Improving Equitable Access to Care: Unpacking Medicare’s New Documentation, Coding, and Billing Requirements

The Association of Cancer Care Centers (ACCC) recently held a 4-part webinar series titled Implementing the New CMS Reimbursement Billing Codes for Patient Navigation Services. Hosted by Teri Bedard, BA, RT(R)(T)(ARRT), CPC, of Revenue Cycle Coding Strategies, the series sought to inform members about recent policy changes relating to patient navigation services.

Part 1 of the series provided a high-level overview of the new Medicare and American Medical Association (AMA) billing codes and previewed the topics to be addressed in subsequent webinars. Part 2 addressed the new Medicare Principal Illness Navigation (PIN) codes and the PIN-Peer Support (PIN-PS) reimbursement codes that went into effect in 2024. The third webinar covered recent changes to the AMA codes for oncology and involving the Cancer Moonshot program in more depth. Read the previous blogs in this series for a recap of Part 2 and Part 3. 

The final installment of the series examined the new Medicare reimbursement codes for community health integration (CHI), social determinants of health (SDOH) risk assessment, and PIN-PS. The information presented in this webinar is summarized below.*

Medicare’s Updated Guidance Reflects Its Ongoing Focus on Equitable Access to High-Quality Care 

Medicare’s shift from a quantity-based approach to a quality-centered model underscores the importance of ensuring equitable access to care for all beneficiaries and particularly those who are not included in clinical trials. These changes are tied to pillars in the Centers for Medicare & Medicaid Services’ (CMS) strategic plan, including improving patient access to care and participation in clinical trials.

The new Medicare codes for CHI, SDOH, and PIN-PS services were designed to improve reimbursement for services that aim to address SDOH or provide behavioral health care. Many cancer care teams are already doing the work recognized by these new codes, but this new reimbursement will support these efforts with additional funding and will hopefully lead to broader availability.

Understanding SDOH 

The SDOH code G0136 is used for administering a standardized, evidence-based SDOH risk assessment. This evaluation, which takes between 5 to 15 minutes to complete, is performed no more than once every 6 months; it should only be administered if the provider identifies potential SDOH that could affect diagnosis or treatment.

Unmet social needs like transportation issues, housing instability, or lack of access to home health care can create significant barriers to effective medical care. The goal of the SDOH risk assessment is to identify these factors and to understand how they impact a patient’s health, allowing for a more personalized care plan.

Medicare provides a recommended tool for conducting these assessments: the Accountable Health Communities (AHC) model. The AHC model covers 4 key areas of SDOH: housing insecurity, food insecurity, transportation needs, and utility difficulties. Health care practices are encouraged to add any other social factors (eg, cultural or geographic challenges) that also may affect their patients.

Documentation of the G0136 assessment must be included in the patient’s medical record to ensure efficient communication between health care providers and to act as a reference for future care.

Billing and Documentation for SDOH Assessments

The G0136 code is billable once every 6 months per practitioner, per beneficiary. The assessment can be conducted through telehealth; it does not need to be performed on the same day as an evaluation and management visit. Multiple practitioners may bill for this service as long as the assessment meets the required guidelines.

Thorough documentation, including identification of any social factors affecting care, is critical to ensure that Medicare understands and reimburses for the work involved. To ensure compliance, health care providers must maintain accurate records of SDOH and time spent on care coordination. The assessment can be performed by the treating physician or other providers, nurse practitioners, physician assistants, or auxiliary personnel under the general supervision of the billing practitioner.

The Role of CHI and PIN-PS 

Key components of CHI services and PIN services overlap. When the SDOH assessment is completed, the care team will assemble a comprehensive care plan that will identify SDOH needs (eg, measurable treatment goals) that significantly limit the diagnosis and treatment of the patient and that will note the staff members responsible for any planned interventions. This care plan will help the patient to navigate the next 3 months with regular follow-ups and documentation.

This plan involves a collaborative approach that includes physicians, nurse navigators, social workers, and other team members. Community-based resources, such as transportation services or food assistance programs, play a key role in helping patients overcome social barriers.

One key component of CHI services is the kickoff visit. This visit must be conducted by a physician, who will inform the patient of identified SDOH and obtain consent prior to the start of care management. If a patient has not been seen in the last year or is new to the practice, an initiating visit is required to assess their current social needs.

Time is an important factor in the documentation of these CHI codes. There is a minimum of 60 minutes per month required for staff; for each additional 30 minutes, they will bill the code G0022. Due to the time involved with these services, it is essential that medical and auxiliary staff communicate regularly to properly document their time. The billing practitioner then will submit documentation on a monthly basis.

Key Considerations for Documentation and Billing

Aside from the kickoff visit, the key components of CHI are a comprehensive care plan and documentation. The patient may have developed new SDOH since they started visiting the practice; these may include losing their job or having to quit work due to treatment adverse effects or the time required to attend medical visits. The same practitioner must conduct the initiating visit and manage services for these patients. The care provider will have a visit with the patient to discuss the identified SDOH and how they impact medical care; they also will discuss services to which the patient can be referred. The patient must provide verbal or written consent to these CHI services annually, and this consent must be documented in their record. If the provider leaves the practice and a new provider takes over, new consent must be obtained.

Unlike the PIN codes, which focus on specific serious conditions, CHI codes emphasize the social factors to be addressed that can impact a patient’s ability to access care. These social factors include transportation, housing, food needs, utilities, and access to other resources that must be detailed in the record. They are also essential for establishing metrics to assess patient outcomes. Such metrics may include the percentage of missed appointments or the number of patients using the resources offered.

PIN-PS Services: Peer Support and Behavioral Health

The PIN-PS services indicated by the G0023 and G0024 codes are intended for patients with high-risk, serious conditions. These services focus on providing behavioral health support that includes peer navigators who assist patients in managing their illness and accessing necessary resources.

Unlike CHI, which focuses on broader social determinants of health, the PIN-PS codes are specifically geared toward services to help patients cope with serious health conditions and the emotional challenges they may face. These services are essential to ensure that patients receive holistic care and to address both their physical and emotional needs.

A Shift Toward Equity and Outcome-Based Care

Medicare’s evolving focus on the delivery of quality health care services reflects a broader trend toward equitable care for all patients regardless of external factors like their geographic location or socioeconomic status. This includes a growing focus on outcomes- and value-based payment policies to help ensure that providers are compensated based on the quality of care they provide and their ability to address access and equity issues.

Access the presentation slides and webinar recordings for the full Implementing the New CMS Reimbursement Billing Codes for Patient Navigation Services series here, and read the 2 previous blogs in this series on the ACCCBuzz Blog. 

References: 

* Bedard T. CHI & SDOH risk assessment documentation, coding, and billing for oncology providers and administrators & series wrap-up. PowerPoint slideshow. September 5, 2024. https://www.accc-cancer.org/docs/documents/advocacy/billing-and-coding/accc-chi-sdoh-for-oncology-providers-and-series-wrap-up.pdf?sfvrsn=88bdb89f_2&utm_medium=email&utm_source=Act-On+Software&utm_campaign=Ed%20-%20FAN