1. Disclosures
Successful completion of this continuing education activity includes the following:
Signing into the conference and providing your address
Attending the entire CE activity
Completing the evaluation
You will receive an ed copy of your certificate
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Institute for Medical Quality/California Medical Association (IMQ/CMA) through the joint providership of Cardea and the Washington Chapter of the American Academy of Pediatrics. Cardea is accredited by the IMQ/CMA to provide continuing medical education for physicians.
Cardea designates this live activity for a maximum of 5.5 AMA PRA Category 1 Credits™. Physicians should claim credit commensurate with the extent of their participation in the activity.

2. Disclosures Faculty: Lori Raney, MD and Liz Arjun, MSW, MPH
CME Committee: David Couch; Kathleen Clanon, MD; Johanna Rosenthal, MPH; Pat Blackburn, MPH; Richard Fischer, MD; Sharon Adler, MD.
Richard Fischer, MD is a member of an Organon speaker’s bureau.
Dr. Fischer does not participate in planning in which he has a conflict of interest, and he ensures that any content or speakers he suggests will be free of commercial bias.
None of the other planners and presenters of this CE activity have disclosed any conflict of interest including no relevant financial relationships with any commercial companies pertaining to this CE activity.
There is no commercial support for this presentation.

3. Disclosures
This conference was supported by: Amerigroup, Coordinated Care, Mary Bridge Children’s Hospital, Molina Healthcare, Seattle Children’s, Swedish Pediatrics, and United Healthcare Community Plan

4. Disclosures
Following completion of this session, learners should be able to:
Discuss the evidence base for the collaborative care model and variations in different populations.
List the key members of the collaborative care team and describe their specific roles and responsibilities.
Describe the cultural differences between primary care and behavioral health and how to address team dynamics.
Explain ways to make integrated care sustainable in the primary care setting.

5. Questions?
If you have any questions about this CE activity, contact Margaret Stahl at or (206)

6. PEDIATRIC INTEGRATED CARE
Lori Raney, MD
Principal
Denver, CO

7. Recipe for Success Ingredients TEMP
Team that consists at a minimum of a PCP, BHP and psychiatric consultant
Evidence-based behavioral and pharmacologic interventions
Measuring care continuously to reach defined targets
Population is tracked in registry, reviewed, used for quality improvement
Accountability for outcomes on individual and population level
Recipe for Success
Process of Care Tasks
2 or more contacts per month by BHP
Track with registry
Measure response to treatment and adjust
Caseload review with psychiatric consultant
LORI
Secret Sauce Whitebird Brand
Strong leadership support
A strong PCP champion and PCP buy-in
Well-defined and implemented BHP/Care manager role
An engaged psychiatric provider
Operating costs are not a barrier

8. Go Upstream: “Sweet” Spot in Primary Care
None
Mild
Target Population
Moderate
Severe
1:4 with mental health or SUD conditions
Issues with depression and substance abuse can be pre-empted, rather than progressing to diagnosis
Goal is to detect early and apply early interventions to prevent from getting more severe

9. Effective Integrated Care
Operationalizes the principles of the chronic care model to improve access to evidence based mental health treatments for primary care patients.
Collaborative Care is:
Team-based effective collaboration and Patient-centered
Evidence-based and practice-tested care
Measurement-based care, treat to target
Population-based care – registry, systematic screen
Accountable care
NARRATION
What makes Collaborative Care different from integrated care? One of the most important distinctions is that Collaborative Care is an evidence-based approach that emphasizes accountability for the care that is delivered. It utilizes a team approach to treat a population of patients. Some of the key components of Collaborative Care are the use of shared team workflow to establish a diagnosis and deliver treatment, the use of a registry to track patients in treatment over time, and the ability to be accountable as a team to these principles and population-level goals.
For the remainder of this training, we will focus on how to use Collaborative Care to deliver mental health care in primary care settings.

10. Collaborative Care Model
Effective
Collaboration
Informed,
Activated Patient and Family
PRACTICE SUPPORT
PCP supported by Behavioral Health
Care Manager
Psychiatric
Consultation
Measurement-guided
Treat to Target
Caseload-focused
Registry review
Training

12. Stepped Care Approach Psychiatric Consultation Van Korff et al 2000
Uses limited resources to their greatest effect on a population basis
Different people require different levels of care
Finding the right level of care often depends on monitoring outcomes
Increases effectiveness and lowers costs overall
Psychiatric
Inpatient tx
BH specialty long term tx
BH specialty
short term tx
Psychiatric consult
(Face-to-face)
1° Care + BHP
1o Care
Self- Management
Psychiatric
Consultation
Van Korff et al 2000

13. Child and Adolescent PHQ-A – Depression Vanderbilt – ADHD SCARED
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14. Measurement Based Treatment To Target

15. What makes a good BHP/CM?
FULFILLIING THE CARE MANAGER ROLE – IMPORTANT HIRE!
Typically MSW, LCSW, MA, LPN, RN
Variable clinical experience – leverage expertise in brief intervention skills
Who are the BHPs/CMs?
Organization
Persistence- tenacity
Creativity and flexibility
Enthusiasm for learning
Strong patient advocate
Willingness to be interrupted
Ability to work in a team
What makes a good BHP/CM?
Reminders about the role of the care manager

16. Tasks Facilitates patient/parent engagement
Performs systematic initial and follow-up assessments
Systematically tracks treatment response using registry
Supports treatment plan with PCP
Reviews challenging patients with the psychiatric consultant weekly
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17. Therapeutic Interventions
Anticipatory Guidance
Stress management
Relaxation/mindfulness
Emotional regulation
Behavioral modification
Cognitive behavioral techniques
Parent education
Prepare for therapy referral if needed

18. Anticipatory Guidance
Educating parents regarding normal social and emotional development
Training parents in basic behavior-modification principles; establishment of consistent expectations and structure, clear limit-setting, praise, and positive reinforcement
Teaching strategies to enhance parent-child relationships
Teaching strategies to improve family cohesion and address sibling conflicts
Coaching parents on bullying issues
Educating parents about the impacts of toxic stress and traumatic experiences
Helping parents become effective advocates for their children with regard to addressing special education needs
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19. cash flow in FFS VS. a value-based environment
Fee-for-Service World
Value-Based Payment World
Provider performs a service and receives payment for it in a quantifiable period of time (30 – 90 days)
Provider performs a service and may receive a FFS payment for some portion of the service
Reimbursement is certain if billing requirements are met
Payments based on contract performance (managing total cost of care and quality measures) are received after the measurement period, and cannot be quantified at the time service is rendered
Steady cash flow throughout the year
Traditionally no payment for care coordination, integration, quality
Some payments may be PMPM
Uncertain cash flow with delays from time service delivered
Providers/systems rewarded for quality and metrics that integrated care addresses
Alignment of incentives around achieving better outcomes
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20. FOCUS OF THE PRESENTATION
Today we are going to focus primarily on billing in the fee-for-service world:
Which staff and/or services you can bill for, and which payers pay for those services
Documentation needed to receive timely payment
Types of encounters
HOWEVER, as the landscape in states and nationwide continues to move toward APMs/value- based payments, we will also look at:
Revenue opportunities through achieving excellent outcomes on quality metrics including P4P, Value Based Payment contracts
Demonstrated savings in Total Cost of Care for patients with co-morbid medical and BH conditions
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21. WHAT CAN YOU BILL NOW in FFS? TRADITIONAL THERAPY
Diagnostic Evaluations – (90792 if psychiatric provider sees patient)
Brief therapy
90832 (30 minutes)
90834 (45 minutes)
Family therapy?
Couples therapy?
Must be able to meet documentation requirements/compliance standards
Chronic care management codes (CCM)
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22. FEE FOR SERVICE: WHAT DO WE HAVE TROUBLE BILLING FOR?
Brief interventions
Stress/no diagnosis
Huddles
Hallway conversations/consultations
Warm hand-offs
Curbside consultations with psychiatric consultants
Phone calls to patients
Repeating rating scales
Interdisciplinary team meetings
Registry management
**Payment approaches are necessary for these services that do not work in a typical FFS environment. “What works can‘t be coded.”

23. NEW MEDICARE CODES FOR CoCM REQUIRE ATTENTION TO DETAIL
99492 (Initial month, CoCM) - $143
99493 (Subsequent month, CoCM) - $126 Billed once a month by the PCP
99494 (Add’l 30 mins, CoCM) - $66
99484 – other models of BHI - $48
Codes cover:
Outreach and engagement by BH Provider or Care Manager
Initial assessment of the patient, including administration of validated rating scales
Entering patient data in a registry and tracking patient follow-up and progress
Participation in weekly caseload review with the psychiatric consultant
Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.
GCCC2 – proposed new code for FQHCs $135/month starting January 1, 2017
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24. BILLING CODES FOR CoCM – 1st MONTH HCPCS Long Descriptor Code
HCPCS
Code
Long Descriptor
 99492
Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:
outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional;
initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan;
review by the psychiatric consultant with modifications of the plan if recommended;
entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and
provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.
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25. BILLING CODES FOR CoCM – SUBSEQUENT MONTHS
HCPCS
Code
Long Descriptor
 99493
Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:
tracking patient follow-up and progress using the registry, with appropriate documentation;
participation in weekly caseload consultation with the psychiatric consultant;
ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers;
additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant;
provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies;
monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.
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26. HCPCS Long Descriptor Code BILLING CODES FOR CoCM – EXTRA TIME
HCPCS
Code
Long Descriptor
99494
Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure). (Use G0504 in conjunction with G0502, G0503).
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27. Time Stamping – per Month
Minutes spent talking to patient (in person or phone)
Minutes spent talking to the PCP
Minutes spent talking to the psychiatric consultant
Minutes spent coordinating care
Minutes spent documenting anything or scoring
Minutes spent reviewing charts/documentation
Minutes spent talking to referral source
ETC! Get it all.
After break of 15 minutes (between 60 and 75 minutes) start the clock for G0507 (30 minutes) and again and again if needed

28. CoCM BILLING MUST HAVES
These codes are billed by the medical provider (primary care provider) once a month
Needs an initiating visit – new patients unless seen in the past year
Must have weekly caseload reviews with a psychiatric consultant
Broad consent obtained
Co-pays apply
Must be able to show time spent – how to time stamp your work?
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For a helpful reference, see:

29. INITIATING VISIT, CONSENT AND CO-PAYMENTS
CMS expects an Initiating Visit prior to billing for the codes.
This visit is required for:
New patients, and
Those who have not been seen within a year of commencement of integrated behavioral health services.
This visit will include:
The treating provider establishing a relationship with the patient,
Assessing the patient prior to referral, and
Obtaining broad beneficiary consent to consult with specialists that can be verbally obtained but must be documented in the medical record.
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30. CARE MANAGER QUALIFICATIONS
CMS states that the behavioral health care manager:
Must have formal education or specialized training in behavioral health
This could include a range of disciplines including social work, nursing, and psychology
Do NOT need to be licensed to bill traditional psychotherapy codes for Medicare
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31. PROVISION OF ADDITIONAL THERAPY SERVICES
Behavioral health care managers (BHCM) qualified to bill traditional psychiatric evaluation and therapy codes for Medicare recipients MAY bill for additional psychiatric services in the same month.
However, time spent by the BHCM on activities for services reported separately may NOT be included in the services reported using time applied to G0502, G0503, and G0504.
In other words, the BHCM can furnish psychotherapy services in addition to collaborative care activities, but may not bill for the same time using multiple codes.
The psychiatric consultant may also furnish face-to-face services directly to the patient but, like the BHCM, the time may not be billed using multiple codes.
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32. PAYMENT FOR OTHER MODELS OF INTEGRATED BEHAVIORAL HEALTH SERVICES
Beginning in 2017, CMS will provide a separate payment for integrated behavioral health services that are delivered under other delivery models, such as the behavioral health consultation model or primary care behavioral health model:
G0507 – 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.
G0507 can only be reported by a treating provider and cannot be independently billed. For G0507, a behavioral health care manager with formal or specialized education is not required. CMS rules allow “clinical staff” to provide G0507 services using the same definition of “clinical staff” as applied under the Chronic Care Management benefit.
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33. How Staff spend their Time Patient Needs, Practice Needs
BRING THE PIECES TOGETHER: BUILD A FINANCIAL MODEL THAT MAKES SENSE FOR YOUR PRACTICE AND NEEDS
Which Staff on the Team
Licensure
Salary
Potential for Visit Revenue in addition to CoCM
How Staff spend their Time
% of time billable
% of time for brief interventions (determines case load)
% of time for registry management, consultations
Patient Needs, Practice Needs
Number of patients who may need CoCM care management
Segmentation of patient needs –where to start
% of patient on the registry that will need 60 minutes per month
Quality metrics related to BH integration
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For additional information, see:

35. Resources for PCPs
Great Resource:
Screening Tools
Brief Interventions
Self-help materials
Parent resources too
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36. Useful Handouts: Need AAP member login.
Resources for PCPs
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Useful Handouts: Need AAP member login.

37. Lori raney, MD Principal
CONTACT ME
Lori raney, MD Principal
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