CMS Sharpens Focus on “Upstream Drivers” of Health in the 2026 Medicare Physician Fee Schedule
The final 2026 Medicare Physician Fee Schedule (MPFS) continues a clear directional shift: Medicare is increasingly paying for the work needed to assess and address the “upstream” drivers that shape chronic disease, including physical activity levels, nutrition access, housing stability, behavioral health determinants, and the support systems that enable patients to follow through on treatment. For digital health companies, value-based care organizations, and providers who design care models around whole-person engagement, these changes can unlock aligned reimbursement and stronger patient outcomes. Below, we summarize three key finalized policies that matter for innovators building and scaling comprehensive care models in 2026 and beyond.
1. HCPCS G0136 Revised: Physical Activity and Nutrition Risk Assessment
CMS has retained HCPCS code G0136 but reframed its purpose. Previously described as a Social Determinants of Health (SDOH) assessment, the code is now explicitly tied to evaluating physical activity and/or nutrition risk factors when those factors influence a patient’s diagnosis or treatment plan. CMS indicates that the new assessment will identify and value the clinician work of administering a validated physical activity and/or nutrition risk assessment as part of a related clinical visit.
When G0136 Can Be Billed:
Once every 6 months when reasonable and necessary to inform the diagnosis or treatment plan
G0136 must be furnished with:
An outpatient E/M visit (other than Level 1), or
A psychiatric diagnostic evaluation (90791), or
A Health Behavior Assessment and Intervention (HBAI) services (96156 series)
As revised, G0136 remains an optional add-on element to the Medicare Annual Wellness Visit with no patient cost sharing.
Validated Assessment Tools include:
Physical Activity Vital Sign (PAVS)
CHAMPS questionnaire (older adults)
RAPA or TAPA assessments
Key Takeaway
If your virtual care, chronic condition management, metabolic health, or behavioral health solution requires consistent lifestyle assessment, HCPCS G0136 is a reimbursable event that aligns with personalized care planning.
2. Community Health Integration (CHI) Services: Updated Code Descriptor for HCPCS G0019
CMS finalized a revised descriptor for G0019, replacing the term “social determinants of health” with “upstream driver(s)” to “better reflect the full spectrum of environmental, behavioral, social, and structural factors that affect treatment adherence and outcomes.’
Updated Code Purpose: G0019 supports community health workers, care coordinators, peer support specialists, and other trained personnel in helping navigate the practical factors hindering diagnosis and treatment of patients.
Examples of Covered Activities:
Person-centered assessments to understand the patient’s lived context
Cultural and linguistic tailoring of care plans
Coordination across primary care, behavioral health, social services, and home/community supports
Access navigation and appointment facilitation
Motivation and behavior change support
Emotional, peer, and lived-experience support
Why the Language Change Matters:
CMS indicates that the term "upstream drivers" explicitly recognizes housing instability, food access, transportation barriers, functional limitations, psychological and social needs, and lifestyle patterns.
Key Takeaway
This change broadens the justification for CHI services and strengthens reimbursement alignment for care models employing community health workers or care navigators at scale.
3. New Practitioner Types May Initiate CHI Services
Under the final 2026 MPFS, CMS clarified that -- like licensed clinical social workers (LCSWs) -- marriage and family therapists (MFTs) and mental health counselors (MHCs) may now initiate and bill CHI services directly when related to the diagnosis or treatment of mental illness.
Key Takeaway
This change opens new billable pathways for virtual mental health providers, collaborative care teams, and integrated primary care + behavioral models.
How Nixon Law Group Can Help
We work with digital health companies, provider groups, and value-based organizations to:
Design compliant CHI and care navigation staffing models
Develop documentation frameworks that satisfy CMS audit expectations
Align payer contracting around whole-person care delivery
Contact us if you are interested in implementing these new codes.