The New Outpatient SDoH Codes: How they Apply and What Can be Done

The New Outpatient SDoH Codes: How they Apply and What Can be Done

Almost two months into the 2024 Outpatient Prospective Payment System (OPPS), I thought I would provide some clarity regarding the new social determinants of health (SDoH) and supportive service codes that have been released – specifically, the SDoH assessment, community health integration, and principal illness integration. This article was prompted after some questions from clients and the case management professional community about who can provide these services. 

SDoH Assessment: G0136

Unlike the social drivers of health screening in the inpatient setting, this SDoH assessment is a 5-15 minute add-on assessment to an existing evaluation and management (E&M) visit or annual wellness visit with a provider to assess social factors that may be impacting a patient’s health status. The assessment must include the domains of housing, food, utility, and transportation needs or insecurity. Consideration should be given to utilizing the Centers for Medicare & Medicaid Services’ (CMS’s) cited SDoH screening tools for convenience to help facilitate conversation, but it is not required. These approved tools can be completed as a self-exam by the patient in the visit; however, the responses and applicable needs must be pulled into the provider’s documentation. CMS has made it clear that in order to bill for G0136, the provider cannot simply screen for SDoH, but must demonstrate an assessment of need and its impact in the medical visit. 

For instance, the patient may complete their Health-Related Social Needs (HRSN) Screening Tool in the lobby prior to the visit, through which they identify that they are struggling with keeping food on the table in their house. During their annual wellness visit (AWV) with their provider, they then discuss how food insecurity has impacted their ability to manage their diabetes. This finding is then incorporated into their care plan, and the patient is referred to the clinic’s case management program to assess further needs to support diabetes management and layout community food options. Ideally, there would also be Z codes that are captured as a result of the documented SDoH factors assessed.

Say the HRSN tool was provided to the patient, yet no SDoH needs were identified – then the provider would have no need to incorporate or bill for G0136 during their visit. The patient would screen negative and be listed as having no further needs. This code can billed every six months, which would allow the provider to follow up with their patients regularly should social factors change, requiring adjustments to the medical plan of care because of new considerations related to social domains.

Community Health Integration: G0019 and G0022

The Community Health Integration (CHI) codes are billed as a monthly charge, initiated after a provider visit in which community health integration needs are identified related to specific SDoH concerns that are impacting the patient’s medical treatment. G0019 is for 60 minutes in the month in which services are performed “incident to” by a community health worker or trained auxiliary personnel representative who is able to assist the patient in addressing their SDoH needs, such as obtaining food assistance, completing a housing voucher, or obtaining a monthly bus pass. 

Community health workers (CHW) are typically frontline public health workers who are trusted members of the local communities they serve. They serve a unique role in receiving training and/or certification to link the healthcare system to local social services and the cultural community. These individuals may provide translation services and typically reside within the community in which they are working. These individuals may work directly under a provider, or serve as auxiliary staff connected under the social work and/or case manager to provide “on-the-ground” and in-home support services for patients receiving services through nontraditional means.

For G0019 to be utilized, there would need to be an initial assessment that would determine the appropriate services and goals that are going to be accomplished between the CHW and the patient. There would then need to be continued documentation demonstrating progress and contact between the patient and CHW throughout the month that demonstrates the time expectation. G0022 would be added for each additional 30 minutes beyond G0019 that is completed within the month.  

Ideally, there would also be Z codes that are captured based on the findings from the provider’s initial visit and the CHW assessment and treatment goals.

Principal Illness Navigation: G0023, G0024, G0140, and G0146

Principal illness navigation (PIN) can best be understood as providing reimbursement to navigators who work with patients with significant chronic conditions. To qualify for PIN, these conditions, such as cancer, chronic obstructive pulmonary disease (COPD), congestive health failure, or HIV/AIDs, must exist for greater than a three-month duration and must present with enough significance that there is risk of hospitalization, nursing home placement, decompensation, or decline, should the condition not be addressed or treated. PIN is billed as incident to where the provider, through an initiating visit, identifies that the patient would receive PIN services appropriately to support and navigate the complexity of their condition(s) to guarantee access to services and avoid unnecessary decline.

G0023 serves as a monthly charge: 60 minutes of time initiated via verbal or written consent for a trained and/or certified professional to provide and assess a patient under the supervision of the provider. This individual would complete a biopsychosocial assessment and treatment plan that would connect the member’s condition to potential SDoH risk factors and identify need for education or supportive navigation services to coordinate care. G0024 would be billed for an additional 30 minutes of services in the month. All information and connections with the patient would be documented with capture of time and updates on treatment and goal progress. At this time, the specialist is listed generically for PIN services; however, in most clinical settings, a chronic disease navigator is often a nurse or social worker. These codes would allow for those individuals to count their time in working with patients to address their disease, medication needs, and psychosocial needs through the treatment planning and intervention process for reimbursement under the patient’s attending provider.

G0140 and G0146 are similar codes; however, they correspond to the principal diagnosis for navigation services in the behavioral health setting. These codes include circumstances in which the “incident-to” specialist is a certified peer support specialist, which is a specific call-out and varies from the PIN chronic medical disease codes.  The SDoH, CHI, and PIN codes are a step in the right direction towards acknowledging the social factors that impact patient complexity of care and navigation of the medical landscape. There are some unknowns in the specialization of certified professional skill sets in each of these codes, which are still broadly defined. Additionally, it appears that these codes are allowed to be billed in conjunction with chronic care management and remote patient monitoring as long as the time is not duplicative, and services are appropriately documented as medically necessary and socially relevant for the patient.

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Tiffany Ferguson, LMSW, CMAC, ACM

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the care management company. Tiffany serves on the ACPA Observation Subcommittee. Tiffany is a contributor to RACmonitor, Case Management Monthly, and commentator for Finally Friday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles for Health and Care Management and c-level responsibility for a large employed medical group. Tiffany received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

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