Clinical Context
A patient with complex behavioral health needs, chronic medical comorbidities, or social instability is enrolled in a targeted case management program billed monthly under T2023. Typical patients include adults with severe mental illness (schizophrenia, bipolar disorder), children with developmental disorders, or individuals experiencing homelessness needing coordination of care across behavioral health, primary care, social services, housing, and community resources. The clinical workflow involves an initial comprehensive assessment by a case manager or care coordinator to identify needs, development of an individualized care plan, regular outreach and contacts (phone, home, clinic, or community visits), coordination of services (appointments, transportation, benefits enrollment), monitoring of adherence and outcomes, and monthly documentation summarizing activities and progress. Interdisciplinary communication occurs with psychiatrists, primary care clinicians, social workers, community service agencies, and payors (for example, Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, BUCA, Medicare) to address barriers and modify the care plan. Billing under T2023 is submitted once per month per eligible beneficiary reflecting the aggregated targeted case management services delivered during that month.