Mental health and medical care belong on the same team.
Patients already bring pain, anxiety, grief, sleep problems, and other mental health needs into ordinary medical visits. The people trained to help are often working somewhere else.
Medicare has paid for a model that brings the two together since 2017. CIN explains the care model, the partnership, and how the payment works.
Primary sources · plain language · publicly available
The need is already in the room. The team usually isn’t.
A visit may be scheduled for chest pain, diabetes, or a medication check. But those problems do not stay outside the exam room, and the doctor still has to respond, in a fifteen-minute slot, without a mental health team.
The schedule · one morning
Chest pain · diabetes follow-up · new patient · hypertension · back pain · annual wellness · pre-op clearance · COPD · abnormal labs · headache · medication review · fatigue
Beneath the schedule
An opioid taper the patient is frightened of. Insomnia no scan will show. A positive depression screen at the desk. Grief after a terminal diagnosis. A caregiver running out of road. A plan not followed because nobody asked what it costs them.
The office may not have a counselor, care manager, or psychiatrist working with the medical team. So the mental health problem gets squeezed into a short medical visit, or the patient leaves with a phone number for someone else.
Figure 01
Two paths for the same patient.
Refer out
Patient
needs support
Referral
sent outside the practice
Phone
the patient follows up alone
Wait
time passes, unrecorded
Appointment
care happens outside the record
Information rarely returns to the medical record.
Integrated care
Patient
needs support
Care manager
stays in touch, tracks progress
Medical team
works one plan
Shared record
the plan lives in one place
The plan changes in the same record.
Integrated care keeps the patient at the center, the team aligned, and the plan alive in one place.
One patient.
One plan.
One record.
A referral is not a bad idea. The problem is how many steps happen after the patient leaves. The patient has to call. Then wait. Then get there. Then keep going. Every extra step is another place the connection can break, and when it breaks, the medical office may never hear what happened.
Integrated care keeps the patient and the information connected to the medical team.
There is more than one way to bring mental health care into a medical practice.
In one model, a counselor provides a covered service as part of the medical practice. The medical provider sets or directs the treatment plan, and the practice bills the service under Medicare’s incident-to rules, when all of those rules are met.
In another model, a small team follows the patient across the month. A care manager stays in touch. A psychiatric consultant reviews the patient list. The medical provider stays responsible for the medical care. Medicare calls this Collaborative Care.
Same goal. Different structure.
Integration can begin from either side.
One patient. One team. One plan.
A medical practice
can add a mental health team to the care it already gives.
The patient
at the center of every decision.
A mental health practice
can partner with a medical practice and bring its clinicians into medical care.
Collaborative Care
gives them a structure for working together, clinically and financially.
Collaborative Care is the team model.
The patient does not have to start over with a separate system. A care manager stays in contact and tracks progress. A psychiatric consultant helps the team when treatment needs to change. The patient’s regular medical provider stays involved, and Medicare pays the practice for qualifying work the team does across the month. CMS describes the roles and billing in booklet MLN909432.
Figure 02
One patient. One team. Four different jobs.
Psychiatric consultant
reviews the patient list and recommends treatment changes
Patient
gets care
Care manager
checks in with the patient and tracks progress
Medical provider
leads the medical care and bills Medicare
Licensure supervisor
a separate licensing role
Supervises the clinician’s professional practice.
CMS describes the psychiatric Collaborative Care codes, 99492 to 99494, in booklet MLN909432.
Two supervisors. Two different jobs.
Psychiatric consultant
Helps the team treat the patient.
Reviews the patient list each week and recommends changes.
Medicare requires this role for Collaborative Care.
Licensure supervisor
Helps the clinician meet state licensing requirements.
A different person, a different record,
and no part of the billing.
Different roles. Different records. Clear boundaries.
03 / Where it works
Collaborative Care grew out of primary care. Integration takes different forms across medical settings.
Integrated mental health care can be useful wherever medical and mental health needs overlap. The best structure depends on the setting, the patient, the clinicians, and the payer.
Primary care
depression / pain / anxiety
Pain management
tapering / fear and coping with pain
Cardiology
depression / following the treatment plan
Oncology
distress / survivorship
Hospitals
readmissions / waiting in the ER
Nursing homes
depression / limited access
The same patient
Chronic care management
mental health alongside chronic care
Hospice and palliative
grief / family / meaning
Rural practice
access / remote consultation
Private practice
narrowing networks
Pediatrics
adolescent mental health
Home-based care
patients cared for by nurse practitioners
Different settings.
Same question: can the medical and mental health care stay connected?
Collaborative Care happens between visits. Medicare counts the work across the month.
Qualifying care-management and psychiatric-consultation time adds up across the month. At the end of the month, the total time helps determine which code the practice bills.
Figure 03
The minutes build all month.
Qualifying care-management and consultation time is recorded as the work happens. Those minutes add up across the month.
Week 1
30 min total
Week 2
45 min total
Week 3
60 min total
Week 4
70 min total
30 min
Enroll + assess
Consent.
Baseline score.
Plan together.
45 min
Check in + review
Follow-up.
Rescore.
Caseload review.
60 min
Adjust the plan
Consultant recommends.
Medical provider decides.
Plan updates.
70 min
Close the month
Total the minutes.
Identify the code.
Submit the claim.
One month. One running total. One claim.
Two models. Two different ways Medicare pays.
Incident to: Medicare pays for a covered service provided under its incident-to rules.
Collaborative Care: Medicare pays for qualifying team-based work accumulated across the month.
Do not mix the rules. They solve related problems, but they are different Medicare payment structures.
Medicare is not the only insurer here. State Medicaid programs and commercial plans across the country recognize Collaborative Care to varying degrees, each with its own rules. In Michigan, for example, Medicaid, Blue Cross Blue Shield of Michigan and Priority Health all do. Incident to also exists in commercial and Medicaid versions, and those are the ones changing on dated deadlines. What applies to one practice depends on its state and its payers, which is what Kedge is for.
Figure 04
Two ways Medicare can pay.
Incident to
Collaborative Care
In one sentence
a counselor working inside medical care
a mental health team wrapped around the medical patient
Mental health role
the counselor performs the covered service under the rules
a care manager follows the patient and tracks progress
Medical role
the medical provider creates and directs the plan
the medical provider leads the medical care
Psychiatric consultant
not a defining feature
built into the model
How payment works
the service is billed under Medicare’s incident-to rules
qualifying team time accumulates across the month
Incident-to and Collaborative Care can both bring mental health work into medical care, but their supervision, staffing, documentation, and billing rules are different; the guide has the mechanics.
A partnership can start from either side.
A medical practice may have the patients, but not the mental health workforce. A counseling practice may have the workforce, but not the medical side of the model. They can work together. The right arrangement depends on the services, the clinicians, the supervision, the setting, the contracts, and the payer’s rules.
Already employing mental health clinicians?
A change in one reimbursement pathway does not necessarily mean a clinician has no place in the practice. Integrated care may create a different role for some clinicians, with different work, different supervision, and different billing rules. That has to be evaluated clinician by clinician and payer by payer.
Figure 05
Collaborative Care changes the unit being paid for.
Ordinary therapy is usually billed visit by visit. Collaborative Care is different: the practice tracks qualifying work across the month, and the total time determines the monthly code.
The first month of Collaborative Care,
about 70 minutes
Code
99492
Each later month,
about 60 minutes
Code
99493
Each extra 30 minutes
in the same month
Code
99494
Does Collaborative Care pay for itself?
The monthly codes are only half the equation. The practice also has to pay the people doing the work. A small panel may not cover those costs; as the panel grows, the same part-time team may support more patients, and the economics can change.
Figure 06
Monthly economics as your panel grows · illustrative model, not a target caseload
The $8,000 example assumes new staffing costs. A practice that already employs a clinician who can appropriately serve as the care manager may have a very different cost structure. That depends on qualifications, workflow, supervision, contracts, and payer rules. Blue Cross designation incentives, where a practice qualifies through its physician organization, sit on top of this example and are not counted in it.
What changes when the team is inside the practice
The patient has someone to follow up.
Between medical visits.
The care manager can check in between visits, and progress and treatment changes stay connected to the medical plan.
The provider does not carry every follow-up alone.
The team shares the work.
Some of the ongoing work moves to the care manager and the psychiatric consultant. The medical team gets information back.
There is a defined payment structure.
When the requirements are met.
Qualifying Collaborative Care work can be billed through the monthly codes.
The rules are changing. Some changes make integration easier. Others change how clinicians can be paid.
Payment rules, enrollment requirements, supervision rules, and deadlines change. CIN teaches the model. Kedge watches the changes that may affect a practice. The Initiative carries research findings into policy and advocacy.
When a rule moves · Kedge
Dated, signed notifications for your practice.
The Brief Wire watches the fee schedules, the bulletins and the deadlines, and tells you when something that affects your situation changes.
When a rule should move · the Initiative
Advocacy, with the field’s evidence attached.
The Integral Neuroscience Initiative carries what the Observatory studies find into comment windows and policy rooms.
Building it takes a team, a workflow, and a way to track the work.
First
Choose the team
Who will be the care manager? Who provides the psychiatric consultation? Who is the medical billing provider? Keep the licensure supervision separate from the caseload review.
Next
Build the system
Consent language, the patient list, documentation, time tracking. This is often where implementation slows: the work is administrative, and ownership has to be clear.
Then
Start small
Enroll patients. Record time as the work happens. Fix what does not work.
Finally
Watch the numbers
Are patients being followed? Is the team keeping up? Are claims being paid? Is the panel large enough to support the staffing?
Nothing here asks you to take our word for it. Every claim points at a document you can open.
CMS
MLN909432
Behavioral Health Integration Services. Defines the CoCM team, the minute thresholds and the supervision.
Verified Aug 2026
Federal regulation
42 CFR §410.26
General supervision for services incident to a physician’s service. Permanent, with no expiration date.
Verified Aug 2026
BCBSM
Provider bulletin
The designation path for collaborative care in Michigan, through the physician organization.
Checked Aug 2026
Two places to read further. The sources is the library underneath all of it. The Brief Wire at Kedge is the dated log of payer and state policy changes, each linked to the original bulletin with the date it was read, and it is where a practice gets notified when a change affects it. Where we cannot verify something, we say so on the page;.
The Observatory · an institutional desk
Six studies of the people doing the work.
License records tell us who holds a credential. They do not tell us what happens after that. Can a new counselor find a supervisor? How long does enrollment take? Do reimbursement changes lead practices to stop hiring? Do patients lose appointments? The Behavioral Health Workforce Observatory studies the questions the rosters cannot answer.
Every study leads with its document, free and ungated. Findings go to respondents first. The Observatory’s index →
Your practice is specific.
CIN explains the public rules. Applying them to one practice means knowing its state, its licenses, its payers, its contracts, its staffing and its rates. Kedge is the separate software platform for applying those rules to one practice.
Run your numbers →Check your structure →
If you would rather 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.
Kedge Software LLC is a separate company affiliated through common ownership. CIN’s public educational material remains freely available.