By the Policy Center for Maternal Mental Health

The following guidance was developed for reference by payors and obstetric providers (midwives, Ob/Gyns and family practice providers who provide maternity care), culling together the latest behavioral health integration protocol, resources from clinical bodies and the National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set (HEDIS) measures for perinatal depression.

Recommended Citation:
Policy Center for Maternal Mental Health. (2024, April). Maternal Mental Health Care - Obstetric Provider Services Billing and Reimbursement Guide. http://www.2020mom.org/blog/2024/obstetric-provider-services-billing-and-reimbursement-guide

Background

Global/Bundled Rate vs. Fee-for-Service

Obstetric providers (Ob/Gyns, Midwives, and Family Practice providers who provide maternity care) may be reimbursed through a global maternity care bundled rate. The insurer/plan might not reimburse for screening and/or management outside of this bundled rate, except for screening after the six-week postpartum visit or when screening is positive and the provider diagnoses a maternal mental health disorder. This is because the global rate is derived for uncomplicated pregnancy, delivery, and/or postpartum care. However, there may be interest among payers to incentivize obstetric providers to provide routine screening, starting in pregnancy. This is advantageous given the link of untreated depression/anxiety in pregnancy to costly preterm birth and low birth weight babies, as well as the introduction of prenatal and postpartum depression screening and follow-up HEDIS measures. This change could be made through pay-for-performance incentives (in addition to the bundled rate) and/or fee-for-service reimbursement.

Screening Frequency

We encourage insurers/payors to reimburse and obstetricians to bill for screening on a fee-for-service basis throughout the perinatal period, following the Alliance for Innovation on Maternal Health’s (AIM’s) Perinatal Mental Health patient safety bundle recommendations for screening timeframes and using the measurement-based approach to follow-up when a patient screens positive.¹

AIM, Universal Screening Recommendations

Screen for perinatal mental health conditions consistently throughout the perinatal period, including but not limited to:
- Obtain individual and family mental health history at intake, with review and update as needed. *
- Screen for depression and anxiety at the initial prenatal visit, later in pregnancy, and at postpartum visits, ideally including pediatric well-child visits. *
- Screen for bipolar disorder before initiating pharmacotherapy for anxiety and depression.
Screen for structural and social drivers of health that may impact clinical recommendations or treatment plans and provide linkage to resources.
Activate an immediate suicide risk assessment and response protocol as indicated for patients with identified: suicidal ideation, significant risk of harm to self/others, or psychosis.

Payment and Billing

Billing Codes

The codes below align with the National Committee for Quality Assurance (NCQA) HEDIS 2022 Volume 2 Technical Specifications for Health Plans. These codes are examples of codes typically billed for the type of service indicated in the table below.

Individual Codes

Definitions

SCREENING CODE

CPT 96160

Obstetric providers should not be limited to billing code 96160, as multiple screening inventories/tools should be used when clinically warranted. For example, if the PHQ is used to screen for depression, the GAD should also be used to assess for anxiety. Additional tools may also be clinically warranted. See the Policy Center for Maternal Mental Health’s Screening Overview and Tools web pages.²

Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation per standardized instrument.

ASSESSMENT/FOLLOW-UP/CARE MANAGEMENT
(Behavioral Health Integration)

Staff providing care management services for general BHI are not required to have additional education or training in behavioral health. These services can be billed monthly, and include:

a systematic assessment
development and monitoring of a personalized care plan
coordination of behavioral health treatment
a continuous relationship with a member of the care team

CPT 99484

Initial assessment or follow-up monitoring, of at least 20 minutes, including use of validated rating scale(s)

Behavioral health care planning, including revisions for patients not progressing or whose status changes
Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling, or psychiatric consultation
Continuity of care with a designated member of the care team
Patient consent (verbal or written) documented in the medical record

MENTAL HEALTH SERVICES: COLLABORATIVE CARE CODES
(CoCM) includes additional services provided by:

a designated behavioral health care manager (must have formal education or specialized training in behavioral health, e.g., social work, nursing, or psychology)
a psychiatric consultant

CPT 99492

Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional

CPT 99493

Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the

CPT 99494

Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional (report in conjunction with 99492, 99493)

CHRONIC CARE MANAGEMENT CODES

The codes were created by CMS for Medicaid/Medicare “Dual Eligibles” with two or more chronic conditions including but not limited to depression, serious mental illness, diabetes, high blood pressure (has or is expected to last 12 months or more).³

These codes should be allowed by commercial payors as well, for those with two or more chronic conditions.

(Patients should not be charged a copay/billed for care management that doesn’t involve direct patient engagement)

CPT 99490

Chronic care management (20 mins)

CPT 99439

Chronic care management (40 mins)

CPT 99439 (x2)

Chronic care management (60 minutes)

Screening for Risk

Further, the U.S. Preventive Services Task Force requires coverage of screening to detect risk for maternal depression. Though not addressed in the AIM bundle or HEDIS measures, obstetric providers should be reimbursed outside of the global maternity bundled rate for the management of patients at risk for maternal depression if the obstetrician provides such care. Standardized depression screening tools with or without the Maternal Depression Risk Factor Checklist derived from the USPSTF recommendation be used to determine risk. https://www.2020mom.org/prevention-and-support-screening-tools⁴

Obstetricians are encouraged to contact the health insurer/plan network management/provider services departments they are contracted with to request the insurer’s billing codes for maternal depression and anxiety screening and treatment.

However, the lack of transparent insurer billing guidance should not preclude obstetric providers from providing this service and billing using the codes above.

Denials can be reported to the state’s Department of Insurance and/or the U.S. Department of Labor Employee Benefit Services Administration.

In no case should a patient be billed for screening

The Affordable Care Act (ACA) requires commercial health insurers to cover preventive care at 100% (no copay/coinsurance/deductible applies), including screening for mental health disorders and interventions to prevent maternal depression. Patients can be billed their copay/coinsurance and an unmet portion of their deductible for treatment of maternal mental health disorders. Insurers should confirm claim systems have disabled applying patient copays or coinsurance and deductibles for screening regardless of whether the patient screens positive unless the provider also conducts further evaluation, management, and treatment in the same visit.

Tech Solutions Can Enable Integration, and Billing

Technology solutions can support obstetric provider integration. For example,

FamilyWell embeds turnkey Collaborative Care (CoCM) integrated behavioral health services in obstetric practices to provide treatment for patients struggling with mental health concerns during pregnancy and postpartum. FamilyWell provides billable, tech-enabled perinatal mental health services covered by insurance from a collaborative team including the patient, OB provider, behavioral care managers, therapists, coaches, and psychiatric consultants.

Psychiatric CoCM CPT billing codes include

99492, 99493, 99494, and General BHI service 99484.

Submit feedback about this resource or its utilization by emailing Info@PolicyCenterMMH.org

References

Alliance for Innovation for Maternal Health. (2022, June 24). Perinatal Mental Health Conditions. https://saferbirth.org/psbs/perinatal-mental-health-conditions/
Policy Center for Maternal Mental Health. (n.d.). Maternal Mental Health Screening Recommendations and Detection. Policy Center for Maternal Mental Health - Formerly 2020 Mom. https://www.2020mom.org/screening-overview
CMS (2022, September) MLN Booklet, Chronic Care Management Services https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
Policy Center for Maternal Mental Health. (n.d.). Maternal Depression Risk Factors Checklist. https://www.2020mom.org/s/USPSTF-Prevention-Screener-Policy-Center.pdf