The 'Why': Why CMS Is Paying You to Stop Ignoring Mental Health

For decades, the system was broken. A primary care doc (PCP) diagnoses a patient with depression, hands them a prescription for an SSRI, and says, "Come back in 6 weeks." The patient goes home, the script side effects are weird, they don't know who to call, and they stop taking it. They fall through the cracks.

The PCP did their job, but the system failed. There was no follow-up. No coordination. No "care management."

BHI codes are CMS's solution. They are monthly management codes, just like Chronic Care Management (CCM). They pay your practice for the "in-between" work: the phone calls, the coordination, the PHQ-9 tracking, the team huddles, the follow-up with specialists. They are designed to fund a team that wraps around the patient and the PCP.

Both 99484 and 99492 aim to solve this problem. They just do it in very different ways.

Contender 1: CPT 99484 (The 'Gateway' to General BHI)

Think of 99484 as the flexible, entry-level BHI. It’s the "let's just start doing something" code.

The official description is "Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month."

What does that actually mean? It means you can bill this code once per month if your team spends at least 20 minutes on BHI-related care management for a patient.

Key Requirements for 99484:

• Time: At least 20 minutes of clinical staff time per calendar month. This is the magic phrase. This can be an MA, an RN, an LCSW, or other clinical staff under the direction of the billing provider.
• Activities: Things like an initial assessment, tracking in a care plan, providing brief counseling, or coordinating with the PCP and any outside therapists.
• Structure: It's very flexible. It doesn't mandate who is on the team (beyond "clinical staff") and it doesn't require a specific software registry.
• Patient Consent: Yes, you still need it. Verbal consent is typically fine, but it must be documented in the chart before you bill.

The bottom line: 99484 is the perfect starting point for a practice that wants to formalize its BHI efforts but isn't ready to hire a dedicated team or buy expensive software. It’s a workhorse.

Contender 2: CPT 99492 (The 'Heavyweight' CoCM System)

Now, we talk about 99492. This is not just a code. It is a specific, evidence-based clinical model: the Psychiatric Collaborative Care Model (CoCM).

If 99484 is a workhorse, 99492 is a thoroughbred racehorse. It’s more powerful, has much higher reimbursement, and requires a ton more infrastructure, training, and support.

Billing 99492 means you are attesting that you are doing the full CoCM model. This model is built on a non-negotiable, three-person team.

The 3 Non-Negotiable Pillars of CoCM (99492):

1. The Primary Care Provider (PCP): The billing provider who oversees the whole thing.
2. The Behavioral Health Care Manager (BHCM): This is the quarterback. This person (often an LCSW, RN, or psychologist) is embedded in your practice and does the day-to-day work: patient check-ins, brief therapy, medication support, and tracking. This is not just any "clinical staff."
3. The Psychiatric Consultant: This is the specialist (a psychiatrist or psychiatric NP). They do not typically see the patient. Instead, they meet with your BHCM weekly (this is called a "caseload review") to give advice, recommend treatment changes, and sign off on care plans.

On top of that team, CoCM requires you to use a patient registry. This isn't just a "list." It's a software tool used to track your entire CoCM patient population, monitor their clinical outcomes (e.g., PHQ-9 scores) over time, and ensure no one is falling through the cracks. A spreadsheet probably won't cut it in an audit.

The bottom line: 99492 is a high-intensity, high-reward program for practices willing to invest in the specific staff and technology to make it work.

The Main Event: BHI Billing Codes 99484 vs 99492 — The 7 Critical Differences

Okay, let's put them side-by-side. This is where you'll make your decision.

Difference 1: The Team (Flexible vs. Rigidly Defined)

• 99484 (General BHI): Can be performed by any "clinical staff" under the PCP's direction. You can use your existing MAs or RNs. It's flexible.
• 99492 (CoCM): Requires the three-person team (PCP, BHCM, Psychiatric Consultant). If you don't have all three, you cannot bill this code. Period. This is the single biggest operational barrier.

Difference 2: Who Does the Work (Clinical Staff vs. BHCM)

This is a subtle but critical point.

• 99484 (General BHI): The 20 minutes are "clinical staff time." This time is supervised and directed by the billing provider, but the provider's own time doesn't count toward the 20 minutes.
• 99492 (CoCM): The time counted is almost entirely the work of the BHCM and the Psychiatric Consultant. The PCP's time is separate (they bill for their E/M visits). You are billing for the work of the care team.

Difference 3: The Registry (A 'Nice-to-Have' vs. Mandatory)

• 99484 (General BHI): You must have a care plan and track the patient, but the method is flexible. Your EMR's built-in tools might be enough.
• 99492 (CoCM): You must use a registry for "population-based care." This tool needs to track outcomes (like PHQ-9s), show follow-up dates, and flag patients who aren't improving. Many EMRs do not have this built-in, requiring a third-party platform.

Difference 4: Time & Add-On Codes (20 mins vs. a 70/60/30 Ladder)

This is where the billing structure itself splits.

• 99484 (General BHI): One code. At least 20 minutes. That's it. Whether you spend 21 minutes or 50 minutes, you bill 99484 once.
• CoCM (The 99492 Series): This is a ladder of codes based on time:
  • CPT 99492: Billed for the first month of service. Covers the first 70 minutes of BHCM/Consultant time.
  • CPT 99493: Billed for subsequent months. Covers the first 60 minutes of BHCM/Consultant time.
  • CPT 99494: This is the add-on code. You bill this for each additional 30 minutes of team time in any given month (used with either 99492 or 99493).

This ladder structure means CoCM scales with patient complexity. A high-needs patient could generate a 99493 + (2 x 99494) billing in a single month.

Difference 5: The Money (Good vs. Absolutely Great)

Let's talk numbers. These are 2024/2025 national Medicare averages (non-facility). Your specific rates will vary wildly based on your geography and commercial contracts. But just look at the comparison.

• 99484 (20 mins): ~$54 per month
• 99492 (Initial 70 mins): ~$145 per month
• 99493 (Subsequent 60 mins): ~$134 per month
• 99494 (Add-on 30 mins): ~$56 per add-on

The math is stark. A single CoCM patient in their first month (99492) reimburses almost 3x as much as a 99484 patient. A subsequent-month patient who needs 90 minutes of care (99493 + 99494) would bring in ~$190.

This is the "purchase intent" moment. The ROI for CoCM is massive, but it has to pay for the BHCM's salary and the psychiatric consultant's time.

Difference 6: Patient Acuity (Mild vs. Moderate-to-Severe)

• 99484 (General BHI): Great for patients with mild-to-moderate depression, anxiety, or substance use issues who just need consistent check-ins and support.
• 99492 (CoCM): Built for your moderate-to-severe patients. These are the folks with complex co-morbidities, treatment-resistant depression, or bipolar disorder who need a psychiatrist's input but can't wait 6 months to see one.

Difference 7: The "Psychiatric Consultant" Role (None vs. Essential)

This is the lynchpin.

• 99484 (General BHI): You might refer to a psychiatrist. That's coordination.
• 99492 (CoCM): You must have a psychiatric consultant as part of your team. They are paid (often a monthly stipend or hourly rate) to review your BHCM's caseload every single week. This is an indirect, "doctor-to-doctor" consultation model, and it is the core of what makes CoCM so effective.

My God, Don't Do This: 4 Costly BHI Billing Mistakes I See Every Week

I see practices making these same painful, costly mistakes over and over. Learn from them.

The Final Gut-Check: A Simple Framework for Choosing Your Path

This isn't about which code is "better." It's about which program is right-sized for your practice today.

Go to the Source: Trusted E-E-A-T Links

Don't just take my word for it. Your E-E-A-T (Experience, Expertise, Authoritativeness, Trustworthiness) in this space comes from standing on the shoulders of giants. Here are the primary sources you should have bookmarked.

Frequently Asked Questions (The BHI Billing Quick-Fire Round)

1. What is the real difference between 99484 and 99492 in one sentence?

99484 is a flexible 20-minute code for general BHI tasks by clinical staff, while 99492 is a rigid, high-reimbursement code for the specific Collaborative Care Model (CoCM) which requires a BHCM, psychiatric consultant, and registry.

2. Can I bill 99484 and 99492 in the same month for the same patient?

No. They are mutually exclusive. You must choose one BHI model for the patient for that calendar month. You also generally cannot bill BHI codes in the same month as other care management codes like CCM (Chronic Care Management), so check NCCI edits carefully.

3. Who can perform the 20 minutes of work for 99484?

The work can be done by "clinical staff" working under the direction of the billing provider (PCP, specialist, etc.). This often includes Medical Assistants (MAs), RNs, LCSWs, or other trained staff. The billing provider's own time does not count toward the 20 minutes.

4. Who makes up the mandatory team for 99492 (CoCM)?

You MUST have three components: 1) The billing provider (PCP/specialist), 2) The Behavioral Health Care Manager (BHCM - the care coordinator), and 3) The Psychiatric Consultant (Psychiatrist/Psych NP) who consults with the BHCM weekly.

5. Is a patient registry really required for 99492?

Yes, 100%. You are billing for a population-based model, and the registry is your tool to prove you are doing it. It must be used to track the patient population, monitor outcomes (e.g., PHQ-9 scores), and facilitate the weekly psychiatric consultant reviews. A simple Excel sheet is a major audit risk.

6. What are CPT codes 99493 and 99494?

They are part of the CoCM (99492) family. 99492 is for the first 70 minutes in the first month. 99493 is for the first 60 minutes in all subsequent months. 99494 is an add-on code for each additional 30 minutes of team time in any month.

7. How much more does 99492 pay than 99484?

As of 2024/2025, the national Medicare average for 99492 (initial month, 70 mins) is around $145, while 99484 (20 mins) is around $54. The CoCM code reimburses at nearly three times the rate, but it is intended to fund the salaries of the dedicated care team.

8. Do I need patient consent for BHI billing?

Yes. Because these services are subject to Medicare Part B co-insurance and deductibles, you must get patient consent (verbal is often sufficient, but must be documented) before you start providing and billing for the service. You must inform them they may have a co-pay.

Conclusion: The Code is Just the Key. You Have to Build the Room.

Here’s the truth: CMS isn't paying for 20 minutes of time. It's not paying for a 70-minute timer to go off. It's paying for a system. It's paying for a new workflow that catches patients before they fall.

Your choice between 99484 and 99492 is a fundamental business decision.

99484 is your minimum viable product (MVP). It lets you test the waters, prove the value, and build a BHI habit with your current team. You can start tomorrow.

99492 is your scaling-up, Series A. It's a massive investment in people and tech (a BHCM, a consultant, a registry). The payoff is equally massive—not just in revenue, but in the ability to treat complex patients who have no other options.

My advice? Don't chase the shiny, high-reimbursement CoCM codes until you have an honest-to-God blueprint for the program. Start with 99484. Get your workflows right. Prove to your partners and your C-suite that BHI works. Track your 20-minute snippets with ruthless efficiency.

Once you’ve maxed that out—once your "clinical staff" are overwhelmed and your patients are asking for more—then you have the business case to hire your first BHCM and graduate to the Collaborative Care Model.

The codes don't build the program. The program earns the codes.