6. The Evolving Coding and Billing Landscape for Providers
The Evolving Coding and Billing Landscape for Reimbursement of Interprofessional Collaboration
As highlighted in the 2022 policy paper “Beyond the Referral: Principles of Effective, Ongoing Primary and Specialty Care Collaboration” by the American College of Physicians, current payment structures insufficiently account for the time required for crucial tasks essential to meaningful interprofessional collaboration.
These tasks include activities such as:
- Generating summaries to facilitate successful referrals
- Jointly formulating intervention plans with providers from diverse care domains
- Engaging in consultations with cross-sector professionals to optimize treatment and reduce reliance on specialist referrals whenever feasible
- Sustaining ongoing information exchange with fellow care providers to facilitate effective co-management
In essence, the prevailing payment frameworks underestimate the value of non-face-to-face activities integral to quality care and do not adequately incentivize collaborative efforts that transcend the confines of traditional office visits.
To establish a model that truly embraces and promotes collaboration across child-serving sectors, a reimagining of payment and incentive structures becomes imperative. Ultimately, value-based reimbursement frameworks, including pay-for-performance initiatives and notably, capitation-based models, may emerge as viable avenues to stimulate enhanced collaboration between pediatrics and behavioral health, whether the behavioral health services are provided by a clinician working in the community or in a school-based health center.
In the meantime, however, there are interim fee-for-service solutions that have already been activated in other states and can be pursued in Connecticut:
Interprofessional Collaboration Fee-for-Service Billing Codes to Pursue in Connecticut
Interprofessional Telephone/Internet/Electronic Health Records Consultations (eConsults)
These CPT® codes are reported by the consultant when their specific specialty expertise is requested by a patient’s treating/requesting provider:
- 99446: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional,* including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
- 99447: 11-20 minutes of medical consultative discussion and review
- 99448: 21-30 minutes of medical consultative discussion and review
- 99449: 31 minutes or more of medical and consultative discussion and review
- 99451: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional,* including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time
*The wording “or other qualified health care professional” was added to these codes effective January 1, 2023. This language clarifies that behavioral health providers, such as psychologists, who provide assessment and management services conducted through telephone, internet, or electronic health record consultations furnished when their opinion and/or treatment advice is requested to assist with the diagnosis and/or management of the patient’s condition, are eligible to use these codes (provided the codes are active in the state in which the service is conducted). These services do not require the patient to have face-to-face contact with the consulting physician or qualified healthcare professional.
General Behavioral Health Integration Care Management: CPT® Code 99484
This code covers care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
- Initial assessment of follow-up monitoring, including the 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
- Continuity of care with a designated member of the care team
General Behavioral Health Integration Services furnished by Clinical Psychologists and Clinical Social Workers: HCPCS G0323
This new Healthcare Common Procedure Coding System (HCPCS) code initiated by CMS in the CY2023 Physician Fee Schedule Final Rule describes coding and payment for instances when Clinical Psychologists or Clinical Social Workers perform General Behavioral Health Integration Services.
The code is analogous to CPT® code 99484, but instead of the medical provider, the clinical psychologist/social worker is the “treating/billing” provider deciding that care management/care coordination services are needed and with patient consent can do this work themselves.
Clinical psychologists are additionally authorized to furnish and bill for services that are provided by clinical staff incident to their professional services when the “incident to” requirements specified in § 410.26 are met.
20+ minutes of care coordination services can be billed per patient per month.