Sustaining the Collaborative Care Model (CoCM): Billing Newly Available CoCM CPT Codes in an Academic Primary Care System

The collaborative care model (CoCM) is an evidence-based and cost-effective strategy for treating common behavioral health (BH) problems in primary care. CoCM emphasizes key population health principles and hinges on systematic teamwork between the primary care provider (PCP), a designated psychiatric consultant (DPC), and a behavioral health care manager (BHCM). With its efficacy first demonstrated over 15 years ago, CoCM is now validated by more than 80 RCTs across diverse populations and for numerous BH and comorbid medical conditions.

Despite its strong evidence base, critics and proponents have raised questions about the financial sustainability of CoCM. With limited opportunities to capture revenue for services outside of face-to-face visits, implementing organizations have often had trouble financially supporting the model. That changed in 2017, when the Centers for Medicare and Medicaid Services (CMS) announced three new “incident-to” billing codes (i.e., codes reimbursing for non-physician services rendered after an initial physician visit)¹, offering an unprecedented, large-scale opportunity for funding CoCM².

In 2018, the CoCM codes were formally integrated into the Current Procedural Terminology (CPT) code set as 99492, 99493 and 99494¹. Since then, they have been adopted by many commercial payers and a growing number of Medicaid programs³. The codes are designed to reimburse “billing practitioners” (typically the PCP) for the cumulative time the team spends delivering CoCM each calendar month, up to 130 minutes during the initial month and 120 minutes in subsequent months¹, and are available for use in both traditional and some alternate payment model contexts (e.g., Comprehensive Primary Care Plus (CPC+) and Medicare Accountable Care Organizations (ACOs)). The ability to represent all treatment activities gives CoCM codes a formidable advantage over other CoCM billing strategies, including codes for psychotherapy (e.g. CPT 90832) and physician telehealth services (CPT 99441–99443).

Given this, policy leaders predicted extensive interest in the CoCM codes. At the same time, they anticipated slow uptake, similar to CMS’ previously activated Chronic Care Management (CCM) codes⁴, as both models require considerable billing workflow adjustments. Although a recent study confirms the projected sluggish rate of CoCM code uptake⁵, emerging data on early adopters⁶ demonstrates the potential for success. Additionally, freely available information online and published articles provide a blueprint for implementing CoCM billing^2,7,8.

This viewpoint offers a case study in addressing CoCM code-specific challenges based on the initial experiences of the University of Washington Neighborhood Clinics (UWNC), an academically affiliated primary care clinic system in Seattle and the largely urbanized Western Washington region. Of note, the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington (UW), which assists health systems state- and nationwide with CoCM implementation (including billing), did not directly orchestrate billing initiation in the UWNC, though both entities are based at UW. Only freely available resources like the AIMS Center website, billing toolkit⁸ and public office hours were accessed.

One specific CoCM code-related difficulty arises from the potentially cumbersome requirement that teams track all CoCM-specific minutes for each enrolled patient throughout the calendar month. As a solution, UW leverages its electronic medical record (EMR) to track minutes and alert clinicians when billing time thresholds are reached. This has proven to be an effective and efficient system that fits into clinicians’ documentation workflows. In smaller systems where such EMR changes may be cost-prohibitive, a simpler approach using spreadsheets can be equally as effective. Importantly, according to a recent study, the inability to leverage EMR services for time accrual is not an insurmountable barrier to billing the CoCM codes⁶.

Another code-specific challenge is CMS’ stipulation that monthly CoCM minute totals are exclusively based on accrued BHCM time, with the value of other team members’ collective efforts accounted for in one monthly payment. To reflect this, the BHCM continuously tracks all minutes spent coordinating with other team members and incorporates these into monthly totals. When appropriate, UWNC PCPs and DPCs also provide direct patient visits, which are billed separately with traditional fee-for-service codes. The BHCM may also bill fee-for-service for direct care and CoCM codes for indirect care. In one UWNC pilot clinic using this model, the BHCM billed over 160 hours of exclusively indirect services within the first six months of CoCM code billing.

An additional barrier to using CoCM codes is the specific “incident-to” requirement that the billing practitioner (often the PCP) must acquire and document patients’ verbal consent to participate in the program, even though they do not directly render the majority of the clinical service. This consent discussion must include mention of possible cost-sharing and occur prior to the delivery of CoCM services. PCPs may find this task challenging, as it is potentially time-consuming and involves talking about payment.

In order to mitigate the impact of these consent-related challenges, UWNC developed a set of resources to simplify the process, including a consent script (a “pitch” to obtain consent and provide answers to frequently asked questions), EMR documentation shortcuts, patient-friendly handouts (including instructions to help patients contact their insurance company for a cost estimate), a table of CoCM CPT codes, and alternative workflows for obtaining consent after the visit (e.g., via telephone or patient portal). In the UWNC system, all consented patients receive a brief, unbilled telephone orientation with the BHCM to help answer any further questions about CoCM or its associated billing practices.

Although the involvement of a DPC is required to provide effective CoCM services and bill its associated codes, some organizations may find it challenging to secure such support in the context of funding and workforce shortages. The UWNC system optimizes limited DPC time through weekly one-hour case reviews with the BHCMs. When indicated, the DPC may also individually see CoCM-enrolled patients in person or via tele-video. This model carries less financial risk than hiring a full-time psychiatrist and also allows for the use of a remote DPC, which is especially advantageous in rural areas⁹.

For the aforementioned and other reasons, the CoCM CPT codes and their associated workflows necessitate a comprehensive implementation strategy. The UWNC system tasked an interdepartmental, interdisciplinary project team with understanding the coding nuances and tailoring plans to each individual clinic. This team, which included a population health program manager, the UWNC social work manager, and the CoCM Medical Director, provided training and oversight of the billing program before, during, and after the initial implementation phase. While this team increased the program’s cost, it was instrumental to have dedicated staff focused on training providers, identifying PCP champions, troubleshooting, tracking code utilization, and ensuring workflow maintenance. To effectively address known and unexpected challenges, other large healthcare systems aiming to adopt the CoCM codes should consider dedicating a project team or manager to implementation oversight.

In the UWNC system, the aforementioned strategies helped facilitate the launch and ongoing use of CoCM billing codes. However, the codes remain imperfect and a variety of modifications have been proposed to facilitate broader uptake, particularly in lower resourced settings. Examples include reducing BHCMs’ documentation burden, removing the cap on billable time per month, and easing the billing provider consent stipulation (which is not explicitly required for Medicare’s CCM codes). Despite some challenges, the UWNC experience thus far demonstrates that CoCM codes can successfully be used in a large academic primary care system to help move this highly effective service model toward financial sustainability.