When to bill CHI, PIN or CCM: A practical framework for independent practices

When CMS introduced Chronic Care Management codes in 2015, primary care practices spent years figuring out how to operationalize them. A decade later, many practices that did the work are still running care coordination programs under that same CCM-only mental model, even though the reimbursement landscape has shifted.

In January 2024, CMS introduced two new sets of codes under the Physician Fee Schedule: Community Health Integration (CHI), using HCPCS codes G0019 and G0022, and Principal Illness Navigation (PIN), using G0023, G0024, G0140 and G0146. Both expand what Medicare reimburses for between-visit coordination. Both have specific qualifying conditions and documentation requirements. And both are currently uncaptured in most independent practices I encounter.

The gap is rarely about willingness. It is about decision-making. When a practice manager is asked which code to bill for a given patient, the honest answer is often “I don’t know,” and so they default to billing nothing, billing CCM for everyone or running an informal coordination program off the books. None of those serve the patient or the practice.

A simple decision framework can clarify the choice.

Question 1: Does the patient have two or more chronic conditions expected to last at least 12 months?

If yes, CCM is in play. The patient qualifies for ongoing chronic care management: care coordination, medication management and between-visit support. The practice can bill the corresponding CCM codes for the time spent. CCM is the workhorse. Most patients with multiple chronic conditions in a primary care panel qualify, and most practices have at least started billing it.

Question 2: Does the patient have unmet health-related social needs that affect their care?

If yes, Community Health Integration enters the picture. CHI was designed to reimburse for the coordination work that addresses social drivers of health: transportation barriers, food insecurity, housing instability and social isolation, when those barriers are documented as affecting the patient's clinical condition. G0019 covers the first 60 minutes per calendar month; G0022 covers each additional 30 minutes.

CHI is not a replacement for CCM. A patient may qualify for both, with the practice billing each for distinct services on different days. The key is documentation. The social need must be identified, the intervention must be tied to a clinical concern, and the time must be tracked under the appropriate code.

Question 3: Does the patient have a serious, high-risk illness requiring active navigation?

If yes, Principal Illness Navigation may be the right code. PIN was created for patients with serious, high-risk conditions expected to last at least three months, including cancer, COPD, congestive heart failure, dementia, HIV/AIDS, severe mental illness and substance use disorder, where the patient is at risk of hospitalization, nursing home placement, acute exacerbation or functional decline. PIN reimburses for the navigation work that helps these patients move through the health care system, manage symptom burden and execute their treatment plan. G0023 covers the first 60 minutes per calendar month; G0024 covers each additional 30 minutes.

PIN doesn't apply to every patient with a chronic condition. It's specifically for serious illness with high navigation need. But for the patients it does fit, the reimbursement is meaningful and the clinical benefit is real.

Putting the framework into practice

The framework above is simple in concept and harder in execution. Capturing the right code for the right patient requires three things working together: clear identification of which patients qualify for which programs, documentation that meets each code's specific requirements and time-tracking that holds up under audit.

That infrastructure is where most practices stall. The codes exist. The patients exist. What's missing is the operational layer that connects them: the workflows, the documentation templates, the staff time and the EHR integration to make sure that what's clinically happening is also what's getting billed.

Related content from Medical Economics: New Medicare codes could transform how physicians serve their most vulnerable patients: here's how to use them

Bottom line

The codes have been live since January 2024, with federal reimbursement authorized. The patients these codes were designed for are sitting in independent primary care panels right now, often receiving the coordination work informally and unbilled. Practices that operationalize CHI and PIN now will be ahead of the value-based care curve. Practices that don't will keep leaving Medicare revenue uncaptured and, more importantly, will keep leaving their most complex patients without the coordinated care those codes were designed to fund.

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4 ways autonomous coding prevents claim denials at the source

Healthcare providers face an unprecedented challenge with claim denials. Nearly $20B is lost fighting denied claims annually, while two-thirds of organizations report increasing reimbursement times. These trends are concerning: 55% of revenue cycle leaders experience rising claim errors, and 77% face more frequent payer policy changes than in the previous year. Across the board, each metric has worsened since 2022, pointing to systemic issues in how claims are processed and submitted.

While most organizations look for temporary fixes, forward-thinking industry leaders are finding promising results with autonomous coding as an initiative for denial prevention. By addressing potential denials before claims are submitted, AI coding offers a path to sustainable improvement in denial outcomes. To understand how autonomous coding can help prevent denials, let's first examine the headwinds facing coding today and the coding-related factors that contribute to claim denials.

Examining today's coding challenges

Behind today's high denial rates lies a fundamental tension – coding requirements grow increasingly complex as coding resources lessen. Consider the typical workflow in a practice's revenue cycle. Understaffed coding teams juggle mounting backlogs of encounters while trying to maintain accuracy. Billing staff spend hours on administrative tasks that could be automated. Physicians get pulled away from patient care to address documentation gaps discovered days or weeks after the encounter. These inefficient processes lead to denials that cost an average of $43.84 to rework, while the accompanying reimbursement delays strain operational budgets.

The staffing crisis in medical coding makes these challenges even more acute. With 30% of organizations reporting coding staff shortages, and experienced coders retiring faster than new ones joining the field, the pressure continues to build. Higher workloads lead to more errors, creating more denials that require staff time – a cycle that traditional solutions can't break.

Overall, as coding-related drivers of claims denials, missing or inaccurate data accounts for 46% of denials, followed by authorization issues at 36%, and incomplete patient information at 30%. Manual approaches to these processes struggle to maintain accuracy and velocity at sufficient scale with today's resourcing.

Breaking the denial cycle with AI

This is where autonomous coding provides relief. The way claims are coded plays a critical role in whether they're paid or denied. While basic automation tools can help human coders, they don't address the fundamental challenges in the coding process that lead to denials.

Let's examine four key ways coding impacts claim denials and how autonomous coding helps prevent these patterns.

1. Checking documentation and finding errors: Many denied claims are due to missing or incomplete documentation. In manual coding workflows, documentation gaps often aren't discovered until weeks after the encounter. By then, getting accurate information from providers becomes difficult or impossible. These delayed discoveries are one of the leading causes of preventable coding-related denials. In contrast, because AI coding analyzes documentation immediately after each visit, it prompts providers to correct deficiencies when the information is still fresh and readily available.
2. Coding accuracy and consistency: Inaccurate coding leads to denied claims when the codes assigned don't properly reflect the care provided or don't comply with payer-specific rules. In manual workflows, accuracy inevitably fluctuates with coder fatigue, varying expertise levels, and high workloads. As coding volumes increase and guidelines grow more complex, these inconsistencies multiply. Autonomous coding eliminates these variables by applying coding rules uniformly regardless of volume or complexity, maintaining consistent accuracy that helps to prevent denials.
3. Guideline changes: Keeping up with changing payer requirements is crucial for clean claims. When policies change, manual coding teams typically need months to learn and implement new guidelines proficiently, leading to increased denials during the transition period. The 2023 E/M guidelines change proved this point as practices saw spikes in denials while coders got up to speed. AI coding systems, however, update instantly to reflect new guidelines, maintaining compliance from day one and preventing these transitional denial surges.
4. Resource allocation: The availability of coding resources directly impacts denial rates. In manual coding environments, organizations face a difficult choice: either invest heavily in expanding coding teams or distribute coding duties across clinical staff to help bear the load. Both approaches drain resources while failing to address the root cause of denials. Autonomous coding offers a different path by handling the vast majority of encounter volumes automatically, allowing both coding teams and clinicians to focus on work that makes better use of their expertise.

Building a sustainable future

With denial rates climbing and organizations losing billions in denied claims each year, healthcare leaders need to consider new approaches to prevention. Autonomous coding offers powerful capabilities that can help reduce denials – bringing precision to documentation, reliability to coding, and speed to the entire process. The benefits extend beyond denial reduction: practices gain more efficient revenue cycles while their teams gain the bandwidth to focus on higher-value activities.

For organizations focused on reducing denials and building sustainable financial operations, autonomous coding represents a significant opportunity to make progress toward these goals.

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How much do prior authorizations cost you?

In this article I share how much income prior authorizations (prior auths) are costing you annually. Be forewarned: it’s a lot of money.

Background

I live with Long Covid. It sucks. However, it gives me rare nights when I am wide awake at 2:00 a.m., in the zone, and laser-focused. One of those nights, I calculated how much income prior auths cost the average physician annually.

My exercise, or challenge if you will, involved pulling together disparate data from the American Medical Association (AMA), the Medical Group Management Association (MGMA), and the Coalition for Affordable Quality Healthcare (CAQH). Claire Ernst, MGMA’s Director of Government Affairs, vetted my extrapolations and calculations, so I feel pretty good with my effort.

The bottom line

Prior auths reduce your personal bottom line by an estimated $11,046.67 annually.

Let’s extrapolate. It’s important to include nurse practitioners, physician assistants and other clinicians seeing patients in the office, as they generate prior auths as well.

10 clinicians: $110,466.70 annually

25 clinicians: $276,166.75 annually

50 clinicians: $552,333.50 annually

Want to know something scary? Those expenses do not factor in appeals of prior auth denials. Appeals increase the expense quickly because appeals involve your time as well.

I looked at 2,000 upper endoscopy prior auths over 18 months with one payor. Our first pass success rate was 97.3%, but it cost us $9,740 in employee expense. We appealed the residual 54 denials and got all but 8 overturned.The cost of these appeals in lost clinician time? $9,450 over and above the $9,740 spent in employee time.

What you should do

Prior auths are overhead. They take money out of your pocket.

1. Refer to testing and infusion centers that do the prior auths for you. Let them spend their employee time on the auths.

2. Whether you refer to places that do them for you or your office does the prior auths, get your documentation and ICD-10 codes right the first time. Know what is needed by the payor, and get it right the first time. It will save you time and money, and it will get your patients the care they need sooner.

3. Consider gold carding* with guardrails. You don’t need blanket gold carding that covers anything you could conceivably order, and no payor will grant it. Instead, you want to ask that you be given a gold card for certain procedures/tests you order frequently so that you don’t need to go through the prior authorization process for them.

In the aforementioned upper endoscopy example, I used my documented 97.3% first pass and 99.6% second pass success rates in my gold card request. I did not ask for gold carding for things gastroenterologists don’t normally do or order; I kept the focus tight to succeed in my request.

4. Change never happens for the better when we stand on the sidelines. Make your voices known legislatively. I use ‘voices’ rather than ‘voice’ because prior auth delays impact your patients (care delays) and your employees (more expenses means less money for raises). Via e-mails, flyers in exam rooms, and the like, each of them can take 2-3 minutes to make their voices heard and thereby make a difference. Here are the things to include in the ask:

1. Automate the prior authorization process. Practices pay employees thousands upon thousands of dollars annually to wait on hold for payers.
2. Standardize the prior authorization guidelines and processes across payers, including step therapies.
3. Adopt reasonable and achievable gold carding thresholds for procedures/tests.
4. Finally, it is important to know your numbers to put things in perspective. Sharing my upper endoscopy statistics, including care delay time frames, makes it real. And if I can share how the care delay impacted the care of a patient, it makes it human. A little work on the front end is needed to bear fruit on the back end.

Does it seem like you're doing more prior auths than ever?

If it does, you are right. I have estimated the volume of prior auths is up 23.9% over pre-pandemic levels. That’s scary. If first-pass prior auths cost your practice $100,000 in 2019, it is costing you $123,900 this year. And that errantly assumes you are paying your staff what you did in 2019; your actual overhead increase is much higher.

In a subsequent article, I will get into the math that went into my calculations. I will share the reasons I believe prior authorizations are increasing.

For now, I ask that you focus on reducing your prior auth overhead. Refer to those who do the prior auths for you, fine-tune your documentation, track your numbers, and make your legislative voices known.


* Gold carding is the term used when a payor permits a clinician to forego the prior authorization process for a procedure, test, or group of either.

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Fixing the broken medical coding system

The rules of other consumer commerce sectors somehow do not apply to medical billing. Stop and think about that for a moment. It’s easier to make sense of how much we spend for goods and services such as groceries, clothing, and gasoline because we know how much it costs up front. No smoke and mirrors. No hidden expenses we are billed for days, weeks, or even months later. Imagine buying gasoline and two weeks later receiving a bill from the station owner because he didn’t include the excise tax on the pump price – would you pay that?

Yet that kind of scenario is exactly what healthcare consumers have learned to expect when it comes to their medical bills. Medical billing and collection is a broken system with far-reaching negative consequences-it’s about time we got down to fixing it.

What we don’t know CAN hurt us

Lack of timely payment or no payment at all is leading to a crisis in healthcare. The simple fact is that in comparison to other products and services, people do not understand how much healthcare costs. In fact, a recent report by the research company West stated that 75 percent of patients don’t know what they’ll owe until they see a bill. 75 percent! Imagine if you went to the store and purchased a gallon of milk but had no idea what it cost until a bill came later. Oh, and add to that the fact that the price of milk would vary wildly from store to store. In all likelihood, people would stop purchasing a product with such an unpredictable cost structure. Perhaps we’re onto something here…if people know prices upfront, they are more likely to pay them.

The need for clear and understandable statements

How many times have you tried in vain to decipher an Explanation of Benefits (EOB) from your insurance company? Sometimes it seems these things are written in some kind of code, seemingly with the intent to obscure benefit information from patients. It’s no surprise to many that trying to understand the healthcare billing system, how benefits are applied, and what balance patients are ultimately responsible for paying has traditionally been as confounding as trying to understand a garbled voicemail-if the message is unclear, it is impossible to take the appropriate action. No wonder so many patients struggle to meet their medical financial responsibilities.

Lack of price transparency killing private practice

As the proportion of patient financial responsibility grows with the rise in high deductible health plans (HDHP), profit risks are pushed higher for independent practices. Small practitioners are seeing larger write-offs, higher costs to collect, and longer revenue collection cycles. We seem to be amid a healthcare payment system crisis that is squeezing these small practitioners the most, forcing them out of independent practice.

Consider these statistics:In 2016 33 percent of physicians reported as independent compared to 48.5 percent in 2012
In 2016 20 percent of doctors worked in groups of 100+ compared to 12 percent in 2012
73 percent of those in independent practice would remain so if they could maintain stability and profitability, but 44 percent expect to sell their practice in the next 10 years
Research shows that small practices deliver better care, especially in areas where high-quality primary care makes a difference: lower hospital readmission rates, better outcomes for patients with diabetes, etc.

These statistics paint a distressing picture-one that shows an eroding of independent practice that ultimately leads to poorer overall health outcomes for everyone.

What can we do?

The solution to this problem is taking a price transparency cue from the retail sector to help patients more clearly understand the why and what of payment responsibility so they can make smarter decisions about healthcare consumption and budget accordingly.

Here are additional suggestions for medical providers to move toward more effective solutions to the pressing issue of poor revenue cycle management:

• Have frank discussions with patients about ability to pay before care is delivered (only a quarter of healthcare providers do this now)
• Embrace patient revenue cycle technology solutions that make it easier for patients to understand and make payments upfront and on-time. This will lead to greater rates of patient engagement, participation, and bill payment:
• 77 percent of healthcare consumers say it’s important or very important to know costs before treatment
• Just one in five (20 percent) physicians currently send reminders about payments on or near due dates
• Join an independent physician association (IPA) or similar organization to enjoy some of the benefits of being part of a larger group of physicians without sacrificing independence, allowing the opportunity to:
• Negotiate with payers
• Enjoy bulk rates on malpractice insurance
• Leverage billing companies to ensure timely and accurate notifications of patient payment responsibilities (most practices fail to bill for about 12 percent of the work they do)

More broadly, the healthcare industry needs sounder infrastructure to support independent physicians and, in turn, medical practices must be more proactive to research and adopt innovative technology tools that can successfully simplify and streamline both time-of-service and residual balance patient payments. We already know the demand is there-49 percent of physicians expect they will have to develop innovative billing and payment models to stay independent.

Healthcare price transparency and payment convenience pays dividends

One of the core faults of our healthcare pricing system is that patients aren’t required to pay for healthcare in any consistent way. As a result, one of the most pressing needs is to implement technology solutions that push healthcare providers to think less like an institution and more like a small business. The simple fact is, if you make the payment process clearer and convenient, more patients will fulfill their financial obligations. Medical providers must tailor billing and payment process to patient needs and desires, implementing tools and resources the modern healthcare consumer has come to expect-such as the ability to pay online or via a smart phone app. Providers should seek to create more of a convenient patient “experience” than an unpleasant episode.

By implementing patient revenue cycle solutions that promote price transparency and offer payment convenience, patients will experience higher levels of satisfaction, peace of mind, and trust. After all, the next generation of healthcare consumers are watching you more closely than ever, are eager to share their experiences via social media and review sites and have a virtual global peer-to-peer network right at their fingertips.

If we don’t proactively tackle the growing fiscal problems that are essentially forcing many smaller medical practitioners to fold their tents, we can’t realistically expect our healthcare system to evolve into a leaner entity with better outcomes.

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