Behavioral health services

Medicare pays for behavioral health services that may improve outcomes for Medicare patients. They include:

• Behavioral health integration (BHI) services
• Psychotherapy for crisis
• Opioid use disorder (OUD) screening and treatment

BHI services 

BHI is a model of care incorporating behavioral health care into other care, like primary care, to improve mental, behavioral, or psychiatric health for many patients. These BHI services may be particularly helpful for patients who aren’t improving under other models of care.

In addition to payment for evaluation and management (E/M) services, Medicare covers two types of BHI services: 

• Psychiatric Collaborative Care Model (CoCM):
  • A team of three individuals delivers CoCM:
    • Behavioral health care manager
    • Psychiatric consultant
    • Treating (billing) practitioner
  • This model enhances primary care by adding two key services to the primary care team:
    • Care management support for patients getting behavioral health treatment
    • Regular psychiatric inter-specialty consultation
  • To bill for psychiatric CoCM services use CPT codes 99492, 99493, 99494 and HCPCS code G2214. Payment is for services supplied over a calendar month.
• General BHI services using models of care other than CoCM:
  • To bill, use CPT code 99484 and HCPCS code G0323 to account for monthly care integration.
  • General BHI includes service elements like:
    • Systemic assessment and monitoring
    • Care plan revision for patients whose condition isn’t improving adequately
    • Continuous relationship with an appointed care team member

BHI procedure code reporting

References

• CMS MLN fact sheet: Behavioral health integration services
• Frequently asked questions about billing Medicare for BHI services 

Psychotherapy for crisis 

Psychotherapy for crisis services is appropriate for patients in high distress with life-threatening, complex problems requiring immediate attention. These services can help reduce a patient’s mental health crisis (including substance use disorder [SUD]) through: 

• Urgent assessment and history of a crisis state
• Mental status exam
• Disposition (or what happens next for the patient) 

Physicians and non-physician practitioners whose scope of covered Medicare services includes diagnosis and treatment of mental illnesses can offer these services. This includes clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, physician assistants, and certified nurse midwives. Medicare pays for these services under the Physician Fee Schedule. 

CMS issued the CY 2024 Physician Fee Schedule (PFS) proposed rule announcing proposed policy changes for Medicare payments under the PFS and other Medicare Part B payment policy issues. This rule includes increased payment for psychotherapy for crisis equal to 150% of the fee schedule amount for services furnished in non-facility sites of service, other than a physician or practitioner’s office. This information is outlined in the Consolidated Appropriations Act (CAA), 2023 and is effective January 1, 2024. 

Psychotherapy for crisis procedure code reporting

Note:  Psychotherapy for crisis codes cannot be reported with 90791, 90792, 90785-90899 and 90832-90838.

References

• CMS MLN fact sheet - Medicare mental health booklet
• Psychotherapy for crisis
• LCD L33252 - Psychiatric diagnostic evaluation and psychotherapy services
• LCA A57520 - Billing and coding: psychiatric diagnostic evaluation and psychotherapy services

Opioid use disorder (OUD) screening and treatment

Medicare pays OUD screenings performed by physicians and non-physician practitioners. These services include:

• Screening for OUD is a required element of Medicare’s initial preventive physical exam (HCPCS G0402) and annual wellness visits (HCPCS G0438 and G0439).
• During visits in physicians’ offices and outpatient hospital settings:
  • Medicare will pay for screening, brief intervention and referral to treatment (SBIRT):   
    • SBIRT is an evidence-based, early intervention approach for people with non-dependent substance use before they need more specialized treatment. 

SBIRT procedure code reporting

Evaluation and management (E/M) visits

If a patient is diagnosed with OUD, Medicare pays for certain treatment services, including:

• E/M visits for medication management:
  • Use CPT codes 99202-99499 to represent visits and services involving evaluating and managing patient health.
  • Use E/M visits to provide medication management to ensure patients take medications (like buprenorphine) properly as part of their recovery process:
    • E/M service must be reasonable and necessary and meet the E/M criteria.
• Office-based SUD treatment services offer a way to bill for a group of services for the treatment of SUDs in the office setting.
  • Office-based SUD treatment services include:
    • Overall management
    • Care coordination
    • Individual and group psychotherapy
    • Substance use counseling
    • Add-on code for additional counseling
  • Medicare pays for a monthly bundle of services (for patient prescribed buprenorphine or naltrexone in the office setting) for the treatment of OUD or other SUDs.

Office-based OUD treatment procedure code reporting

Reference

• CMS MLN fact sheet: SBIRT services 

Opioid treatment program (OTP)

OTPs provide medications for opioid use disorder (MOUD), including methadone, buprenorphine, and naltrexone, as well as a range of other services including individual and group therapy, substance use counseling, and toxicology testing, for patients diagnosed with OUD. 

Payments are made to the OTP through a bundled payment for OUD treatment services. Under the OTP benefit Medicare covers:

• U.S. FDA-approved opioid agonist and antagonist medication assisted treatment (MAT) medications
• Dispensing and administering MAT medications, if applicable
• Substance use counseling
• Individual and group therapy
• Toxicology testing
• Intake activities
• Periodic assessments

OTP procedure code reporting - MAT 

OTP procedure code reporting - non-drug bundle

OTP procedure code reporting - add-on codes

Intensive outpatient program (IOP) services

References

• CMS MLN fact sheet: SBIRT services
• Opioid use disorder screening and treatment
• Provider specialty: Opioid treatment program (OTP)
• CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 17, section 20 C.
• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 39, section 30.2