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Rural Health Information Hub
Rural Health Information Hub

Community Health Integration Services

What are Community Health Integration (CHI) Services?

The Centers for Medicare & Medicaid Services (CMS) began reimbursing for Community Health Integration (CHI) Services on January 1, 2024. CHI services address a Traditional Medicare patient's upstream drivers — the full spectrum of environmental, behavioral, social, and structural factors — affecting treatment adherence and outcomes.

CHI services include:

  • Person-centered assessment and planning
  • Care coordination and health system navigation
  • Patient education and self-advocacy skill building

Why provide CHI services?

Upstream drivers — such as smoking, nutrition, physical activity, substance misuse, transportation, housing, food, financial security, and social support — can affect a patient's ability to manage their condition. CHI services are intended to support patients in accessing the needed resources to help treat their medical condition. For example, a patient without transportation may not be able to access necessary testing or treatment services. Addressing these needs can help patients receive timely care, enhance your practice's efficiency, and improve patient compliance and satisfaction. Further, CHI services can support providers participating in alternative payment models to achieve quality goals.

Who can provide CHI Services?

CHI services must be initiated by a billing practitioner during an initiating visit where the practitioner identifies upstream drivers that may affect treatment adherence and outcomes. The billing practitioner can be a physician, nurse practitioner, physician assistant, or certified nurse midwife. Licensed clinical social workers (LCSWs), marriage and family therapists (MFTs), and mental health counselors (MHCs) may also initiate and bill CHI services directly when related to the diagnosis or treatment of mental illness. However, MFTs and MHCs cannot bill for CHI services if they are provided by auxiliary personnel, as they are not authorized to supervise, bill, and be paid directly by Medicare for services that are provided by auxiliary personnel incident to their professional services.

Auxiliary personnel — including community health workers (CHWs), nurses, social workers, MFTs, or MHCs — may perform CHI services incidental to the billing practitioner under general supervision. The same practitioner bills for the subsequent CHI services provided by the auxiliary personnel. If LCSWs, MFTs, and MHCs are performing the services as auxiliary personnel under the general supervision of a billing practitioner for a medical problem that is not considered a mental illness, they should meet the certification or training requirements to perform all CHI service elements.

Auxiliary personnel who provide CHI services may be employed by the billing practitioner or may be external to, and under contract with, the practitioner. For example, a physician practice may contract with a community-based organization employing CHWs or other auxiliary personnel if they meet all “incident to” requirements and conditions for payment of CHI services.

If your practice chooses to use auxiliary personnel, note that they must meet all applicable state requirements, including licensure. If your state does not have any applicable requirements, these personnel must be certified and trained in the following competencies:

  • Patient and family communication
  • Interpersonal and relationship-building skills
  • Patient and family capacity building
  • Service coordination and systems navigation
  • Patient advocacy, facilitation, individual and community assessment
  • Professionalism and ethical conduct
  • Development of an appropriate knowledge base, including of local community-based resources

What is required for a CHI initiating visit?

CHI services require an initiating visit with a billing practitioner prior to the start of CHI services. An initiating visit can be:

  • An Evaluation and Management (E/M) visit, with the exception of level 1 visits performed by clinical staff,
  • an E/M visit provided as part of Transitional Care Management services,
  • a Psychiatric diagnostic evaluation,
  • a Health Behavior Assessment and Intervention (HBAI) services, or
  • An Annual Wellness Visit (AWV)

During the initiating visit, the practitioner should identify and document the upstream drivers affecting the ability to diagnose and/or treat the patient. During this visit, the practitioner will also establish the CHI services.

The practitioner or the auxiliary personnel providing CHI services must get patient consent in advance of providing CHI services to ensure patients are aware of cost sharing requirements. Consent can be written or verbal and documented in the patient's medical record.

What are the billing codes for CHI Services?

There are two CPT codes for CHI services:

  • G0019: CHI services performed by certified or trained auxiliary personnel under general supervision, including a community health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month.
  • G0022: CHI services, each additional 30 minutes per calendar month (Listed separately in addition to G0019)

While CHI services should include some in-person interaction, services can also be provided virtually, including videoconference and audio-only.

Only one practitioner can bill for CHI services per month for a patient. Other care management services can be furnished in the same month if the services are medically reasonable and necessary, meet the requirements, and efforts are not counted more than once.

How do I document CHI services in my electronic health record (EHR)?

During the initiating visit, the billing practitioner must document the patient's upstream drivers that will be addressed with CHI services in the medical record. ICD-10 Z-codes can be used to document any unmet social needs. Further, the billing practitioner must document patient consent, including that the patient acknowledges cost sharing and that services may only be provided by one practitioner per month.

When providing CHI services, the amount of time spent with the patient and the types of activities conducted should be documented in the patient's medical record.

Are there any special considerations for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) billing for CHI services?

RHCs and FQHCs should bill the individual HCPCS codes for CHI services (G0019 and G0022). The payments for these codes are the national non-facility PFS payment rates when the individual code is on an RHC or FQHC claim, either alone or with other payable services and the payment rates are updated annually based on the PFS amounts for these codes.

CMS allows RHCs and FQHCs to bill concurrently for care management services. This means that RHCs and FQHCs can provide CHI, Transitional Care Management (TCM), and other care management services for the same patient in the same service period.

Additionally, note that group health behavioral assessment and intervention (HBAI) services (CPT codes 96164, 96165, 96167, and 96168) are not qualifying visits for RHCs or FQHCs and may not serve as initiating visits for CHI services.

Resources

Last Updated: 02/20/2026
Last Reviewed: 02/20/2026