Medical Records Issues
It is important that all providers have the necessary information needed to make informed decisions about patient care. The management of medical records in integrated settings is a topic that continues to generate discussion. One of the management decisions that will often arise is related to whether or not to have a combined record that has both behavioral and medical components or to keep the records separate and send progress updates back and forth as one might do when sharing a case with another provider entity. The concern about a combined record usually centers from concerns about patient privacy with respect to the confidentiality required in substance abuse and mental health conditions. Strict substance abuse privacy laws can strengthen the argument to have a separate record. Some Electronic Medical Records (EMRs) will allow a hybrid of the two options by limiting access to certain portions of the record to personnel who do not need access. In addition, an EMR may allow only certain portions of a provider’s note to be accessible, such as the plan for follow-up. Robinson and Reiter (2007) reference that some clinics have chosen to color code this sensitive material in a separate portion of the chart to avoid releasing the information by accident when general record requests, that do not have specific releases for this information, are made. Practices that do share a combined record often make this known to the patient in a written statement that is also reviewed verbally. In addition, most BHPs are trained to discuss confidentiality issues with their patient, which usually involves some examples of when information will be shared. A comment by Robinson and Reiter (2007) to consider is that by keeping behavioral health records in separate files we are continuing to act as if the mind and body are not connected. Another factor that may make this determination is the level of integration and relationship between providers. In some cases co-located services may actually be comprised of two different businesses under the same roof; the services may choose to keep many logistical components separate from one another. Lastly, a BHP may determine that his/her professional licensing organization may encourage keeping separate records. Issues of record keeping are currently being discussed by licensing boards and guidelines for integrated settings may soon be developed.
  • Consent for treatment forms
    Patients entering medical practices will sign a consent for treatment. BHPs can include their programming and services in this consent to inform patients that their PCPs practice in collaboration with behavioral health. BHPs may also develop a secondary consent that is specific to their services. Ethical issues lading to the development of the secondary consent were discussed in the section, “Ethical Issues, Informed Consent”.
  • Consultation request/ Response to request
    BH consultation requests can be made through the use of electronic medical records, on paper, verbally or by phone or pager. Chosen systems should be easy to use and responses should be promptly.
  • Release of information
    Some BHPs will use a typical release of information to safeguard discussions with PCPs in the same clinic. This may be more common when substance abuse issues are present or the patient’s case is in legal litigation. BHPs should routinely attain releases when communicating with outside providers.
  • SOAP note writing
    The SOAP note style of writing has been used in medical and behavioral health settings since the 1960’s. It provides a brief and concise method for documenting patient encounters. The “S” stands for subbjective information, “O” for objective information, “A” for assessment summary, and “P” for the plan (Robinson and Reiter, 2007)
  • Crisis Intervention
    The BHP will find that they can be helpful with many types of crises that can occur in the primary care setting. In mild situations, the BHP can help to stabilize patients who are escalating for any reason, by working to calm the patient with some breathing exercises. For example, assisting with a child who is agitated with a procedure. Crisis intervention is a familiar role for BHPs who have worked in specialty behavioral health settings, when the patient is experiencing suicidal or homicidal ideation and needs to be assessed. If needed, BHPs can provide a specialist’s service by providing a comprehensive evaluation. He or she may work with their PCP to address hospitalization, involuntary commitment procedures, or an alternate plan for the patient. Some crisis situations can be very time-consuming for all involved. BHPs should gather information about the different crisis-related resources in the community, meet with their supervisor, and discuss the role he/she will have in managing crises in the clinic.
  • Patient Goals/Self Management contract
    When identifying patient goals and outcomes it is important to consider additional goals (medical/behavioral/lifestyle) the patient may have. Their expectations, which may not routinely be discussed in brief engagements inherent in patient/provider interactions in medical settings, should also be discussed. Goals that are concise, patient-centered, documented clearly with in behavioral teams, and realistic will encourage better outcomes. Hunter, et al. (2009), suggests using Agree, Assist, and Arrange as three action words to guide in the development of goals. The BHP and patient should agree on goal(s), assist with defining the goal with patient input, and arrange an agreed upon treatment plan.
  • Resources:
Paneling for Insurance Reimbursement
BHPs will need to apply to become empanelled with private insurance carriers. In some instances, the insurance company may state that the panel for your community is closed because they have enough providers to serve local consumers. BHPs may need to contact the insurer’s empanelling agent and make him/her aware of the service they provide in the integrated clinic. In conversation with the agent, BHPs may need to highlight that without becoming empanelled, their clinic’s physicians cannot refer to them in-house, and will have to refer to outside providers. The application may need to be sent directly to the agent rather than reapplying in the traditional manner to avoid being denied a second time.
Behavioral Health Provider Billing and Coding

BHPs who provide services beyond traditional psychotherapy will need to be familiar with the ways in which to use additional Current Procedural Terminology (CPT) coding options to bill for services provided in integrated primary care behavioral health settings.

  • How billing codes for behavioral health providers are used, including limitations and their use by different providers

    Traditional psychotherapy codes (CPT codes 90801 to 90899) are billable based on diagnoses described in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is published by the American Psychiatric Association, is in its fourth edition, and should be familiar to BHPs. Reference the training resources in the next section of the curriculum to learn which codes will be useful in your setting.

    Health and Behavior Assessment/Intervention Codes (CPT codes 96150-96155) are used to address the behavioral health aspects of non-psychiatric physical health conditions where a patient’s cognitive, emotional, social, or behavioral health is counterproductive to the management and treatment of their condition (Robinson & Reiter, 2007; Noll & Fischer, 2004). The patient’s physical health condition is documented and diagnosed by the PCP using a diagnosis from the International Classification of Diseases, 9th edition (ICD-9). This reference is transitioning to a 10th edition. When using health and behavior assessment codes, the BHP’s services to the patient will need to be provided “Incident To” the PCP. The requirements for the use of these codes are described in the training links in the next section of the curriculum. Psychologists with doctoral degrees have an advantage when using these codes; in many cases they do not have to provide these services “Incident To” a physician, which affords extra flexibility and independence in patient care routines.

    Smoking and Tobacco Use Cessation Codes (CPT codes 99406 & 99407): When using Smoking and Tobacco Use Cessation Codes, the BHP’s services to the patient may need to be provided “Incident To” the PCP. The requirements for the use of these codes are described in the training links in the next section of the curriculum.

    Alcohol and/or Substance Abuse Assessments (CPT Codes G0306 & G0307): When using Alcohol and/or Substance Abuse Assessments codes, the BHPs services to the patient may need to be provided “Incident To” the PCP. The requirements for the use of these codes are described in the training resources in the next section of the curriculum.

    In general, Health and Behavior Assessment/Intervention Codes cannot be billed on the same day as a traditional psychotherapy code (90801 to 90899).

    Diagnosis and V coding: There are instances such as the initial sessions with a child who has Medicaid as their insurance carrier where a DSM V-code such as V61.8: Sibling Relational Problem, may fit while evaluating the child and family. These codes are helpful for coding and treating common developmental and familial transitions that children encounter when the clinical variables needed to identify a disorder are not present.

  • Medicare and NC Medicaid coding guides and training modules
    Emily Hill, PA, and ICARE have developed instructional podcasts which include accompanying Powerpoint handouts. Each training was originally delivered as a live webinar and provides a good illustration of how to code and bill in integrated care settings. Links to resources are provided below.