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New Services for Vulnerable Patients

CMS has new service codes for vulnerable patients in 2024 for combatting health related social barriers.


  1. SDOH Risk Assessment - Social Determinants of Health Needs.

  2. CHI - Community Health Integration Services

  3. PIN - Principal Illness navigation.

(Auxiliary staff can provide all 3 services incident to practitioner's professional services under general supervision.)


SDOH Risk Assessment - Social Determinants of Health Needs.

Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, racism, climate change, and political systems. Centers for Disease Control and Prevention (CDC) has adopted this SDOH definition from the World Health Organization.


HCPCS G0136 - defined as “Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.” The risk assessment is in relation to the patient’s social risk factors that influence the diagnosis and treatment of medical conditions.


This assessment can be done on the day of an E/M service and an AWV, not including code 99211.


G0136 will be subject to cost sharing, (co-pay and deductible) unless it is done at an Annual Wellness Visit (AWV).


G0136 may be billed with discharge visits from the hospital. However, it is CMS’s expectation that for patients with unmet needs, there will be follow up visits either as outpatients or a transitional care management visit to try and meet those needs.


CMS is not requiring that if a practice reports G0136 that they also must have the capacity to furnish Community Health Integration (CHI) services, Principal Illness Navigation (PIN) or other care management services. However, they do expect that a practitioner who furnishes the risk assessment would at a minimum, refer the patient to relevant resources and take into account the results of the assessment in their medical decision making, or diagnosis and treatment plan for the visit.


Diagnosis coding for SDOH

CMS is requiring that the SDOH needs that are identified during the assessment be documented in the medical record and “actively encouraging Z-code reporting to improve our data. The Z codes in question are in categories Z55-65. That is, you must document the SD0H condition in the record and you are encouraged to add that to the claim form. If you are part of an ACO or have risk based contracts, report these codes on a claim form.


CMS leaves open the opportunity to reevaluate whether to pair SDOH risk assessment with (i.e., condition payment on) capacity to furnish CHI services, PIN services, or other care management services, or have partnerships with CBOs to address identified SDOH needs.


CHI - Community Health Integration Services

CMS lists the following 8 categories: person-centered assessment; 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; and leveraging lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals.


CHI services must be furnished by the billing practitioner of the initiating visit or under the general supervision of the billing practitioner. The practitioner may arrange to have services provided by auxiliary personnel who are external to, and under contract with, the practitioner or their practice, such as through a community-based organization (CBO) that employs CHWs or other auxiliary personnel. CMS describes itself as aiming for balance between clinical and community engagement. “We are allowing for the broadest level of supervision possible (general supervision) and contracting with third parties (such as CBOs) in accomplishing the furnishing of CHI services but this must be part of clinical care and treatment by the billing practitioner.”


HCPCS G0019 - 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.

HCPCS code G0022, Community health integration services, each additional 30 minutes per calendar month.


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.


Patient consent is required in advance of providing CHI services. Consent may be obtained either in writing or verbally, as long as the consent is documented in the patient’s medical record. 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. Consent for CHI services may be obtained by auxiliary personnel and must be obtained if there is a change in the billing practitioner.

  • CMS acknowledges that CHI services may be available in person, virtually, or through a mix of interactions. However, the Agency also expects that most elements of CHI services will involve direct contact between providers and patients. (Note: CMS does not add CHI services to the Medicare Telehealth List. This is because elements of CHI services may not require face-to-face interaction with patients.)

  • The final rule does not impose a frequency limit for HCPCS code G0022. However, only one practitioner may furnish and bill the services in a given month.


PIN - Principal Illness navigation.

HCPCS 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.

HCPCS G0024 - Principal Illness Navigation services, additional 30 minutes per calendar month.

HCPCS code 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.

HCPCS code G0146, Principal Illness Navigation – Peer Support, additional 30 minutes per calendar month.


PIN services will be reimbursable where a patient has a “serious, high-risk condition” with certain additional characteristics. The condition must be expected to last at least 3 months, place the patient at “significant risk of hospitalization, nursing home placement, acute exacerbation/decompensation, functional decline, or death,” and require development, monitoring, or revision of a disease-specific care plan.

  • Peer support codes are limited to the treatment of behavioral health conditions.


CMS lists the following 8 categories: person-centered assessment; 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; and leveraging knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals.


Before PIN services can start, there must be an initiating visit. A PIN initiating visit can be an E/M visit, an annual wellness visit, a psychiatric diagnostic evaluation, or a visit involving Health Behavior Assessment and Intervention services.


PIN services must be furnished by the billing practitioner of the initiating visit or under the general supervision of the billing practitioner. The practitioner may arrange to have PIN services provided by auxiliary personnel who are external to, and under contract with, the practitioner or their practice, such as a CBO.


PIN service providers must be certified or trained to perform all included service elements, and authorized to perform them under applicable State laws and regulations.

o In states with applicable rules, training/certification must meet any applicable requirements to provide the services that are imposed by the State.


CMS does not specify a required number of training hours that need to be obtained in states that do not have an applicable rule to specify the number of required hours.


Patient consent is required in advance of providing PIN services. Consent may be obtained either in writing or verbally, as long as the consent is documented in the patient’s medical record. The consent process must include explaining to the patient that cost sharing applies. Consent for PIN services may be obtained by auxiliary personnel and must be obtained annually.


CMS acknowledges that PIN services may be available in person, virtually, or through a mix of interactions. (Note: CMS does not add PIN services to the Medicare Telehealth List. This is because elements of PIN services may not require face-to-face interaction with patients.



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