Aligning Billing with Health Equity: New Social Determinants of Health and Community Health Integration Billing Codes

In pursuit of fostering health equity and mitigating health disparities, the Centers of Medicare and Medicaid Services (CMS) has implemented several new billing codes aimed at reimbursing healthcare teams for work addressing social determinants of health (SDOH) as part of the 2024 Medicare fee schedule.^{1, 2} The creation of billing codes G0136, G0019, and G0022 signifies a strategic shift towards recognizing and valuing more holistic patient care. With these codes, CMS aims to support healthcare teams in addressing SDOH, thus fostering more equitable healthcare and improved outcomes for all beneficiaries. Healthcare teams and SGIM clinicians should utilize billing of codes G0136, G0019, and G0022 to maximize coverage and payment.

Social Determinants of Health Risk Assessment Code: G0136

G0136 is a stand-alone code intended to allow healthcare teams to bill for services for assessment of SDOH (as opposed to screening). It should only be used when a healthcare provider believes the patient may have unmet SDOH needs which may impact the diagnosis or treatment of an illness, choice of treatment, or care plan. Utilization of this code has several key requirements:

• Assessment must be completed during an evaluation and management (E/M) visit (including annual wellness), on the day of hospital discharge (as long as there is outpatient follow-up), during a behavioral health office visit, or with a transitional care management service visit.
• Code can be billed by physicians, advanced practice providers, other medical professionals (including registered nurses, licensed clinical social workers, health educators, registered dietitians, or other licensed practitioners).
• Assessment should take 5-15 minutes to complete.
• SDOH conditions identified during the assessment must be documented and providers may document the conditions using ICD-10-CM SDOH-related Z codes.
• Healthcare professionals should administer a standardized, evidence-based SDOH risk assessment tool, which includes assessment of housing and food insecurity, transportation needs, and utility difficulty. This tool can be filled out by the patient 7-10 days in advance of the visit, but the assessment by the medical professional must be done as part of the visit.
• Practices that are Accountable Care Organizations (ACO) or enrolled in risk-based contracts should report the Z-codes on the claims form.
• Billing of code should not be performed more than once every six months.
• Code can be used for in-person or telehealth (visual or audio) visits.

Payment for G0136 is subject to cost sharing (Medicare Part B coinsurance or deductible) unless performed at an annual wellness visit. The code will have wRVU of 0.18.

Billing Examples

Acceptable: A patient is seen for uncontrolled diabetes (DM) at a follow up visit. The primary care provider is concerned about the patient’s frequent difficulties adhering to their medication regimen. The clinician asks the staff to give the patient a SDOH questionnaire during triage. The patient reports difficulty paying for food and medications. The provider documents food insecurity and financial difficulties as they relate to uncontrolled DM, optimizes the medications for the patient’s financial situation, and refers the patient to the clinic social worker to discuss community-based resources. The provider can bill for G0136 in this scenario.

Unacceptable: A primary care clinic sends out a survey to all their patients regarding poverty and food accessibility. Mr. X has hypertension controlled with medication and a low salt diet. He denies any issues with paying for food, medications, or transportation. The provider cannot bill G0136 because (1) screening was performed without an assessment and (2) the patient does not have any identified SDOH needs.

Community Health Integration Codes: G0019 and G0022

G0019 and G0022 are Community Health Integration (CHI) codes that are intended to follow up on unmet SDOH needs that have been identified and documented in a prior visit that impact a healthcare provider’s ability to provide quality care. Healthcare providers (i.e. the billing provider) must perform the initiating visit and must document the SDOH and what intervention(s) were implemented. G0019 and G0022 are not used during the initiating visit but can be used in subsequent visits to address the unmet SDOH. The SDOH need can be identified in an E/M visit (cannot be level 1), transitional care management (TCM) visit, or annual wellness visit.

Following the initiating visit in which the initiating/billing provider identifies the SDOH need, further services to address that need can be performed by both the billing healthcare provider and auxiliary staff (community health workers, etc.) as well as by community-based organizations that are under contract with a medical provider. When a CHI code is billed by auxiliary staff, it should be billed as incidental-to the original provider who identified the unmet SDOH.

CHI Services can include the following:

•  Person-centered planning
• Health system navigation
• Facilitating access to community-based resources
• Practitioner, home, and community-based care coordination and
• Patient self-advocacy promotion.

For billing, the following key components must be heeded:

• Only one practitioner can bill for CHI per month to help avoid fragmentation. Services performed by different auxiliary staff are billed under the initiating provider.
• Prior to billing, the healthcare provider or auxiliary personnel must document patient consent due to the cost-sharing that will be incurred by the patient.
• Consent must be redone if the healthcare provider changes.
• Which SDOH are being addressed and how must be documented and may be documented as ICD-10-CM SDOH-related Z codes.
• For the first 60 minutes of care, providers should use code G0019 and for each additional 30 minutes thereafter, use code G0022.
• Code can be used for in-person or telehealth (visual or audio) visits.

CHI codes allow for billing of time spent supporting and helping patients navigate healthcare and community resources to improve their SDOH. However, these codes may require careful coordination amongst care teams.

Billing Scenarios

Acceptable: A patient with DM lost their Supplemental Nutrition Assistance Program (SNAP) benefits. The patient informs the nurse practitioner at the diabetes clinic who performs a risk assessment using a SDOH questionnaire. The provider documents the impact that food has on the patient’s diabetes control and need for assistance in re-enrollment. The diabetes clinic social worker has a phone visit the next day and spends 60 minutes on the phone with the patient to assist with re-enrollment. The social worker bills code G0019.

Unacceptable: The following week, the patient follows up with their primary care physician who also charts that food insecurity is impacting the patient’s diabetes. They cannot bill for CHI because it is within the same month that another provider (i.e., the nurse practitioner) billed for CHI and this provider is not providing a service to address the SDOH.

CMS recognizes that whole-person health care is most efficient when each team member operates at the top of their scope of practice, and the SDOH and CHI codes encourage this. The structure of the SDOH and CHI codes allows additional members of the healthcare team to carry out and bill for assessments. However, the limits on billing frequency and care coordination requirements when patients often see multiple providers may limit a care team’s ability to fully capture care coordination and social determinants of health simultaneously.

Another limitation of these new codes is their focus on appointment-based provisions of care. Care coordination done during an in-person or virtual patient encounter is preferred. Though CMS has taken steps to recognize care coordination provided between patient visits (e.g., the new G2211 code), codes G0136, G0019, and G0022 require assessment during an initial E/M visit and subsequent billing emphasizes most services should occur during in-person or virtual encounters. Future directions should evaluate whether this is the most effective way to capture work done addressing social determinants of health and connecting patients to community resources.

While individual billing codes insufficiently address existing health inequities, they are an important step to financially capture the work that SGIM physicians and healthcare teams already do and incentivize the promotion of whole-person health. CMS and other payers should continue to work towards reimbursing providers and health systems that address the broader social and community level factors that impact patient health. This reimbursement should focus on rewarding team-based provisions of care and whole person health.