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Module 28: Advanced Collaborative Care Services and Revenue Integration
Section 28.3: Advanced Care Planning and Behavioral Health Integration
An exploration of two critical, yet often underutilized, service lines. We will break down the CPT codes for Advance Care Planning and the codes for Behavioral Health Integration, providing a playbook for how pharmacists can lead these vital—and reimbursable—conversations and care models.
SECTION 28.3
Leading Critical Conversations and Integrating Whole-Person Care
Mastering the Art and Science of Reimbursable, Patient-Centered Communication.
28.3.1 The “Why”: Moving Beyond the Pill to the Patient
In your pharmacy education and practice, the primary focus has been on the safe and effective use of medications. You are a master of pharmacology, pharmacokinetics, and therapeutics. However, the most effective medication regimen in the world is of little value if it does not align with a patient’s personal goals, or if its effectiveness is undermined by an unaddressed mental health condition. True collaborative practice requires us to look beyond the prescription vial and engage with the whole person—their values, their fears, their emotional state, and their vision for their own life.
This section delves into two of the most profound and impactful service lines a pharmacist can be involved in: Advance Care Planning (ACP) and Behavioral Health Integration (BHI). These services represent a deliberate shift from a purely biomedical model of care to a biopsychosocial one. They are also two areas where pharmacists, as the most accessible healthcare providers and trusted medication experts, are uniquely positioned to lead. For too long, conversations about goals of care have been seen as the sole domain of physicians, and mental health has been siloed away from primary care.
CMS has recognized the immense clinical and economic costs of this fragmentation and has created robust reimbursement pathways to encourage and sustain these services. Learning to provide and bill for ACP and BHI is not just an opportunity to add new revenue streams to your practice; it is a professional and ethical imperative. It allows you to practice at the absolute top of your license, using your communication skills and clinical knowledge to ensure that the care provided is not only medically sound but also deeply respectful of the patient’s humanity. This is where you transition from a medication manager to a true partner in a patient’s life journey.
Pharmacist Analogy: The Expert Travel Agent for Life’s Journey
Imagine your patient is planning a complex, lifelong journey. Your role as a pharmacist has traditionally been to act as the “supply officer”—making sure they have all the necessary supplies (medications) for the trip, that the supplies are high quality, and that they know how to use them.
Now, your role is expanding to that of an expert travel agent and navigator.
- Advance Care Planning (ACP) is Destination Planning: Before the journey begins, a good travel agent sits down with the traveler and asks, “What kind of trip do you want? Are you looking for a high-adventure trek through the mountains (aggressive, life-prolonging treatment), or a peaceful, comfortable stay at a scenic resort (comfort-focused care)? What happens if the weather turns bad (if you get sicker)? Who do you trust to make travel decisions for you if you’re unable to (your healthcare proxy)?” ACP is the process of creating this detailed itinerary for their healthcare journey, ensuring the entire travel team (the doctors, nurses, and family) knows the traveler’s desired destination.
- Behavioral Health Integration (BHI) is Managing the Traveler’s Morale: You can give a traveler the best supplies and the most detailed map, but if they are overwhelmed by anxiety, fear, or depression, they may never leave their hotel room. The journey will fail. BHI is the service of recognizing and managing the traveler’s mental and emotional state. As the BHI care manager, you are the navigator who checks in regularly, helps them manage their fears (anxiety), lifts their spirits (depression), and works with the expedition leader (the PCP) and a consulting psychologist (the psychiatric consultant) to make sure the traveler’s morale is high enough to continue the journey successfully.
By providing both ACP and BHI, you are no longer just handing out supplies. You are co-designing the entire journey, ensuring it aligns with the traveler’s deepest wishes and that they are mentally and emotionally equipped to handle its challenges. You are ensuring the journey is not only possible but also meaningful.
28.3.2 Deep Dive: Mastering Advance Care Planning (ACP)
Advance Care Planning is often misunderstood as being solely about end-of-life care. While it does address preferences for treatment in the face of serious illness, its true purpose is much broader: it is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. As a pharmacist who often has the most longitudinal and trusting relationship with a patient, you are in an ideal position to initiate and facilitate these crucial conversations.
A Critical Distinction: ACP is NOT the Same as Completing an Advance Directive
An advance directive (like a living will or a healthcare power of attorney form) is a legal document—it is an output of the ACP process. Advance Care Planning itself is a billable clinical service—a face-to-face conversation between a provider and a patient, family, or surrogate. You can bill for the conversation itself, even if no forms are completed during that visit. The value is in the conversation, the counseling, and the shared understanding that results from it.
Deconstructing the ACP CPT Codes
CMS provides two simple, time-based codes for ACP. Billing is straightforward, but documentation must be precise.
| CPT Code | Description | Who Can Bill? | Pharmacist’s Role & Key Considerations |
|---|---|---|---|
| 99497 | Advance care planning including the explanation and discussion of advance directives such as standard forms, with or without completion of such forms, by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. | Physicians, NPs, PAs, CNSs. Can be billed “incident to” by pharmacists in many settings. Some states may allow direct billing by pharmacists under specific collaborative practice agreements. |
The pharmacist’s role is to lead or co-lead these conversations, bringing a unique medication-focused perspective.
|
| 99498 | Each additional 30 minutes. (List separately in addition to code for primary procedure). |
The Pharmacist’s ACP Playbook: From Introduction to Documentation
Leading an ACP discussion requires skill, empathy, and a structured approach. You are not there to tell the patient what to do; you are there to help them discover their own wishes and articulate them clearly.
A Scripted Guide to Leading an ACP Conversation
Step 1: Setting the Stage (The Gentle Introduction)
“Mr. Johnson, one of the things we like to do for all our patients is to make sure that the medical care we provide is always in line with what’s most important to you. We call this ‘advance care planning.’ It’s about talking through your hopes and worries for the future, so that if you ever get so sick you can’t speak for yourself, we know what your wishes are. Is this something you’d be open to talking about today?”
Step 2: Exploring Values (The “What Matters Most” Questions)
- “When you think about the future, what are you hoping for?”
- “What does a ‘good day’ look like for you right now?”
- “What are your biggest fears or worries about your health?”
- “Are there any abilities that are so critical to your life that you can’t imagine living without them?” (e.g., being able to recognize family, being able to communicate).
Step 3: Connecting Values to Treatment Options (The Pharmacist’s Unique Contribution)
“Thank you for sharing that. It’s really helpful. Let’s talk about how that connects to your medical care and your medications. For example, we have medications that can be very aggressive in treating your heart failure. They might help you live longer, but they also have side effects that could make you feel tired and require more frequent trips to the clinic. On the other hand, we have options that focus more on controlling your symptoms and maximizing your quality of life, but they might not extend your life as much. Given what you told me is most important to you, how do you feel about that trade-off?”
Step 4: Choosing a Surrogate (The “Who” Question)
“If you were ever in a situation where you couldn’t make your own decisions, who is the person you would trust to speak for you? Who knows you the best and would honor your wishes, even if they were difficult?”
Step 5: Documentation for Billing and Care Continuity
Your note is not just for billing; it is a sacred document that will guide the patient’s future care. It must be clear, concise, and comprehensive.
Example ACP Note:
“Advance Care Planning Note
Time: Spent 35 minutes in face-to-face discussion with the patient and his son, John (surrogate decision-maker).
Content of Discussion: Patient was engaged and had full capacity. We discussed his understanding of his current health status, including his diagnoses of severe COPD and metastatic prostate cancer. Patient expressed that his primary goal is to maintain his quality of life and remain at home for as long as possible. He values his independence and ability to interact with his grandchildren above all else. He stated, ‘I don’t want to be kept alive by machines if there’s no hope of getting back to who I am.’
Specific Preferences Discussed:
- CPR/Intubation: Patient wishes to be DNR/DNI.
- Hospitalization: Wishes to avoid hospitalization if possible, prefers hospice care at home when the time comes.
- Healthcare Proxy: Confirmed he wants his son, John, to serve as his healthcare proxy. Provided with Healthcare Power of Attorney forms to complete.
Plan: Copy of this note will be placed in the patient’s chart and shared with his oncologist and pulmonologist. Patient and son will return completed forms to the clinic.”
28.3.3 Deep Dive: Mastering Behavioral Health Integration (BHI)
The connection between mental and physical health is undeniable. A patient with uncontrolled diabetes and depression is far less likely to have the energy or motivation for self-management than a patient whose depression is well-treated. Behavioral Health Integration (BHI) is a model of care that seeks to break down the historical silos between mental and primary care. Instead of sending a patient with depression “somewhere else,” the BHI model brings the mental health expertise into the primary care home, treating both conditions in a coordinated, holistic way.
The most evidence-based and robustly reimbursed model of BHI is the Psychiatric Collaborative Care Model (CoCM). This model is built on a team-based structure, and the central, organizing role of the Behavioral Health Care Manager is a perfect fit for a clinical pharmacist with specialized training.
The Core Components of the Psychiatric Collaborative Care Model (CoCM)
The Primary Care Provider (PCP)
The “captain” of the ship. The PCP oversees all aspects of the patient’s care, prescribes medications, and is the billing provider for the CoCM service.
The Behavioral Health Care Manager
The “engine” of the model. This individual (often a pharmacist, nurse, or social worker) works directly with the patient, providing regular assessments, brief counseling, and medication support under the guidance of the PCP and psychiatric consultant.
The Psychiatric Consultant
The expert navigator. This psychiatrist or psychiatric NP consults on the care manager’s caseload weekly, providing recommendations and clinical guidance, but does not typically see the patient directly.
Deconstructing the BHI & CoCM Billing Codes
BHI billing is more complex than other services. It is time-based and billed monthly, but uses a series of codes for initiation and subsequent months. The key is meticulous time tracking.
| CPT/G-Code | Description | Monthly Time Threshold | Pharmacist’s Role & Documentation Keys |
|---|---|---|---|
| 99484 | Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, per calendar month. (This is for general BHI, not the full CoCM model). | ≥ 20 minutes | This is a simpler BHI code for practices without a full CoCM structure. Your time spent on medication management calls for depression/anxiety could be billed here. |
| 99492 | Initial psychiatric collaborative care management, first 70 minutes in the first month of activities. | ≥ 70 minutes (first month only) |
These are the core CoCM codes representing the work of the Behavioral Health Care Manager (you!). Your documentation must be flawless.
|
| 99493 | Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of activities. | ≥ 60 minutes (subsequent months) | |
| 99494 | Each additional 30 minutes in a month of activities for CoCM. (Add-on code for 99492 or 99493). | 91+ minutes (subsequent) or 101+ minutes (initial) | This add-on code allows for billing for higher-touch patients who require more intensive management during a given month. |
The Pharmacist as a Behavioral Health Care Manager: A Practical Tutorial
Your skills in medication management, patient counseling, and systematic data tracking make you an ideal candidate for the Behavioral Health Care Manager role. Here is how you would operationalize it.
The CoCM Workflow in Action
Patient: A 55-year-old female with diabetes, HTN, and a new diagnosis of major depressive disorder. Her PCP starts her on sertraline.
Week 1: Initiation (Part of the 70-min initial month)
- You are introduced to the patient as her “behavioral health pharmacist.”
- You conduct an initial assessment, explain the program, and administer a baseline PHQ-9 (Patient Health Questionnaire-9). Her score is 18 (moderately severe depression).
- You provide education on the new sertraline, focusing on the time to effect and common initial side effects. You schedule a follow-up call.
Week 2: First Follow-Up (15-20 min call)
- “Hi Mrs. Davis, it’s [Name], your behavioral health pharmacist. I’m calling as we planned to see how you’re tolerating the sertraline.”
- You check for side effects. You administer a follow-up PHQ-9. Her score is now 16.
- You provide brief, evidence-based counseling (e.g., behavioral activation – “Have you been able to go for that short walk we talked about?”).
The Psychiatric Consultation
At the end of the week, you have a scheduled 30-minute meeting with the team’s psychiatric consultant. You present your caseload: “For Mrs. Davis, she’s on week 2 of sertraline 50mg. Tolerating well, but PHQ-9 has only dropped from 18 to 16. My recommendation is to continue the current dose for two more weeks and then re-evaluate. Do you agree?” The consultant provides feedback: “Yes, that’s a good plan. If no significant improvement by week 4, we should consider a dose increase to 100mg.” You document this recommendation in the chart.
Weeks 3 & 4: Continued Management
You continue your regular check-in calls, tracking the PHQ-9 score, assessing adherence, and providing support. By the end of the month, you have logged over 70 minutes of work. The PCP can now bill CPT 99492 for the first month of CoCM, a service driven almost entirely by your expert work.
