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Medicare to Start Paying for Community Health Worker Services


Effective January 1, 2024, Medicare will pay for social determinant of health assessments every six months and monthly community health integration and principal illness navigation services provided by certified community health workers and other certified peer specialists.


The Calendar Year 2024 Physician Fee Schedule published by the Centers for Medicare and Medicaid Services (CMS) in November 2023 included new G-codes to be used for the newly covered health-related social needs services, as described in the table below.

Health-Related Social Needs Service

G-Code

Additional Information

Social Determinants of Health Assessment

G0136

With Evaluation & Management (E&M) visit once every six months

Community Health Integration (CHI) Services [to address social needs that are significantly limiting ability to diagnose or treat problem(s)]

G0019 for first 60 minutes each month

 

G0022 for each additional 30 minutes per month

 

G0511 (for FQHCs and RHCs to use for both CHI and PIN services)

Requires initiating E&M visit for subsequent CHI services to be billed incident to professional services. Third-party contracts with community-based organizations allowed. Documentation: written or verbal consent, reasonable and necessary plan, CHI encounter notes, clinical integration meetings, re-evaluations. Deductible/co-insurance requirements apply.

Principal Illness Navigation (PIN) Services [for serious, high-risk disease expected to last at least 3 months]

G0023 for first 60 minutes each month

 

G0024 for each additional 30 minutes per month

 

G0140 and G0146 for PIN-Peer Support for behavioral health conditions

Examples of diseases with significant risk of hospitalization, nursing home placement, acute exacerbation/decompensation, functional decline, or death: cancer, COPD, congestive heart failure, dementia, HIV/AIDS, severe mental illness, substance use disorder. Requires single (not monthly) initiating E&M visit for billing incident to professional services.

Source: Freedman’s Health, Washington, DC

 

CMS is expected to issue an informational bulletin to further clarify how the new services should be coded and will be paid.


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