The 2024 physician fee schedule (PFS) proposed rule from the Centers for Medicare & Medicaid Services (CMS) had a number of noteworthy proposals. Among them: three potential new care management services intended to help patients, including those with unmet social determinants of health (SDOH) needs and cancer, better navigate and overcome barriers to receiving services and support. These services, which CMS indicated it would pay for separately, are community health integration (CHI), principal illness navigation (PIN), and social determinants of health risk assessments.
Here is a summary of what you should know about these proposed new services.
The services are meant to account for when clinicians involve community health workers (CHW), care navigators, and peer support specialists in patient care. These care support staff have been able to serve as auxiliary personnel to perform covered services incident to the services of a Medicare-enrolled billing physician or practitioner. The three new proposed services are the first specifically designed to be furnishable by each of these categories of auxiliary staff.
Community Health Integration (CHI)
CMS requested comments in the 2023 PFS rule related to community health workers and how they are involved in the treatment of Medicare beneficiaries. In the 2024 PFS proposed rule, CMS states they received many comments that physician groups currently utilize CHWs to help patients by "monitoring, interpreting, clarifying, and supporting the plans of care that providers establish."
In light of the feedback the agency received, it is proposing to create two new G-codes describing CHI services. They are as follows:
- 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
- HCPCS GXXX2: Additional 30 minutes
These services may be furnished by auxiliary personnel under general supervision. They would be furnished monthly following an initiating provider visit in which the practitioner establishes or affirms an existing treatment plan and specifies how addressing SDOH need(s) would further the treatment plan.
Covered SDOH needs may include:
- Food insecurity
- Transportation insecurity
- Housing insecurity
- Unreliable access to public utilities
Principal Illness Navigation (PIN)
Principal illness navigation services are intended to help Medicare patients diagnosed with high-risk conditions identify and connect with appropriate clinical and support resources. CMS noted that while it currently covers a number of care management services, these services are "focused heavily on clinical aspects of care rather than social aspects and are generally performed by auxiliary personnel who may not have lived experience or training in the specific illness being addressed."
CMS hopes PIN services will address this shortcoming. The services may be furnished by auxiliary personnel under general supervision on a monthly basis following an initiating provider visit. During this visit, the practitioner will need to establish or affirm a treatment plan for at least one serious, high-risk condition. (e.g., cancer, mental health conditions, substance use disorder). There is an expectation that the condition will require monitoring and possibly frequent adjustments to the care plan, medications, or treatment regimen.
The two proposed principal illness navigation codes are as follows:
- HCPCS GXXX3: Initial 60 minutes per calendar month
- HCPCS GXXX4: Additional 30 minutes per calendar month
Note: We discussed PIN further in this recent blog post.
Community Health Integration and Principal Illness Navigation
There are a few more things to know about CHI and PIN. Both services can be performed by third-party personnel under contract with a provider as long as there is "sufficient clinical integration" between the third-party and provider. They can be billed at the same time as chronic care management (CCM), remote physiologic/patient monitoring, and other remote care management services.
Reimbursement for both CHI and PIN follows CCM billing rules. The first 30 minutes of CHI or PIN reimburse the same as the CPT 99490 CCM code. The additional 30 minutes of CHI or PIN reimburse the same as the CPT 99439 CCM code.
Care management activities are aligned between the two services. They may include the following:
- Conducting SDOH assessments
- Time spent understanding a patient's life story
- Care coordination
- Contextualizing health education
- Building patient self-advocacy skills
- Health system navigation
- Facilitating access to community-based social services
- Behavioral, social, or emotional support
- Mentorship or inspiration
Social Determinants of Health Risk Assessment
To further encourage practitioners to assess and address patients' SDOH needs, CMS is proposing to pay for an SDOH risk assessment using HCPCS GXXX5: Administration of a standardized, evidence-based social determinants of health risk assessment, 5-15 minutes, not more often than every 6 months.
The tool used to perform the risk assessment must be validated and include the following domains:
- Food insecurity
- Housing insecurity
- Transportation needs
- Utility difficulties
CMS notes that qualifying assessments would include the CMS Accountable Health Communities tool and the Protocol for Responding to & Assessing Patients' Assets, Risks & Experiences (PRAPARE) tool.
Reimbursement for the SDOH risk assessment would be the same as the annual depression screening preventive service (HCPCS G0444).
CHI and PIN: Request for Comments
In the proposed rule, CMS requests comments on CHI and PIN concerning a few areas. They include:
- Which E/M visits should be allowed to initiate CHI/PIN? The Medicare annual wellness visit (AWV) seems like a good candidate, particularly if performed with the new SDOH risk assessment.
- What is the typical/appropriate duration for CHI/PIN services?
- Would it be appropriate to have a specified amount of required training for staff performing CHI/PIN?
- How often would CHI/PIN be performed in-person versus via phone or video? CMS is expecting a "substantial portion" to be in-person service delivery but does not propose mandating it for now.
- Should patient consent be required for CHI/PIN like for CCM? Cost sharing will apply.
Find Out More About Remote Care Managed in the 2024 PFS Proposed Rule
To learn more about CHI, PIN, SDOH risk assessments, and the other key remote care managements changes included in the 2024 PFS proposed rule, watch the on-demand recording of the Prevounce special webinar, "Understanding Medicare's 2024 Proposed Additions & Changes to Remote Care Management."
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