This is information from the 2024 Physician Fee Schedule PROPOSED Rule
CMS is proposing to create two new HCPCS codes to describe community health integration (CHI) Services performed by certified or trained auxiliary personnel under the general supervision of a billing practitioner. The services would require an initiating E/M visit, typically an office visit. It would be furnished monthly as medically necessary when the practitioner identifies the presence of Social Determinants of Health (SDoH) needs.
During the initiating visit, the practitioner would assess and identify these SDoH needs that limit the practitioner’s ability to diagnose or treat the patient’s medical condition(s). The practitioner with establish an appropriate treatment plan which would specify how addressing the unmet needs would help accomplish the plan, and establish those services as incident to the billing practitioner’s service. The work of the CHI services would be done by a community health worker or other auxiliary personnel. The services would be billed by the practitioner who initiated the service.
CMS notes that the phrase or term “problem addressed” in this section corresponds to the definition in the CPT book related to E/M services.
CMS discusses the definition of SDoH as it relates to this section and to PIN services (discussed in another article on CodingIntel) and states they “include but are 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 )address at the CHI initiating visit.” p. 240 See our recent Q&A about SDoH. link
They are proposing these code definitions. (The codes in this document are placeholder codes. CMS will release the actual codes in November, in the Final Rule.)
GXXX1 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 ability to diagnose or treat problem(s) addressed in an initiating E/M visit:
- Person-centered assessment, performed to better understand the individualized context of the intersection between the SDOH need(s) and the problem(s) addressed in the initiating E/M visit.
++ Conducting a person-centered assessment to understand patient’s life story, strengths, needs, goals, preferences and desired outcomes, including understanding cultural and linguistic factors.
++ Facilitating patient-driven goal-setting and establishing an action plan.
++ Providing tailored support to the patient as needed to accomplish the practitioner’s treatment plan.
- Practitioner, Home-, and Community-Based Care Coordination
++ Coordinating receipt of needed services from healthcare practitioners, providers, and facilities; and from home- and community-based service providers, social service providers, and caregiver (if applicable).
++ Communication with practitioners, home- and community-based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors.
++ Coordination of care transitions between and among health care practitioners and settings, including transitions involving referral to other clinicians; follow-up after an emergency department visit; or follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
++ Facilitating access to community-based social services (e.g., housing, utilities, transportation, food assistance) to address the SDOH need(s).
- Health education- Helping the patient contextualize health education provided by the patient’s treatment team with the patient’s individual needs, goals, and preferences, in the context of the SDOH need(s), and educating the patient on how to best participate in medical decision-making.
- Building patient self-advocacy skills, so that the patient can interact with members of the health care team and related community-based services addressing the SDOH need(s), in ways that are more likely to promote personalized and effective diagnosis or treatment.
- Health care access / health system navigation
++ Helping the patient access healthcare, including identifying appropriate practitioners or providers for clinical care and helping secure appointments with them.
- Facilitating behavioral change as necessary for meeting diagnosis and treatment goals, including promoting patient motivation to participate in care and reach person-centered diagnosis or treatment goals.
- Facilitating and providing social and emotional support to help the patient cope with the problem(s) addressed in the initiating visit, the SDOH need(s), and adjust daily routines to better meet diagnosis and treatment goals.
- Leveraging lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals.
GXXX2 – Community health integration services, each additional 30 minutes per calendar month (List separately in addition to GXXX1).
CMS is proposing that all auxiliary personnel who provide CHI services are certified or trained in all service elements and authorized to perform them under applicable state laws and regulations. If the state does not have applicable licensure or other laws, they are proposing to require auxiliary personnel to be trained to provide the services.
The time spent furnishing to services must be documented as well as the activities that were performed. They are proposing to require that SDoH needs are documented in the medical record and for data standardization, practitioners are encouraged to use the ICD 10 codes from categories Z55—Z65 in the medical record and on the claim.
CMS believes that a substantial portion of the work would be in person but some could be performed over the phone. They are seeking public comment about whether to require patient consent for CHI services. Similarly to their thoughts on PIN services, they are not proposing to require consent because they believe these services typically would be provided face-to-face. (This is in contrast to other care management services for which large portions of the service are not provided face-to-face with a patient. And for which informed consent is required prior to starting the service.)
The services will be performed incident to the practitioner who performed the initiating visit. If the auxiliary personnel who perform the service are employed by a community based organization or other third-party, CMS wants to be clear that there must be “sufficient clinical integration between the third party and the billing practitioner in order for the services to be fully provided, and the connection between the patient, auxiliary personnel, and the billing practitioner must be maintained.” p. 247. These are the exact words that they use in the section on principal illness navigation.
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