PCP utilization engine
You bill. The psychiatrist reviews. The BHCM runs the month.
How a treating primary-care clinician uses Collaborative Care: enroll, consent, close loops in ~72h, keep usual E/M on a separate clock. De-identified. Not claim autopilot.
Bills
Treating PCP / NP / PA
Orders CoCM, prescribes, closes loops, and is the only NPI on the CoCM claim.
Produces minutes
Behavioral health care manager
Outreach, MBC, registry, huddle docket, contemporaneous time log. Does not bill CoCM.
Reviews
Psychiatric consultant
Systematic caseload review. Recs to the PCP. Usually never meets the patient. Never bills CoCM.
Loops closed
0 / 5
1 safety still open
Who bills CoCM
Treating PCP
Never consultant NPI
30-day launch
0 / 11
Fidelity before scale
PCP quiz
—
Treating-clinician items
How a PCP uses CoCM without becoming a psychiatrist
Keep the patient. BHCM runs the month. Consultant advises you. Close loops in ~72h. Bill a true month under your NPI. NP/PA treating clinicians use the same engine.
1.Find them
PHQ-9 and GAD-7 at rooming when due. Item 9 > 0 pings you the same day. You are not case-finding in a 90-minute huddle.
2.Offer the team
Ninety seconds: depression/anxiety is treated here, a care manager will call, a psychiatrist advises me, you still see me. Consent. Order CoCM.
3.Prescribe as the treating clinician
Start or adjust the SSRI/SNRI (or decline, with a reason). The consultant recommends. You own the prescription.
4.Close the loop in ~72h
After Tuesday review you accept, modify, defer-with-a-date, or step up. Silence is not direction. This is the PCP’s actual weekly CoCM job. 72h is an NEH operating standard, not a CPT time.
5.Keep usual primary care
Same-month 99213/99214 is allowed. Visit minutes are not CoCM minutes. Chronic disease does not move to psychiatry.
6.Bill only a true month
Month-end under your NPI when BHCM time + consultant review + your direction exist. Huddle ≠ 99493. Never the consultant NPI.
Utilize today
Four PCP moves. None of them are “sit in psychiatry clinic.”
Monday-morning briefing
What to tell a PCP who just heard “we’re starting CoCM.”
You do not become a psychiatrist
CoCM puts a behavioral-health care manager and a consulting psychiatrist around you. The patient stays yours.
You are almost never in the huddle
BHCM + consultant review the registry. You receive a short rec list. Sitting the whole hour is a misuse of PCP time.
A rec is not a referral
‘Increase sertraline to 100 mg’ is advice to you. Accepting it does not transfer care.
Your extra time is small — and non-negotiable
Initiating-visit explanation plus 72-hour loop closure. If those slip, fidelity dies and the claim is fiction.
Money follows the team’s minutes, not yours
99492/93/94/G2214 count BHCM time (including BHCM participation in caseload review). Consultant time is a required element of the service, not a second minute pile. Your E/M is a different code.
Operational guidebook
CoCM billing deep dive · multi-cohort panels
Calendar-month codes, midpoint vs program floors, caseload science, and a live book of BHCM panels. Decision support — not claim autopilot. Dollars labeled.
Enrolled / capacity
108 / 119
91% load · 1.9 BHCM FTE
Psych review hours / week
5.2 h
Plan 2–3 h per nearly full-time BHCM
Modeled allowed / month
$14,572.39
Mixed labels — inspect each panel
Collection-adjusted
$12,181.12
4 panels · inside bands
Cohort panels
Load vs typical capacity
Typical caseload is cohort-specific (AIMS-style planning), not a billing maximum.
Panel editor
De-identified staffing model. Change FTE and census — mix is driven by cohort + maturity, not wishful coding.
Modeled month
99492 4.6 · 99493 45.2 · G2214 8.1 · 99494 16.0
$8,394.35 allowed → $7,259.43 after collection/denial
Computed WI PFS allowed · carrier 06302 locality 00 · not receipts
Psych consultant 2.0 h/week for this BHCM FTE · MBC PHQ-9, GAD-7
Book looks operable
Capacity, mix, and consultant hours are inside planning bands. Still run month-end close.
CoCM implementation playbook
Operational checklist that pairs each implementation step with 99492 / 99493 / 99494 / G2214 pathway gates, clinical fidelity requirements, and psych-review metrics. Click product surfaces to jump tabs.
Progress
0%
0/14 steps
Pathway → fidelity gate map
Psych-review fidelity metrics
Track these with claim yield on Command Center — never finance alone.
| Metric | Target | Definition | In product |
|---|---|---|---|
| Psych review completion | ≥ 90% | % of active patients not improving who received consultant caseload review this cycle. | Psych review fidelity % |
| Weekly caseload ritual held | 100% of scheduled weeks | Fixed consultant + CM meeting occurred with priority queue (stuck, worsening, safety). | Outcomes log note |
| Recommendation closed-loop | ≥ 85% within 72h | % of consultant recommendations communicated to treating practitioner and patient within SLA. | Joint fidelity narrative |
| MBC scores current | ≥ 90% active panel | % of active patients with PHQ-9/GAD-7 (or chosen scale) within the last 4 weeks. | Registry gate |
| Not-improving auto-flagged | 100% of stuck cases on queue | Patients below response threshold by week 8–12 appear on this week’s review list. | Ops Lab / registry discipline |
Charter the program
Days 0–14 · Design before you staff
Define population & graduation
Inclusion (e.g. PHQ-9 ≥10), exclusion, step-up criteria, and exit/graduation rules written and signed by clinical lead.
Done when: One-page charter approved; no open “who is CoCM?” debates.
Lock the triad roles
Treating practitioner, BH care manager, psychiatric consultant — with escalation paths and weekly review ownership.
Done when: RACI posted; FMV consultant agreement drafted.
Consent + note templates
CoCM consent form and monthly note skeleton (minutes, interventions, MBC, psych review) ready before first enrollment.
Done when: Templates live in EHR or Notes builder workflow.
Stand up the operating system
Days 7–30 · Registry, MBC, review ritual
Launch the living registry
Active patients, last/next contact, scores trajectory, treatments, psych-review flags, graduation status. Inbox alone is not enough.
Done when: CM starts each day from registry priority list.
Measurement-based care cadence
Baseline + re-measure every 2–4 weeks while active. Define “not improving” (e.g. <50% reduction by week 8–12) and auto-flag for review.
Done when: ≥90% of active panel has current scores.
Book permanent weekly psych caseload review
60–90 min fixed slot. CM presents priority queue (worsening, stuck, complex meds, safety). Consultant documents recs; CM closes loop with PCP ≤72h.
Done when: Four consecutive weeks held; recs closed-loop tracked.
Publish stepped-care algorithms
Depression, anxiety, safety/SI, SUD warm handoff, when to exit CoCM to specialty. Consultant uses them instead of reinventing weekly.
Done when: Algorithms in CM + consultant shared folder; referenced in notes.
Wire billing to fidelity
Days 21–45 · Pathways are gates, not targets
Train pathway selection (99492 / 99493 / G2214 + 99494)
Initial ~70, subsequent ~60, short month ~30. Stack 99494 only from total minutes. Never bill 99494 as base. Prefer G2214 over under-documented full months.
Done when: Coding + CM pass synthetic pre-check scenarios without coaching.
Hard-block NPI rate shopping
Billing NPI must have treating relationship. 15% NP differential is never a reason to reassign physician NPI.
Done when: Written billing SOP + pre-check blocks rate-shopping scenarios.
Contemporaneous time documentation
Minutes attributable to psychiatric CoCM activity for the calendar month. Reconstructing time at month-end is a red flag.
Done when: Note skeleton captures time; random audit of 10 charts clean.
Pilot first 20 claims with dual adjudication
Run de-identified / synthetic claims through Pre-check + Ops Lab batch. Coding + compliance adjudicate every mismatch before live volume.
Done when: ≥90% pilot agreement; remediation playbooks applied to misses.
Track clinical + financial together
Days 30–90 · One dashboard, then scale
Stand up joint KPI board
Psych review fidelity, MBC response/remission, claim yield, denials, labor cost, contribution margin — same cadence, same owners.
Done when: Command Center (or equivalent) updated monthly with both sides.
Pilot panel 20–40 before scale
Single site/condition first. Expand only after fidelity ≥ target (e.g. ≥85% psych review for non-improvers) for 4+ weeks.
Done when: Fidelity gate score ≥ target; no chronic under-time claims.
Scale only through the fidelity gate
Add conditions/sites only when registry, weekly psych review, and clean pathway coding hold. Bigger panel with weak fidelity destroys outcomes and margin.
Done when: Written scale criteria met; leadership sign-off on dashboard.
Scale rule: expand panel size or sites only when psych-review fidelity for non-improvers stays ≥85% and pathway pre-checks pass without time/NPI blocks for two consecutive reporting cycles.
Tour 1/15: PCP utilization engine
Release readiness
Go / caution / hold for scaling CoCM claim volume. Weighted across fidelity, pilot, workqueue, and training.
Hold — resolve before scale
- Fewer than half of fidelity gates signed
- Fewer than half of compliance gates signed
CoCM + LAI outcomes completeness
Master review of model fidelity, coding, FQHC 2026 transition, LAI unit/ownership/REMS, denials, and governance — open the full checklist.
Command center
Joint view: fidelity, claim yield, denials, workqueue, margin, playbook, refresh. Local-only; no PHI.
Psych review fidelity (latest)
—
Enter below or load demo
Monthly joint tracker
Capture outcomes + operations together. De-identified aggregates only.
Fidelity × yield × outcomes trend
Fragile implementation points show up as diverging lines — e.g. yield high while psych-review fidelity falls.
No monthly snapshots yet.
Weekly ops ritual
Joint clinical + billing cadence. 0/6 this week.
Registry hygiene
Care manager · Active panel, MBC due dates, patients without contact this week, consent gaps.
Psychiatric caseload review
Psych consultant + CM · Structured review of escalations, new starts, non-responders. Capture date + summary for notes.
Closed-loop recommendations
Treating practitioner · Confirm psych recommendations actioned or deferred with reason within 72h.
Time & pathway pre-check
CM lead / coding · Minutes vs 99492/99493/G2214/99494. Hold under-threshold claims. Run batch on de-identified sample.
Joint KPI huddle
Ops + clinical leads · Psych fidelity, closed-loop %, claim yield, denials, workqueue aging, contribution model.
Workqueue scrub
Billing + compliance · Clear hold/counsel items, map denials to playbooks, re-save adjudications after fixes.
Claim pre-check
Interactive rule engine with remediation playbooks. Separates hard edits from payer policy, watchlist, and counsel — not claim autopilot.
Teaching tip
Adjudication result
Hard edits · payer policy · watchlist · counsel · remediation
Time threshold met
70 min documented against ~70 min operational threshold for 99492.
Treating relationship affirmed
Billing as physician with treating relationship present.
Registry discipline present
Clinical-fidelity gate satisfied for this pathway.
Care-manager documentation present
Clinical-fidelity gate satisfied for this pathway.
Psychiatric case review present
Clinical-fidelity gate satisfied for this pathway.
Patient consent present
Clinical-fidelity gate satisfied for this pathway.
Role clarity present
Triad roles and escalation paths affirmed for this claim shape.
WI allowed amount ≈ $153.19
Base 99492: $153.19. CMS CY 2026 WI PFS carrier 06302 locality 00 nonfacility non-QP. Physician full rate. Not cash received — excludes deductible, coinsurance, denials, sequestration, bad debt.
MD vs NP for this claim shape: $153.19 vs $130.21
Differential $22.98. Use realized collections and labor for margin — never NPI reassignment for rate alone.
A/B pathway compare
Side-by-side CoCM claim shapes (e.g. under-threshold 99493 vs G2214). Decision support only.
Shape A
Subsequent CoCM
$117.90
Shape B
Short CoCM month
$49.31
Prefer the shape with fewer hard blocks and accurate time support — not simply the higher allowed amount. NPI must still follow treating relationship.
Guided product tour
Walk the demo narrative end-to-end. Each step opens the right tab.
PCP utilization engine
How a treating PCP uses CoCM: enroll from PHQ/GAD, 90-second scripts, Tuesday huddle with a 72-hour loop, PCP time budget, 30-day launch. You bill. The psychiatric consultant reviews and does not bill CoCM.
Start → Enroll Maria → copy the intro script → Huddle A-17 Accept rec
Pathway recommender
Enter documented care-manager / CoCM minutes → suggested base + 99494 stack. Does not release claims.
Physician
$197.43
NP (85%)
$167.81
- Base 99493 requires ~60 min. Documented 95 min supports 1 × 99494 (+30 min).
- 5 leftover minutes do not support another 99494 unit — document but do not over-bill.
- Stack 99494 only when contemporaneous documentation supports each additional 30 minutes.
Synthetic pilot suite
Ten teaching scenarios. Expected severity bands lock regression on NPI, units, J0013, and fidelity.
Claim workqueue
Status over saved pre-checks (hold / ready / counsel / released / denied). Local-only decision support — not claim submission.
Workqueue empty. Save adjudications from Pre-check, or Load demo.
De-identified batch claim intake
CSV of claim shapes (no PHI). Run adjudication, open rows in Pre-check, or push blocks to the workqueue.
Denial playbook library
First-response steps for common CoCM / LAI / esketamine denials with illustrative CARC/RARC hints — map to your remits before go-live. Not claim autopilot.
G0512 rejected / wrong setting
Service not covered for this place of service / provider type, or incorrect care-management packaging.
CARC 96CARC B15CARC 16RARC N115RARC M16highEligibility / packaging
G0512 rejected / wrong setting
Service not covered for this place of service / provider type, or incorrect care-management packaging.
Root causes
- G0512 billed from non–FQHC/RHC site
- Office CoCM rates applied to G0512
- Duplicate office CoCM + G0512 same month
First response
- Confirm site type (FQHC/RHC) on DOS.
- If office practice, recode to 99492/99493/G2214 — never G0512.
- If FQHC/RHC, pull MAC packaging article; do not rebill office amounts.
Prevent next
- Hard site gate on G0512 in Pre-check.
- Setting tab FQHC track before claim build.
99484 vs CoCM model mismatch
Documentation supports a different care-management level than billed.
CARC 151CARC B12RARC N362mediumMedical necessity / fidelity
99484 vs CoCM model mismatch
Documentation supports a different care-management level than billed.
Root causes
- Full CoCM program under-coded as general BHI
- BHI billed without clinical staff time support
First response
- Map clinical model: general BHI vs psychiatric CoCM triad.
- Recode to CoCM pathway if psych consultant caseload model is in place.
Prevent next
- Adjacent pathway label in Pre-check before release.
CoCM time not supported
Documentation does not support the time threshold for the billed collaborative care code.
CARC 4CARC 151RARC N362RARC M77highCoding
CoCM time not supported
Documentation does not support the time threshold for the billed collaborative care code.
Root causes
- Full-month code billed with short-month minutes
- 99494 stacked without +30 min documentation per unit
- Estimated rather than contemporaneous care-manager logs
First response
- Pull month time log (care manager + attributable CoCM activity).
- If ≥30 but below full pathway, recode to G2214 when clinically accurate.
- If minutes truly insufficient, void/correct and do not appeal with inflated time.
Prevent next
- Hard stop in Pre-check when minutes < threshold.
- Weekly time-gap report from registry before claim batch.
Billing practitioner / NPI mismatch
Rendering/billing provider does not match the treating relationship on file.
CARC 185CARC B7RARC N290highCompliance / NPI
Billing practitioner / NPI mismatch
Rendering/billing provider does not match the treating relationship on file.
Root causes
- NPI selected for physician rate differential only
- Incident-to or reassignment applied without required relationship
First response
- Identify actual treating practitioner for the CoCM month.
- Correct claim to that NPI; never resubmit under higher-paid NPI for rate alone.
- Document internal incident if rate-shopping was attempted.
Prevent next
- NPI gate as hard edit in Pre-check.
- Staff training: 15% differential ≠ lawful NPI switch.
Psychiatric consultation not documented
Missing psychiatric case review or collaborative care team documentation.
CARC 50CARC 151RARC N115highMedical necessity / fidelity
Psychiatric consultation not documented
Missing psychiatric case review or collaborative care team documentation.
Root causes
- Weekly caseload review cancelled without make-up
- Consultant notes not filed to chart before claim drop
First response
- Locate caseload review note (date, participants, recommendations).
- If review never occurred, hold claim — do not fabricate review language.
- Track closed-loop % on Command Center for the same month.
Prevent next
- Psych-review fidelity ≥85% as scale gate in Playbook.
- Note builder → Apply to Pre-check only when review date/summary present.
LAI unit / dose band error
Units billed do not match HCPCS dose descriptor or billed quantity exceeds medically reasonable dose.
CARC 151CARC 16RARC N362RARC M53highUnits / dose
LAI unit / dose band error
Units billed do not match HCPCS dose descriptor or billed quantity exceeds medically reasonable dose.
Root causes
- Milligrams entered as units (e.g. 300 for Sublocade 300 mg)
- Wrong weekly vs monthly Brixadi code for therapy days
First response
- Correct to 1 unit per syringe/dose for Q9991/Q9992/J0577/J0578.
- Confirm dose band (≤100 vs >100; ≤7 vs >7 days).
- Reverse any dual clinic/pharmacy lines for the same dose.
Prevent next
- Med map Pre-check defaults + unit hard block.
- Pharmacy ownership exclusivity before administration.
Vivitrol J2315 unit error (per-mg)
Units billed do not match HCPCS dose descriptor (1 mg).
CARC 151CARC 16RARC N362RARC M53highUnits / dose
Vivitrol J2315 unit error (per-mg)
Units billed do not match HCPCS dose descriptor (1 mg).
Root causes
- Staff applied Sublocade/Brixadi 1-unit-per-syringe logic to J2315
- Units not equal to milligrams administered
- Missing NDC / wrong benefit path (Part B vs D)
First response
- Recode J2315 units = mg administered (standard kit = 380).
- Confirm clinic supplied the drug (buy-and-bill) vs specialty pharmacy (admin only).
- Add NDC (e.g. 65757-0300-01) if payer requires.
Prevent next
- Pre-check defaults Vivitrol to 380 units.
- Train contrast: Vivitrol 380 vs Sublocade 1.
J0013 Medicare non-coverage
Service/item not covered under Original Medicare (coverage indicator I).
CARC 96CARC 50RARC N115highCoding
J0013 Medicare non-coverage
Service/item not covered under Original Medicare (coverage indicator I).
Root causes
- Separate drug billed instead of G2082/G2083 Medicare bundle
- Commercial J0013 rules applied to Original Medicare
First response
- Recode to G2082 (≤56 mg) or G2083 (>56 mg), units = 1.
- Do not appeal J0013 on Original Medicare as a unit-fix issue.
Prevent next
- Federal hard block on J0013 + Medicare in rule engine.
- Payer-policy layer cannot override this rule.
Duplicate drug billing (clinic + pharmacy)
Same drug service already paid or pending under another NPI.
CARC 18CARC B13RARC N522highDuplicate billing
Duplicate drug billing (clinic + pharmacy)
Same drug service already paid or pending under another NPI.
Root causes
- Buy-and-bill and specialty pharmacy both submitted
- Ownership not decided before administration
First response
- Identify exclusive biller; reverse the other claim.
- Route contract/ownership questions to counsel (AKS/Stark risk).
Prevent next
- Ownership gate before any drug line release.
- FMV counsel checklist on Gates tab.
Missing prior authorization
Prior authorization required and not obtained / invalid.
CARC 39CARC 197RARC N30mediumAuthorization
Missing prior authorization
Prior authorization required and not obtained / invalid.
Root causes
- MA/Medicaid/commercial PA not on file at administration
- PA expired or wrong product strength
First response
- Confirm PA number, dates, product NDC/HCPCS match.
- If no PA and required, do not appeal without retrospective auth pathway.
Prevent next
- Payer-policy requiresPriorAuth watch before release.
- Ops Lab policy layer updated after each contract change.
99494 billed without base month
Add-on code billed without required primary procedure.
CARC 4CARC 16RARC M15highCoding
99494 billed without base month
Add-on code billed without required primary procedure.
Root causes
- 99494 submitted as standalone month code
First response
- Pair with 99492 or 99493 supported by total minutes.
- Use pathway recommender to rebuild the stack.
Prevent next
- Hard block when 99494 selected as base pathway.
Patient not enrolled / wrong benefit
Member not eligible for behavioral health integration on date of service.
CARC 27CARC 32RARC N30mediumEligibility / packaging
Patient not enrolled / wrong benefit
Member not eligible for behavioral health integration on date of service.
Root causes
- Commercial carve-out not configured in payer layer
- FQHC/RHC packaging assumed to equal MPFS office rates
First response
- Verify benefit for CoCM / BHI on DOS.
- If site is FQHC/RHC, confirm MAC packaging on Setting tab — do not rebill office rates blindly.
Prevent next
- Eligibility check outside this tool; document plan IDs in payer layer notes.
Staff hard-rules quiz
Eight questions on NPI, units, time, esketamine, ownership, and fidelity. Feeds release readiness. No PHI.
1.A claim for subsequent CoCM could bill under a physician NPI (higher rate) or an NP NPI. The NP performed the treating work. Which is correct?
2.Sublocade 300 mg is administered. How many HCPCS units for Q9992?
3.Original Medicare esketamine 56 mg session — correct coding?
4.Documented CoCM minutes for a subsequent month are 40. What is the safest next step?
5.Clinic buy-and-bill and specialty pharmacy both plan to bill the same Sublocade dose. Correct action?
6.Which fidelity gap most often determines whether CoCM is clinically real vs paper billing?
7.Can 99494 be billed as the only CoCM code for a month?
8.Brixadi weekly syringe (≤7 therapy days) — correct code family?
9.FQHC, Original Medicare, DOS in 2026 — psychiatric CoCM packaging default?
10.Before billing a Medicare esketamine session, which is required?
11.Patient is on CoCM and receives Sublocade the same month. How should time be handled?
12.Standard Vivitrol 380 mg IM is administered (clinic buy-and-bill). Correct J2315 units?
Payer-policy layer
Configurable coverage and PA. Cannot override federal hard rules (e.g. J0013 on Original Medicare).
Quarterly refresh registry
Effective-dated source refreshes with reviewer sign-off — HCPCS, ASP, PFS, MAC, payer layer.
HCPCS quarterly update
CMS HCPCS · Quarterly · next due 2026-10-01
ASP drug payment files
CMS ASP · Quarterly · next due 2026-10-01
Physician Fee Schedule / carrier files
CMS PFS · Annual + mid-year · next due 2027-01-01
MPFS / OPPS final rule scan
Federal Register · Annual · next due 2026-11-15
WI MAC / NGS local policy
MAC / LCD / article · Quarterly · next due 2026-10-01
Org payer-policy layer re-sign-off
Contracts + medical policy · Quarterly · next due 2026-10-01
Adjudication log
Local-only decisions from Pre-check (last 50). Feeds workqueue.
No saved adjudications yet. Use Pre-check → Save adjudication.
Compliance audit pack
One markdown export: outcomes, workqueue, policies, refresh sign-offs, adjudication summary. No PHI. v2.11-mix
Monthly note builder
De-identified CoCM month skeleton for EHR paste. Suggests pathway from minutes; Apply opens Pre-check with that pathway.
Suggested pathway
From documented minutes — Apply opens Pre-check with this pathway mounted.
Physician allowed
$138.71
NP allowed
$117.90
Base 99493 requires ~60 min. Documented 75 min supports 0 × 99494 (+0 min).
15 leftover minutes do not support another 99494 unit — document but do not over-bill.
Note preview
# CoCM monthly documentation **Service month:** 2026-07 **Patient (initials / local ID only):** ____ **Month type:** subsequent ## Suggested coding (decision support) - Pathway: `1× 99493` - Documented minutes: **75** - Base 99493 requires ~60 min. Documented 75 min supports 0 × 99494 (+0 min). - 15 leftover minutes do not support another 99494 unit — document but do not over-bill. ## Team - Care manager: ____ - Treating practitioner: ____ - Psychiatric consultant: ____ - Consent on file: Yes ## Measurement-based care - Registry updated: Yes - PHQ-9: ____ (prior ____) ## Care-manager activity _Not documented_ ## Psychiatric case review - Date: ____ _Not documented_ ## Goals / plan _Not documented_ > **Gaps before release:** Care manager; Treating practitioner; Psychiatric consultant; MBC score; Psych review date; Psych review summary _v2.11-mix_
Margin simulator
Panel economics for CoCM + optional Sublocade / Brixadi / esketamine contribution proxies. WI rates. Not cash received.
Never reassign NPI solely for the rate differential shown below.
Monthly loaded cost
LAI + esketamine proxies
Proxies are contribution assumptions, not ASP or allowed amounts. Esketamine uses G2082/G2083 coding on Medicare — never J0013.
Contribution
-$24,037.66
-$50.08 / pt-mo
Collected
$70,762.34
92% of post-denial
Labor + overhead
$94,800.00
12 months
CoCM gross
$70,691.90
WI allowed × mix
LAI layer
$6,576.00
Sublocade + Brixadi proxies
Esketamine layer
$6,336.00
Session proxies (not ASP)
MD vs NP CoCM gross (same panel)
$70,691.90 vs $60,086.57delta $10,605.34
Waterfall
MOUD off contribution: -$34,966.37 · Break-even collection rate on post-denial allowed: 100%
LAI + esketamine ops (beyond codes)
8 critical items: units, exclusive ownership, Medicare bundle, medical vs pharmacy benefit, REMS. Full joint checklist on Outcomes.
- One HCPCS unit per syringe/dose (never mg). Q9991/Q9992 (Sublocade) and J0577/J0578 (Brixadi): units = 1 per administered syringe/dose. Entering 100/300/128 as unit…
- Correct dose/duration band code. Sublocade: Q9991 ≤100 mg, Q9992 >100 mg. Brixadi: J0577 ≤7 therapy days, J0578 >7–28 days. Match the product actually ad…
- Medicare esketamine = G2082/G2083 only. ≤56 mg → G2082 ×1; >56 mg → G2083 ×1. J0013 is not payable on Original Medicare (coverage code I). Do not dual-bill drug…
- Exclusive biller for each dose. Decide clinic buy-and-bill vs specialty pharmacy. Same dose cannot be billed by both. Document ownership before administ…
- Esketamine REMS compliance. SPRAVATO REMS: certified healthcare setting, patient enrollment, monitoring for 2 hours post-dose, pharmacy certificatio…
- Medical vs pharmacy benefit path chosen. Buy-and-bill (medical benefit) vs specialty pharmacy (pharmacy benefit) changes who bills drug vs admin. Wrong path = de…
Sublocade
Q9991 · ≤100 mg · 1 unit/dose
Q9992 · >100 mg · 1 unit/dose
Brixadi
J0577 · ≤7 therapy days · 1 unit/syringe
J0578 · >7–28 therapy days · 1 unit/syringe
Vivitrol
J2315 · 1 mg per unit · 380 units for standard kit
Esketamine (Medicare)
G2082 · ≤56 mg · 1 bundle
G2083 · >56 mg · 1 bundle
Esketamine (non-Medicare only)
J0013 · mg units only if payer accepts · never Medicare
Medication code map
July 2026 HCPCS pathways. Open any row in Pre-check to stress-test unit, ownership, and Medicare hard rules. Not claim autopilot.
G2082
Esketamine
up to 56 mg
1 bundled service
Common error: Billing J0013 alongside or instead of the G-code on Medicare
G2083
Esketamine
greater than 56 mg
1 bundled service
Common error: Using G2082 when dose >56 mg
J0013
Esketamine
1 mg per unit
56 or 84 units only when a non-Medicare payer accepts separate drug billing
Common error: Submitting J0013 to Original Medicare
J0577
Brixadi
≤ 7 days of therapy
1 unit per weekly syringe
Common error: Entering mg as units or monthly code for weekly syringe
J0578
Brixadi
greater than 7 through 28 days of therapy
1 unit per monthly syringe
Common error: Milligram-as-unit or dual clinic/pharmacy billing
Q9991
Sublocade
≤ 100 mg
1 unit per administered dose
Common error: Billing 100 or 300 units (mg) instead of 1
Q9992
Sublocade
> 100 mg
1 unit per administered dose
Common error: Billing 300 units for a 300 mg syringe
J2315
Vivitrol
1 mg per unit (standard kit 380 mg)
380 units for a standard 380 mg kit
Common error: Billing 1 unit (syringe logic) instead of 380 mg units
| Code | Product | Dose / duration | Billing unit | Medicare status | Action |
|---|---|---|---|---|---|
| G2082 | Esketamine | up to 56 mg | 1 bundled service Billing J0013 alongside or instead of the G-code on Medicare | Medicare bundle Medicare bundle — do not bill drug separately with J0013 | |
| G2083 | Esketamine | greater than 56 mg | 1 bundled service Using G2082 when dose >56 mg | Medicare bundle Medicare bundle — do not bill drug separately with J0013 | |
| J0013 | Esketamine | 1 mg per unit | 56 or 84 units only when a non-Medicare payer accepts separate drug billing Submitting J0013 to Original Medicare | Not payable by Medicare Coverage code I — not payable by Original Medicare | |
| J0577 | Brixadi | ≤ 7 days of therapy | 1 unit per weekly syringe Entering mg as units or monthly code for weekly syringe | Carrier judgment Carrier judgment; coverage is payer-specific. Never bill milligrams as units. | |
| J0578 | Brixadi | greater than 7 through 28 days of therapy | 1 unit per monthly syringe Milligram-as-unit or dual clinic/pharmacy billing | Carrier judgment Carrier judgment; coverage is payer-specific. Never bill milligrams as units. | |
| Q9991 | Sublocade | ≤ 100 mg | 1 unit per administered dose Billing 100 or 300 units (mg) instead of 1 | Carrier judgment Carrier judgment; coverage is payer-specific. One unit per syringe/dose — not mg. | |
| Q9992 | Sublocade | > 100 mg | 1 unit per administered dose Billing 300 units for a 300 mg syringe | Carrier judgment Carrier judgment; coverage is payer-specific. One unit per syringe/dose — not mg. | |
| J2315 | Vivitrol | 1 mg per unit (standard kit 380 mg) | 380 units for a standard 380 mg kit Billing 1 unit (syringe logic) instead of 380 mg units | Carrier judgment Per-mg HCPCS (unlike Sublocade/Brixadi). Standard dose = 380 units. Confirm Part B vs Part D / specialty-pharmacy path. |
Setting / packaging
Office CoCM, FQHC/RHC (G0512), general BHI (99484), facility, and telehealth tracks. Decision support only — confirm MAC before release.
Physician office / nonfacility (primary model in this product)
Standard psychiatric CoCM under 99492 / 99493 / 99494 / G2214 on the MPFS nonfacility fee schedule. WI rates in this tool use carrier 06302 locality 00, non-QP.
Notes
- Document care-manager minutes, psychiatric consultant review, treating practitioner relationship, consent, and registry/MBC.
- Independently billing NPs typically reimburse at 85% of the physician fee schedule amount when billing under their own NPI.
- APCM (advanced primary care management) may coexist for some patients but is a separate service family — do not double-count the same care-management minutes across exclusive pathways.
- General BHI 99484 is adjacent only — use Pre-check adjacent pathway, not office CoCM rates.
Risks
- Billing full-month codes without contemporaneous time support
- NPI reassignment solely for the MD/NP differential
- Stacking exclusive care-management codes without time segregation
- Billing G0512 from a non–FQHC/RHC office
Open questions
- Does the org bill APCM for the same panel? If so, publish a written time-allocation SOP.
APCM vs CoCM (do not autopilot)
- Advanced Primary Care Management (APCM) is a distinct CMS care-management construct from psychiatric Collaborative Care (CoCM).
- When both are available in an organization, publish a written SOP for which patients sit on which pathway and how minutes are segregated.
- Never use this tool to auto-select APCM vs CoCM for a live claim — confirm current CPT/HCPCS descriptors, NCCI edits, and MAC articles.
- Clinical CoCM fidelity (registry, psych review, measurement-based care) remains the outcome engine even if a different care-management code set is used for payment.
Clinical fidelity gates
Evidence supports CoCM outcomes; fidelity determines real-world value. Every billing pathway pairs with these gates.
Patient registry maintained
Active CoCM registry with measurement-based care scores tracked over time.
Care manager time documented
Care-manager minutes meet the billed pathway threshold for the calendar month.
Psychiatric case review completed
Treating practitioner + psychiatric consultant review is documented for the month.
Treating relationship established
Billing practitioner has an established treating relationship; NPI is not chosen for rate alone.
Patient consent on file
Informed consent for CoCM participation is documented.
Role clarity (CM / PCP / psych consultant)
Roles, escalation paths, and communication cadence are defined.
Federal escalation gates
Unsupported time, units, ownership, NPI selection, or documentation can create FCA and overpayment risk.
Time is supported
Minutes claimed are supported by contemporaneous documentation.
Units match product rules
No milligram-as-unit, no multi-unit per single syringe/dose unless rule allows.
Drug ownership resolved
Clinic vs pharmacy ownership decided before any drug line is released.
NPI selection is lawful
Billing NPI has treating relationship and meets service conditions — never rate shopping.
Consultant / vendor FMV
Psychiatric consultant, care-manager vendor, and pharmacy contracts are FMV and commercially reasonable.
Records retention ≥ 7 years
Part B ordering, referral, prescription, and drug records retained per 42 C.F.R. 424.516(f).
Recommended next steps
- 1Load payer contracts and written policies into a separate payer-policy layer; do not overwrite federal source records.
- 2Pilot the rule engine against synthetic and de-identified historical claims; coding + compliance adjudicate every disagreement.
- 3Establish quarterly HCPCS, ASP, PFS, final-rule, MAC, and payer-policy refreshes with effective dating and reviewer sign-off.
- 4Track clinical outcomes, psychiatric review fidelity, claim yield, denials, labor cost, and contribution margin together.
- 5Use Playbook for the 90-day fidelity-before-scale checklist; use Setting tab for APCM / FQHC / RHC packaging questions.
- 6Seed demo workspace; run guided tour; complete staff quiz; export readiness + audit pack — no PHI.
- 7Map local CARC/RARC codes to the Denial library before production go-live.
- 8Use release readiness scorecard as the go/no-go for scaling claim volume.
- 9Adjudicate 99484 / G0512 only as labeled adjacent pathways — never mix into WI office CoCM rates.
- 10Complete the CoCM + LAI Outcomes Review checklist before scaling (Command → Outcomes).
- 11For FQHC: Original Medicare DOS ≥ 2026 uses component 99492/993/994/G2214 — G0512 is the legacy package era.
- 12Vivitrol J2315 is per 1 mg (380 units for a standard kit) — opposite unit model from Sublocade/Brixadi.
- 13Use Protocol (CIV-1) as the four-gate operating law: authority → fidelity → claim release → yield/value.
- 14Use Guide (multi-cohort panels) to staff BHCM FTE, psych hours, and month-end close across depression, perinatal, SUD/MOUD, geriatric, SMI-lite, and ADHD books — never pool minutes across patients.
- 15Use PCP Engine → Matrix for the PCP × psychiatric-consultant coworker LP: $/BHCM-min ranking, binding-cap n*, FMV (not collections split), shadow prices.
Open configuration questions
Product remains a knowledge registry until privacy design is scoped for any patient-level processing phase.
CIV-1 — CoCM Integrity-to-Value Protocol
Enroll only under written or ERA-proven authority, run the triad until fidelity is high, release claims only through hard-edit pre-check with labeled dollars, convert minutes to yield before growing the panel, and negotiate shared savings only on outcomes you already measure — keeping LAI, DEA, and esketamine on their own clocks.
0%
0/22 · 0/4 gates clear
Four sequential gates. A failed gate blocks everything downstream. Checklist is local and de-identified — not a claim file.
Gate 0 — Authority
If this gate fails: Do not enroll. No claim. No panel growth.
Payer, product, and funding type named
criticalFully insured vs self-funded vs Medicaid FFS vs HMO/MCO vs MA. Benefit coverage is not implied by a network contract.
Fail → Hold enrollment until product is identified in writing.
99492 / 99493 / 99494 coverage written or ERA-proven
criticalWPS: inclusion-under-dynamic RBRVS is an argument, not a guarantee. Curative Exhibit A is the drafting model because it names the range.
Fail → Send confirmation request. Do not full-scale WPS.
G2214 booked as $0 on WI Medicaid until written
criticalG2214 is active Medicare PFS (WI NF $58.01). It is absent from the current ForwardHealth CoCM table. Medicare-payable ≠ Medicaid-confirmed.
Fail → Remove G2214 from Medicaid revenue models.
WI Medicaid treating/billing practitioner is not a psychiatrist
criticalForwardHealth: billing practitioner is E/M-qualified and not a psychiatrist. Psychiatrist / psych APN / psych PA = consultant (referring).
Fail → Rebuild roster. Psychiatrist consults; does not bill WI Medicaid CoCM.
CM + psychiatric consultant agreements on file
highWritten employment or contractor terms. FMV / AKS / Stark facts go to counsel — not a billing checkbox.
Fail → Route to counsel. Do not enroll.
Consent and initiating visit documented
criticalGeneral CoCM consent plus initiating visit per payer. No reconstructed consent language.
Fail → No claim for that member-month.
LAI / esketamine / DEA clocks separated
criticalSame patient may be on CoCM and MOUD/CS. Ownership exclusive. Vivitrol 380 vs Sublocade 1. Pure-tele CII flex ends 12/31/2026.
Fail → Hold the drug line and do not pollute CoCM minutes.
Ledger A — FFS yield
Nominal code rate is not realized revenue per staff hour.
- 1.Paid clinical minutes
- 2.Countable CoCM minutes (non-clerical, not double-counted)
- 3.Minutes that clear a base-code threshold
- 4.Add-on-eligible minutes (99494 stacks)
- 5.Minus denial + collection leakage
- 6.Minus consultant + registry overhead
- 7.Equals realized $ per CM hour
Ledger B — value / shared savings
Negotiate only after Ledger A is reproducible on that payer.
PHQ-9 response
≥50% drop or score <10 at 3–6 months — outcome bonus qualifier only if measured
GAD-7 / ASRS as indicated
Diagnosis-specific; same honesty rule
Retention 90 / 180 days
Engagement gate — not a CPT substitute
Stimulant / MOUD adherence (if in program)
Separate clock from CoCM minutes
Avoided ED / IP
Only if the payer will share claims data
Hard facts (labeled)
Computed PFS · contract-formula · modeled proxy · unverified — do not mix.
- WI Medicaid billing role
- Not a psychiatrist
- WI Medicaid consultant
- Psychiatrist / psych APN / psych PA
- G2214 · WI Medicare NF
- $58.01 (computed PFS)
- G2214 · WI Medicaid
- $0 until written
- WPS MD 99492 (formula)
- $183.83 (120% WI NF) — not an ERA
- Minute conversion prior
- Start 52–56% until your ERAs beat it
- 99484
- Different model — never a silent fallback
- DEA CII tele flex
- Ends 12/31/2026 — not a CoCM authority
Days 0–30 — Establish authority
- ForwardHealth max-fee export for 99492–99494 (intended taxonomy / POS / plan).
- Written WPS + each HMO confirmation (codes, G2214, telehealth, taxonomy).
- Templates: consent, time log, weekly review, registry.
- Quiz: NPI, both LAI unit models, J0013, G0512 2026, WI Medicaid role.
- If CS overlap: never-in-person CII inventory (flex ends 12/31/2026).
Days 31–60 — Controlled adjudication
- Pilot only written or strongly supported payers.
- Test claims: base and add-on combinations.
- Reconcile each 835 to labeled expected amount.
- Appeal config/underpay inside contract clocks (WPS 9.3 ≤12 months).
- Do not scale.
Days 61–90 — Scale or renegotiate
- Scale only reproducible clean payer/products.
- WPS side letter if still unsigned.
- Reprice staffing on realized conversion — not nominal rates.
- Open value-based talk only with MBC + retention data.
- Combined mock CoCM + DEA audit.
Weekly-to-event cadence
| When | Who | Artifact |
|---|---|---|
| Daily | Prescriber / CM | |
| Weekly | Treating + CM + psych | |
| Month-close | Billing + CM | |
| Monthly | RCM | |
| Quarterly | Compliance + MD | |
| Event | Counsel | Dual-bill, Stark/AKS, board, WPS 9.3 / 10.4 |
WPS confirmation request
Inclusion-under-RBRVS is an argument. Written confirmation is stronger.
Please confirm in writing whether CPT 99492, 99493, and 99494, HCPCS G2214, CPT 99484, and HCPCS G2211 are Covered Services under WPS Statewide fully insured and self-funded products. For each code, please identify the applicable benefit, provider types/taxonomies permitted to bill, credentialing or roster requirements for the behavioral care manager and psychiatric consultant, prior authorization/referral requirements, place-of-service and telehealth rules, modifier and unit edits, and whether reimbursement is calculated under Exhibit 2(B)’s Wisconsin Medicare RBRVS percentage or the 65%-of-billed-charges provision. Please also identify the 2026 Medicare fee-schedule version/conversion factor used and whether claims denied solely because of code-loading or configuration issues will be reprocessed retroactively.
Proposed amendment
Curative-style named codes + WPS Exhibit 2 rate math. Counsel review required.
Collaborative Care Model Services. Effective [date], CPT codes 99492, 99493, and 99494 shall be recognized as Covered Services under the Agreement. Reimbursement shall equal the lesser of the Provider’s submitted charge or the applicable percentage of the current Wisconsin non-facility Medicare Physician Fee Schedule assigned to the billing practitioner under Exhibit 2. These codes shall not be classified under the Agreement’s “all other Covered Services” provision. Rates shall update automatically when the referenced Medicare fee schedule is updated. Claims denied solely because a code was not loaded or configured shall be reprocessed retroactively to the effective date. Coverage remains subject to applicable coding, medical-necessity, documentation, eligibility, credentialing, and benefit-plan requirements. The parties shall separately specify provider-type eligibility, behavioral care manager and psychiatric consultant roster requirements, place-of-service/telehealth rules, 99494 unit limits, fully insured and self-funded product applicability, and treatment of G2214, 99484, and G2211.
This protocol refuses
- Autopilot claims or E/M leveling
- 99484 as “almost CoCM”
- Booking G2214 as WI Medicaid revenue without written confirmation
- Psychiatrist as WI Medicaid treating/billing NPI
- Mixing WI office allowables into FQHC remittance
- Treating WPS silence as coverage or as exclusion
- Shared-savings math without MBC and a signed metric spec
- One unit model for all LAIs
- Scaling panel to fix a conversion or fidelity problem
- Dumping LAI / REMS / CII time into CoCM minutes
CoCM + LAI outcomes review
Master checklist for clinical outcomes, clean billing, LAI safety, FQHC packaging, and governance. Check items as your org completes them — saved locally (no PHI).
0%
0/36 complete
FQHC packaging eras
FQHC/RHC CoCM: G0512 package → 2026 component codes
Classic G0512 monthly package (pre-unbundle / non-Medicare lag)
DOS before 2026-01-01 on Original Medicare, or contract still on G0512
Typically ≥60 minutes clinical staff CoCM time per calendar month (confirm descriptor). Clinical program still targets ~70 first / ~60 subsequent. Classic packaging often did not use CPT midpoint add-ons.
2026+ component CoCM (G0512 unbundled for Medicare)
DOS on/after 2026-01-01 (Original Medicare default)
99494 stacks when minutes support each +30. G2214 for short months. Do not also bill G0512 same month.
Payment follows current FQHC/RHC care-management construct (often national non-facility PFS-style for unbundled care management — NOT automatic paste of local WI office allowed amounts). Finance + MAC must map remittance.
LAI / esketamine code quick ref
Unit rules only — ownership and REMS still apply.
Sublocade
- Q9991≤100 mg · 1 unit/dose
- Q9992>100 mg · 1 unit/dose
Brixadi
- J0577≤7 therapy days · 1 unit/syringe
- J0578>7–28 therapy days · 1 unit/syringe
Vivitrol
- J23151 mg per unit · 380 units for standard kit
Esketamine (Medicare)
- G2082≤56 mg · 1 bundle
- G2083>56 mg · 1 bundle
Esketamine (non-Medicare only)
- J0013mg units only if payer accepts · never Medicare
19 LAI ops items folded into the master list below (coding, ownership, admin, REMS, inventory, joint minutes).
CoCM model
0/3 checked
CoCM coding
0/4 checked
CoCM fidelity
0/1 checked
FQHC / RHC
0/2 checked
LAI (Sublocade / Brixadi)
0/12 checked
Esketamine
0/3 checked
Joint ops
0/6 checked
Governance
0/4 checked
Refresh calendar
0/1 checked
Decision support, not claim autopilot
Hard edits are separated from payer-configurable policies, proposed watchlist items, and counsel-review triggers.
2026 Medicare pathways are current
Wisconsin payment amounts, APCM context, RHC/FQHC transition notes, and July 2026 HCPCS/ASP medication records reconciled to primary CMS files.
Highest-risk errors are preventable
Brixadi and Sublocade: one unit per syringe or dose band. Medicare esketamine: G2082/G2083 only. J0013 is not payable by Medicare.
Clinical value ≠ practice margin
Outcomes evidence is strong; sustainability still depends on adoption, psychiatric review fidelity, collections, staffing, and local rates.
Wisconsin CoCM allowed amounts
Physician vs independently billing NP (85%). Carrier 06302 · locality 00 · nonfacility · non-QP. As of July 30, 2026.
How to read the comparison
The largest absolute differences occur on initial and subsequent base months because their allowed amounts are highest.
The 15% NP differential is material but cannot justify choosing a physician NPI without the required treating relationship and service conditions.
Use realized collections and attributable labor cost for margin decisions — switch to the Margin tab to model panel economics.
Multi-state rate comparison
Pre-check always uses Wisconsin SOT. Other states are illustrative placeholders for multi-site orgs.
| Code | WI MD | WI NP | TX MD* | TX NP* | WI−TX MD |
|---|---|---|---|---|---|
| 99492Initial CoCM | $153.19 | $130.21 | $148.40 | $126.14 | $4.79 |
| 99493Subsequent CoCM | $138.71 | $117.90 | $134.20 | $114.07 | $4.51 |
| 99494Additional 30 min | $58.72 | $49.91 | $56.90 | $48.37 | $1.82 |
| G2214Short CoCM month | $58.01 | $49.31 | $56.10 | $47.69 | $1.91 |
* Illustrative comparison set for multi-state org demos. Replace with current TX MAC locality rows before contracting.
WI rate table (adjudication SOT)
| Code | Pathway | Minutes (ops) | Physician | NP (85%) |
|---|---|---|---|---|
| 99492 | Initial CoCM | 70 min psychiatric CoCM | $153.19 | $130.21 |
| 99493 | Subsequent CoCM | 60 min psychiatric CoCM | $138.71 | $117.90 |
| 99494 | Additional 30 min | +30 min | $58.72 | $49.91 |
| G2214 | Short CoCM month | 30 min psychiatric CoCM | $58.01 | $49.31 |