Services for Vulnerable Patients Included in the Final 2024 Medicare Physician Fee Schedule
Reimbursement for Community Health Integration, Social Determinants Risk Assessment, and Principal Illness Navigation
On November 2, the Centers for Medicare and Medicaid Services (“CMS”) released the 2024 Medicare Physician Fee Schedule (“2024 MPFS”) final rule. In the proposed rule, which was published in July, CMS proposed three new CPT code sets to provide reimbursement for services related to social determinants of health (“SDOH”). In alignment with the Department of Health and Human Services’ commitment to health equity, the 2024 MPFS finalizes these new services.
CMS defines SDOH as including, but not limited to, “food insecurity, transportation insecurity, housing insecurity, and unreliable access to public utilities, when they significantly limit the practitioner’s ability to diagnose or treat the problem(s).”
These new codes were finalized to reflect the value of practitioners’ efforts to reduce/remove health-related social barriers for patients with serious illnesses. Prior to this rule, reimbursement for these activities was assumed in payment for other services, such as evaluation and management (E/M) visits and care management. Importantly, CMS is now recognizing the value of these services in standalone reimbursement while allowing them to be billed in conjunction with existing care management services like Remote Physiologic Monitoring, Chronic Care Management, and Behavioral Health Integration.
Below is a summary of CMS’ responses and final decisions relating to new CPT codes to facilitate reimbursement for healthcare providers who help patients overcome social and environmental health barriers.
Social Determinants of Health
CMS proposed a new stand-alone G code to separately identify and value the work involved in administering a SDOH risk assessment as part of a comprehensive history when medically reasonable and necessary in relation to an E/M visit. This code has now been assigned permanent status on the Medicare Telehealth list, making it easy to determine, based on the assessment, whether CHI services are warranted and for what kinds of needs.
The risk assessment is intended to be used when a practitioner has reason to believe there are unmet SDOH needs that are interfering with diagnosis and/or treatment of a patient’s condition or illness.
In the proposed rule, the SDOH risk assessment must be furnished by the practitioner on the same day as an E/M visit and requires the administration of a standardized, evidence-based SDOH risk assessment tool that has been tested and validated through research, and includes food insecurity, housing insecurity, transportation needs, and utility difficulties. The proposed rule included a limitation on payment for the SDOH risk assessment service of once every 6 months per practitioner per beneficiary.
The 2024 MPFS finalized the SDOH risk assessment requirements, including the limitation of one assessment per six-month timeframe. However, CMS did not finalize the requirement that the SDOH risk assessment must be performed on the same date as the associated E/M or behavioral health visit. CMS emphasized that the code is not designed to be a screening, but rather tied to one or more known or suspected SDOH needs. In addition to an outpatient E/M visit, the code can also be furnished with the psychiatric diagnostic evaluation code (90791) and the Health Behavior Assessment and Intervention services codes (96156, 96158, 96159, 96164, 96165, 96167, and 96168). The code may also be used in conjunction with an AWV.
The code has been assigned permanent status on the Medicare Telehealth List, meaning that the SDOH risk assessment need not happen in person, and may be administered via telehealth.
The finalized code:
HCPCS G0136 - Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months
Key Takeaway: Practices utilizing a tested and validated SDOH risk assessment tool may use this code to receive standalone reimbursement for administering that assessment as a part of a patient’s comprehensive history.
Community Health Integration
CMS proposed two new G-codes for the provision of Community Health Integration (CHI) services to address the particular SDOH needs identified during an initiating visit or by a SDOH Risk Assessment that present barriers to patient care. The proposed codes included CHI services performed remotely by certified or trained auxiliary personnel, incident to the professional services and under the general supervision of the billing practitioner.
Under the proposed rule, CHI services could be furnished monthly, as medically necessary, following an initiating visit where the practitioner identifies the presence of SDOH need(s) that significantly limit their ability to diagnose or treat the problem(s) addressed in the visit. The initiating visit would be separately billable, but certain E/M visits, such as emergency room, inpatient, and observation visits would not qualify as a CHI initiating visit. Only one practitioner is permitted to bill for CHI services each month.
CMS finalized the CHI proposal largely as proposed, though notably, CMS removed “E/M” from the code descriptor and replaced it with “initiating visit” to allow E/M visits (including those that are part of transitional care management services) and annual wellness visits (“AWVs”) to serve as the initiating visit for CHI services. CMS did not finalize any limitation for the number of monthly add-ons for HCPCS code G0022.
The final rule further states that patient consent is required in advance of providing CHI services, and can be obtained either in writing or verbally. The consent process must include explaining to the patient that cost sharing applies and that only one practitioner may furnish and bill the services in a given month. All auxiliary personnel who provide CHI services must be certified or trained to perform all included service elements, and authorized to perform them under applicable State laws and regulations.
The finalized codes:
HCPCS G00019 - Community health integration services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month; in the following activities to address social determinants of health (SDOH) need(s) that are significantly limiting the ability to diagnose or treat problem(s) addressed in an initiating visit:
Person-centered assessment
Practitioner, Home-, and Community-Based Care Coordination
Health education
Building of patient self-advocacy skills
Health care access / health system navigation
Facilitating behavioral change
Facilitating and providing social and emotional support
Leveraging lived experiences
HCPCS G0022 - Community health integration services, each additional 30 minutes per calendar month (list separately in addition to G0019).
Key Takeaway: Practices can utilize the CHI codes to provide reimbursement for auxiliary personnel’s activities addressing SDOH needs identified during initiating visits.
Principal Illness Navigation
CMS proposed two new G-codes for Principal Illness Navigation (“PIN”) to allow reimbursement for auxiliary support staff like patient navigators or certified peer specialists who provide guidance services to patients. Patients diagnosed with cancer or other severe, debilitating illnesses may benefit from PIN services. These services may be used in conjunction with CHI services when a patient has SDOH needs.
The proposed rule stated that PIN services could be furnished following an initiating E/M visit addressing a serious high-risk condition/illness/disease. The patient eligibility requirements were similar to those of the existing Principal Care Management codes:
One serious, high-risk condition expected to last at least 3 months and that places the patient at significant risk of hospitalization, nursing home placement, acute exacerbation/decompensation, functional decline, or death; and
The condition requires development, monitoring, or revision of a disease-specific care plan, and may require frequent adjustment in the medication or treatment regimen, or substantial assistance from a caregiver.
PIN services were largely finalized as proposed, with the addition of a service element addressing unmet SDOH needs as a part of the person-centered assessment activity included in the code descriptor. The final rule does not include a limit for the duration of PIN services, but it does require that a new initiating visit be conducted once per year. Patient consent is required for PIN services and can be either written or verbal, documented in the medical record. Consent must be obtained annually by the auxiliary personnel either before or at the same time that they begin performing PIN services.
PIN services can be provided more than once per practitioner per month for any single serious high-risk condition and they can be furnished in addition to other care management services as long as all requirements are met.
The finalized codes:
G0023 - Principal Illness Navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator or certified peer specialist; 60 minutes per calendar month, in the following activities:
Person-centered assessment
Identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services
Practitioner, Home, and Community-Based Care Coordination
Health education
Building patient self-advocacy skills
Health care access / health system navigation
Facilitating behavioral change
Facilitating and providing social and emotional support
Leverage knowledge of the serious, high-risk condition and/or lived experience
G0024 - Principal Illness Navigation services, additional 30 minutes per calendar month (List separately in addition to G0023).
In response to public comment, CMS also finalized two new codes for Principal Illness Navigation - Peer Support (“PIN-PS”). The codes are limited to the treatment of behavioral health conditions that otherwise satisfy the definition of a high-risk condition.
The finalized codes:
G0140 - Principal Illness Navigation - Peer Support by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a certified peer specialist; 60 minutes per calendar month, in the following activities:
Person-centered interview
Identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services
Practitioner, Home, and Community-Based Care Communication
Health education
Building patient self-advocacy skills
Developing and proposing strategies to meet person-centered treatment goals
Facilitating and providing social and emotional support
Leverage knowledge of the serious, high-risk condition and/or lived experience
G0146 - Principal Illness Navigation - Peer Support, additional 30 minutes per calendar month (List separately in addition to G0140).
Key Takeaway: PIN services can be furnished alongside other care management services, such as PCM, RPM, and BHI, which will ensure that practices are being reimbursed for both their care management and navigation activities for patients who can benefit from these services.
What These New SDOH and Navigation Services Codes Signal
The 2024 Medicare Physician Fee Schedule final rule opens doors for providers to receive reimbursement for addressing social determinants of health and providing critical navigation services to vulnerable patient populations – services they have often provided without recognition or reimbursement. As digital health companies and healthcare organizations look to enhance support for underserved communities, understanding these new codes in collaboration with existing care management codes will be key to creating sustainable revenue models. There is now a pathway to secure compensation for auxiliary personnel efforts on the frontlines of whole-person care transformation.
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