Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care SEPTEMBER 2020 AUTHOR Lori Raney, MD, Health Management Associates Contents About the Author 3Background Lori Raney, MD, is a board-certified psychia- trist and principal with Health Management 4The CoCM Model Associates (HMA), an independent national 5Medicare's Payment Model: CoCM Billing Codes research and consulting firm in the health care industry. HMA helps organizations work- Billing ing in the publicly funded health care sector Time Stamping/Tracking by providing technical assistance, resources, Federally Qualified Health Centers and Rural Health Clinics decision support, and expertise. Medicare Uptake Since 2016 Rollout of Codes About the Foundation 7Findings from a Review of State Medicaid The California Health Care Foundation is Approaches to Implementing CoCM Codes dedicated to advancing meaningful, measur- able improvements in the way the health care 9Barriers to Uptake delivery system provides care to the people of California, particularly those with low incomes 10Best Practice Recommendations for Medicaid and those whose needs are not well served Reimbursement of CoCM by the status quo. We work to ensure that 10Conclusion people have access to the care they need, when they need it, at a price they can afford. 11Appendices A. Key State Experiences - Interviews with New York and CHCF informs policymakers and industry Washington State Medicaid Authorities leaders, invests in ideas and innovations, and connects with changemakers to create B. Attestation Examples from New York and Washington, a more responsive, patient-centered health January 2020 care system. 26Endnotes For more information, visit www.chcf.org. California Health Care Foundation www.chcf.org 2 Background Integrating behavioral health into primary care is an Physical and Substance-use Syndromes (COMPASS), important way to increase access to effective behav- revealed two key findings: (1) CoCM was about as clin- ioral health treatment while maximizing the capacity of ically effective in the real world as in prior trials,11 and our very limited behavioral health workforce. There are (2) CoCM could not be sustainably financed without many approaches to integration, but the Collaborative new billing codes to support the work of the collab- Care Model (CoCM) has the most robust evidence base, orative team, as illustrated in Figure 1.12 In response especially for anxiety and depression.1 Compared to to the latter finding and feedback from stakeholders, the usual primary care approach to managing behav- CMS ultimately created a set of new billing codes ioral health needs, in which a provider either refers the unique to CoCM and issued them in 2016. patient to a specialist or manages needs on their own, CoCM offers supports for the providers and delivers Figure 1. Schematic of the CoCM Team superior clinical outcomes for common, less complex behavioral health conditions. In 2002, one of the earliest significant trials of CoCM, known as Improving Mood Promoting Access to Collaborative Treatment (IMPACT), demonstrated that the model doubles the effectiveness of the treatment of depression in elderly adults.2 Since then, more than 80 randomized controlled trials3 have demonstrated CoCM's clinical effectiveness for patients across many age groups, races, and ethnicities and with a range of common diagnoses, including depression, anxi- ety,4 PTSD,5 attention deficit hyperactivity disorder, and substance use disorder.6 The trials also showed the model could work in both rural and urban set- tings and across multiple payers including Medicaid.7 Furthermore, CoCM proved cost-saving, returning $6.50 for every dollar spent according to one study looking at older adults8 and demonstrating savings in multipayer populations with diabetes and depression.9 Source: University of Washington Advancing Integrated Mental Health Less is known about the model's cost-effectiveness Solutions Center, "Collaborative Care: Team Structure." in Medicaid, an important avenue for future inquiry given the strong evidence of its clinical effectiveness for low-income populations. CoCM only becomes economically viable Researchers also wanted to demonstrate that CoCM could be effective outside the controlled and rigid envi- for a practice when all payers reimburse ronment of a randomized trial. In 2012, the Centers for the codes. If more of these payers adopt Medicare & Medicaid Services (CMS) funded a large study of real-world CoCM implementation spanning the codes, the hope is more practices multiple community settings in eight states, including will in turn adopt CoCM, and ultimately, California, and reaching more than 3,000 patients.10 more patients will benefit. That randomized trial, known as Care of Mental, Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 3 When new codes are released by CMS, they can be immediately used by providers for Medicare enroll- The CoCM Model ees, but state Medicaid agencies and commercial The Collaborative Care Model extends the capabil- carriers make independent decisions regarding if, ity of primary care teams to identify and treat people when, and at what rate they will reimburse the new with common, less complex behavioral conditions like codes. Those non-Medicare payers can also choose depression and anxiety.16 It adds two new members to add their own requirements or restrictions to the with behavioral health expertise to the primary care codes. Currently, the majority of commercial car- team, and they provide treatment in tandem with the riers reimburse for the CoCM codes, also known as primary care provider (PCP). The model also includes the Psychiatric Collaborative Care Codes, but just other elements, such as a patient registry and vali- 17 state Medicaid agencies do. This uneven adop- dated screening tools, designed to standardize care tion of CoCM codes among payers is a barrier to the and follow-up. All these components are requisite model's spread, as evidenced by financial modeling for any practice intending to fully implement CoCM. studies showing that CoCM only becomes economi- If one or more these components are absent, there cally viable for a practice when all payers reimburse is scarce evidence that the model remains effective, the codes.13 If more of these payers adopt the codes, either clinically or financially. the hope is more practices will in turn adopt CoCM, and ultimately, more patients will benefit. As defined by CMS,17 the team members required to implement CoCM include: This paper examines the progress of states whose $ Behavioral care manager (BCM). Someone Medicaid agencies are reimbursing the CoCM codes with formal education or specialized training in to identify lessons learned and best practices, and to behavioral health, which could include a range inform the approaches of other states in the future. of disciplines including social work, nursing, or While the focus of this paper is on state-level imple- psychology. Importantly, CMS does not require mentation, the approaches and lessons learned also a minimum education requirement or licensure.18 apply to individual Medicaid managed care plans, which have the flexibility to pay for integrated care $ Psychiatricconsultant. A psychiatrist, psychiatric using these codes or other value-based payment advanced practice nurse, or psychiatric-certified approaches in many states. For example, at least one physician assistant.19 In practices where CoCM of Oregon's Medicaid Coordinated Care Organizations is used to treat substance use disorders, the has elected to reimburse the codes,14 and in Chicago, consultant can also be any physician that has the Medical Home Network accountable care orga- completed an addiction medicine fellowship. nization reinvested savings from its risk-based payer contracts to implement collaborative care.15 CoCM requires specific tasks be completed, primar- ily by the BCM, with the goal of reaching a clinically significant reduction in symptoms. These tasks are reflected in the CoCM billing code requirements and necessitate changes to the standard primary care workflow. They include: $ PCP assesses the patient using a validated rating scale and presents CoCM treatment option and copay (if applicable) for patient consent. $ BCM develops an individualized treatment plan with the patient and psychiatric consultant. California Health Care Foundation www.chcf.org 4 $ If needed, the PCP prescribes psychotropic medications, with guidance from the psychiatric Medicare's Payment consultant. Model: CoCM Billing $ BCM engages patient in treatment either in person or by televideo or phone using brief evi- Codes dence-based interventions, such as motivational As mentioned above, reimbursing CoCM used to be interviewing and problem-solving therapy, as difficult because the model includes some aspects directed by the treating PCP. that do not neatly map to traditional therapy and medical fee schedule billing codes, also known $ BCM regularly assesses the patient using vali- as Current Procedural Terminology (CPT) codes. dated rating scales, working toward defined Particularly incompatible aspects included the psy- treatment targets (e.g., a 50% reduction in PHQ-9 chiatric consultation, registry tracking, and follow-up. score and remission of depression defined as a CMS introduced the unique CoCM CPT codes in 2016 PHQ-9 score <5). to address these issues and help improve the model's $ BCM enters patient data (e.g., PHQ-9 scores, potential for financial sustainability. contact dates, etc.) into a registry, using it to track patient follow-up and progress over time with the PCP and psychiatric consultant. Billing CoCM codes (see Table 1) are billed by the patient's $ BCM participates in weekly caseload review with PCP 20 under their National Provider Identifier (NPI) the psychiatric consultant and adjusts care for number. The codes generate monthly care manage- patients who are not improving. ment fees to reimburse the time and activities of the $ BCM partners with patient on relapse prevention BCM and psychiatric consultant, and the PCP's col- planning and returning patient to usual primary laboration with this team. Although the BCM and care once treatment targets are met, or refers to the psychiatric consultant may have their own NPI higher level of specialty behavioral health care if numbers, they are not allowed to bill these codes not improving. independently. Instead, they are treated as part of Table 1. Collaborative Care CPT Codes MEDICARE REIMBURSEMENT DESCRIPTION (NONFACILITY RATE) 99492 First month of collaborative care, 70 minutes $157 99493 Subsequent months of collaborative care, 60 minutes $126 99494 Each additional 30 minutes of collaborative care $64 (up to two per month without prior authorization) G0512 Single monthly (inclusive of all time frames) rate for 60 minutes or more of collaborative $142 care in Federally Qualified Health Clinic / Rural Health Clinic settings Note: CMS also developed CPT code 99484 for "Other behavioral health integration models" in recognition that some providers may not be able to furnish or want to provide all the requirements for CoCM. For this code, at least 20 minutes of care coordination must be delivered by either the medical provider or another member of the team. Source: Centers for Medicare & Medicaid Services, "Physician Fee Schedule Search Tool." Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 5 the primary care team (contracted or on staff) and are reimbursed using the payment received by the PCP Federally Qualified Health Centers for billing these codes. BCMs qualified to bill tradi- and Rural Health Clinics tional diagnostic, evaluation, and therapy codes for In 2018, CMS created a separate, single CPT code Medicare recipients are allowed to bill for those ser- (G0512) for CoCM to be billed monthly by Federally vices in the same month that CoCM codes are billed, Qualified Health Centers and Rural Health Clinics. It but time spent on those additional activities may not requires BCMs to complete 60 minutes or more of col- be included in the time applied to the CoCM codes. laborative work per patient per month and requires the Likewise, if the psychiatric consultant directly evalu- same tasks be completed as the 99492–94 codes.22 ates a patient, they can bill traditional evaluation and management codes, but their time cannot be counted toward the monthly CoCM calculation. Medicare Uptake Since 2016 Rollout of Codes Table 2 reflects the most up-to-date information on Time Stamping/Tracking CoCM code usage for Medicare enrollees. Adoption The time used to provide CoCM must be tracked for of the codes has been low for Medicare providers,23 each patient each calendar month, and the CoCM particularly relative to the significant growth in adop- code can only be billed if these time specifications tion of the CCM codes (mentioned above) after which and the task requirements described above are met the CoCM codes were modeled. Medicare claims for at the end of each calendar month. Medicare CPT CCM have increased from approximately one million coding rules consider the time requirement met when in 2015 to four million in 2018. the time exceeds the halfway point. For example, the 99492 code specifies 70 minutes of treatment by the Table 2. U se of Collaborative Care Codes in Traditional BCM during the first month of CoCM. Accordingly, the Medicare, United States, 2017 and 2018 code can be billed when at least 36 minutes of CoCM DESCRIPTION 2017 2018* has been provided. For the subsequent-month code 99492 First month 845 3,381 (99493) that specifies 60 minutes of care, the code can be billed when at least 31 minutes of time has been 99493 Subsequent months 813 5,884 reached. 99494 30 minute add-on 596 2,903 *Adjusted by CMS to address data issues. It is important to note that when the original CoCM tri- Source: Medicare Part B FFS data, 2017– 2018. Custom data request als were conducted, time requirements were not part provided to the author. of the model. CMS modeled the CoCM codes after the existing chronic care management (CCM) code (99490), which also has time requirements.21 As it turns One likely reason for this discrepancy between the out, time tracking has posed an additional implemen- adoption of CCM codes and CoCM codes is that a tation and administrative burden that was not fully high percentage of the patients who benefit from anticipated. The effects of that additional burden have chronic care management are Medicare patients, so yet to be thoroughly studied but may include con- practices can still justify adopting workflows for chronic straining caseload sizes, which in turn makes financial care management even if not all payers reimburse for sustainability and scale harder to achieve. it. In addition, the CCM model is more likely to lever- age existing practice staff. Further possible barriers to adoption of the CoCM codes are described below. California Health Care Foundation www.chcf.org 6 Findings from a Review state-by-state differences in how Medicaid agencies are choosing to implement and reimburse the CoCM of State Medicaid codes. Information was either gleaned from publicly Approaches to available provider guidance documents or from the author's contacts in the field.24 In states where neither Implementing CoCM was available, it was assumed the state was following Medicare guidance. Codes Although CMS has established requirements for pro- As of August 2020, 17 states (see Figure 2) are reim- viders billing the CoCM codes for Medicare enrollees, bursing the codes in their Medicaid programs. Most other payers, including state Medicaid authorities, can of these states have only activated the codes since choose either to copy the CMS guidance, to revise the 2019. Just a few have multiple years experience with guidance, or to decline to implement the codes alto- the codes. gether. For this paper, an understanding was sought of Figure 2. S tate Medicaid Programs Currently Reimbursing CoCM, as of August 2020 WASHINGTON Medicaid agencies reimbursing CoCM codes MAINE MONTANA NORTH DAKOTA MINNESOTA VT OREGON NH IDAHO WISCONSIN MA SOUTH DAKOTA NEW YORK MICHIGAN CT WYOMING RHODE ISLAND NJ IOWA PENNSYLVANIA NEBRASKA NEVADA OHIO DELAWARE ILLINOIS INDIANA UTAH MARYLAND COLORADO WV DC KANSAS VIRGINIA CALIFORNIA MISSOURI KENTUCKY NORTH CAROLINA TENNESSEE OKLAHOMA ARIZONA SOUTH NEW MEXICO ARKANSAS CAROLINA ALABAMA GEORGIA MS TEXAS LOUISIANA ALASKA FLORIDA HAWAII Source: The author reviewed online the Physician Fee Schedule for all 50 states and DC, and looked for any Medicaid provider bulletins for states that had codes listed in the Physician Fee Schedule. Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 7 Table 3 summarizes the ways in which state Medicaid its rates.25 A key finding is that most state Medicaid agencies' implementation policies differ from agencies provide reimbursement below the Medicare Medicare's. Notably, some states' policies are more rate, averaging about 75% of Medicare rates. While restrictive than Medicare, adding complexity for this is consistent with typical rate setting for state practices implementing CoCM. Table 4 summarizes Medicaid programs, it may not be sufficient to spur the range of Medicaid reimbursement rates found uptake. For example, New Hampshire Medicaid has across 15 of the 17 states for each for the main CoCM seen very low uptake of CoCM, and Montana's lower codes (see page 8). New York's rates are not included reimbursement rates for FQHCs may present chal- because the state uses a different code, and Illinois's lenges for clinics and their patients. are excluded because the state has not yet published Table 3. Overview of State-Specific Differences in Implementation Policies STATE MEDICAID POLICIES THAT MEDICARE REFERENCE DIFFER FROM MEDICARE COMMENTS Attestation required No attestation required, New York and Washington (signed document stating retrospective audit used require attestation. provider is providing key instead in cases of suspected elements of CoCM) fraudulent billing. Diagnoses allowed No diagnostic exclusions Michigan prohibits serious Research shows CoCM is effective mental illness diagnoses and for depression, anxiety, PTSD, and using CoCM for medication- substance use disorder. assisted treatment for opioid use disorder. New York limits diagnosis to depression and anxiety disorders only. Prior authorization Medicare requires PA only Michigan requires PA at 6 months. Research shows an episode of CoCM (PA) requirements if provider wants to use care is typically 6 to 9 months, but Washington requires PA at 6 and more than two 99494 can be longer, or as short as 3 to 12 months. add-on codes. 6 months. Team credentials BCM can come from a range Michigan requires psychiatric One study shows nonlicensed of disciplines but must have consultant to be a psychiatrist. paraprofessionals can do BCM "some formal or specialized work adequately. 26 North Carolina requires BCM behavioral health training." to be a licensed mental health Psychiatric consultant can be therapist. MD or NP. Required metrics None New York has required list. Enables states to track and report reporting quality measures such as National Quality Forum 1884/1885 (depression response at 6 and 12 months) and 710/711 (depression remission at 6 and 12 months). Billing provider Any provider qualified to use Arizona does not allow nephrolo- limitations evaluation and management gists and other specialists to bill. codes, except psychiatrists Only Arizona, Michigan, Montana, Separate code for FQHCs New York, and Washington allow FQHCs to bill. Source: Author anaylsis. California Health Care Foundation www.chcf.org 8 Table 4. CoCM Reimbursement Rates for Medicaid and Medicare, by Code MEDICAID RATE AS A PERCENTAGE MEDICAID-ONLY RANGES 27 MEDICAID-ONLY MEDICARE 28 OF NATIONAL MEDICARE RATE (NONFACILITY; FEE-FOR-SERVICE) (MEAN) (NATIONAL NONFACILITY) (AVERAGE) 99492 $56 (New Hampshire) to $114 $157 73% $176 (Montana) 99493 $51 (New Hampshire) to $94 $126 74% $140 (Montana) 99494 $27 (New Hampshire) to $49 $64 76% $82 (Montana) Note: These data can change. Authors recommend checking the state Physician Fee Schedule regularly for updates. Source: The author reviewed online Physician Fee Schedules for all 50 states and DC, looked for any Medicaid provider bulletins for states that had codes listed in the Physician Fee Schedule. end of each calendar month the BCM must count all General Behavioral Health Integration - the minutes they have spent doing the required tasks CPT Code 99484 and then match them to the given code to see if they At the same time as the CoCM codes were rolled can bill for each patient on their registry. This requires out, Medicare also introduced an additional code developing a tracking system to collect this informa- for behavioral health integration services that do not tion for a caseload of 60 to 80 patients that could pass conform to the specific Collaborative Care Model. scrutiny if there were ever an audit of the practice site. All state Medicaid programs except those in Illinois, Michigan, North Carolina, New York, and Washing- Registry. The use of a registry to track patient progress ton are reimbursing this code, which only requires 20 minutes of time per calendar month and can be is a key population management tool and a require- delivered by a broader set of team members or the ment for CoCM, but a registry is not yet a standard PCP alone.30 Like the CoCM codes, some specific feature of most electronic health record (EHR) systems. tasks must be performed to bill the 99484 code. Without this feature, providers must double-enter cer- tain data into a separate registry tool or modify other business intelligence tools, a process that can be time- consuming and costly. According to adopters in the field, Epic is the only major EHR vendor that can con- Barriers to Uptake struct a data set adequate to meet CoCM's tracking Nearly four years after Medicare first launched the requirements. CoCM billing codes, a few common barriers to adop- tion have become clear. First and foremost, busy Workforce. Finding psychiatric consultants can be primary care providers can be hesitant to adjust challenging due to the well-documented shortage of workflows and take time to learn how to work in the psychiatrists and advanced practice practitioners.31 team-based approach CoCM requires. Stigma around Many BCMs also do not arrive on the job with train- behavioral health conditions also remains a persistent ing in the principles and practice of collaborative and pervasive barrier. Others include: care, and providing appropriate training is not a trivial task.32 Furthermore, not all PCPs have the desire or the Time tracking. Providers repeatedly point to the appropriate training to manage behavioral health con- process of tracking or "stamping" the time spent on ditions, and not all behavioral health providers want to collaborative care as one of the most burdensome work in a primary care setting. requirements of the CoCM codes. Essentially, at the Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 9 Giving providers funding for technical assistance can role. Set rates at or close to Medicare rates to help lessen some of the aforementioned training barri- make CoCM more financially feasible for primary care ers and encourage uptake. For example, New York clinics to adopt. State has an extensive technical assistance program for clinics that want to implement CoCM provided by Consider requiring attestation. Attestation involves the Office of Mental Health under contract with the requiring a provider to sign a document stating that University of Washington AIMS Center. The Montana all key elements of CoCM are being provided. While Primary Care Association provided grant funding this additional step can be a barrier, New York and for eight primary care clinics to implement CoCM. Washington - two Medicaid agencies that require However, technical assistance cannot solve the final attestation before CoCM reimbursement - have barrier: reimbursement. found it useful in ensuring provider fidelity to the model. Reimbursement. The financial sustainability of CoCM faces dual barriers: the number of payers adopting Consider providing or funding technical assistance. the codes and the rates paid for the codes. Multiple Because the initial barriers to implementing the CoCM approaches33 have demonstrated that the CoCM codes can seem daunting for practices, technical assis- codes can generate revenue over and above the costs tance can act as an impactful catalyst. Implementation of implementation only when all payers are reimburs- aspects that can benefit from technical assistance ing at or near Medicare rates.34 include provider training, registry development, work- flow implementation, and practice assessment. Best Practice Conclusion Recommendations for As COVID-19 catalyzes an increase in behavioral Medicaid Reimbursement health needs, the case for implementing CoCM is only growing clearer and more urgent. That is especially of CoCM true for the people of color and with lower incomes Despite these barriers, the research for this paper being hit hardest by COVID-19 and the underlying revealed some promising practices that can guide inequities that have exacerbated this pandemic. The adoption of these codes by other state Medicaid pro- strong evidence demonstrating CoCM's effectiveness grams. In drawing lessons from the experiences of for those populations should compel all Medicaid pro- the 17 states actively reimbursing CoCM codes it is grams to make this service available to their enrollees. important to note that most are still only one or two Seventeen Medicaid programs have already taken years into implementation, so this is an early look at an that step, and their early experiences offer valuable evolving field. Promising practices include: lessons that should help other states and managed care plans refine their approaches to reimbursing and Align with Medicare codes and rules where pos- regulating this promising care model. sible. Doing so reduces administrative complexity and optimizes implementation flexibility. In particu- lar, follow Medicare's lead in allowing billing by PCPs and specialists (including those at FQHCs) for a full range of diagnoses. Similarly, replicate Medicare's rules around BCM eligibility, which allow a broad set of paraprofessional and licensed disciplines to fill that California Health Care Foundation www.chcf.org 10 Appendix A. Key State Experiences - Interviews with New York and Washington State Medicaid Authorities Due to the relatively low numbers of adopters and the Diagnosis restrictions. Limitations on diagnoses are relatively short time since reimbursement began, there used to manage the Medicaid budget allocated to is limited public data on states' varied approaches to CoCM. However, they can also restrict the growth of implementation. To gather more in-depth information the model. New York has restricted reimbursement to on how states are implementing these codes, key staff patients with anxiety disorders or depression or both. in two states were interviewed. New York began using CoCM codes for Medicaid enrollees in 2015, predat- Many practices do not see the investment in CoCM ing even Medicare's implementation of the codes. As as worthwhile if it cannot be used for the many other a result, the state has developed a rich set of insights mental health needs their patients have. The state is into its implementation experience, and has also cre- looking at adding substance use diagnoses, which ated many resources and guidelines for providers. CoCM has proven effective at treating, but a separate Washington State Medicaid was the first to use the agency funds substance use disorder, so the process Medicare billing codes that CMS launched in 2016 and is more complicated.35 The state is also considering provided guidelines and requirements for providers. reimbursing CoCM for pediatric patients with atten- tion deficit hyperactivity disorder. NEW YORK Care manager credentials. The BCM does not have Collaborative Care Medicaid Program to be licensed, although licensing is strongly encour- New York's provider community was an early adopter aged so the manager can bill additional psychotherapy of CoCM, with grant-funded implementations ongoing codes as needed to increase revenue and cover costs. for many years before Medicare began to reimburse. As there was no CPT code available at the time for col- Key tasks required. At least one clinical contact per laborative care, the state started a Collaborative Care month (in person or virtual) is required, along with the Medicaid Program and devised their own code for administration of at least one validated measurement reimbursing providers: T2022. The program is admin- tool (i.e., PHQ-9 or GAD7). In addition, at least one istered from the Office of Mental Health (OMH) and face-to-face meeting every 90 days is required (a PCP the reimbursement procedure has been in place for visit can fulfill this criterion). However, counting min- five years. A major differentiator between New York utes is not required (New York uses its own codes that Medicaid's code and the Medicare codes is that the predate the CMS codes). state does not require providers to track minutes per month. Other billing specifications and implementa- Metrics reporting. Providers must submit a set of tion aspects include: required metrics. Using those data, the state is regu- larly seeing 40% to 50% of patients achieving a 50% Attestation. Goes beyond Medicare by listing the reduction in depressive symptoms, consistent with the required elements of CoCM and requiring the PCP or literature on CoCM. clinic to sign a form (see Appendix B) guaranteeing that all elements of CoCM are being provided. The Uptake. Has been constant but less than OMH would state believes that by making providers explicitly com- like to see. As mentioned above, limiting the diagno- mit to fully implementing the model before billing for ses to depression and anxiety is a contributing factor, it, they are likely to more closely replicate the version along with the other aforementioned common barri- of CoCM proven by all the clinical trials. Modified or ers to implementing CoCM. Providers have reported partial versions of that model have not been proven to that the claims process is also cumbersome, which has deliver equally effective results. caused some issues with reimbursement. Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 11 Virtual CoCM. A pilot to test virtual CoCM is under- FQHC billing. FQHCs have a Prospective Payment way to help address the workforce shortages that limit System (PPS) rate higher than the CoCM rate, so some adoption in more rural areas of the state. A toolkit is forgo billing CoCM codes and instead opt to bill the being designed for virtual CoCM. PPS rate for a single visit, which pays more. Implementation science exploration. There is ongo- Metric reporting. No metrics are required to be ing interest by OMH in better understanding which reported to the state authority. qualities lead to more successful implementation and in defining barriers and solutions. Low uptake. The state attributes low uptake to the model being "too complex" to implement for most Technical assistance. The state has provided several primary care practices without significant techni- supports to increase adoption of CoCM, including cal assistance. Providers have expressed a desire for administering learning collaboratives and offering a "start-up" funding, and the HCA has said it is "not in web-based Care Management Tracking System regis- a position to fund training." The state urges sites to try for optional use. understand the implementation challenges upfront, especially the time tracking requirement, and to "identify champions" to help foster full adoption. WASHINGTON Washington State Health Care Authority Policy clarity for Medicaid coding. There is no official Washington Medicaid began reimbursing the CoCM guidance on whether providers have to complete the codes shortly after Medicare. The decision to reim- entire required time interval for Medicaid billing or if burse was funded through legislative action, so they can abide by Medicare's rule, which allows bill- reimbursement is required unless the law is changed. ing once more than half of the required time has been In the state budget, $1.7 million was set aside, as the worked. This has caused confusion and still needs to state decided that CoCM would not produce suffi- be clarified. cient overall health care savings to offset the cost of reimbursing it. In addition, the legislation required reimbursement at Medicare rates for the first year. Code 99484, which reimburses for other models of integrated care, was not included in the legislation. Other key aspects of implementation include: Attestation. Both interviewees believe attestation is a good thing because it holds providers accountable to delivering the CoCM to fidelity. The attestation step has caught some providers who "try to bend the model to what they want to provide" and are miss- ing certain components. Attestation is approved at the Medicaid Health Care Authority (HCA) level and then sent to the Medicaid managed care plans for oversight. Care manager credentials. Care managers do not have to be licensed. California Health Care Foundation www.chcf.org 12 Appendix B. Attestation Examples from New York and Washington, January 2020 NEW YORK STATE MEDICAID COLLABORATIVE CARE PROVIDER CERTIFICATION If you are a primary care provider seeking supplemental monthly case rate Medicaid payment for Collaborative Care, please see these terms. Article 28 of the Public Health Law allows primary care practices to deliver Collaborative Care health services to patients with certain behavioral health diagnoses. Prior approval from the Commissioner of the Department of Health and the Commissioner of the Office of Mental Health, or their designees, must be obtained. Submit your application in the format described below. 1. NYS Collaborative Care Medicaid Program Requirements  Includes introductory billing guidance and pay-for-performance standards 2. Appendix 1 – State Approved Registries 3. Three (3) Part Provider Application:  Site Applicant Demographics  Medical Director Attestation  CEO Letter of Support (addressed to Dr. Jay Carruthers, MD, Medical Director) Completed applications should be sent to NYSCollaborativeCare@omh.ny.gov, along with a letter of support from the applying organization's CEO or executive director. Questions should be directed to the same email address. PAGE 1 OF 11 Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 13 TERMS FOR PROVIDERS PARTICIPATING IN NYS COLLABORATIVE CARE MEDICAID PROGRAM (CCMP) If you are a primary care provider seeking supplemental monthly case rate Medicaid payment for Collaborative Care please see these terms. Article 28 of the Public Health Law allows primary care practices to deliver Collaborative Care health services to patients with certain behavioral health diagnoses. Prior approval from the Commissioner of the Department of Health and the Commissioner of the Office of Mental Health, or their designees, must be obtained. Submit your application to the Commissioner of the Office of Mental Health, in the format described below. Eligibility Criteria: A Primary Care clinic must deliver the following essential elements of Collaborative Care:  Trained Behavioral Health Care Managers in the primary care setting who oversee and provide mental health care support; screening; patient engagement, education and follow-up; ongoing patient contact; monitoring of adherence with psychotropic medications; mental health and substance disorder referrals; brief interventions appropriate for primary care settings; and related activities. Some acceptable individuals for this role are: LCSW, LMSW, BSW with appropriate supervision, LMHC, LMFT, RN with behavioral health training (for job description see: http://aims.uw.edu/collaborative-care/team-structure/care-manager )  Designated Psychiatric Consultant who provide caseload-focused consultation at least weekly with the Depression Care Managers or primary care providers on patients, for those not responding to care. Psychiatrist, or Psych NP with Psychiatrist backup, can provide caseload supervision remotely (e.g. by phone or video) but must have access to the patient care registry.  Use of a state-approved patient care registry* for ongoing performance monitoring that includes the delivery of services; patient responses through routine use of the relevant screening tool; and ongoing performance improvement. *see Appendix 1 for details  Trained primary care providers in screening and providing evidence-based, stepped care for certain behavioral health diagnoses. Additional factors considered in determining who will receive this supplemental payment include: 1. Past performance delivering Collaborative Care 2. Capacity to scale up Collaborative Care PAGE 2 OF 11 California Health Care Foundation www.chcf.org 14 January 2020 2 Billing NYS Medicaid for Collaborative Care Payment for Collaborative Care services will only be made for patients that meet diagnostic criteria for behavioral health conditions approved by OMH; Patients' scores are actively tracked in a registry; and who receive evidence-based BH care in a primary care setting by primary care providers, where trained Behavioral Health Care Managers (BHCM) are in place and actively providing services; and where a designated consulting psychiatrist regularly reviews, with either the primary care provider or the BHCM, the needs of all patients under care who are not improving and makes recommendations for changes in treatment as needed. NOTE: The Behavioral Health Care Managers may provide evidence-based treatments such as brief, structured psychotherapies or work with other mental health providers when such treatment is indicated and within the scope of their training and licensure. If Behavioral Health Care Managers provide psychotherapeutic treatment, they will require the clinical licensure/certifications to do so (e.g., Licensed Mental Health Counselor, Licensed Marriage and Family Therapist, Licensed Clinical Social Worker, Licensed Master Social Worker, Certified Counselor, Licensed Psychologist, Licensed Registered Nurse, or Nurse Practitioner; BSW can provide these services when under supervision of a Masters Social Worker). If BH care managers perform all functions except the delivery of psychotherapeutic treatment, they can be a paraprofessional (e.g., Bachelor's or Associate level Counselor, Mental Health Aide, Behavioral Health Aide, Medical Assistant, Vocational Nurse, or Nursing Assistant). If the BHCM is not licensed, there must be a process in place to provide therapy to patients that need it, ideally without having to refer all of these patients out. Billing shall be on a monthly basis. To bill for services for a Medicaid patient receiving Collaborative Care, the primary care provider and/or Behavioral Health Care Managers must:  Enter the patient into a state-approved registry based on an initial diagnosis of the PCP and completion of an initial assessment and treatment plan by the Behavioral Health Care Manager  Have a minimum of one clinical contact with the patient and a completed symptom scale (e.g. GAD-7, PHQ-9) every 30 days; [A "clinical contact" is defined as a contact in which monitoring may occur and treatment is delivered with corroborating documentation in the patient chart. This includes individual or group psychotherapy visits and telephonic engagement as long as treatment is delivered.]  Have seen the patient face-to-face with a licensed provider for at least 15 minutes at least once during the most recent three months (90 days); this may be their PCP, Licensed BHCM or other licensed professional staff.  Keep a record of all patient contacts; and  Consult for one hour or more per week, depending on case load, with a designated consulting psychiatrist regarding patients in the registry, including all patients who are not improving in terms of their symptom scores. This psychiatrist cannot bill Medicaid for the Collaborative Care consultation work unless they perform in-person evaluations and consultation services. PAGE 3 OF 11 January 2020 3 Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 15 After a patient scores positive on the screening tool, is diagnosed with a Behavioral Health condition by a primary care provider, has an initial assessment and treatment plan done by the Behavioral Health Care Manager, and has been entered into the approved registry, billing for Collaborative Care may begin. The initial monthly payment for this service shall be $112.50. This amount shall be subject to periodic adjustment by NYS. For Article 28 practices, there is the potential to earn an additional 25% quality incentive payment. This "retainage" shall be paid to the provider retroactively after the patient has completed at least three months of Collaborative Care based on attestation that the provider has complied with all aspects described above, as well as all applicable billing and programmatic guidelines AND approval has been granted by NYS or its designee. Please note, the retainage does not apply to non-Article 28 practices due to their unique billing processes. To qualify for the retainage, the patient must have been enrolled in the Collaborative Care program for a minimum of 3 months of treatment and in addition to being in full compliance with the terms of this program, the provider must document in the patient record that one of the following outcomes was achieved:  Demonstrable clinical improvement, as defined by: 1. A drop in the relevant symptom score to below 'positive' level; for PHQ-9 and GAD-7, this is below 10 2. Or a 50% decrease in the symptom score from the level of the original score  In cases where there was no demonstrable clinical improvement, there must be documentation in the medical record of one of the following: 1. Psychiatric consultation (defined here as review of the case by the designated collaborative care psychiatrist with either the care manager or primary care provider) and a recommendation for treatment change by the psychiatric consultant 2. Change in treatment (e.g., change in medication*, change in psychotherapy type or frequency, or completed referral to more intensive specialty mental health treatment). *Please note, change in dosage may constitute a change in medication only if the dose change does not represent a titration up to treatment dose, but a true modification of the patient's course. In order to capture this, we will limit the window for change in dose to between 6 weeks and 12 weeks after starting treatment. A patient is limited to 12 months of Collaborative Care treatment. The 12 months do not have to be consecutive. However, with prior approval from the Office of Mental Health's Medical Director, or designee, an additional 12 months is permitted at two-thirds of the monthly rate of the initial 12 months if the treatment team demonstrates the need for ongoing depression care management. The retainage rules above also apply to the second 12 month period. Billing Start Date: Certified providers in compliance PAGE with all requirements described herein will be given 4 OF 11 an approval date after which they can begin billing. Services for a given month will be billed on the first of the next month, i.e. January 2018 services would then be billed in February 1, 2018; and so forth, such California Health Care Foundation www.chcf.org 16 January 2020 4 the patient's course. In order to capture this, we will limit the window for change in dose to between 6 weeks and 12 weeks after starting treatment. A patient is limited to 12 months of Collaborative Care treatment. The 12 months do not have to be consecutive. However, with prior approval from the Office of Mental Health's Medical Director, or designee, an additional 12 months is permitted at two-thirds of the monthly rate of the initial 12 months if the treatment team demonstrates the need for ongoing depression care management. The retainage rules above also apply to the second 12 month period. that allStart Billing Date: services delivered Certifiedare billed during providers the subsequent in compliance with allmonth. Claims described requirements must be submitted herein willwithin 90 be given days an of the date approval dateof service after to they which avoidcantimely filing begin denial. billing. Sites will Services for abegiven notified month when willthey are approved be billed and on the first of eligible the nextto bill. The month, i.e. Collaborative January 2018 Care program services wouldwill bebe then subject billedto inaudit by a 1, February designated 2018; andNYS entity.such so forth, In casesallwhere that thedelivered services provider has are failed to comply billed during the with all clinical subsequent and reporting month. requirements, Claims must be submittedrates codes within 90will January 2020 be inactivated and 4 days of the date of payments service to will avoid betimely recovered. filing denial. Sites will be notified when they are approved and eligible to bill. The Collaborative Care program will be subject to audit by a designated NYS entity. In NOTE: SBIRT Billing - When appropriate, billing for SBIRT services delivered may also occur, using existing fee- cases where the provider has failed to comply with all clinical and reporting requirements, rates codes will for-service or managed care payment methods. This payment would be in addition to that paid for be inactivated and payments will be recovered. Collaborative Care. NOTE: SBIRT Billing - When appropriate, billing for SBIRT services delivered may also occur, using existing fee- for-service or managed care payment methods. This payment would be in addition to that paid for Collaborative Care. PAGE 5 OF 11 Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 17 January 2020 5 APPENDIX 1: State-Approved Depression Care Registry* Effective management of common behavioral health conditions requires the ability to track clinical outcomes for populations of patients and to support systematic changes in treatment for patients who are not improving as expected. This measurement-based, treatment-to-target approach is one of the core principles of Collaborative Care and is essential in ensuring stated goals are being met. It requires a systematic method of tracking information on all patients being treated for behavioral health conditions, like anxiety or depression. How it is done is much less important than that it is done. Registries must be able to support the following functions:  Track clinical outcomes and progress at the individual patient and caseload levels.  Track population-based outcomes.  Prompt treatment to target by summarizing patient's improvement and challenges in an easily understandable way, such as charts.  Facilitate efficient case review, allowing providers, including the psychiatric consultant, to prioritize patients who need to be evaluated for changes in treatment or who are new to the caseload.  Able to extract the relevant data for the required quarterly reporting to NYS OMH.  Able to supply de-identified reports to outside auditors to demonstrate regulatory compliance, intensity of clinical contacts, staffing ratios, and outcomes. Sites use a variety of programs to perform these functions.  Many clinics begin their Collaborative Care programs using a spreadsheet as a registry.  The AIMS Center offers a Patient Tracking Spreadsheet Template for providers to use.  The AIMS Caseload Tracker is a cloud-based, HIPAA compliant registry that was introduced in 2017. This simple registry is useful for integrated care sites when the psychiatric consultant has direct access to the EHR.  The AIMS Center offers an online, HIPAA compliant Care Management Tracking System (CMTS) that is particularly useful for healthcare organizations using multiple EHRs and diverse primary care practices. NYS OMH has designed a build that address all reporting criteria. If you are interested in using CMTS, please contact NYSCollaborativeCare@omh.ny.gov for information on access to this version.  Some organizations have customized registry builds for their EHR or in a care management software system. For more information on registry requirements and the various options, see https://aims.uw.edu/sites/default/files/CollaborativeCareRegistryRequirements.pdf PAGE 6 OF 11 California Health Care Foundation www.chcf.org 18 January 2020 6 NYS COLLABORATIVE CARE MEDICAID PROGRAM CERTIFICATION: PROVIDER APPLICATION Please provide all the information requested below. Organizations seeking certification for multiple sites must complete a separate application for each site, patient volume, and readiness data. Groups of sites that share leadership and process may only submit one workflow and one letter of support for all. Incomplete applications will not be processed. Complete applications should be sent to NYSCollaborativeCare@omh.ny.gov Name of point of contact for this application: Email: Phone: Name of Practice: Physical Address: Zip code + 4: Mailing Address (if different from above): County: Facility License Type: (FQHC / Article 28 / Private Practitioner) _____________________________ (*Private Practitioner, NON-Art 28, see Appendix2*) *For private practitioners, you will also need to submit names, Medicaid IDs, and NPIs for each individual physician. (See Appendix 2). Clinic Medicaid ID #*: and Locator Code: Clinic NPI: Clinic Director (if applicable): Medical Director: Name of current BH Care Manager(s) with associated NYS license: Current BH Care Manager FTE: Planned staffing FTE: How many Primary Care Providers (MD/DO, NP, PA) are at this site? ___________________ Total annual patient volume at your site: Number of patients currently receiving collaborative care at your site, If any: Anticipated maximum number of patients enrolled in collaborative care at any given time: What EMR does the practice use? Are you already providing Collaborative Care services? If not, when do you anticipate starting? January 2020 PAGE 7 OF 11 7 Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 19 Current Collaborative Care Registry:__________________________________________ Your registry should be able to perform the following functions? (check all that apply): Ability to track and manage caseloads toward evidence-based care delivery – a core registry design feature Supports treatment to target and caseload review for BH care manager with psychiatrist consultation for those not improving Supplies reports to program managers and clinical leadership to monitor progress toward goals, including processes of care, quality of care and patient outcomes metrics Able to supply de-identified reports to outside auditors to demonstrate regulatory compliance, intensity of service, staffing ratios, process measures, such as screening, diagnose and enrollment rates, and clinical outcomes Staffing: In order to participate in the Collaborative Care Learning Network, proper staffing is required. Please provide the contact information for the team members listed in this table. For more information, see the Team Roles Flyer for definitions of each role. Degree/ Telephone Role Name Email address licensure Number Program Lead BH Care Manager PCP Champion Psychiatric Consultant Billing & Data Lead The BH Care Manager should have training in one or more of the following psychotherapy interventions.  True Behavioral Activation  Problem Solving Therapy  Cognitive Behavioral Therapy  Interpersonal Therapy The BH Care Manager should devote at least .5 FTE to the role. A CM may be shared between sites, but sharing 1.0 FTE between more than two sites is not recommended. If the CM is not available for a minimum amount of time, hand-offs are not consistent, and the CM becomes distant from the Primary Care team. This impact both provider and patient engagement. If the CM is not available every day, there should be a formal process to supplement the hand-off and for the CM to follow up in a timely manner. Find a CM job description and details on the recommended type of candidate on the AIMS website: https://aims.uw.edu/resource-library/care-manager-role-and-job-description PAGE 8 OF 11 January 2020 8 California Health Care Foundation www.chcf.org 20 Case Review: A key component of Collaborative Care is the weekly, 1-hour systematic case review of patients who are not improving between the care manager and the psychiatric consultant. Please enter the set day and time each week your care manager and psychiatric consultant will meet, whether this will occur in person or over the phone, and whether the consultant has access to your clinic's EHR and/or registry. Note, even if you do not believe you have significant caseload to warrant a full hour each week, it is recommended that you continue to meet for one hour. This reserves the time in case needs change later on, but also allows the CM to ask questions of the psychiatric consultant that they may not otherwise have the opportunity to, such as guidance on pharmacology. Case Review: Workflow: Please submit your Collaborative Care workflow along with this application. In addition to the basic Collaborative Care workflow elements, the reviewers will also be looking for the following processes to be addressed:  Consistent administration of BH Screening tools (75% or more), review, and recording of scores  Ability to do a live warm connection (warm handoff) between PCP and care manager some or most of the time and plan for when this is not possible  Communication plan in place for getting PC recommendations to the PCP and monitoring the PCP's response PAGE 9 OF 11 Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 21 January 2020 9 VIOLATIONS SUBJECT TO PENALTY: Clinics participating in the Collaborative Care described above must comply with the terms and standards set forth by NYS DOH and OMH and are subject to audit. Reimbursement is contingent on full compliance therein. Clinics found to be in violation of standards will be subject to financial penalty. CLINIC MEDICAL DIRECTOR ATTESTATION: I, [clinic medical director], understand the terms and standards for participation for the NYS Medicaid Collaborative Care Program and attest that [practice name] meets all specified eligibility requirements, including currently having in place all the required service elements for delivering Collaborative Care (e.g. state-approved patient care registry, outside caseload consultant psychiatrist(s), Behavioral Health Care Manager(s), and primary care providers trained to deliver Collaborative Care for depression). Furthermore, I understand full compliance with the terms and standards above is required for reimbursement; and that failure to comply may result in financial penalty. Name: Title: Signature: ________________________________ Date: **Please attach to this application: 1. Letter of support from the Executive Leadership of your organization or health system demonstrating support for this implementation and commitment to the standards. Incomplete Applications will not be reviewed PAGE 10 OF 11 California Health Care Foundation www.chcf.org 22 January 2020 10 APPENDIX 2: Private Practitioner Information *Only Non-Article 28 practices should complete this form* Please complete the table below with information for each physician. Note: The specialty code required to bill for Collaborative Care services can only be added to physician files, please do not include nurse practitioner or physician assistant information. Site Name Physician Last Physician First Physician NPI Physician Group NPI Name Name Medicaid ID PAGE 11 OF 11 January 2020 11 Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 23 Attestation for Collaborative Care Model (CoCM) This attestation is for any single provider or provider group to attest that they are actively providing care consistent with the core principles and specific function requirements with the Collaborative Care Model (CoCM) as described in the agency's Collaborative Care Model Guidelines. Submission on behalf of individual billing provider or billing group practice: Individual billing provider Billing address: Billing NPI number: Billing/lead provider must be one of the following provider types: Telephone number: (Check your provider type.) MD DO ND ARNP Email: NOTE: requires each billing provider submit an attestation Provider Name: Billing group practice Billing provider name: Billing NPI number: Servicing provider name(s): Servicing provider(s) location: Servicing provider(s) NPI: Billing address: Telephone number: CoCM lead provider must be one of the following provider types: Email: (Check the provider type of provider[s]) in your practice.) MD DO ND ARNP NOTE: attestation must cover all servicing providers within the practice attesting that they are actively leading care consistent the core principles and specific function requirements with the CoCM, and ensure new medical provid- ers that will be leading the collaborative care are trained in CoCM. PAGE 1 OF 2 California Health Care Foundation www.chcf.org 24 HCA 13-0017 (8/18) (continued on next page) If your practice bills under one base location and has several servicing locations, each servicing location must submit an attestation to provide and be reimbursed for CoCM service. For practices with multiple sites with their own billing NPI's, each site must submit its own attestation. If there are multiple providers within the practice, you are attesting that those individuals being identi- fied as the servicing provider on the claim billing the CoCM services, are one of the above provider types, are trained and actively providing care consistent with the core principles, and specific function requirements for CoCM. You attest that your practice is actively providing care in a Collaborative Care Model as described in the agency guidelines. This CoCM includes the following required principles: (Check each to verify.) Patient Center Team Care I. Primary care/medical provider leading the collaborative care team II. Behavioral health care manager working with the lead medical provider III. Psychiatric consultation working with the lead medical provider IV. Beneficiary-client Team structure with staff identified in the guideline Measurement-based treatment to target using validated tools Accountable care using a registry I have received and reviewed the CoCM guidelines, understand them, have received training, and have implemented the CoCM consistent with said guidelines, and agree to comply with said guidelines. By signing this attestation, you are attesting that you, the individual, or the group practice are actively prac- ticing a collaborative care model consistent with that described in the agencies CoCM guideline. If at any time you, the individual, or the group practice no longer meets the requirements for CoCM, you will im- mediately notify the agency by contacting provider enrollment at 360-725-2144. The person signing this form must have the authority to attest that the CoCM guidelines are being ad- hered to. Print name and title ___________________________________________________________ Signature Date Fax, mail or scan and email this completed and signed form to: Provider Enrollment PO Box 45562 Olympia, WA 98504-5562 Or fax to 360-725-2144, Attn: Provider Enrollment Or email providerenrollment@hca.wa.gov PAGE 2 OF 2 Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 25 Endnotes Dissemination of Integrated Care within Adult Primary 1. 14.E. Dawn Creach, Mike Franz, and Janet Foliano, Key Factors Care Settings: The Collaborative Care Model (PDF), for Advancing Integrated Care in Central Oregon: Payer, Amer. Psychiatric Assn. and Academy of Psychosomatic Provider, Policy, and Technical Assistance (PDF) (presented Medicine, 2016. at the Collaborative Family Healthcare Assn. Annual Conference, Denver, Colorado, October 18, 2019). 2.Jürgen Unützer et al., "Collaborative Care Management of Late-life Depression in the Primary Care Setting: A 15.Collaboration Under Value-Based Payment: Lessons Learned Randomized Controlled Trial," JAMA 288, no. 22 (2002): (PDF), National Partnership for the Health Care Safety Net, 2836–45, doi:10.1001/jama.288.22.2836. July 2017. 3.Janine Archer et al., "Collaborative Care for Depression 16.The Collaborative Care Model was initially evaluated for and Anxiety," Cochrane Database of Systematic Reviews 10 use in depression, but has since been shown to be effective (2012): CD006525, doi:10.1002/14651858.CD006525.pub2. for anxiety, PTSD, and substance use disorder as well as for behavioral health patients with comorbid medical conditions 4.Peter Roy-Byrne et al., "Delivery of Evidence-Based like cancer, diabetes, and heart disease. Treatment for Multiple Anxiety Disorders in Primary Care: A Randomized Controlled Trial," JAMA 303, no. 19 (2010): 17.42 CFR §§ 405, 410, 414, 424, and 425 (2017) (PDF). 1921–8, doi:10.1001/jama.2010.608. 18.This is different than what would be required for a BCM to bill 5.Charles C. Engel et al., "Centrally Assisted Collaborative Medicare independently. Telecare for Posttraumatic Stress Disorder and Depression 19.The psychiatric consultant is not required to be a Medicare Among Military Personnel Attending Primary Care: A provider. Randomized Clinical Trial," JAMA internal Medicine 176, no. 7 (2016): 948–56, doi:10.1001/jamainternmed.2016.2402. 20.While PCP is used as an example, the codes can be billed by physicians and nonphysician practitioners whose scope of 6.Katherine E. Watkins et al., "Collaborative Care for practice includes evaluation and management (E/M) services Opioid and Alcohol Use Disorders in Primary Care: The and who can independently report services to Medicare. SUMMIT Randomized Clinical Trial," JAMA Internal This includes physicians of any specialty, physician assistants, Medicine 177, no. 10 (2017): 1480–88, doi:10.1001/ nurse practitioners, clinical nurse specialists, and certified jamainternmed.2017.3947. nurse midwives. 7.Jürgen Unützer et al., The Collaborative Care Model: An 21.The CCM code was designed to reimburse nurse care Approach for Integrating Physical and Mental Health Care managers for providing care for patients having two or more in Medicaid Health Homes (PDF), Centers for Medicare and chronic medical conditions. It requires at least 20 minutes of Medicaid Services, May 2013. care management tasks (e.g., coordination with specialists, 8.Jürgen Unützer et al., "Long Term Cost Effects of systematic assessment of needs, care plans, outreach and Collaborative Care for Late-Life Depression," Amer. Journal engagement, medication reconciliation, etc.) be provided per of Managed Care 14, no. 2 (Feb. 2008): 95–100. month. 9.Gregory E. Simon et al., "Cost-Effectiveness of Systematic 22.As with the 99492–94 codes, BCMs qualified to bill traditional Depression Treatment Among People With Diabetes diagnostic, evaluation, and therapy codes for Medicare Mellitus," Archives of General Psychiatry 64, no. 1 (2007): recipients are allowed to bill for those services in the same 65–72, doi:10.1001/archpsyc.64.1.65. month as billing G0512. Time spent on those additional activities may not be included in the time applied to G0512. 10.Rebecca C. Rossom et al., "Impact of a National In the FQHC and RHC setting, the BCMs bill and receive Collaborative Care Initiative for Patients with Depression the PPS/AIR rate for these services rather than the specific and Diabetes or Cardiovascular Disease," General Hospital codes. FQHCs and RHCs are paid based on a system that Psychiatry 44 (Jan.–Feb. 2017): 77–85, doi:10.1016/j. was historically tied to their costs. As a result, each center has genhosppsych.2016.05.006. its own rate for every qualifying visit. For FQHCs, this is the 11.Rossom et al., "Impact." Prospective Payment System (PPS) rate and for RCHs, the All Inclusive Rate (AIR). The median PPS/AIR rate in California 12.Henry Ireys et al., Evaluating the HCIA - Behavioral Health/ may be higher than the monthly CoCM reimbursement Substance Abuse Awards: Third Annual Report (PDF), for the G0512 code. For example, in Washington, FQHCs Mathematica Policy Research, January 23, 2017. delivering CoCM have not used the CoCM codes but instead 13.Sanjay Basu et al., "Behavioral Health Integration into have billed under their traditional PPS rate, which is much Primary Care: A Microsimulation of Financial Implications for higher than the G0512 reimbursement. Practices," Journal of General Internal Medicine 32 (2017): 1330–41, doi.org:10.1007/s11606-017-4177-9. California Health Care Foundation www.chcf.org 26 23.Dori A. Cross et al., "Use of Medicare's Behavioral Health Integration Service Codes in the First Two Years: An Observational Study," Journal of General Internal Medicine (published ahead of print, Dec. 16, 2019), doi:10.1007/ s11606-019-05579-2. 24.The author reviewed online Physician Fee Schedules for all 50 states and DC, looked for any Medicaid provider bulletins for states that had codes listed in the Physician Fee Schedule, and conducted two key informant interviews in Washington and New York, the states with the longest implementation experience. 25.New York's implementation predates the CoCM codes. As a result, New York uses a proprietary code (T2022) that is billed at $150 per month. However, there is a 25% quality and outcome withhold, resulting in more typical reimbursement of $112.50 per month. 26.Pamela B. Pietruszewski et al., "Effects of Staffing Choices on Collaborative Care for Depression at Primary Care Clinics in Minnesota," Psychiatric Services 66, no. 1 (October 1, 2014): 101–3, doi:10.1176/appi.ps.201300552. 27.These rates were found in the Physician Fee Schedule published online by the individual state Medicaid authorities. Rates presented are for fee-for-service billing, but managed care entities may pay higher negotiated rates for the CoCM codes than fee-for-service. 28.Medicare has differential rates by geographic region. 29.Montana has allowed FQHCs to use the 99492–4 codes, but reimburses them at a lower rate ($99/$90/$48). 30.Some practices use this code to help capture revenue for tasks and activities related to collaborative care that do not meet the requirements for billing the CoCM codes (e.g., when a patient is improving and does not need the full 60 minutes, or when the first contact is near the end of a calendar month). Medicare reimburses $48 for 99484, and the Medicaid rate as a percentage of the Medicare rate for this code is similar to the CoCM codes. 31.Mary K. Morreale et al., "Supporting the Education of Nurse Practitioners and Physician Assistants in Meeting Shortages in Mental Health Care," Academic Psychiatry 44 (2020): 377–79, doi:10.1007/s40596-020-01256-3. 32.Katherine Sanchez, "Collaborative Care in Real-World Settings: Barriers and Opportunities for Sustainability," Patient Preference and Adherence 11 (Jan. 5, 2017): 71-74, doi:10.2147/PPA.S120070. 33.Basu et al., "Behavioral Health Integration"; and Cory Page et al., Financing Behavioral Health Integration and Collaborative Care Models (PDF), Univ. of Michigan Behavioral Health Workforce Research Center, December 2019. 34.Andrew D. Carlo et al., "Financing for Collaborative Care - a Narrative Review," Current Treatment Options in Psychiatry 5 (2018): 334–44, doi:10.1007/s40501-018-0150-4. 35.Watkins et al., "Collaborative Care." Cracking the Codes: State Medicaid Approaches to Reimbursing Psychiatric Collaborative Care www.chcf.org 27