Collaborative Care Billing Question
Anyone out there doing Collaborative Care in Illinois and/or other states where Medicaid is NOT yet reimbursing the CoCM codes?
We're in Illinois, and although the IL Collaborative Care bill was signed into law 1/1/2020 ( mandating all payers, including Medicaid) cover the CoCM codes, we have not yet seen that happen. We're told the CoCM codes are not on the IL Medicaid fee schedule, so therefore not billable.
AIMS Center has advised us we can, alternatively, bill psychotherapy codes for the time/work done by the care manager( since the CoCM codes were reimbursed for Medicaid patients.) Are LCPCs permitted to bill psychotherapy codes to Medicaid in Illinois? We've been told this was a no.
Appreciate any input!
Well, that is not good news. We are getting ready to launch the use of the CoCM codes. I think we need to talk to someone about getting these codes added to the Il Medicaid fee schedule. Do you happen to have Governor Pritzker’s direct lineJ LCPC’s cannot bill Medicaid unless there is a contract, e.g., Molina, Illinicare and Meridian.
Seriously, I wonder how we can expedite the implementation of this law. I believe I will be calling some of our representatives.
Thanks for the information.
Unfortunately what was passed in Illinois was the American Psychiatric Associations model law which had a good goal, but as we are seeing has a number of deficits:
1. It only included 3 of the 4 collaborative care codes that cover consultation with a psychiatrist. IT specifically did not include the 4th code where a PCP could be reimbursed for consulting with a non-psychiatrist mental Health professional.
2. It did not address the issue of dual co-payments by patients when seen by health and mental health in the same setting.
3. It did not address the obstacles that some mental health providers (psychologists, counselors, social workers) run into when billing in a primary care office.
A thorough bill that was truly patient focused, rather than guild focused, would have included what is needed for psychiatry services to get paid but also included all of the other mental health professions.
Knowing how legislatures work, since this went through last year in Illinois, it will be years before you can take another shot at getting a new bill.
In a way CoCM gets around the issues below (2&3) since it entails team-based billing by the cumulative minute/month all under the PCP’s NPI. So there is no BH copay or psychiatry consult bill per patient. Psychiatrists and therapists working the model would be paid a flat rate per hour (maybe salary for therapist) or RVUs towards their productivity totals. The practice would need to attribute revenue appropriately since the majority would not be from PCP services and I’d encourage the PCP to continue using their E&Ms to keep it all straight. For #1, NC did the same thing and did not include the 4th code. My guess is that they were nervous about runaway care management costs from agencies not running CoCM and who are using the code for filling casework gaps that are not typically reimbursed in another way. With that said, the fourth code is valuable when a referral that does not cleanly fit the model needs triage. Each time we use the 4th code for Medicare it MAY represent an opportunity for educating the team on appropriate CoCM referrals.
The 4th code (99484) is used when the consultant is not a psychiatrist, psychiatric NP or Psychiatric PA - so the first three codes specify a prescribing consultant - and thus tip the scales toward medication as first line treatment.
Coming from a pediatric background, where disruptive behaviors such as oppositional defiant disorder and/or ADHD are the most common referrals, I think this poses a problem since behavioral parent training is the first line treatment for children under age 6 and is one of two first line treatments for children 6-12. (The American Academy of Pediatrics treatment guidelines for ADHD) So the appropriate consultant for the majority of cases (and nearly all cases of a child under 6 years) would be someone who is skilled in that particular intervention, not a prescriber. So this payment model tilts services for children away from effective first line interventions supported by AAP and towards medication. I am not opposed to medication, I am, however, fully supportive of first line interventions being used first, and for children CoCM does not support that.
It’s curious that there are concerns about “runaway management costs” from those not running the CoCM - when the Institute for Clinical & Economic Review of programs in 2015 clearly shows that CoCM is the most expensive integrated care option,
These codes were originally written in Medicare as Part B services, so they do have a 20% co-pay attached. My colleagues at one major commercial insurer has emphasized that to me, saying that cannot be changed.
These codes are odd, to say the least. In Medicare they require a co pay like a fee for a service, but they are care management codes requiring documentation of time spent.
Good legislation would pay for consultation by psychiatry, psychology, social work and counselors, and care management, eliminate dual co pays. Allowing all mental health professionals to work in the consultant role allows the PCP to consult with the most appropriate professional for the situation.
I would like to address Doug’s assertion that it is not appropriate for a psychiatrist to provide a consultation via CoCM for ADHD evaluations. Psychiatrists, especially child psychiatrists, are experts in the evaluation and diagnosis of ADHD. They are also savvy enough to make appropriate recommendations for or against medications vs behavioral treatment. ADHD is no different than depression or anxiety in that there are roles for environmental supports as well. While behavioral interventions are the first line treatment for children under age 6, medications are the first line intervention for ages 6+ (per American Academy of Child and Adolescent Psychiatry practice parameters). There are more than 30 studies, including seminal works such as MTA and PATS to support the use of medication in ADHD. PATS defines the role of medications (when indicated) for children under 6 years. Let’s use this forum to advance the field and decrease pop culture stigma.
I did not refer to any specific profession, I was discussing pharmacological versus non-pharmacological interventions, particularly in the preschool age group.
But lets start with guidelines since that has been brought up, in the CoCM model it is the primary care clinician in charge of the case, the rest of us are consultants, then they should be following the practice guidelines of their discipline or specialty. The AAP guidelines (which have been adopted verbatim by AAFP) are clear that parent training is first line for all children preschool through school age, and that stimulants are an alternative first line treatment for school age children. This is based on research done in the past ten years. With all due respect AACAP needs not to impose their older, perhaps outdated guidelines on the primary care clinicians. Pediatricians and family practice physicians follow their guidelines not those of AACAP.
Dr Chairelli brings up the Preschool ADHD Treatment Study (PATS) an very detailed set of studies done primarily by the same group that did the Multimodal ADHD. Treatment study (MTA) in the late 90’s. This team was led by Dr. Larry Greenhill, a very thoughtful and thorough psychiatrist and researcher.
It is a complex study, and as most complex studies its a Rorschach test, people see what they want to see.
So lets look at the actual results published between 2006 and 2015 on these children,. First they started with 303 very, very hyperactive kids - not borderline, we are talking children who are 1.5 to 2.0 standard deviations the top 5% to top 1% , not the usual case seen in primary care. All were enrolled in a 10 week behavior therapy (unfortunately not designed for this age group - even though Those programs were available) and after 10 weeks 120 children no longer met criteria for the study, so 40% of these very hyperactive children got better without medicine.
183 started a titration trial, a washout period, a second titration trial, and then a placebo vs treatment and then an open maintenance trial, at that point 95 were left in the study., so only 31% found medication treatment tolerable and effective. It is reported that 30% of these 95, approximately 28, had moderate to severe adverse events mostly sleep and appetite disruption. MT Stein reported in a separate paper that of these 95, 20% had lower height over time and 55% lower weight. So side effects are real and significant in this age group.
Of the 95 who persevered in the last part of the medication trial 21%, or 19 children of the original 303 who continued on a stimulant reached remission. Curiously, 13% in the final placebo group (12 children) ALSO reached remission of symptoms.
So from the original 303, all of 19 reached remission. This is touted by some as a success. Keep in mind, however, that of the 303, there were 120 who got better with behavior therapy.
120 vs 19 - please tell me which is more effective.
Last, just to push further, Mark Riddle published the 6 year follow up on the kids treated with medication. At that point in time. 89% still met criteria for ADHD, and Dr. Riddle suggested we need to work on other treatment options, that using these medications with this group is not effective.
Having spent 12 years collocated in a private pediatric office, followed by another 12 years helping to develop integration in the Nemours system, and I am very familiar with the exemplary work done by Joe Evans in Nebraska, and all of this was started by Carolyn Schroeder in Chapel Hill Peds in the 1970’s. All of us have emphasized prevention, early intervention, helping parents with their skills, consultation with schools, and consultation with psychiatry as needed. But the bulk of the day to day work in primary care pediatrics does need a psychiatric overseer.
What should be funded in pediatrics is a system that pays for services for all licensed mental health professionals and maternal/child nursing staff to achieve the prevention, early intervention and treatment goals. To only fund psychiatry consultation is paying attention to the very top of the iceberg and ignoring everyone else.
I seem to have killed the thread with my lengthy response, but for those who don't know me, I did run an ADHD specialty program at two major children's hospitals, was a senior consultant on mental health for Head Start at HHS (2003-2006) and was on the faculty of GWU Psychiatry Dept for 12 years and as the psychology internship director at Children's National Medical Center worked very closely with the child psychiatry fellowship directors, so I know very well how our professions are trained, and we all have strengths and weaknesses. In my opinion both child psychiatrists and psychologist need more education in basic child development - we are way too pathology oriented.
From my read of the research literature and the conclusions of a a number of senior child psychiatrists who I greatly respect, my conclusion is that for ADHD symptoms in preschoolers, first basic parent training, if that is not sufficient then more intensive Parent Child Interaction Therapy - they have a national directory with a large number of therapists nationally. I also recommend referral to the state IDEA Part C child find birth to three program, or the Part B IDEA for children over 4, for an evaluation. many of the children who have these severe problems also have language delay which is not always apparent. These children are entitled to services under the IDEA.
I see medication for this group as a last option, after you have exhausted therapy, a therapeutic Head Start or preschool placement. Yes there is some positive outcome, but the medicines have a high rate of side effects, and as already cited, no long term benefit. Exhaust the other options first.
99484 - Payment for Other Models of Integrated Behavioral Health Services
Care management services for behavioral health conditions, at least 20 minutes of clinical staff time per calendar month. Must include:
Initial assessment or follow-up monitoring, including use of applicable validated rating scales;
Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes;
Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and
Continuity of care with a designated member of the care team.
99484 can only be reported by a treating provider and cannot be independently billed. For 99484, a behavioral health care manager with formal or specialized education is not required. CMS rules allow “clinical staff” to provide 99484 services using the same definition of “clinical staff” as applied under the Chronic Care Management benefit.
Thanks Lori! Very helpful.
...99484 is a useful code for PCBH model clinicians.
...appropriate use of it by PCBH practitioners may help to “raise up” PCBH work.
... PCBH work lacks visibility in the healthcare system because it lacks specific codes to “flag” it is happening.
In actual practice/implementation the PCBH footprint is substantial despite our low-visibility at the system-level.
IMHO this says something about what we do as PCBH clinicians...
We need opportunities to highlight PCBH work at the system-level... we could use some PCBH codes!
I wanted to highlight two other things
1. Primary care clinicians will bill EM for their services. They will likely not bill 99484 except if it were in support of the work of their care team members doing the work.
2. It does not seem like this code is only intended for “one time or so” use given this statement cut from the below guidelines.
Continuity of care with a designated member of the care team.
Am I reading the idea of continuity wrong?
All the best,
Does anyone know what the patient is actually billed for on a 99484 if it is a covered service? Is it an office co-pay or co-insurance? I recognize each plan will be slightly different, but just want to gather an idea of what you've seen.
We take both medicare and all commercial insurance and are planning to start billing, but I want to ensure we are getting consent from the patient on what exactly they could be responsible for. Thank you!
I'm the Medical Director of BH at PacificSource, a medium sized non-profit health plan in the Northwest. We've been able to eliminate co-pays for all CoCM codes across all lines of business (Medicare Advantage, Commercial, Medicaid).
Dr. Franz- Woah, how did you do that? Via contracting? This would go a long ways toward improving access, workflows, and patient satisfaction. Teach us your ways!
I made it a priority within our leadership -- explaining that CoCM really doesn't work if there is cost-share since members will not opt into something where they could be getting multiple bills for same day primary care visits. Then I asked our operational folks to make it so. The ROI based on an overwhelming literature base makes this a no-brainer from the health plan perspective.