Behavioral Health Integration (BHI / CoCM)
Behavioral health care inside primary care, with a registry behind it
Most depression and anxiety is first seen in primary care. We design the screening, warm handoff, care management and follow-up workflows for General BHI or the Psychiatric Collaborative Care Model, so patients are treated to target and the monthly work is documented.
- General BHI 99484
- CoCM 99492 · 99493 · 99494 · G2214
- Registry and validated scales
- FUH / FUM / FUI follow-up
Who it's for
Built for the teams that run this program
Primary care practices
Practices that screen for depression but have no reliable path from a positive screen to treatment and follow-up.
Practices with a behavioral health clinician
Teams with an embedded social worker, counselor or psychologist who want a structured model and the documentation to support it.
Groups measured on behavioral health follow-up
Organizations in contracts that include depression screening and follow-up, or follow-up after a mental health hospitalization or ED visit.
Design & launch
How we design and launch it
First we help you choose the model that matches your staffing; then we build it.
- 1
Choose the model
General BHI suits practices with a care manager and no psychiatric consultant. CoCM needs a behavioral health care manager and a psychiatric consultant under contract.
- 2
Screening workflow
Validated tools such as the PHQ-2/PHQ-9 and GAD-7 at rooming, with rules for repeat screening and positive results.
- 3
Warm handoff
A same-day introduction to the behavioral health care manager, in person or by video, while the patient is still in the office.
- 4
Registry and caseload
A registry that tracks every enrolled patient, their scores and their contacts, with caseload targets for each care manager.
- 5
Consultant agreement
For CoCM: the psychiatric consultant's role, review schedule and how recommendations reach the treating practitioner.
Gate: Pilot with one provider team first.
- 6
Consent, templates, training
Patient consent, monthly time logs, care plan and note templates, and training for providers, care managers and front desk.
Operations
How the program runs day to day
General BHI or Collaborative Care
General BHI
99484
- Initial assessment or follow-up monitoring, including validated rating scales
- Behavioral health care planning, revised for patients not progressing
- Coordination of treatment such as psychotherapy, medication management and psychiatric consultation
- Continuity of care with a designated member of the care team
Psychiatric Collaborative Care Model
99492 · 99493 · 99494 · G2214
- Team of treating practitioner, behavioral health care manager and psychiatric consultant
- Registry tracking and measurement-based care with validated scales
- Regular caseload review with the psychiatric consultant
- Brief interventions such as behavioral activation and motivational interviewing
Who does what
Treating practitioner
Directs care, prescribes, and stays the billing practitioner. Sees the patient for the initiating visit when required.
Behavioral health care manager
Engages the patient, runs the registry, delivers brief interventions and tracks scores and contacts.
Psychiatric consultant
In CoCM, reviews the caseload, advises on diagnosis and medication changes, and usually does not see the patient.
Follow-up after acute care
Workflows aligned to the HEDIS follow-up measures your contracts may include.
- FUH: follow-up visit within 7 and 30 days after a hospitalization for mental illness.
- FUM: follow-up within 7 days of an emergency department visit for mental illness.
- FUI: follow-up after high-intensity care for substance use disorder.
- Discharge alerts route to the care manager, who books the visit and confirms it happens.
- Positive depression screens get a documented follow-up plan, supporting depression screening and follow-up measures.
Documentation & compliance
Documentation and compliance essentials
Medicare fee-for-service rules for CY 2026.
BHI and CoCM codes
99484
- Service
- General BHI
- Time basis
- At least 20 minutes of clinical staff time per calendar month, directed by the billing practitioner
99492
- Service
- CoCM, initial month
- Time basis
- First 70 minutes of care manager time in the first calendar month
99493
- Service
- CoCM, subsequent months
- Time basis
- First 60 minutes of care manager time in a subsequent month
+99494
- Service
- CoCM add-on
- Time basis
- Each additional 30 minutes in an initial or subsequent month
G2214
- Service
- CoCM, initial or subsequent month
- Time basis
- First 30 minutes, for months with less time than 99492 or 99493 require
Apply current CPT and CMS time-counting rules. General BHI and CoCM are not billed for the same patient in the same month.
Documentation essentials
- An initiating visit by the billing practitioner for new patients or those not seen within the past year (for example an E/M visit, AWV or IPPE).
- Patient consent, verbal or written, documented in the record, including that cost-sharing applies.
- A monthly time log by staff member, with dates and activities.
- Validated rating scale results and a care plan revised when the patient is not improving.
- For CoCM: registry entries and documented psychiatric consultant review and recommendations.
KPIs we track
What we measure with you
Screening rate
Eligible patients screened for depression (and anxiety where used) with a validated tool.
Positive screens with follow-up
Positive screens with a documented follow-up plan or handoff.
Warm handoff rate
Positive screens introduced to the care manager the same day.
Enrollment and caseload
Active patients per care manager and contacts per month.
Response and remission
Change in PHQ-9 scores over time for enrolled patients, measured, not promised.
FUH / FUM / FUI timeliness
Follow-up completed within the measure windows after acute care.
Baselines and targets are set from your own data at the start of an engagement. We do not promise specific results.
FAQs
Common questions
Do we need a psychiatrist on staff for Collaborative Care?
No. CoCM needs a psychiatric consultant who reviews the caseload and advises the team. Many practices contract for this role. We help you define the arrangement; your counsel reviews the contract.
Can BHI be billed alongside Chronic Care Management?
CMS has allowed BHI or CoCM and CCM in the same month when time and effort are not counted twice. We set up time logs so each minute is assigned to one service.
What about patients enrolled in APCM?
APCM has its own behavioral health add-on codes (G0568–G0570) billed by the same practitioner on the same claim. We help you decide which path fits each patient and month.
Related services
Programs that work alongside this one
Advanced Primary Care Management (APCM)
G0556–G0558 monthly care management, levels by complexity.
Learn moreChronic & Principal Care Management (CCM / PCM)
Care plans, monthly time-based care management and documentation.
Learn morePractice Transformation & Quality Improvement
HEDIS and Star measures, care gap closure, AWV campaigns and care team redesign.
Learn moreTransitional Care Management (TCM)
Two-business-day contact and 7/14-day face-to-face after discharge.
Learn more
Ready to simplify the complex?
Book a consultation.
A working conversation about your patients, payers, EHR and staffing, and whether this program fits. Please do not send patient information.