Get Help Managing Your Pediatric Patients' Mental Health

Medscape

19-06-2025

Simple tests or treatments aren't readily available for our patients with mental health problems.
Although we are the ones who have known the patient and their family for years, that does not mean that we can see mental health disorders developing. We bear a huge responsibility, because, generally, earlier detection can lead to better long-term outcomes for mental health disorders. However, the typically brief pediatric visit does not lend itself to the deeper investigations that help us know what to do next.
Barbara J. Howard, MD
What can we do to get help figuring out what is going on when mental health issues are the concern? Our questions may be about the diagnosis, how to tell how serious it is, what work up is appropriate, what medication to use, how to handle side effects, or how to move the family or child toward more specialized care. Even when we or the family want a referral, getting one can take a long time and doesn't often include timely communication. What our patients need is coordinated, ongoing mental healthcare that connects our care with that of behavioral health specialists.
You can always call a psychiatrist from the emergency department to discuss urgent cases. But for ongoing support, another possibility is to establish relationships with one or more psychiatrists in your community. You may start with a psychiatrist in your affiliated hospital or one in the community who has cared for a patient of yours already. You can ask if they might be willing to provide consultation on your management of other patients for a fee. This could be just for you or organized with a group of pediatricians. I arranged this kind of consultation early in my career with support from my department.
But there are now other ways to obtain and even be paid for collaborations between pediatricians and psychiatrists. The Health Resources and Services Administration established the Pediatric Mental Health Care Access program. This initiative supports state-level Child Psychiatry Access Programs (CPAPs), which provide real-time teleconsultation, training, and care coordination to pediatric primary care providers. The National Network of Child Psychiatry Access Programs serves as a hub for these efforts, supporting existing and emerging CPAPs to integrate mental health and substance use disorder services with primary care. These programs' goals are to increase pediatric primary care clinicians' comfort and skill in managing mild to moderate mental health and substance use disorders, thereby augmenting the limited supply of child and adolescent psychiatrists.
In Maryland, the Behavioral Health Integration in Pediatric Primary Care (BHIPP) program is one example of this model. BHIPP offers free services to providers and their patients, including in-person and web-based training opportunities with continuing medical education, workforce development through co-location of social work interns in primary care practices, web-based longitudinal learning through multiple Project ECHO tracks, direct telemental health services, and care coordination. BHIPP operates as a partnership among several universities, including the University of Maryland, Baltimore, and Johns Hopkins University, ensuring a multidisciplinary approach to pediatric mental healthcare. The services and models in other states vary, along with the numbers of participating medical centers. In most cases you can call a central number to be connected to a psychiatrist.
More recently, standards have been established for more structured 'Collaborative Care Management' (CoCM) that formalizes coordinated care between the child, family, primary care provider, and mental health specialists. While we primary care clinicians remain the center of this care, a behavioral care manager (perhaps a social worker, nurse, or psychologist) helps monitor the patients' symptoms and progress, often using standardized tools, and a child and adolescent psychiatrist consults regularly with the care manager and with us, providing treatment guidance, sometimes without seeing the patient directly. This method of care has been proven effective in multiple trials, showing improvements in depression, anxiety, and behavioral outcomes.
In January 2023, the American Medical Association and the Centers for Medicare & Medicaid Services introduced new current procedural terminology (CPT) codes specific to collaborative care in pediatric primary care: 99492, 99493, and 99494. These codes pay for our time and effort in coordinating mental healthcare, reviewing behavioral data, consulting with psychiatric colleagues, and monitoring a child's progress over time.
Code 99492 covers the first 70 min of collaborative care in the first calendar month, including time spent reviewing screening results, developing a care plan, and communicating with the psychiatric consultant and the family. Code 99493 covers 60 min of care in a subsequent month. Code 99494 is anadd-on code for an additional 30 min in any given month. These codes can be used for children with disorders but also for those with symptoms or issues that don't yet meet formal diagnostic thresholds but are clearly impairing them.
There are other new CPT codes to help pay for our work managing patients with mental health needs beyond the 96127 code for screening. For shorter collaborative care visits for behavioral health problems, code G2214 may apply. G2214 is specifically for billing CoCM services, which involve a primary care team working in collaboration with a behavioral health professional. It can be used for both the initial 30 min of CoCM services and in subsequent months of care. The code applies to the first 30 min of behavioral healthcare manager activities, consultations with a psychiatric consultant, and direction from the treating physician.
Remember also to use code G2211, available since January 1 this year, as an add-on code with a -25 extender that may be reported with new and established evaluation and management services (codes 99202-99215), including telehealth visits, when you are the continuing focal point for all healthcare services for the patient with a chronic condition. This code is not for time-limited patient relationships or if you do not plan to take responsibility for subsequent, ongoing medical care with consistency and continuity over time.
Note that patients may have a copay or coinsurance and that private insurance is not required to pay for this code (G2211). We are all caring for children with ADHD, depression, school refusal, autism, anxiety, and oppositional behaviors who qualify and whose care requires repeated phone calls, reviewing teacher forms, checking PHQ-9s or SCARED scores, and communicating back and forth with schools and psychiatrists. Now, we can be paid, in part, for our efforts.
To provide this collaborative care and bill for it, you need to set up a structure. You may need a behavioral healthcare manager. This could be someone already in your office who can take on the role with some training. You do need a consulting child psychiatrist, who could be consulted via telehealth. You will need a system for tracking symptoms and outcomes, ideally using validated screening or monitoring questionnaires. Electronic health records may help but there are also third-party platforms — such as CHADIS for all mental health or MeHealth for ADHD — that support the use of pre-visit questionnaires, symptom tracking, automated scoring of validated instruments, and guideline-based documentation to share online with your consulting psychiatrist. Sharing this patient data asynchronously may be more feasible, increase the validity of the consultation, and assist in the required documentation for billing.
Workflow change is difficult, but you can start a collaborative care approach with just one or two patients. Once the process is in place, you are likely to find that it not only improves care but also improves overall workflow. Instead of running over time from the behavior-focused visit into the next appointment, you can engage the care manager to set up a consultation and let the family know about the process.
While we are the primary professionals who have the relationship with the patient and family, we no longer have to be providing this essential care alone and uncompensated.