Community Health Integration (CHI) Services

Community Health Integration (CHI) is a Medicare benefit that supports care coordination services. These services can be provided by auxiliary personnel-such as community health workers (CHWs)-as long as they are delivered under the general supervision of a physician or other billing practitioner and are considered part of the practitioner's professional services. CHI services may not be billed to Medicare until an initiating visit is done by the billing practitioner.

Initiating visit: personally performed by the billing practitioner*, and include (either):

  • An Evaluation and Management (E/M) visit
    • Cannot be a low-level (level 1) E/M visit performed by clinical staff
    • Can be the E/M visit provided as part of Transitional Care Management (TCM) services
  • An Annual Wellness Visit (AWV) - if performed by the billing practitioner

Note: Certain types of E/M visits, such as inpatient and observation visits, emergency department

(ED) visits, skilled nursing facility (SNF) visits, and those provided to beneficiaries currently under a home health plan of care would not serve as CHI initiating visits because the practitioners providing the E/M visit would not typically be the ones providing continuing care to the patient, including providing necessary CHI services in the subsequent months.

Incident To Services: The purpose of the initiating visit is for the billing practitioner to establish their reasonable and necessary professional services, serving as the Medicare beneficiary's physician or Qualified Healthcare Professional (QHP) who will be evaluating and treating a medical condition(s). During this encounter, the billing practitioner would identify and document any SDOH needs their patient will require assistance with that have been deemed by the billing practitioner as interfering with their ability to diagnose and/or treat the problems addressed**. In addition, specify how addressing the unmet SDOH needs would help accomplish their overall diagnostic work up (if applicable) and treatment plan. CHI services can only be furnished by the billing practitioner who performed this initiating visit.

Auxiliary Personnel

Subsequent CHI services may be performed by auxiliary personnel under general supervision of the billing practitioner if all other 'incident to' requirements are met. The service would be submitted by the billing practitioner that furnished the initiating visit. There is not a Medicare benefit for paying community health workers and other auxiliary personnel directly.

Auxiliary personnel must meet applicable state requirements, including licensure. In states with no applicable requirements, auxiliary personnel must be certified and trained in the following competencies:

  • Patient and family communication
  • Interpersonal and relationship-building skills
  • Patient and family capacity building
  • Service coordination and systems navigation
  • Patient advocacy, facilitation, individual and community assessment
  • Professionalism and ethical conduct
  • Development of an appropriate knowledge base, including local community-based resources

As with all 'incident to' services, it is the billing practitioner's responsibility to ensure that all payment rules and applicable state requirements are met including licensure, certification, and/or training.

Patient Consent

The billing practitioner, or the auxiliary personnel under general supervision, are required to obtain advance patient consent before furnishing CHI services. Consent can be written or verbal, so long as it is documented in the patient's medical record. As part of consent, the patient is educated on cost sharing requirements with only one practitioner able to bill the service each month. Additional consent would be necessary if the practitioner furnishing and billing CHI changes.

Documentation Required

  • Patient's unmet social needs that CHI services are addressed in the medical record, to include the SDOH identified by the billing practitioner as interfering with, or presenting a barrier to, diagnosis or treatment of the (medical) problems addressed.
  • Time spent with the patient and the nature of the activities

Note: In instances where the provider would need to support medical necessity for coverage and payment purposes, Noridian recommends that the billing practitioner have readily available for review medical documentation supporting the initiating visit, including the (medical) problem(s) being addressed and identified SDOH needs; obtainment of beneficiary consent; as well as medical documentation to support the billing practitioner's ongoing active participation in the course of a patient's treatment as required under 'incident to'.

HCPCS Codes

Two codes may be billed for CHI services:

  • 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 significantly limit the ability to diagnose or treat problem(s) addressed in an initiating visit:
    • Person-centered assessment, performed to better understand the individualized context of the intersection between the SDOH need(s) and problem(s) addressed in the initiating visit
    • Practitioner, home and community-based care coordination
    • 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 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 health care 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
    • Health care access/health system navigation
    • 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)

Services are expected to be delivered through a combination of in-person and virtual formats, including audio-video or two-way audio communication. This approach is supported by evidence indicating that some level of in-person interaction is beneficial.

Only time addressing SDOH needs identified by the billing practitioner in the initiating visit count towards fulfillment of these code descriptors. Addressing additional SDOH needs identified by auxiliary personnel without involvement of the billing practitioner are not counted. Activities are individualized to the patient and directly address the SDOH need. For example, general education or research, driving or travel time, do not count towards these activities.

*Billing Practitioner - (MD, NP, CNS, CNM, PA) who follow the patient longitudinally in the community, are able to bill E/M visits, and who are eligible to bill for services under "incident to" rules including demonstration of active participation in the patient's course of treatment. (42 CFR § 410.26; 88 FR 78818)

**Problem addressed - "[a] problem is a disease, condition, illness, injury, symptom, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter. A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified healthcare professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in patient's medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified healthcare professional reporting the service. Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified healthcare professional reporting the service. (CPT and AMA E/M Guidelines; 88 FR 78818).

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