CMS Proposes New Services for Vulnerable Patients: Reimbursement for Community Health Integration, Social Determinants Risk Assessment, and Principal Illness Navigation
One of the greatest challenges facing the U.S. healthcare system is access to equitable care for our most vulnerable patient populations. In many cases, practitioners are forced to work around barriers to care posed by social determinants of health (SDOH).
In the proposed 2024 Medicare Physician Fee Schedule (MPFS), the Centers for Medicare and Medicaid Services (CMS) proposes new CPT codes to facilitate reimbursement for healthcare providers who help patients overcome social and environmental health barriers.
Rethinking Healthcare: Addressing Social Determinants in Patient Treatment
Practitioners and their staff often dedicate valuable time and resources to understanding the social determinants that may impact their ability to successfully treat a patient.
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).”
In cases where the patient suffers from a “serious, high-risk illness” like cancer and is limited by SDOH, a practitioner must dedicate significant time and resources to ensure the patient can access the right care.
Currently, this work is captured in evaluation and management (E/M) visit codes, but CMS believes the current coding is both underutilized and undervalued.
To better characterize the work of combatting health-related social barriers, CMS proposes new reimbursement codes for three types of services:
SDOH risk assessment
Community health integration (CHI) services
Principal illness navigation (PIN)
Auxiliary staff can provide all three services “incident to” a billing practitioner’s professional services under “general supervision.”
Identifying Social Determinants of Health Needs
CMS proposes a new SDOH Risk Assessment code to provide reimbursement for the additional effort and resources needed to address a patient’s SDOH needs.
HCPCS GXXX5 – Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months
Practitioners can use this code to bill for an SDOH risk assessment that includes food insecurity, housing insecurity, transportation needs, and utility difficulties. The proposal allows for billing GXXX5 concurrently with an evaluation and management (E/M) visit and includes the option for this assessment to be conducted via telehealth by practitioners or their auxiliary staff if preferable. This expands the accessibility of assessments.
A practitioner would be able to bill GXXX5 in conjunction with (and on the same day as) an E/M visit.
Elevating Patient Care with Community Health Integration Services
CMS proposes two new G-codes for the provision of CHI services to address the particular SDOH needs that present a barrier to patient care as identified during an initiating visit. Similar to other care management programs, CHI services would be furnished monthly and facilitated by certified or trained auxiliary staff, including community health workers (CHWs), under the general supervision of the billing practitioner.
The initiating visit would be separately billable, but certain E/M visits like inpatient/observation visits, emergency room visits, and skilled nursing facility visits would not qualify as a CHI initiating visit. While CMS believes that CHI services are likely to occur in person, they are requesting feedback as to the potential efficacy of providing services via two-way audio communications. The proposed Community Health Integration (CHI) codes create a holistic approach to patient care that potentially improves outcomes and simplifies billing processes for practitioners.
HCPCS 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
HCPCS GXXX2 – Community health integration services, each additional 30 minutes per calendar month
CMS envisions that these codes will involve coordination among healthcare practitioners, social services, and caregivers, and will include health education around patient self-advocacy skills, healthcare access and navigation, and facilitating behavioral change.
Navigating Health Challenges: Proposed PIN Codes for High-Risk Illnesses
In the proposed 2024 MPFS, CMS explicitly notes that care navigation services provide significant benefits to patients suffering from “high-risk, serious illnesses” such as cancer. This is especially important when a patient is first diagnosed, as they may need to access care from several different providers (e.g., a cancer patient may need to see an oncologist, surgeon, radiologist, and psychiatrist). The need for navigation services for patients suffering from these illnesses is even higher for patients who also face socioeconomic barriers to care.
CMS is therefore proposing two new codes for Principal Illness Navigation to allow reimbursement for auxiliary support staff like patient navigators or certified peer specialists who provide guidance services to patients. Patient eligibility requirements may be similar to those of the existing Principal Care Management services:
One serious, high-risk disease expected to last at least 3 months that places the patient at significant risk of hospitalization or 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.
HCPCS GXXX3 – 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 GXXX4 – Principal Illness Navigation services, additional 30 minutes per calendar month
CMS is proposing to classify the following activities as Principal Illness Navigation services:
Person-centered assessment
Identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services
Practitioner, Home, and Community-Based Care Coordination
Facilitating behavioral change
Health education
Building patient self-advocacy skills
Healthcare access/health system navigation
Facilitating and providing social and emotional support
The ultimate aim is to help patients better understand their conditions, navigate the healthcare system, and achieve treatment goals while addressing their social determinants of health.
Key Takeaways
The proposed CPT codes to reimburse for SDOH assessments, CHI services, and PIN services are in keeping with the Administration’s commitment to health equity—a key component of what is now the Quintuple Aim of healthcare. If finalized, these new codes should allow practitioners to allocate additional resources specifically to assisting patients who must navigate socioeconomic barriers to care.
The new code sets are designed to work in tandem with the current designated care management codes such as Chronic Care Management services, Remote Monitoring, and Behavioral Health Integration services.
CMS’s request for stakeholder input on various aspects of its proposals—including delivery modalities, who can provision the services, code requirements, and even what sort of visits can count as an initiating visit—provides a tremendous opportunity for stakeholders to shape final policy.
Make Your Voice Heard
CMS is accepting public comment on the above proposals through 5 p.m. ET on September 11, 2023. If you have feedback for CMS and are interested in submitting comments to this Proposed Rule, we’re here to help!
The due date is approaching quickly, so please contact us as soon as possible to learn more.