Community Health Integration
A monthly service for connecting patients to community-based resources that address unmet social needs, such as housing, food, or transportation, that are interfering with an existing medical treatment plan.
What it is
Community Health Integration (CHI) services pay for monthly, non-face-to-face work by certified or trained auxiliary personnel, such as a community health worker or patient navigator, who help a patient connect with community-based resources to address unmet social determinants of health (SDOH) needs.
The service is grounded in an SDOH risk assessment that identifies a specific, unmet social need (for example housing instability, food insecurity, or transportation barriers) that is interfering with the practitioner's diagnosis or treatment of the patient's medical problem, and it covers person-centered planning, resource identification and referral, and follow-up to confirm the patient actually connected with the community resource.
Who qualifies
- An initiating visit (typically an E/M, AWV, or similar visit) identifies a problem and documents an SDOH risk assessment showing at least one unmet social need that is interfering with treatment of that problem
- The unmet social need is not itself the medical diagnosis, CHI addresses a social barrier to care, not the underlying condition
- Documented patient consent to CHI services, including any applicable cost-sharing
- Services are personally furnished by certified or trained auxiliary personnel (e.g., a community health worker) under the general supervision of the billing practitioner
- Only one practitioner bills CHI for a given patient in a given month
Codes at a glance
| Code | What it covers | Threshold | Approx. payment | Details link |
|---|---|---|---|---|
| G0019 | Community health integration, first 60 minutes per calendar month of auxiliary personnel time | 60 minutes of certified/trained auxiliary personnel time | ~$86 | Details → |
| G0022 | CHI add-on, each additional 30 minutes of auxiliary personnel time | Each additional 30 minutes, requires G0019 first | ~$54 | Details → |
Approximate CY2026 Medicare Physician Fee Schedule national non-facility payment benchmark for non-QP clinicians, before geographic, sequestration, and claim-specific adjustments. Actual reimbursement varies by locality, practitioner status, payer, and billing circumstances. Verify the applicable amount with CMS or your Medicare Administrative Contractor.
What's required to bill
- Documented SDOH risk assessment identifying an unmet social need interfering with the patient's medical treatment plan
- Documented patient consent to CHI, including any applicable cost-sharing
- Person-centered plan for addressing the identified social need, developed with the patient
- Identification of, referral to, and follow-up with community-based resources and organizations
- Services personally furnished by certified or trained auxiliary personnel under the billing practitioner's general supervision
- Only one practitioner bills CHI per patient per calendar month
Documentation checklist
- Signed or verbally-documented CHI consent in the chart
- SDOH risk assessment results and the specific unmet need(s) identified
- Person-centered plan for connecting the patient to community resources
- Time log showing auxiliary personnel time for G0019/G0022
- Notes on referral outcomes and follow-up with community organizations
Common billing mistakes
- Billing CHI without a documented SDOH risk assessment showing a specific unmet social need
- Billing G0022 without first meeting the G0019 60-minute threshold
- Using CHI to address the medical condition itself rather than a social barrier interfering with its treatment
- More than one practitioner or practice billing CHI for the same patient in the same month
- Billing CHI alongside CCM, PCM, or TCM for the same patient using the same time or activities, instead of separating the distinct work performed under each
FAQ
What counts as an unmet social need for CHI?
Any documented social determinant of health, such as housing instability, food insecurity, transportation barriers, or utility needs, that is interfering with the practitioner's ability to diagnose or treat the patient's medical problem. CHI addresses the social barrier, not the medical condition itself.
Can CHI be billed alongside Chronic Care Management (CCM)?
Both can be furnished, but the same practitioner can't bill CHI and CCM for the same patient using the same time or activities in the same month; each service needs its own distinct, non-duplicated time and documentation.
Does CHI require a face-to-face initiating visit?
Yes. An initiating visit is required to identify the medical problem and document the SDOH risk assessment that establishes the unmet social need before ongoing CHI services can be billed.