The Centers for Medicare & Medicaid Services (CMS) continues their commitment to advancing healthcare equity through various initiatives, policies, and programs to reduce disparities in healthcare access and clinical outcomes.
CMS promotes value-based care models that focus on quality of care rather than quantity of services. This approach looks to improve health outcomes while reducing the overall cost of care and puts an emphasis on addressing health disparities among vulnerable populations. Health equity ensures that the entire population has the opportunity to reach their optimal health status regardless of their economic or social status. Reaching health equity as a society requires the elimination of avoidable, unfair, or remediable differences in health among different populations.
Addressing social determinants of health helps reduce health disparities and promotes fair distribution of healthcare resources.
To improve value-based initiatives and to support the agency’s continued commitment to health equity, CMS finalized its 2024 Medicare Physician Fee Schedule to include policies that expand access to care and advance healthcare equity. CMS finalized coding and payment for Social Determinants of Health (SDOH) Assessments, Caregiver Training, Community Health Integration, and Principal Illness Navigation (PIN) services.
SDOH Assessments
The World Health Organization defines SDOH as the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.1 SDOH, which significantly impact health outcomes, include factors such as safe housing, food insecurity, transportation, education, and economic stability. Addressing SDOH helps reduce health disparities and promotes fair distribution of healthcare resources. CMS encourages healthcare providers to address these social factors as part of a comprehensive approach to healthcare equity. CMS allows the SDOH risk assessment to be provided in addition to the Medicare Annual Wellness Visit (AWV) or in conjunction with a qualifying evaluation and management or a behavioral health visit.2 The patient will not incur a copayment or coinsurance when the assessment is performed during an AWV. The assessment code should be reported when the practitioner believes the patient has unmet SDOH needs that are interfering with the diagnosis or treatment of an illness. The evidence-based, standardized SDOH risk assessment tool used must cover domains such as housing insecurity, food insecurity, transportation needs, and utility difficulty, but practitioners may choose to add other domains if prevalent or culturally significant to their patient population.3
Caregiver Training Services (CTS)
A caregiver provides care and support to individuals who may need assistance due to illness, disability, aging, or other physical and emotional challenges. Caregivers help with a variety of tasks ranging from assistance with activities of daily living, administering medications, providing companionship, providing emotional support, and advocating for the well-being of the patient. CMS revised its definition of a caregiver to read “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation,” and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”4 CMS now allows reimbursement to physicians, nonphysician practitioners, and therapists for training one or more caregivers to assist patients with certain diseases or illnesses in carrying out an individualized treatment plan or therapy treatment plan without the patient present.5
The training must be reasonable and necessary and related to the person-centered treatment plan developed specifically for the patient. The training is permitted without the patient’s participation so that the practitioner and caregiver can focus exclusively on the training goals. During the training, the practitioner instructs the caregivers on how to properly assist the patient with their specific needs. Caregiver training will help minimize the negative effects of the patient’s diagnosis and recognize the caregiver as an effective member of the care team. The goal of the training is to supply quality, personalized, and cost-effective care that promotes the patient’s health, safety, and independence.
The volume and frequency of caregiver training services are dependent on changes in the patient’s condition or medical status or if there is a change in the caregiver.
Community Health Integration (CHI) Services
CHI services refer to initiatives or programs that aim to integrate healthcare services with community-based resources to improve overall health outcomes and enhance coordination of care between healthcare providers, community organizations, social service providers, and other stakeholders.
CMS established separate coding and payment for CHI services, which include person-centered planning, health system coordination, promoting patient self-advocacy, and facilitating access to community-based resources to address unmet social needs that interfere with the practitioner’s diagnosis and treatment of the patient. CHI services are designed to specifically include care provided by community health workers, who link underserved communities with critical health care and social services in the community and expand equitable access to care.2
PIN
PIN services are a new navigation service designed to help patients with complex, high-risk conditions, such as dementia and cancer, navigate their healthcare treatment plan by connecting with clinical and support resources.2 CMS considers these to be incident to services and must be performed by certified trained auxiliary personnel under the direction of a physician or other practitioner in a nonfacility setting. CMS also added PIN codes for services that involve auxiliary personnel, such as peer support specialists who can provide more specialized support for patients with behavioral health conditions, such as severe mental illness and substance use disorder.2 Even though certified or trained auxiliary personnel may contract with medical practices, communication and clinical integration with the billing practitioner must be ongoing.
An initial evaluation, management visit, and informed consent submission from the patient are required before billing for PIN services. PIN services include a person-centered assessment that explores the patient’s medical history, care coordination, and health education. This assessment is tailored to the patient’s condition, patient self-advocacy skills, health system navigation, behavior change support, social and emotional support, and linkage to community-based social services that address SDOH needs.
Coding for Proper Reimbursement
CMS recognizes costs associated with patient-centered care and therefore established the following codes to reimburse providers and acknowledge that access to these services could improve health equity and improve outcomes for patients where disparities exist.
SDOH Assessment3
- G0136—Administration of a standardized, evidence-based SDOH risk assessment tool, 5-15 minutes
CTS4,5
- 96202—Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by a physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes
- 96203—Each additional 15 minutes
- 97550—Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem-solving, safety practices) (without the patient present), face-to-face; initial 30 minutes
- 97551—Each additional 15 minutes
- 97552—Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem-solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers
CHI Services3
- HCPCS G0019—CHI 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 SDOH need(s) that are significantly limiting ability to diagnose or treat problem(s) addressed in an initiating E/M visit
- HCPCS G0022—CHI services, each additional 30 minutes per calendar month
PIN3
- HCPCS G0023—PIN services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator or certified peer specialist; 60 minutes per calendar month
- HCPCS G0024—PIN services, additional 30 minutes per calendar month
- HCPCS G0140—PIN—Peer support by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a certified peer specialist; 60 minutes per calendar month
- HCPCS G0146—PIN—Peer support, additional 30 minutes per calendar month (list separately in addition to G0140)
Summary
CMS continues to evolve its strategies and policies to advance healthcare equity, and ongoing efforts are necessary to address the complex challenges associated with disparities in healthcare. Focusing on healthcare equity and SDOH is essential for creating sustainable healthcare for all. By addressing underlying social factors, the burden on healthcare systems can be decreased, leading to more efficient and effective healthcare, and creating a just, fair, and healthy society. Practitioners, caregivers, and patients must all be actively involved members of the care team to promote engagement, patient safety, and quality of care. We must recognize and tackle the root causes of health disparities and work toward more inclusive and equitable healthcare for all.
References
- World Health Organization. Social determinants of health. Accessed January 30, 2024. www.who.int/health-topics/social-determinants-of-health
- Centers for Medicare & Medicaid Services. CMS finalizes physician payment rule that advances health equity. November 2, 2023. Accessed January 30, 2024. www.cms.gov/newsroom/press-releases/cms-finalizes-physician-payment-rule-advances-health-equity
- HCPCSData.com. HCPCS ‘G’ Codes. Accessed January 30, 2024. www.hcpcsdata.com/Codes/G
- CodingIntel. CMS adopts codes for caregiver training services (CTS). Updated December 18, 2023, Accessed February 2, 2024.
https://codingintel.com/caregiver-training-services-cts/#:~:text=One%20set%20of%20codes%20(96202,can%20be%20in%20the%20training - MLN Matters. Medicare physician fee schedule final rule summary: CY 2024. Accessed January 30, 2024. www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdf
About the Reviewer
Jan Hailey, MHL, CMC, CMCO, CMIS, CMOM, CMCA-E/M, is a WPS Government Health Administrator (Medicare) Provider Outreach and Advisory Group member and has been instrumental in developing Practice Management Institute’s Workforce Initiatives program. She has a Master of Health Leadership degree and holds 5 professional certifications in office management, coding, insurance processing, auditing, and compliance.