A three-physician family practice we work with screens every adult with the PHQ-9 at the annual visit. About one in seven scores 10 or higher. The physician adjusts a medication or writes a referral, the patient leaves, and the next contact is a year later when the score is the same. The practice manager knows this is bad care and also knows the physicians have no time between visits to call anyone. What she did not know is that Medicare and most commercial payers will pay a monthly fee for a staff member to do exactly that calling, tracking and coordinating, under a set of codes called behavioral health integration.
Behavioral health integration billing is one of the few places where doing the right thing clinically and getting paid for it line up cleanly. It is also one of the more frequently mis-billed programs we audit, because the codes have time thresholds, team requirements and consent rules that nobody explains to the medical assistant who ends up running the program.
Key takeaways
- Behavioral health integration (BHI) is a set of monthly care management codes: 99484 for general BHI, 99492 to 99494 and G2214 for the psychiatric Collaborative Care Model (CoCM), and G0323 for clinical psychologists and clinical social workers.
- Every code is billed once per calendar month by one practitioner, requires documented patient consent, and requires a time log or activity record that supports the threshold.
- CoCM pays more than general BHI because it requires a behavioral health care manager, a psychiatric consultant and a registry with systematic case review. General BHI needs only 20 minutes of clinical staff time and a validated rating scale.
- Since January 1, 2026, practices billing Advanced Primary Care Management (APCM) can add G0568, G0569 or G0570 for BHI without tracking time. The CPT codes remain for patients not in APCM.
- The program pays for itself only if the care manager's caseload and time are tracked from day one, so build the log before the first patient is enrolled.
What behavioral health integration billing covers
All BHI codes pay for work done between visits: assessing the patient with a validated scale such as the PHQ-9 or GAD-7, building a care plan, tracking whether the patient is improving, adjusting the plan with the treating physician, and keeping a designated person on the care team in contact with the patient. None of it requires a face-to-face visit in the month. All of it requires that a physician or other qualified health care professional (QHP) direct the work and that the patient have a behavioral health condition, including substance use disorders, that the practice is treating.
| Code | Service | Monthly time threshold | Who performs the work |
|---|---|---|---|
| 99484 | General BHI care management | At least 20 minutes of clinical staff time | Clinical staff under a physician or QHP |
| 99492 | CoCM, initial month | 70 minutes of behavioral health care manager time | Care manager with psychiatric consultant |
| 99493 | CoCM, subsequent month | 60 minutes | Same team |
| 99494 | CoCM, each additional 30 minutes | Add-on to 99492 or 99493 | Same team |
| G2214 | CoCM, initial or subsequent month, first 30 minutes | 30 minutes (Medicare) | Same team |
| G0323 | BHI care management by a clinical psychologist or clinical social worker | At least 20 minutes | CP or CSW and their clinical staff |
| G0568, G0569, G0570 | CoCM initial, CoCM subsequent, general BHI as APCM add-ons | None; based on services furnished | Practices billing APCM (2026) |
Two definitions matter. Clinical staff means employees or contractors working under the physician's supervision, typically a registered nurse, licensed practical nurse or medical assistant with training in the program. A behavioral health care manager, for CoCM, is a clinical staff member with formal training in behavioral health who keeps the registry and does the patient contact. The psychiatric consultant is a psychiatrist or other qualified psychiatric prescriber who reviews the caseload with the care manager and advises the treating physician; the consultant does not see the patient and does not bill separately.
Choosing between general BHI and collaborative care
General BHI under 99484 is the entry point for most independent primary care offices. A nurse or trained medical assistant administers the scale, calls the patient, checks medication adherence and side effects, coordinates a therapy referral and documents 20 minutes across the month. The physician reviews and adjusts. There is no consultant requirement and no registry requirement, though a simple spreadsheet of enrolled patients, scores and last contact is how we recommend running it anyway.
CoCM pays roughly two to three times as much per patient per month, in our experience, because it requires more. The practice needs a behavioral health care manager, a contracted psychiatric consultant who reviews the caseload weekly or biweekly, a registry that tracks every enrolled patient's scores over time, and a treat-to-target approach where the plan changes when the patient is not improving. The care manager time is what is counted: 70 minutes in the first month, 60 in later months, with 99494 added for each further 30 minutes. Medicare's G2214 covers months where the care manager reaches 30 minutes but not 60, which happens with stable patients.
A practice cannot bill general BHI and CoCM for the same patient in the same month. It can bill BHI alongside chronic care management (99490 and its relatives) for the same patient if the time is not counted twice and the conditions justify both. In audits, the double-counted minute is the first thing a reviewer looks for.
G0323 and who can bill what
CPT 99484 and the CoCM codes are billed by a physician or QHP, meaning a nurse practitioner, physician assistant or clinical nurse specialist. Clinical psychologists and clinical social workers cannot bill those codes because their Medicare benefit does not include general E/M-type services. CMS created G0323, effective January 1, 2023, so that a clinical psychologist or clinical social worker can bill BHI care management for at least 20 minutes a month of their own or their clinical staff's time. For a primary care office with an embedded psychologist, this means the psychologist can bill G0323 for patients whose behavioral care plan they direct, while the physicians bill 99484 for patients they direct. The same patient cannot generate both in one month.
The 2026 APCM add-ons
The CY 2026 Medicare Physician Fee Schedule final rule, published in the Federal Register on November 5, 2025, added three optional add-on codes for practices that bill Advanced Primary Care Management, the monthly primary care bundle introduced in 2025 under G0556, G0557 and G0558. G0568 mirrors 99492 for the initial CoCM month, G0569 mirrors 99493 for subsequent months, and G0570 mirrors 99484 for general BHI. The difference is that the APCM add-ons have no time threshold. The practice documents that the service elements were furnished in the month rather than counting minutes.
The CPT codes did not go away. A practice not billing APCM continues to use 99484, 99492 to 99494, G2214 and G0323 with their time requirements. A practice that does bill APCM uses the G-code add-ons for its APCM patients and can still use the CPT codes for patients outside APCM. What you cannot do is bill both an APCM add-on and the corresponding CPT code for the same patient in the same month. We think the add-ons are a good reason for primary care offices already doing APCM to start BHI now; the time-tracking barrier that stopped many of them is gone for that population.
Consent, cost sharing and the rules that trip practices
Patient consent is required before the first month is billed. It can be verbal or written, and the note must record that the patient was told what the service is, that only one practitioner can bill it per month, that the patient can stop at any time, and that Medicare Part B cost sharing applies. That last point is where programs fail. Part B coinsurance is 20 percent of the allowed amount, and a patient who gets a monthly bill for a service they do not remember agreeing to calls the office, angry, and disenrolls. Explain it plainly at enrollment. Many patients with supplemental coverage owe nothing, and knowing that in advance keeps them in the program.
Other rules: the physician must have an initiating visit (an E/M, annual wellness visit or similar) within the prior year for a new patient or one not seen recently; the same practitioner bills every month; and the care plan must be documented and available to the patient. Physician time does not count toward the thresholds; the codes are built on care manager or clinical staff time, and the physician's own work is billed through E/M visits.
A worked month for one care manager
Suppose a practice hires one full-time care manager and runs general BHI under 99484 for its own patients while it recruits a psychiatric consultant. Use round numbers for illustration, not your fee schedule: assume a 99484 allowable of $50.
- Month one: 40 patients enrolled after consent, 20 minutes documented for each. Billable: 40 units of 99484, about $2,000 in allowed charges.
- Month four: caseload grows to 90. Ten patients have fewer than 20 minutes because they did not answer calls, and those months are not billable. Billable: 80 units, about $4,000.
- Month seven: the consultant contract starts and 30 of the sickest patients convert to CoCM. If the CoCM allowables are, for illustration, $150 for 99492 and $120 for 99493, month seven bills 30 units of 99492 plus 60 units of 99484, about $7,500.
Against that sits the care manager's salary and a share of the consultant's fee, so the program clears its costs only at a caseload most offices reach around month four to six. The single largest variable is the unbillable month: patients who were called twice, did not answer, and accumulated 12 minutes. A care manager who schedules calls the way the front desk schedules visits, with reminders, converts many of those months into billable ones.
Questions we hear
Can our medical assistant do the general BHI work?
Yes, as clinical staff under the physician's direction, provided state scope-of-practice rules allow the tasks involved and the MA has been trained on the rating scales and the care plan process. Document the training. For CoCM, the care manager needs formal behavioral health training, and most practices use a nurse, a licensed counselor or a social worker.
Does the patient have to be on the phone for the 20 minutes?
No. The time includes reviewing scores, updating the care plan, coordinating with a therapist or pharmacy, and communicating with the treating physician about the patient, as well as direct patient contact. What it cannot include is time already counted toward another care management code, or time on a day when the same staff member's work is billed as part of a visit.
Which denials should we expect?
Frequency denials (one unit per month, one practitioner), bundling denials when BHI and another care management code are billed by different practices for the same patient, and eligibility denials when the patient is in a Medicare Advantage plan that requires prior authorization for care management. Our denial management team sees far fewer of these when the enrollment consent is scanned to the chart and the time log is attached to the monthly claim on request.
What to do this week
- Pull a list of patients with a PHQ-9 of 10 or higher, or an active depression, anxiety or substance use diagnosis, in the last 12 months. That is your candidate population.
- Decide who will be the care manager and how many hours a week are protected for the program.
- Write the consent script and a one-paragraph patient handout that names the cost sharing.
- Build the time log: patient, date, activity, minutes, staff member. A spreadsheet is fine to start; an EHR flowsheet is better.
- Check whether your practice bills APCM. If it does, plan to use G0568 to G0570 for those patients; if not, start with 99484 and add CoCM when a consultant is signed.
- Talk to a psychiatrist or psychiatric nurse practitioner about a consulting arrangement; our RCM training sessions cover how to structure the CoCM registry and case review.
