CurrentASAMPolicy N/A

Health-Related Social Needs FAQ (Caregiver Training, SDOH RA, CHI, PIN, PIN‑PS)

Frequently asked questions on billing and coverage rules for Medicare physician payment codes addressing health-related social needs (Caregiver Training Services, Social Determinants of Health Risk Assessment, Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation–Peer Support) and who may furnish and bill these services.

Policy Summary

PayerASAM

PolicyHealth-Related Social Needs FAQ (CTS, SDOH RA, CHI, PIN, PIN‑PS)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document beneficiary consent and perform any required initiating visit before billing CHI or PIN services; document medical need for each occurrence.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

G0019,G0022,G0023,G0024,G0140,G0146Codes discussed

Jan 1, 2025HCPCS caregiver codes eff.

Jan 1, 2024Many codes effective

q6mG0136 limit

monthlyPIN billing limit

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$80Office first hour rate

Coverage criteria for HRSN services

Covered when ALL of the following are met:

HRSN services (CTS, SDOH risk assessment, CHI, PIN, PIN-PS) are furnished consistent with Medicare PFS policy and accepted as reasonable and necessary for the individual beneficiary as documented in the medical record.

Documented need: the treating practitioner must document the medical necessity for each occurrence of caregiver training (CTS) and any SDOH needs identified via the SDOH risk assessment (G0136); Z codes (Z55–Z65) may be used to document SDOH when appropriate.

Consent: advance or contemporaneous beneficiary consent is required for CHI, PIN, and PIN-PS services (and for PIN annually); consent may be written or verbal but must be documented in the medical record.

Initiating visit requirement (CHI and PIN): a qualifying initiating visit performed by the billing physician or practitioner who will furnish and bill the CHI or PIN services is required; the initiating visit is a prerequisite and is billed separately if appropriate.

Frequency and duplication limits: G0136 (SDOH RA) is limited to once every 6 months per practitioner per beneficiary; PIN may be billed no more than once per practitioner per month for any single serious high‑risk condition; CTS has no numeric visit limit but must be medically necessary and documented; PIN and PIN-PS must not be billed concurrently for the same serious high‑risk condition.

Who may furnish services: physicians, authorized non‑physician practitioners, and auxiliary personnel (when provided incident to and under general supervision and meeting all 'incident to' requirements) may furnish these services; auxiliary personnel must meet applicable state requirements or specified competency training/certification.

Telehealth and settings: G0136 may be furnished in facility and non‑facility settings and is on the Medicare Telehealth list; CTS, CHI, PIN, and PIN‑PS can be furnished in facility and non‑facility settings with place of service reported to reflect ordinary in‑person care; CTS and G0136 may be furnished via telehealth as permitted by CMS guidance.

Cost sharing: usual Part B deductible and coinsurance apply to CTS and G0136 (except where G0136 is furnished as an optional element of the AWV), and beneficiaries should be informed that cost sharing applies.

Documentation and billing rules: time, activities, and relation to the practitioner's plan of care performed by auxiliary personnel must be reflected in the patient's medical record and verifiable by the billing practitioner; one practitioner per month can bill CHI services for a patient.

Exclusions: the SDOH risk assessment should not be performed in conjunction with a level 1 E/M visit or other low‑level visits that could be performed by clinical staff; CHI/PIN initiating visits cannot be an ED or inpatient visit when subsequent CHI/PIN services will not be furnished by the same practitioner.

Coverage criteria and operational rules for CHI, PIN, and PIN-PS under Medicare PFS

Coverage stance and operational criteria for CHI, PIN, and PIN-PS services under Medicare PFS.

Coverage statement: CHI, PIN, and PIN‑PS services are covered and payable under the Physician Fee Schedule when furnished personally by physicians and authorized nonphysician practitioners or when furnished by auxiliary personnel incident to the billing practitioner's services and meeting all 'incident to' requirements.

Consent requirement: PIN‑PS (and PIN/CHI) require beneficiary consent before or at service start and annually thereafter; consent may be written or verbal but must be documented in the medical record.

Billing entity and supervision rule: services must be furnished and billed by the same physician or practitioner who performs the initiating visit; auxiliary personnel cannot bill Medicare directly for CHI or PIN and do not have statutory authority to bill or supervise other auxiliary personnel, but may provide services incident to the billing practitioner if all requirements are met.

Auxiliary personnel requirements: auxiliary personnel must be supervised by the billing practitioner, must not be excluded from federal programs, must meet state 'incident to' requirements (including licensure/certification where applicable), and in states without requirements must meet CMS‑specified competency training for CHI; in states with SAMHSA‑consistent peer support standards, those apply to PIN‑PS.

Medicare HRSN and related codes

Medicare HRSN codesmixedCovered

96202	CPT group behavior management/modification (first 60)
96203	CPT group behavior management/modification (each additional)
97550	CPT caregiver training, strategies and techniques (individual)
97551	CPT caregiver training, additional
97552	CPT caregiver training, group
G0539	HCPCS caregiver training behavior management/modification (individual)
G0540	HCPCS caregiver training behavior management/modification (additional)
G0541	HCPCS caregiver training strategies (individual)
G0542	HCPCS caregiver training additional
G0543	HCPCS caregiver training group

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CHI / PIN / PIN-PS codesCPTCovered

G0019	Community Health Integration (CHI) - referenced
G0022	Community Health Integration (CHI) - referenced
G0023	Principal Illness Navigation (PIN) - referenced
G0024	Principal Illness Navigation (PIN) - referenced
G0140	PIN-Peer Support (PIN-PS) - referenced
G0146	PIN-Peer Support (PIN-PS) - referenced

G0136 frequency limit

Limit1 per practitioner per beneficiary every 6 months

ScopeApplies to HCPCS code G0136 (SDOH risk assessment)

RationaleEstablished in the CY 2024 PFS Final Rule as a payment limitation

PIN frequency limit

Limit1 per practitioner per month per single serious high-risk condition

Applies toPrincipal Illness Navigation (PIN) services billed with G0023/G0024 (and related PIN codes)

Restriction

Billing and operational rules for providers

Billing Rule

Billing rules for CTS (group vs individual)

Practitioners must select group or individual Caregiver Training Services (CTS) codes based on the number of beneficiaries represented by caregivers receiving training. If multiple caregivers for a single beneficiary attend the same session, bill the applicable "individual" CTS code (97550, 97551, G0539, G0540, G0541, G0542) one time for that beneficiary — do not bill separately for each caregiver. If caregivers for more than one beneficiary attend the same session, bill the applicable "group" CTS code (96202, 96203, 97552, G0543) once per beneficiary represented. In all cases, practitioners bill one service per beneficiary regardless of the number of caregivers present.

Individual CTS codes: 97550, 97551, G0539, G0540, G0541, G0542 — bill once per beneficiary when multiple caregivers of the same beneficiary attend.
Group CTS codes: 96202, 96203, 97552, G0543 — bill once for each beneficiary represented when caregivers of multiple beneficiaries attend.

Billing Rule

SDOH RA billing frequency and settings

Key definitions

Caregiver (CMS definition)

DefinitionAn 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

Unpaid assistanceA caregiver furnishes unpaid assistance and is in a position to assist the patient in carrying out an established treatment plan or plan of care

Role in CTSCaregiver is the intended recipient of caregiver training services when in a position to implement the patient's care plan

SDOH risk assessment tool

RequirementUse a standardized, evidence-based SDOH risk assessment tool tested and validated through research

Core domainsTools should include domains such as food insecurity, housing insecurity, transportation needs, and utility difficulties

Policy Summary

PayerASAM

PolicyHealth-Related Social Needs FAQ (CTS, SDOH RA, CHI, PIN, PIN‑PS)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document beneficiary consent and perform any required initiating visit before billing CHI or PIN services; document medical need for each occurrence.

SourceLink

On This Page

Settings and place of service: CHI and PIN can be furnished in facility and non‑facility settings; the billing practitioner should report the place of service where they would ordinarily provide in‑person face‑to‑face care; payment rates differ by facility status.

Documentation requirements: the time and activities of auxiliary personnel related to the practitioner's plan of care must be reflected in the medical record; unmet SDOH addressed should be documented and may use ICD‑10‑CM Z codes (Z55–Z65), though documentation of Z codes alone is not separately payable.

Concurrent billing and care management: CHI and PIN may be furnished in addition to other care management services provided that time and effort are not counted more than once and other services meet their billing requirements.

Community‑based organizations and enrollment: Medicare will not pay CBOs directly for CHI/PIN services; auxiliary personnel employed by or contracted through CBOs may furnish services incident to a billing practitioner who is enrolled in Medicare and bills for the services, provided all 'incident to' conditions are met.

Payment rates and variability: example payment approximations are office‑based approximately $80 for the first hour and $50 for each additional half hour, and facility‑based approximately $50 for the first hour and $35 for each additional half hour; actual rates vary by geography and year.

Z‑code payment clarification: Medicare does not make separate payment for documentation of Z codes; documentation alone does not constitute a separately payable Medicare service under current statutory interpretation.

PIN and PIN-PS should not be billed concurrently for the same serious high-risk condition

Payment rate examples

Office-based rates (example)Approximately $80 for the first hour; $50 for each additional half hour

Facility-based rates (example)Approximately $50 for the first hour; $35 for each additional half hour

NoteRates vary geographically and annually; look up exact PFS amounts by area and facility status

HCPCS code G0136 (SDOH risk assessment) is limited to once every 6 months per practitioner per beneficiary. The SDOH risk assessment may be performed in facility and non‑facility settings and may be furnished in conjunction with outpatient E/M visits (including transitional care management and hospital discharge visits) and certain behavioral health visits and the Annual Wellness Visit, but not with level 1 or similar low‑level E/M visits that could be performed by clinical staff. G0136 may also be furnished via telehealth.

Frequency limit: G0136 — once every 6 months per practitioner per beneficiary.
Settings: facility and non‑facility; may be furnished with outpatient E/M visits (excluding low-level visits), certain behavioral health visits (e.g., 90791, HBAI codes 96156, 96158, 96159, 96164, 96165, 96167, 96168), and the Annual Wellness Visit.
Telehealth: G0136 is on the permanent Medicare Telehealth Services List.

Billing Rule

Initiating visit requirement for CHI and PIN

An initiating visit performed by the billing practitioner is required before furnishing CHI or PIN services. The initiating visit may be an E/M visit (other than a low‑level E/M that can be performed by clinical staff), certain behavioral health visits (e.g., CPT 90791, HBAI codes), an AWV if performed by the practitioner who will furnish the CHI/PIN services, or an E/M visit included in bundled services (e.g., transitional care management), provided the same practitioner who performs the initiating visit will furnish and bill the subsequent CHI or PIN services. ED or inpatient visits cannot serve as initiating visits when the practitioner furnishing the visit will not also furnish the subsequent CHI/PIN services. The initiating visit is billed separately from CHI/PIN services when requirements for billing the visit are met.

CHI initiating visit: must be performed by and billed by the same practitioner who will provide CHI services.
PIN initiating visit: may be E/M (not low‑level), AWV (if by the billing practitioner), or certain behavioral health visits; prerequisite to billing PIN services.
Initiating visit billing: bill the initiating visit separately when its billing requirements are met.

Documentation Required

Provider actions and requirements for CHI/PIN/PIN-PS

CHI, PIN, and PIN‑PS services require beneficiary consent (advance consent for CHI; consent before or at start and annually for PIN‑PS) documented in the medical record; the billing practitioner must explain that cost sharing applies. Auxiliary personnel may provide CHI, PIN, and PIN‑PS services incident to and under general supervision of the billing practitioner but must meet applicable State requirements (certification/licensure) or, where no State requirements exist, meet specified training competencies. Auxiliary personnel must not be excluded from federal health programs and must satisfy 'incident to' statutory and regulatory conditions. PIN‑PS auxiliary personnel should be trained consistent with SAMHSA National Model Standards for Peer Support Certification where applicable. CHI, PIN, and PIN‑PS services must be furnished and billed by the same practitioner who performs the corresponding initiating visit; auxiliary personnel cannot bill or supervise others independently.

Consent: CHI requires advance consent (documented; written or verbal). PIN‑PS requires consent before/at start and annually; renew consent when billing practitioner changes.
Auxiliary personnel qualifications: meet State certification/licensure where required; otherwise trained in competencies such as communication, relationship-building, capacity-building, service coordination, advocacy, professionalism, and knowledge of local resources.
PIN‑PS training: where applicable, align with SAMHSA National Model Standards for Peer Support Certification.
Billing and supervision: services must be furnished and billed by the same practitioner who provides the initiating visit; auxiliary personnel provide services incident to and under general supervision and may not independently bill or supervise other auxiliary personnel.
Exclusions: auxiliary personnel must not be excluded from Medicare/Medicaid or federally funded programs.

ExamplesExamples include the CMS AHC tool and the PREPARE tool; tools identified for Medicare Advantage Special Needs Population HRAs may also be used

Serious high-risk condition (for PIN eligibility)

DefinitionA serious, high-risk condition expected to last at least 3 months that places the patient at significant risk of hospitalization, nursing home placement, acute exacerbation/decompensation, functional decline, or death

Care-plan requirementCondition requires development, monitoring, or revision of a disease‑specific care plan and may require frequent adjustment of treatment or substantial caregiver assistance

ExamplesExamples include cancer, COPD, congestive heart failure, dementia, HIV/AIDS, severe mental illness, and substance use disorder

Auxiliary personnel

DefinitionIndividuals supervised by physicians or other billing practitioners to perform services incident to the practitioner's professional services (employees, leased employees, or independent contractors)

ExclusionsMust not be excluded from Medicare, Medicaid, or other federally funded health care programs and must meet state 'incident to' requirements

BillingAuxiliary personnel may provide CHI/PIN/PIN-PS services incident to and under general supervision but cannot bill Medicare directly for these services

PIN-PS auxiliary personnel training/certification

State requirementsAuxiliary personnel providing PIN-PS must meet applicable State requirements, including certification or licensure where required

SAMHSA standardsIn States with training consistent with the SAMHSA National Model Standards for Peer Support Certification, those Standards apply

Consent and documentationPIN-PS requires beneficiary consent before or at service start and annually; consent can be written or verbal but must be documented in the medical record