Psychiatric Collaborative Care Monthly Summary (CoCM)

Note Title: Psychiatric Collaborative Care (CoCM) — Monthly Summary

Month Covered: [Start date] — [End date] ([Calendar month, year])

Patient: [Full name] | [MRN / DOB]: [Identifier per local policy]

Behavioral Health Care Manager (BHCM): [Name, credentials]

Treating/Billing Practitioner: [Name, credentials]

Psychiatric Consultant: [Name, credentials]

Enrollment & Consent: [Consent obtained (date); initiating visit (date) on file / Not documented — reason and plan to obtain]

Registry & Clinical Status

Registry status: [active / on hold / discharged] (If on hold or discharged, include date and brief reason.)

Caseload review: [Dates of systematic review sessions this month] | Patient discussed with consultant: [yes (date) / no]

Measurement-based monitoring:

• PHQ-9: Prior [score (date)] → Current [score (date)] | [improved / stable / worse]; At target: [yes / no]
• GAD-7: Prior [score (date)] → Current [score (date)] | [improved / stable / worse]; At target: [yes / no]
• Other: [Measure name] — Prior [score (date)] → Current [score (date)] | [improved / stable / worse]; At target: [yes / no] (Include only if applicable.)

(If measures not obtained, state "Not obtained" with reason and plan to administer.)

Interval summary: [2–3 sentences: symptom course, contacts and outreach this month with number and modality, care gaps or barriers identified and plan to address]

Psychiatric Consultant Review

Date of review: [Date / Not reviewed this month]

Clinical question: [Focused question posed by BHCM or treating practitioner]

Consultant recommendations: [Specific, actionable recommendations — may include medication changes with rationale, diagnostic considerations, psychotherapy recommendations, safety recommendations, referral indications as applicable]

Communication: [How and when recommendations were conveyed to treating practitioner]

(If not reviewed this month, document reason and note billing implications per organizational policy.)

Assessment & Plan

[Behavioral health problem #1]

Assessment: [Current symptom severity, measurement trajectory, treatment response, functional impact. Include risk status if clinically relevant: suicidal ideation status, safety plan status, escalation actions taken. If risk assessment indicated but not completed, note as care gap with follow-up plan.]

• Medication plan: [Action and who will implement]
• BHCM follow-up: [Interval]; next contact [date]
• Patient tasks: [Self-management assignments]
• Stepped-care rationale: [Reason for current treatment intensity based on measurement trajectory] (Include when intensifying or changing treatment.)

[Behavioral health problem #2]

(Include additional problems as applicable using same format.)

Time & Billing

Total CoCM billable minutes this month: [XX minutes]

Minutes by activity: Patient contacts: [XX] | Care coordination: [XX] | Registry/consultant review: [XX] (Reference detailed time log on file if applicable. Exclude administrative time; do not double-count time billed separately.)

Billing code(s): [99492 / 99493 / 99494 / G2214]

BHCM attestation: I attest that the time recorded reflects only eligible CoCM services and excludes administrative activities.

Treating practitioner attestation: I reviewed and oversaw CoCM services for this patient during the month covered and remain responsible for the patient's care.

Signatures:

• BHCM: [Name, credentials, signature] — Date: [date]
• Treating/Billing Practitioner: [Name, credentials, signature] — Date: [date]
• Psychiatric Consultant: [Name, credentials, signature] — Date: [date] (Optional per organizational policy.)