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2024 Social Determinants of Health Codes

New for 2024 from CMS are the Community Health Integration (CHI) Codes. This is a new code set (G0019 and G0022) released from CMS in the Final Rule published in November 2023. These codes, like other care management codes, are time-based, require an initiating visit, and documentation of patient consent, whether verbal or written, in the patient’s medical record.

Review the detailed code descriptions below and reach out to the experts at The Rybar Group to see how we can help you implement these and other exciting new services outlined in the CY 2024 Medicare Physician Fee Schedule Final Rule.

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 the ability to diagnose or treat the 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 the 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 caregivers (if applicable).
    • Communication with practitioners, home- and community-based service providers, hospitals, and skilled nursing facilities (or other healthcare 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 healthcare 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 healthcare 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 healthcare 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.
  • Healthcare 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.

G0022: Community health integration services, each additional 30 minutes per calendar

month (List separately in addition to G0019).

View the press release for the final rule here: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule

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