We are big believers in the need for real payment reform in primary care to drive enough prospective revenue to practices so that they can have the staff and infrastructure on hand to deliver efficient, effective team-based care. However, we are also realists and cannot ignore the existing imprint of fee-for-service.
Given this, each year, we look for CMS’ finalization of updating Medicare fee-for-service policies and payment approaches. Here is an overview of the areas that caught our eye in the finalized 2024 CMS Physician Fee Schedule (PFS) from a primary care and population health lens in mind.
Add-on Complexity Code – G2211
After years of back-and-forth consideration, the G2211 add-on complexity code has finally been added.
G2211 is an add-on code to office and other outpatient services (99202–99215). The intent is to more fairly reimburse the work involved in caring for patients with complex conditions and to support longitudinal relationships and care coordination across teams. It is especially applicable for primary care and speaks to its role as a patient’s ongoing source of expert partnership, guidance and coordination in their health journey.
SDOH Risk Assessment – G0136
Consistent with its emphasis and strategy of acknowledging and valuing the impact of Social Determinants of Health (SDoH) on health status, CMS has introduced a new code, G0136, that will reimburse for SDoH screenings conducted by practices in E/M visits. The code requirements leverage the developments that have been made by the Gravity project and other organizations in SDoH data standardization and codification. For example, a validated screening tool must be used. The questions in these instruments have associated LOINC codes, universal identifiers that are key in coding and standardizing information.
Examples of such tools include:
- The CMS Accountable Health Communities (AHC) tool
- Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) tool
- AAFP Social Needs Screening Tool
- Health Leads Screening Panel®
- Hunger Vital Sign™
- Safe Environment for Every Kid (SEEK)
- We Care Survey
- WellRx Questionnaire
- Housing Stability Vital Signs™
- Comprehensive Universal Behavior Screen (CUBS)
- PROMIS
- USDA Food Security Survey
While additional domains may be included, at a minimum, G0136 requires that practices screen for “food insecurity, insecurity, housing insecurity, and unreliable access to public utilities, when they significantly limit the practitioner’s ability to diagnose or treat the patient’s medical condition(s)”.
The code cannot be billed more than once every six (6) months and documentation must be included in the EMR. It can be done face-to-face in the office or via audio-visual telehealth. A copay applies unless the screening is done in concert with an Annual Wellness Visit (AWV).
Community Health Integration (CHI) – G0019 and G0022
In addition to screening for SDoH, CMS also wants support for those identified with unmet needs. To help practices provide this support, CMS also established Community Health Integration (CHI) codes for certified or trained auxiliary personnel, including community health workers to link patients with community services. Such services would be incident to the professional services of the practitioner that bills the initiating visit.
Code G0019 reflects the first 60 minutes of CHI servicing per calendar month. Code G0022 captures each additional 30 minutes per calendar month. No frequency limitations were identified, though only one provider can bill for CHI services for the same beneficiary, during the same month. The first claim in will be the one that is paid.
CHI services require an initiating visit (E/M or Transitional Care Management (TCM)) performed by the billing practitioner who would be furnishing the CHI services. Patient consent must be documented in the medical record. During the initiating visit the billing practitioner would “assess and identify SDOH needs that significantly limit the practitioner’s ability to diagnose or treat the patient’s medical condition and establish an appropriate plan”.
The majority of CHI servicing is intended to be provided in-office or via audio-visual telehealth, though CMS would permit some limited phone use.
A provider may elect to contract with a community-based organizations (CBO) to deliver CHI services. This would require sufficient clinical integration be established (e.g., documentation in the EMR of the billing provider; ability of the provider to review documentation in a CBO system, etc.). The practitioner (not the CBO) would bill the CHI services to Medicare, as CMS does not have the ability to reimburse CBOs directly under the Physician Fee Schedule.
And in addition to Medicare providing access to CHW services via the CHI codes, Medicaid in our own state will be initiating a CHW servicing benefit in 2024. Watch out for our January/February issue where we will compare and contrast the Medicare and Medicaid approaches to CHW policies and requirements.
Michigan Multipayer Initiatives 