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A collaborative care note is the registry-backed record a behavioral health care manager keeps for each patient in the psychiatric Collaborative Care Model (CoCM) or general behavioral health integration (BHI). It logs contacts, validated symptom scores, psychiatric consultant recommendations, and clinical minutes across the calendar month. The billing practitioner's monthly claim under 99492, 99493, 99494, or 99484 stands on that time-and-registry trail.
The behavioral health care manager, under general supervision of the billing practitioner; consultant recommendations may be entered by either
The CoCM team, the billing practitioner, payers, and auditors reconstructing the month
75 to 250 words per registry entry · 3 to 8 minutes per entry by hand (clinical team estimate)
Registry-based monthly care management record (CoCM/BHI family)
Every calendar month of a CoCM or BHI episode, from initiating visit through relapse-prevention planning and discharge
Medicare payment policy dictates the content; no statute mandates a note format, and retention is the part that is law
A collaborative care note is the running record a behavioral health care manager (BHCM) keeps for each patient enrolled in the psychiatric Collaborative Care Model: dated registry entries for every contact, validated symptom scores, the psychiatric consultant's recommendations, and a log of clinical minutes that accumulates toward the month's billing threshold. The model traces to the IMPACT trial (Unützer and colleagues, JAMA, 2002), which randomized 1,801 older adults across 18 primary care clinics in 5 states; at 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms against 19% in usual care, and a follow-up analysis found lower total healthcare costs over 4 years. The University of Washington's AIMS Center, established by the trial's principal investigator, turned that protocol into the registry-and-caseload workflow the note now documents. CMS built the payment scaffolding in two steps: temporary codes G0502, G0503, G0504, and G0507 effective January 1, 2017, replaced by CPT 99492, 99493, 99494, and 99484 on January 1, 2018. You will also hear the note called a registry note, caseload review note, care manager contact note, BHCM note, or, for the lighter model, a general BHI note.
Two boundaries do most of the work. First, this is not a generic care coordination note: CoCM documentation is registry-driven, measured with validated scales, reviewed weekly with a named psychiatric consultant, and banded to the calendar month, while general coordination notes follow no billing clock at all. (Tracking scores inside ordinary therapy belongs in an outcome measure review note.) Second, the "required fields" clinicians trade lists of are almost entirely payer policy, not law: CMS publishes no note template, and the registry, rating-scale, and weekly-review expectations live in the January 2026 MLN909432 booklet as conditions of Medicare payment. What is law: retention, 7 years from the date of service under 42 CFR 424.516(f), and the boundary in 45 CFR 164.501 that keeps this material out of protected psychotherapy-notes status, because registry entries, scores, medications, and session times belong to the ordinary medical record.
The daily author is the behavioral health care manager embedded in a primary care practice, though the model runs anywhere a billing practitioner with E/M scope operates: family medicine, internal medicine, pediatrics, and specialty clinics such as oncology or cardiology. The psychiatric consultant, typically remote, reviews the caseload weekly and leaves recommendations without seeing the patient; the treating practitioner bills the month. Clinical psychologists and clinical social workers keep the same style of record under G0323, with a psychiatric diagnostic evaluation (90791) as the initiating visit. Reach for this format when a patient is enrolled in CoCM or general BHI and the calendar month has to be reconstructable for a claim. Reach for a plain care coordination note when you are coordinating outside any billing model, and a discharge summary when the episode ends and care hands back to the referring or ongoing clinician.
Team and month header. Patient identifiers, the calendar month, and the three named roles: treating (billing) practitioner, behavioral health care manager with credentials, and psychiatric consultant. CMS describes the BHCM as having "formal education or specialized training in behavioral health" (MLN909432), so record the credential you are relying on. Pitfall: a consultant who is never named in the record makes the three-member team unverifiable and the month's claim unsupportable.
Consent and initiating visit. One line anchoring the consent conversation (date, who obtained it, cost sharing explained) and the visit that started services: an annual wellness visit, IPPE, comprehensive E/M, or TCM visit, or a 90791 evaluation for G0323. Consent may be verbal, is documented once, and is refreshed only if the billing practitioner changes. Pitfall: consent that lives in a clinician's memory instead of the record; auditors read absence as never obtained.
Contact and activity log. The spine of the note: one dated entry per contact or care activity with the mode (phone, portal, video, in person), what clinically happened, and the minutes. Time spent documenting in the registry or EHR counts; scheduling, reminders, translation logistics, and travel do not. Pitfall: a single end-of-month block of minutes with no activities attached; time that cannot be reconstructed is time a reviewer will not credit.
Validated measure tracking. The month's score on the scale the registry tracks (PHQ-9, GAD-7, or another validated instrument; CMS names no specific tool) beside the baseline and prior scores so the trajectory is visible at a glance. Pitfall: a filed score with no response to it; flat or worsening numbers over an unchanged plan invite the medical-necessity question.
Psychiatric consultant review. The date the patient was covered in the weekly caseload review, the consultant's recommendations, and who entered them. The care manager may record the recommendations; the consultant is not generally expected to see the patient. Pitfall: a standing weekly meeting that never shows up in this patient's chart; for audit purposes it did not happen for this patient.
Treatment-to-target response. What changed because of the numbers: a medication recommendation relayed to the prescriber, a brief evidence-based intervention such as behavioral activation or motivational interviewing, a stepped referral toward specialty care. Pitfall: describing activity without linking it to the target the registry tracks; "supportive contact" is not a treatment adjustment.
Monthly time summary and code. Total countable clinical minutes for the calendar month and the code that total supports: 70 minutes for the first month, 60 for subsequent months, each additional 30 for the add-on unit, 30 for a partial month under G2214, 20 for general BHI. The month is the unit; minutes do not carry forward. Pitfall: quietly rolling leftover minutes into next month, or letting the billing practitioner's solo registry review pad the care manager's total.
Next month and exit plan. What the team watches next, the re-administration date for the scale, and, as scores approach remission, relapse-prevention planning toward discharge from active treatment. An episode also ends after 6 consecutive months without CoCM services. Pitfall: episodes with no exit logic; a registry full of indefinite maintenance patients is a signal reviewers notice.
COLLABORATIVE CARE (CoCM/BHI) MONTHLY NOTE Patient: ____________________ DOB: __________ Month/Year: __________ Billing practitioner: ________________________________________________ Behavioral health care manager (credentials): ________________________ Psychiatric consultant: ______________________________________________ Consent documented (date / verbal / cost sharing explained): _________ Initiating visit (type and date): ____________________________________ CONTACT AND ACTIVITY LOG (clinical minutes only) Date Mode Activity and clinical content Minutes _____ _______ _________________________________________ ______ _____ _______ _________________________________________ ______ _____ _______ _________________________________________ ______ _____ _______ _________________________________________ ______ _____ _______ _________________________________________ ______ VALIDATED MEASURES Scale: ________ Baseline: ____ Prior: ____ This month: ____ (date: _____) PSYCHIATRIC CONSULTANT REVIEW Caseload review date: ________ Recorded by: _________________________ Recommendations: _____________________________________________________ Relayed to billing practitioner (date / action taken): _______________ TREATMENT-TO-TARGET RESPONSE ______________________________________________________________________ MONTH TOTAL: ______ clinical minutes Code(s) supported: ___________ Clerical, travel, and non-BHCM time excluded from total: [ ] confirmed PLAN FOR NEXT MONTH / RELAPSE PREVENTION AND EXIT ______________________________________________________________________ Signature / credentials / date: ______________________________________
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: a 58-year-old man enrolled in his primary care clinic's CoCM program for recurrent depression, month 3 of the episode. This is a complete month of collaborative care documentation: the registry contact log, the score trend, the consultant's recommendation, and the time total behind the claim. All details are fictional.
Collaborative Care Monthly Note (CoCM). Patient: D.M., 58M · Month: July 2026 (month 3 of episode) · Dx: F33.1 · Billing practitioner: Dr. A. Patel (family medicine) · BHCM: L. Moreno, LCSW · Psychiatric consultant: Dr. R. Ellison, MD
Consent and initiating visit: Verbal consent documented 05/06/2026 at comprehensive E/M visit with Dr. Patel; cost sharing explained; billing practitioner unchanged, no new consent required.
Contact and activity log (clinical minutes):
07/02, phone: PHQ-9 administered, score 11; sleep log reviewed; behavioral activation plan reinforced. 14 min
07/08, video: behavioral activation session; activity scheduling around work shifts; barriers to walking plan addressed. 28 min
07/09, team: weekly caseload review with Dr. Ellison; case presented, recommendation below. 12 min
07/10, phone: consultant recommendation relayed to Dr. Patel; sertraline increased 50 mg to 100 mg, prescription filled 07/11. 8 min
07/16, clinic: brief in-person check; PHQ-9 8, GAD-7 7; medication tolerated, no side effects reported; walking goal met 4 of 7 days. 22 min
07/23, registry: flowsheet updated with treatment-to-target status; relapse-prevention items drafted for August. 8 min
Validated measures: PHQ-9: 16 baseline (05/06), 12 (06/11), 11 (07/02), 8 (07/16). GAD-7: 9 (06/11), 7 (07/16). PHQ-9 item 9 scored 0 at both July administrations.
Psychiatric consultant review (07/09): Partial response on sertraline 50 mg with PHQ-9 stalled near 11 for four weeks. Recommendation: increase to 100 mg, re-check score in 4 weeks, continue behavioral activation. Recorded by L. Moreno, LCSW; Dr. Ellison had no direct patient contact. Relayed to and actioned by Dr. Patel 07/10.
Treatment-to-target response: Medication adjusted per consultant recommendation; behavioral activation continued with activity scheduling; PHQ-9 fell from 11 to 8 after the change.
Month total: 92 clinical minutes. Supports 99493 (subsequent month) plus one add-on unit of 99494 for the additional 30 minutes. No clerical or travel time counted. No general BHI code reported this month.
Plan: Re-administer PHQ-9 and GAD-7 first week of August; if PHQ-9 holds under 10, begin relapse-prevention planning toward discharge from active treatment around month 5; patient remains on the weekly caseload review list.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsEverything in the CoCM record, registry entries included, is ordinary medical record. 45 CFR 164.501 reserves psychotherapy-notes protection for a therapist's separated process notes and expressly excludes medication monitoring, session times, modalities, and clinical test results, which covers most of what a collaborative care note contains. It sits in the designated record set, patients can access it, and it is discoverable. Retention is the genuinely statutory layer: Medicare enrollment rules require the documentation behind orders, referrals, and payment requests to be kept for 7 years from the date of service (42 CFR 424.516(f)), CMS can revoke enrollment for failing to keep or produce it (42 CFR 424.535(a)(10)), Medicare Advantage contracts carry a 10-year federal audit window (42 CFR 422.504), and state medical-records law can extend the clock further. Hold the month's record for the longest rule that touches it.
The payer chain is where collaborative care documentation actually fails. Reading Medicare's own claims data, Marcotte and colleagues found denials rose from 5% of CoCM and general BHI services in 2017 to 32% in 2018 while volume grew eightfold (Psychiatric Services, 2021), and early adopters interviewed by Carlo's team described the cumulative minute tracking and once-monthly claim entry as the arduous part of the model (Journal of General Internal Medicine, 2019). The conditions themselves are stable and knowable: an initiating visit on file, consent documented once, a named three-member team, a registry with a validated scale in active use, a documented consultant review, and a time log that clears the threshold for the code billed, with clerical, travel, and practitioner-solo time excluded and no general BHI code in the same month as CoCM for the same patient. The note's format is a convention; that evidence chain is the requirement. Keep the claim arithmetic beside the clinical story the way a billing note does, and keep the measurement thread consistent with the outcome measure review notes your therapists write outside the model.
There is no CoCM-specific OIG audit to point to: a July 2026 search of OIG's public reports returns none, and the audit heat in the care-management family sits on Chronic Care Management instead (Work Plan project OAS-26-09-007, announced March 16, 2026, covers CCM payments from 2019 through 2024). The warning lives in the denial data: Medicare denied 32% of CoCM and general BHI services in 2018, up from 5% in 2017, even as volume grew eightfold (Marcotte et al., Psychiatric Services, 2021). The BastionGPT Clinical Advisory Board sees the same errors most often in collaborative care note reviews:
| Aspect | United States | Canada | Australia |
|---|---|---|---|
| Status | Payer policy: a Medicare code family (99492, 99493, 99494, 99484) whose conditions of payment shape the note; no statute prescribes a format | No CoCM billing analog; collaborative mental health care runs on provincially funded shared-care models and team programs | No CoCM billing analog; the nearest MBS structures are episodic plan and case-conference attendance items |
| Terminology | CoCM note, registry note, caseload review note, BHCM note, general BHI note | Shared care, collaborative mental health care (the CCMHI lineage), interprofessional team-based care | GP Mental Health Treatment Plan, multidisciplinary case conference, team care arrangement |
| What changes | The calendar month is the unit: time thresholds, registry tracking, and weekly consultant review must be reconstructable for every month billed | No time-banded month exists; physician billing is provincial fee-for-service and team funding flows through programs, so the record follows college documentation standards rather than a payment clock | Items pay per attendance, not per month: a plan item such as 2715 pays a single preparation attendance, and case-conference items in the 735 family pay time-tiered conferences |
| Retention | 7 years from the date of service is law (42 CFR 424.516(f)); Medicare Advantage adds a 10-year audit window; state rules can run longer | College standards govern; CPSO in Ontario requires 10 years from the last entry, or 10 years after a child patient turns 18 | Whole record 7 years from last entry, until age 25 for clients under 18 |
The clinical model itself travels: measurement-based caseloads, a consulting psychiatrist, and treatment to target all exist inside Canadian shared-care programs and Australian integrated-care arrangements, and the logic of this note transfers with them. The billing scaffolding does not. Import the workflow rather than the US payment rules, and document to your province's college standard or to the MBS item actually being claimed.
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Enough that a stranger can rebuild the month. Each registry entry carries the date, the mode of contact, what clinically happened, and the minutes, which usually lands between 75 and 250 words. The monthly total then has to be traceable to those entries: six short, dated entries that sum to 92 minutes beat one polished paragraph sitting over a bare total. The sample above shows the full pattern.
No. CMS has never published a collaborative care note template, and no statute prescribes a format. What exists are conditions of payment in the MLN909432 booklet (January 2026): an initiating visit, documented consent, a registry in active use, validated rating scales, weekly psychiatric caseload review, and time thresholds per calendar month. Meet those on paper however your EHR allows; the format is yours, the evidence chain is not.
No. CMS is explicit in MLN909432: "We don't require written consent." Verbal consent works, but it must be documented in the medical record, the patient must be told cost sharing applies, and a new consent is needed only if the patient changes billing practitioners. The recurring audit failure is not the consent conversation; it is the missing line documenting it.
Only the behavioral health care manager's clinical time: contacts with the patient, coordination with the team and outside providers, and time documenting in the registry or EHR, per the AIMS Center finance FAQ. Scheduling, appointment reminders, translation logistics, travel, and the billing practitioner's solo registry review do not count. A licensed care manager can also bill psychotherapy in the same month, but the same minutes can never serve both codes.
The psychiatric CoCM family: 99492 for the first calendar month (70 minutes of care manager time), 99493 for subsequent months (60 minutes), 99494 for each additional 30 minutes, and G2214 for a 30-minute partial month. General BHI runs on 99484 (20 minutes of clinical staff time), with G0323 as the clinical psychologist and clinical social worker version. CoCM and general BHI are never billed in the same month for the same patient, and the July 2026 CMS practitioner file lists a medically unlikely edit value of 4 for 99494, with payer variation, so confirm your own payer's limit.
Neither. The care manager may record the consultant's recommendations, and CMS describes the consultant as not generally expected to have direct patient contact, prescribe, or deliver treatment directly. The consultant does not bill these codes either: the CMS FAQ published by the APA notes that "psychiatric work is defined as a sub-component of the psychiatric CoCM codes," so payment flows through the treating practitioner, who holds the consultant relationship by contract or employment.
Scope and clock. A care coordination note records coordination work wherever it happens, with no registry, no consultant, and no monthly arithmetic. The collaborative care note is a payment-bearing record: registry-driven, scale-measured, consultant-reviewed, and banded to the calendar month. In between sits measurement-based care in ordinary therapy, which belongs in an outcome measure review note, and the end of any episode can feed a discharge summary.
No. Neither country has a monthly, time-tracked CoCM code family. Canada funds collaborative mental health care through provincial shared-care and team programs, with documentation governed by college standards such as CPSO's 10-year retention rule in Ontario. Australia's nearest structures are episodic MBS attendances: Better Access plan items such as 2715 and time-tiered case-conference items in the 735 family. The clinical workflow transfers; the US billing rules do not.
Bring the month however it exists: call notes, a dictated recap, the registry export. BastionGPT drafts the dated entries with minutes and clinical content in place, then checks what reviewers read first: the time total against the code, the consultant review, the score trend and the response to it, and the consent anchor. BastionGPT is HIPAA-compliant with a signed BAA, and data is never used to train models.
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.