CMS details new opportunities to get paid for health equity services

As part of the 2024 Medicare physician fee schedule, the Centers for Medicare & Medicaid Services (CMS) implemented coverage and payment for four types of services for health-related social needs: caregiver training, social determinants of health risk assessment, community health integration, and principal illness navigation.

To help physicians better understand how to code and bill for these services, CMS recently published a booklet entitled, Health Equity Services in the 2024 Physician Fee Schedule Final Rule. Here are some of the highlights:

1.     Caregiver training: CMS will pay for caregiver training services for patients under an individualized treatment plan or therapy plan of care, without the patient present. Use codes 96202 (initial 60 minutes) and 96203 (each additional 15 minutes) for multi-family group behavior management/modification training for caregivers of patients with a mental or physical health diagnosis. Use codes 97550 (initial 30 minutes), 97551 (each additional 15 minutes) and 97552 (multiple sets of caregivers) for training caregivers in strategies and techniques to help patients function in their home and community (e.g. activities of daily living).

2.     Social determinants of health (SDOH) risk assessment: CMS finalized G0136, a standalone code for administering an evidence-based SDOH assessment. It can be provided with evaluation and management (E/M) visits, behavioral health office visits, or annual wellness visits, but no more than once every six months.

3.     Community health integration (CHI): CMS created two new codes for CHI services that auxiliary staff provide incident-to the services of a physician or other billing clinician. Examples of CHI services, meant to address SDOH needs, include health system navigation or facilitating access to community-based resources. You must document the unmet social needs the services are addressing (you can do this using ICD-10 Z codes). Cost-sharing may apply and patient consent is required. The codes are G0019 (first 60 minutes per calendar month) and G0022 (each additional 30 minutes).

4.     Principal illness navigation (PIN): CMS created four new codes for PIN services that auxiliary staff provide incidental to the services of a physician or other billing clinician. The billing physician or clinician initiates PIN services following a serious, high-risk condition (including behavioral health) with significant chance of hospitalization, nursing home placement, acute decompensation or death (e.g., cancer, congestive heart failure, dementia). PIN services are similar to CHI and include health system navigation and person-centered planning. The codes for general PIN services are G0023 (first 60 minutes per calendar month) and G0024 (each additional 30 minutes). The codes for peer support PIN services are G0140 (first 60 minutes) and G0146 (each additional 30 minutes).

For more information on CMS’ efforts to address health equity, see the “Health Equity” page on the agency’s website and check out its related strategic plan.

— Kent Moore, AAFP Senior Manager, Payment Strategies

Posted on Feb. 28, 2024