Important: New Reimbursement Options for Caregiver Training & Community Health Workers

I thought it would be helpful to discuss over the next couple of weeks the Medicare Physician Fee Schedule (PFS) for the 2024 calendar year (CY), as it pertains to the advancement of health equity. Today I will dive specifically into the additional CPT® codes and clarification on reimbursement for caregiver training and the addition of community health workers (CHWs).

In CY 2022, the Centers for Medicare & Medicaid Services (CMS) received recommendations for two codes: CPT code 96202, which is multiple-family group behavior management/modification training for individuals who care for patients with a mental or physical health diagnosis, administered by a physician or other qualified healthcare professional, without the patient present, 60-minutes, and CPT code 96203, the code for each additional 15 minutes beyond 96202. In CY 2023, CMS added additional codes for therapy disciplines (PT, OT, and speech) to provide similar caregiver support. Although these codes existed in previous years, CMS had debate about reimbursement, because they do not involve the presence of the patient, thus creating some difficulty regarding the “reasonable and necessary” guidelines for reimbursement. However, for CY 2024, CMS has concluded that under certain circumstances, caregiver training can be medically necessary for the care of the patient, even if the patient is not present for the visit, and appropriate for reimbursement. Guidelines for caregiver training services (CTS) begin on page 221 of the proposed rule.

Now, on to major inclusion and advancements for community health workers (CHWs). CMS is proposing additional reimbursement for what is called Community Health Integration (CHI) services. These are the services that a physician or provider office coordinates and utilizes as extenders of social workers or other licensed professionals, which help in addressing unmet social determinants of health (SDoH) needs.

The proposal is two G codes that could be billed monthly under the general supervision guidelines: the initiating G code for the first 60 minutes of appropriate services, and then the following G code for additional services in 30-minute increments. Services for CHI are expected to be conducted by CHWs; however, at this time official certification for CHWs is not required for billing. As this is being clarified by CMS, I would ensure that healthcare systems and primary care clinics have a mechanism for describing the role and training of these extenders that match the expectations in the proposed ruling, even if they are not titled CHWs.

I have seen many titles out there for this exact role, such as community care technicians or navigators, that likely meet the requirements inclusive of these services for reimbursement. Additionally, CHI services must tie back to SDoH factors that are present in the physician documentation. These codes can serve as additional and separate reimbursement from the existing chronic care management services that clinics may be currently providing. Guidelines for CHI begin on page 236 of the proposed rule.  

To help explain the services, I will provide an example – like what CMS provided in the ruling. Say a patient is being seen for a follow-up PCP visit to a recent ED visit, where the patient arrived with elevated glucose levels, because he continues to lose his medications. The PCP discovers that the patient routinely goes to the ED for medication support secondary to being homeless, and not having means to manage and store his diabetes medication. This patient is high-risk, and because of their need for chronic diabetes management, the PCP has requested chronic care management services.

The case manager starts working on this case and identifies that the patient will need outreach and support at the local homeless shelter and transportation assistance to obtain his medications, as well as coordinated efforts for storage and potentially continual ride assistance for diabetes management.

The case manager recommends these needs in the care plan to the PCP, who adds the appropriate order for CHW services. The CHW services will support this individual with outreach and coordination between the pharmacy and the local community social service programs, including the homeless shelter, to make sure he can store his medications and have access to the resources necessary for checking his insulin levels.

The time spent by the case manager and now the CHW can be listed and billed monthly on the claim under the general supervision of the physician.

Next week I will be covering the SDoH assessment and Z-code capture in the outpatient setting.

Programming note: Listen to live SDoH reports by Tiffany Ferguson, every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.