New Reimbursements for Holistic Health Integration and Management

Your mom has a dementia diagnosis. A younger brother has a schizophrenia diagnosis. You have a recent cancer diagnosis. Frequently in these situations, you face everything alone or a family member takes on those additional caregiving needs — often without any assistance, training, community connections, or peer support. This can be even harder when facing other social determinants of health (SDOH).

That may be beginning to shift with new payments finalized by the Centers for Medicare & Medicaid Services (CMS) that enable your health care team — physicians and behavioral health providers, among others — to provide additional assistance. The payments would reimburse for caregiving training, community health integration, SDOH, and principal illness navigation.

For several years now, CMS has increased its suite of care management codes for providers to better treat patients with these conditions — chronic care management, transitional care management, and behavioral health integration care management, among others — but there are still reimbursement gaps in addressing care more holistically.

While at the state level there may be some assistance via state Medicaid plans, home and community-based supports or other programs, along with the potential for Medicare Advantage to offer some supplemental benefits, these can be limited and vary considerably by plan or state. With CMS finalizing the 2024 physician fee schedule, there are now across-the-board opportunities for providers in traditional Medicare to be reimbursed for helping patients and their caregivers navigate illnesses.

Final 2024 physician fee schedule (PFS) payments

Each year, CMS updates Medicare payments and policies for physicians and other professionals paid through the PFS. The final 2024 PFS rule released on November 2, 2023, includes key new payments to consider.

Caregiver training services

CMS finalizes reimbursement codes for behavior management/modification and functional performance training in both group and individual settings. This is the first time payments are available for these caregiver training services.

Two codes — 96202 and 96203 — relate to 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 physicians or other qualified health care professionals (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s) for the initial 60 minutes and each additional 15 minutes, respectively.

Three other codes — 97550, 97551, 97552 — relate to caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding problem solving, safety practices) (without the patient present), face-to-face for the initial 30 minutes, each additional 15 minutes, and in a group setting.

How it could be used — If we go back to our earlier example, this could be used to help with a parent’s dementia diagnosis. A health care provider could host a monthly group educational program on dementia care topics. Topics could cover how to handle mental and functional decline, behavioral changes, and how to create a safer home environment.

Community health integration (CHI)

CHI reimbursements are to better integrate patient needs with community services and resources. CMS finalizes new codes — G0019 and G0022 — to pay for CHI services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner for 60 minutes (plus a code for each additional 30 minutes) per calendar month, in various activities to address SDOH that are significantly limiting ability to diagnose or treat problem(s) addressed in an initiating evaluation and management (E/M) visit. The primary care provider (PCP) identifies the SDOH that impact the care of the patient. Those could be recorded using ICD-10-CM diagnosis codes of Z55-Z65.

Covered activities include:

• A person-centered assessment,
• Practitioner, home-, and community-based care coordination,
• Health education,
• Patient self-advocacy skills,
• Health care access/health system navigation
• Facilitating behavioral change,
• Facilitating and providing social and emotional support, and
• Leveraging lived experience of others.

Of note, CMS finalizes that CHI services may not be billed concurrently while the patient is under a home health plan of care.

How it could be used — Let’s say there’s an individual with a recent heart event. The doctor knows the patient would greatly benefit from cardiac rehabilitation classes and follow-up visits but discovers the patient is not going because he lacks transportation. In addition, the patient is still smoking. Through CHI services, the patient could get transportation to cardiac rehab classes, related health education, self-advocacy skills, and behavior modifications related to smoking cessation.

Principal illness navigation (PIN)

PIN relates to when an individual has one high-risk condition that is expected to last a minimum of three months.

CMS finalizes two G codes — G0023 and G0024 — for 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 for 60 minutes (and for each additional 30 minutes) per calendar month, in the following activities:

• Person-centered assessment,
• Identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services,
• Practitioner, home, and community-based care coordination,
• Health education,
• Self-advocacy skills,
• Health care access/health system navigation,
• Facilitating behavioral change,
• Facilitating and providing social and emotional support, and
• Leveraging lived experience of others.

In response to stakeholder feedback, CMS also finalizes two more new codes — G0140 and G0146 — specific to PIN-Peer Support (PIN-PS). Given the nature of work typically performed by peer support specialists in certain situations, CMS limits these codes to the treatment of high-risk behavioral health conditions. The activities are similar to G0023 but not identical.

How it could be used — In the case of the cancer diagnosis in the example, you are now faced with information, treatment visits, and physical/mental health challenges. You have multiple physicians involved with your care but are struggling to coordinate and understand it all. PIN services can be used to help you navigate, set goals, and work with others who have also lived through a cancer diagnosis. If we take the brother with schizophrenia, similarly, PIN services can assist with setting life goals, scheduling treatment appointments, finding local supportive services, and leveraging others who are successfully living with schizophrenia.

SDOH assessment

CMS finalizes a new stand-alone G code to address assessing patients for SDOHs. The code, G0136, requires use of a standardized, evidence-based SDOH analysis tool for between five and 15 minutes, not more than once every six months. CMS emphasizes this is an SDOH risk assessment, not a screening. As such, the risk assessment is for when a practitioner has reason to believe an unmet SDOH need is interfering with the practitioner’s diagnosis and treatment of a condition or illness. It would be done in conjunction with either an E/M visit, an annual wellness visit, or by behavioral health practitioners during behavioral health office visits for mental illness and substance use disorders.

Additionally, the code may be furnished during hospital discharge visits, with transitional care management visits, and may be billed in the outpatient setting. The SDOH needs identified must be documented in the medical record. CMS doesn’t require the use of “Z codes” (Z55-Z65) to document SDOH but encourages it. Reporting these codes can also help support moderate levels of medical decision making as well as showing higher levels of resources needed for patients.

On a related note but outside of the 2024 PFS rule, the CMS Innovation Center is testing a model that includes payments for caregiver training and respite services through its new GUIDE dementia care model. The goal of the GUIDE model is to test a new comprehensive care coordination approach for those with dementia while also providing several specific payments.

The GUIDE model will run nationwide for eight years. The model is open to Medicare-enrolled Part B providers and practitioners and other Medicare providers/supplies may be a part of the model as a “partner organization.” There are several payments under GUIDE specifically for caregiver training and support services, respite care, and navigating community-based services.

Read CLA’s GUIDE model blog or visit CMS’s GUIDE model webpage for more details. The model is now open for applications through January 30, 2024.

How we can help

There are many opportunities to provide better, coordinated, and supportive holistic care with these reimbursements and models. If you are interested in learning more about these new payments or the GUIDE model, we’re here to help you unpack the details and strategize for the future. Reach out today.