Care Model Eligibility – CMS Psychiatric Collaborative Care Model (CoCM)

Patients with a mental, behavioral health, or psychiatric condition being treated by the billing practitioner, including substance use disorders, that, in the clinical judgment of the billing practitioner, warrants BHI services.

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Patient Segment Eligibility Description Data Source
Patients with mental, behavioral health, or psychiatric condition Any patient with a mental, behavioral health, or psychiatric condition being treated by the billing practitioner, including substance use disorders, that, in the clinical judgment of the billing practitioner, warrants BHI services.

The diagnosis or diagnoses could be either pre-existing or made by the billing practitioner and may be refined over time.

 Predictive model, similar to chronic conditions warehouse (CCW), that uses claims data to predict which patients are eligible for CoCM because of a mental, behavioral health, or psychiatric condition*

*This predictive model will not be able to pick up on substance abuse disorders

Care Model Implementation – CMS Psychiatric Collaborative Care Model (CoCM)

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Time Frame Action
Trigger event Beneficiary diagnosed with any mental, behavioral health, or psychiatric condition, including substance use disorders, that, in the clinical judgment of the billing practitioner, warrants Behavioral Health Integration (BHI) services.
Within 30 days of trigger event (flexible) For beneficiaries not seen within one year prior to commencement of BHI services, treating (billing) practitioner conducts “initiating visit.” This visit ensures the practitioneFor beneficiaries who have already had a visit with their treating (billing) practitioner, the practitioner prescribes BHI services.

r assesses the beneficiary prior to initiating BHI services.
First month of treatment within 30 days of BHI recommendation for beneficiary (flexible) Each member of the care team contributes to carrying out BHI service:

  1. Treating (billing) practitioner (typically a PCP or NP but may also be a specialist):
    • Coordinates with behavioral health care manager and psychiatric consultant
  1. Behavioral Health Care Manager (social worker, nurse or psychologist trained in behavioral health): 70 minutes of time in first month
    • Provides assessment and care management services, including the administration of 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; provision of brief psychosocial interventions; ongoing collaboration with the billing practitioner; maintenance of the registry; all in consultation with the psychiatric consultant.
    • Available to provide services face-to-face with the beneficiary; has a continuous relationship with the beneficiary and a collaborative, integrated relationship with the rest of the care team.
    • Able to engage the beneficiary outside of regular clinic hours as necessary to perform the behavioral health care manager’s duties.
  1. Psychiatric Consultant (psychiatrist)
    • Participates in regular review of clinical status of patients receiving BHI services.
    • Advises the billing practitioner (and behavioral health care manager) regarding diagnosis; indicates options for resolving issues with beneficiary adherence and tolerance of behavioral health treatment; makes adjustments to behavioral health treatment for beneficiaries who are not progressing; manages any negative interactions between beneficiaries’ behavioral health and medical treatments. May be remotely located; is generally not expected to have direct contact with the beneficiary, nor prescribe medications or furnish other treatment to the beneficiary directly.
    • Facilitates referral for direct provision of psychiatric care when clinically indicated.
Monthly treatment thereafter The primary care team (billing practitioner and behavioral health care manager) review at least weekly the beneficiary’s treatment plan and status with the psychiatric consultant and maintain or adjust treatment, including referral to behavioral health specialty care, as needed

Behavioral Health Care Manager: Minimum of 60 minutes of time per month; may add up to 30 additional minutes for each month

Care Model Implementation – CMS Psychiatric Collaborative Care Model (CoCM)

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Intervention Intervention Description Data Source
Furnish CCM Service The CCM service includes structured recording of patient health information, an electronic care plan addressing all health issues, access to care management services, managing care transitions, and coordinating and sharing patient information with practitioners and providers outside the practice.

See detailed information on these services on the previous slide for Care Model: Chronic Care Management – Implementation.

 Claims:

Procedure HCPCS codes to identify CCM billing*

*CCM cannot be billed during the same service period as Transitional Care Management (TCM)