Behavioral Health Integration Monthly Summary (General BHI)

(Complete all compliance-critical fields. If information is unknown or unavailable, use explicit placeholders such as "Not on file," "Not obtained—do not bill," or "Threshold not met." Do not infer clinical status without direct contact or objective data.)

Service Period: [YYYY-MM-DD through YYYY-MM-DD (calendar month)]

Date Authored: [YYYY-MM-DD]

Patient: [Full name], DOB: [YYYY-MM-DD], MRN: [Medical record number]

Documenting Staff: [Name, role/title]

Billing Practitioner: [Name, credentials]

BHI Code Intended: [99484 (General BHI) / Not billed this month]

BH Condition(s) Addressed: [Diagnosed behavioral health condition(s) driving BHI activity this month]

Consent Status: [Obtained / Not obtained—do not bill], [date], [verbal / written]

Initiating Visit: [Date and type of qualifying visit / On file: date, type]

Clinical Status

[Monthly clinical summary] (Narrative paragraph describing: why BHI was active this month; whether patient contact occurred and modality; clinically significant events such as ED visits, hospitalizations, therapy changes, or new stressors; and current symptom and functional status with source attribution. Include validated rating scale results inline with tool name, date, score, and trend. Document treatment engagement and barriers. If no patient contact was achieved, list outreach attempts with dates/methods and state that status update was unavailable.)

Risk & Safety

(Include this section when any safety concern exists, screening is positive, or behavioral health is a primary focus. Omit only if no BH condition with safety implications is addressed and no concerns exist.)

[Risk and safety assessment] (Document whether suicide/self-harm screening was performed this month and the result. If positive or any concern exists, document ideation, plan/intent, risk and protective factors, overall risk level with rationale, and mitigation plan including safety plan status, crisis resources provided, and follow-up interval. Note overdose risk and naloxone status if relevant. If patient was unreachable and history indicates risk, document that safety could not be assessed and escalation steps taken.)

Interventions & Care Plan

[Care coordination activities] (Summarize assessment/monitoring, care planning, referral coordination, communication with external providers, and continuity actions completed this service period.)

Care Plan Status: [Reviewed—no changes / Updated as described below]

[Care plan update by BH problem] (For each active BH problem: state current status with basis, goals, active interventions, barriers or SDOH factors, responsible parties, and next steps with timeframe. Use brief narrative or a single consolidated list; do not create separate subsections per problem.)

Time Summary

Total Qualifying Minutes: [Total minutes] — Threshold: [Met / Not met—not billed]

Time by Role: [Clinical staff: X min; Billing practitioner: Y min]

(Administrative/clerical time excluded. Minutes not counted toward other time-based care management services billed this month.)

Attestation

[Attestation statement] (Confirm the billing practitioner directed/oversaw BHI services for this month, required consent was obtained and documented, and the care plan was reviewed or updated as appropriate.)

Documenting Staff Signature: [Name, credentials, date]

Billing Practitioner Signature: [Name, credentials, date]