) services. The purpose of this visit is to establish a prior relationship between the billing practitioner and the patient, if the patient has not been seen by that physician within the last one year. During this visit, the patient can be assessed for BHI services.
Again, just as with chronic care, BHI services may be billed by qualified healthcare professionals under general supervision from a physician. The primary care physician can lead the behavioral health integration efforts without physically being present in the same building.
Both face to face and non face to face services are provisioned under the integration of behavioral health. Remote Patient monitoring codes can be billed in the same month as behavioral health integration codes. Just as with chronic care, the services are looked at as complementary to each other and there is no scope of overlap.
The diagnosis for behavioral health or psychiatric conditions can be pre-existing or made by the billing practitioner during initial assessment. Verbal consent from patients must be acquired before consulting any relevant specialists.
Choosing the Right Reimbursement code for Integrating Behavioral Health
When deciding on how to bill behavioral health integration services, the fork road is the choice of models. You can either use Psychiatric Collaborative Care Model (CoCM), for which you will need the CoCM codes. For any other models, or even if no particular model is adhered to, you need the general behavioral health integration code. It’s important to make a decision, because both of these types of codes cannot be billed in the same month. We explain both types of codes in the following paragraphs.
General Behavioral Health Integration Codes
The general behavioral health integration code is billed specifically for services provided by clinical staff under the direction of the treating practitioner. It doesn’t however specify an exact model of care to be followed, or the type of roles that should be on the care team. The type of activities covered are behavioral health care planning, coordinating treatment such as psychotherapy, pharmacotherapy, counselling, and providing continuity of care with the designated member of the care team.
CPT 99484- Covers 20 minutes or more of behavioral health condition management services per calendar month, performed by clinical staff and directed by a physician or other qualified healthcare professional.
Psychiatric Collaborative Care Management Codes
Psychiatric CoCM codes are billed specifically for activities performed by the behavioral health (BH) care manager only. The BH care manager coordinates care for the beneficiary by frequently communicating with the treating practitioner and the psychiatric consultant. These three mentioned roles form the care team which administer CoCM.
The types of activities that can count toward billing include: outreach and engagement, administration and monitoring of validated scales, entering patients into a registry and tracking progress, providing interventions based on review with psychiatric consultants, etc.
The three psychiatric CoCm codes are defined as follows:
CPT 99492- Covers the first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a physiatric consultant and directed by the treating physician or other qualified healthcare professional.
CPT 99493- Covers the first 60 minutes in the subsequent calendar months of behavioral health care manager activities, in consultation with a psychiatric consultant and directed by the treating physician or other qualified healthcare professional.
CPT 99494- This is an add on code for both CPT 99492 or CPT 99493, which covers each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a physiatric consultant and directed by the treating physician or other qualified healthcare professional.
It can be added on to either CPT 99492 in the first month, or CPT 99493 in subsequent months, if more time is needed for behavioral health integration.
In 2021, CMS introduced HCPCS code G2214 after listening to stakeholders who wanted a code to cover shorter increments of time spent with the patient. The 70 and 60 minutes of CPT 99492 and CPT 99493 respectively were deemed too long for some types of services. G2214 is thus defined as follows:
G2214 – Covers the first 30 minutes in the initial or subsequent calendar months of behavioral health care manager activities, in consultation with a psychiatric consultant and directed by the treating physician or other qualified healthcare professional.
Rural Health Clinics and Federally Qualified Health Centers
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) provide care to underserved populations, either because of geographic isolation or because of lack of the beneficiary’s financial means. There are multiple differences between the two, the most common one being that RHCs operate only in rural areas, whereas FQHCs can be found in both urban and non-urban locations. But they are united in characteristics which allow them to have their own separate reimbursement codes for the same service.
Both RHCs and FQHCs are in areas which have a shortage of healthcare professionals. They are both designated as non-facility sites, and hence are reimbursed at a higher rate. Additionally, they have to compete with retail clinics and urgent care centers for the population of patients who reside in such areas. To their advantage, such codes enable them to provide continuity of care which retail clinics and urgent care centers cannot do.
The behavioral health integration reimbursement codes we covered earlier also apply to both RHCs and FQHCs. It’s the same code for the same service, but reimbursed at a more expensive rate.
G0511- Covers 20 minutes or more of behavioral health condition management services per calendar month in a RHC or a FQHC.
G0512- Covers 60 mins or more of psychiatric collaborative care model management services per calendar month in a RHC or a FQHC.
In the first calendar month, it covers the first 70 minutes of behavioral health care manager time, in consultation with a psychiatric consultant and directed by the treating physician or other qualified healthcare professional. It covers the same activities in subsequent calendar months of the psychiatric collaborative care model, but for the first 60 minutes.
The Way Forward
We have explored the many parallels between chronic care and behavioral health. Just as chronic care needs remote care to succeed, it’s the same for behavioral health. The good news is people are fast becoming aware of the vital role mental health plays in one’s overall health, and so there is widespread acknowledgement that it needs to be integrated into manifold healthcare in some capacity.
The Bipartisan Policy Center recommends forgivable loans which will help behavioral health providers pay for the right type of remote technology to make integration possible. Having the right technological tools will help behavioral healthcare providers be more efficient.
The reimbursement codes in place have paved the way for behavioral health to be integrated into primary care. But effective integration hinges on the adoption of telehealth and remote patient monitoring. It transforms any ordinary behavioral health service into a truly interoperable and interconnected service.
This wraps up our three part series on remote care. We began with its broadest application, namely remote patient monitoring, in part 1. We discussed its fit with chronic care in part 2. Finally, we discussed how it is used for behavioral health in this article.
While there are myriads of other uses for remote care as well, we hope this introduction series was a good starter in understanding how remote care affects the long term physical (chronic) and behavioral condition of patients.