Your patients have mental health problems. Your practice can get paid to treat them.
Medicare pays a doctor’s office to run a small mental health team inside it. It has paid for this since 2017. Very few practices do it, because nobody explained how. This site explains how, in plain words. It is free.
Written for family doctors and their staff, counseling practices, practice owners, and the people who do the billing. If you have ever handed a patient a phone number and hoped, this is for you.
A doctor with a fifteen-minute slot and a patient who is not sleeping, not taking the medication, and not saying why, is doing mental health care. She is just doing it without a plan, without a team, and without being paid for it.
Count a single morning in a primary care office. Twelve visits: chest pain, a diabetes follow-up, a new patient, hypertension, back pain, an annual wellness visit, a pre-op clearance, COPD, abnormal labs, a headache, a medication review, fatigue.
Underneath those twelve are eighteen other things. An opioid taper the patient is frightened of. Insomnia that no scan will show. A positive depression screen at the desk. Grief after a terminal diagnosis. A caregiver running out of road. Someone who will not take the plan because nobody asked what the plan costs them.
None of those eighteen have anywhere to go. They squeeze into the medical slot, or they leave with a phone number.
Twelve visits. Eighteen needs. Nowhere to land.
Figure 01
Two paths for the same patient.
The usual answer is to refer out. It is the right instinct and it mostly does not work, for reasons that have nothing to do with how good anyone is at their job.
The patient has to call. Then wait. Then get there. Then keep going. Each of those is a place the chain breaks, and when it breaks the practice usually does not find out. The next visit arrives and the doctor asks how the counseling is going, and the answer is that it never started.
Meanwhile the medical plan and the mental health plan are being made in two buildings by two people who will never speak.
Everyone agrees mental health matters. Almost no one gets paid to integrate it.
Stop sending the patient out. Put the mental health work inside the practice, give it a small team, and let the doctor keep the case.
There have only ever been two ways to get paid for mental health work inside a medical practice, and right now one of them is closing while the other opens.
The closing one is incident-to. A physician sets the plan, a clinician on staff carries it out with the doctor in the office, and the claim goes out under the physician’s name. It is how counselors got into medical practices in the first place, and for limited-license clinicians the commercial and Medicaid versions of it are ending on dated deadlines.
The opening one is Collaborative Care, and it is not new. It has been tested for three decades and paid for by Medicare since 2017. The reason it feels unfamiliar is not that it is unproven. It is that adoption has stayed low, because nobody explained the mechanics in a way a practice could act on.
Both of these are the same argument. Mental health work happens inside medical practices whether or not anyone funds it. The question has always been which arrangement pays for it, and that answer just changed.
The patient gets seen
An outside referral often never turns into a first appointment. A care manager inside the practice can see the patient the same week, sometimes the same day.
The physician gets time back
The behavioral work happens without the physician in the room. They stay the name on the claim and keep the visit for medicine.
The work gets measured
A registry tracks every patient month to month. Cases that are not improving get changed rather than repeated.
Figure 02
One patient. Four roles. Two kinds of supervision.
Scroll the figure sideways to see all of it.
The model was built in primary care and it is not confined there. Anywhere a medical problem and a mental health problem share a patient, this is the structure.
- Primary careFifteen-minute visits and a panel full of depression, anxiety and pain. You refer out and rarely hear back.
- Pain managementTapering opioids without anywhere to send people for the psychological half of chronic pain.
- CardiologyDepression after a cardiac event predicts readmission, and nobody on the team is funded to treat it.
- HospitalsReadmission penalties, behavioral patients boarding in the ED, and length of stay driven by problems nobody is treating.
- Nursing homes and long-term careDepression is close to the norm, psychiatric coverage is thin, and survey pressure keeps rising.
- Chronic care managementYou already bill CCM. Mental health is the piece most of those care plans leave out.
- Hospice and palliative careExistential distress and family grief, with a benefit that barely funds the counseling those need.
- OncologyDistress screening is required. Doing something about the result usually is not funded.
- Rural and small-town practiceThe nearest psychiatrist is an hour away and not taking new patients. Consultation can be remote.
- Private practicePayers are narrowing who can bill. Solo economics are getting harder every year.
- PediatricsAdolescent mental health arrives in your exam room whether or not you have anywhere to send it.
- Home-based careNurse practitioners carrying panels alone, with mental health the biggest thing they cannot cover.
The doctor never has to be in the room. The doctor does have to be on the claim.
Four weeks of small, tracked contact, and at the end of it a bill. From inside the practice it does not look dramatic, which is why it is easy to run badly.
Week 1
Enroll and assess
The patient says yes once, and it goes in the chart. A short symptom check (the PHQ-9) gives a starting score, and the care manager and patient make a plan.
30 minutes counted so far. On pace for 99492, the first-month code.
Week 2
Follow up and review
The care manager checks in and runs the score again. The psychiatrist looks over the whole list and marks anyone who is not getting better.
45 minutes counted so far. On pace for 99492.
Week 3
Adjust the plan
For anyone marked, the psychiatrist suggests a change and the doctor decides. The patient never waits for an outside appointment.
60 minutes counted so far. Past 60 minutes. In later months, 60 minutes is a full month (code 99493).
Week 4
Close the month
Add up the minutes and the month tells you which code to bill. The claim goes out under the doctor’s name.
70 minutes counted so far. About 70 minutes. That bills 99492 in a first month, 99493 in the months after.
Minutes decide the code. The code decides the payment.
First month. About 70 minutes of care-manager and consultant time.
Each month after. About 60 minutes.
Add-on. Each extra 30 minutes in the same month.
The physician or other billing provider submits the claim under their own name, with the patient’s consent on file. General supervision applies, which means nobody has to be in the building. That rule sits in permanent federal regulation with no expiration date.
A practice carrying forty enrolled patients, most of them past their first month, bills somewhere near six thousand dollars in a month on these codes. The two rented roles, a care manager and a few hours of psychiatric consultation, cost somewhere near eight thousand. That practice is short, and it is short until the panel grows.
That is the honest shape of it and it is the number nobody publishes. The model does not pay from the first patient. It pays once the panel is large enough to carry two part-time roles, and the only question that matters when you are deciding is where that line falls for you.
The arithmetic is not complicated. Your rates, your panel, your costs. What makes it hard is that your rates depend on your state, your line of business and your contract, and those are the three things a general page cannot know.
Two clocks are running. Permission is loosening. Payment is tightening.
It is getting easier to be allowed to see the patient, and harder to be paid for it. National policy is settling in favor of this model while payer and state rules close the older path underneath it. Both of those are happening this year, which is why a practice that waits is choosing the harder version of the same decision.
Michigan gives limited license clinicians until November 1.
Medicaid now wants each limited license clinician enrolled in CHAMPS under their own NPI. Claims change September 1. Miss November 1 and the clinician is disenrolled. Many practices have not heard about this one.
The doctor does not have to be in the building.
Behavioral health incident to needs only general supervision, and that now sits in permanent federal regulation with no expiration date. It is not a pandemic allowance waiting to lapse.
Telehealth is safe through the end of 2027.
Congress extended it in February 2026 and pushed the in person visit requirement out to January 1, 2028. You can plan two full years around this.
Medicare wants to pay more for collaborative care.
The 2027 proposal raises the work value of 99492 by about 46 percent. It is not final. Public comment closes September 14, 2026, so this is a rare month when saying something actually counts.
It is three decisions, one filing cabinet, and a habit.
First 30 days
Decide who does what
Name the care manager. Find a psychiatric consultant to rent a few hours a week. Sort out who supervises whom, and keep that separate from the caseload review.
Days 30 to 60
Set up the paperwork
Consent language, the registry, the log. This is where most practices stall, because it is unglamorous and nobody owns it.
Days 60 to 90
Run it and watch the minutes
Track time as the work happens. Reconstructing a month at the end of it is the most expensive habit in integrated care.
Nothing here asks you to take our word for it. Every claim on this site points at a document you can open.
Two places to look. Direction is a dated log of payer and state policy changes, each linked to the payer’s own bulletin, with the date we read it. The sources is the library of primary documents underneath all of it, starting with CMS MLN909432.
Where we cannot verify something, we say so on the page rather than round it off. We pulled an entry from the log this month for exactly that reason.
You can build this from what is on this site. Most practices do not want to.
Kedge is software that reads the rules for your state, your licenses and your payers, and tells you what to do next. It is a separate company, run by the same person, and it exists because reading a national log and working out what it means for one practice is a job.
If you would rather just ask a person, ask.
One reply from a person. No sequence. If what you want is a warning the next time a rule moves, that is the Brief Wire at Kedge, not this.