Social & Community Health

Q: Who qualifies for Social & Community Health (CHI · G0019 · G0022)?

Patient is a Medicare beneficiary. An initiating visit the billing practitioner personally performed — an E/M other than 99211, an AWV, the TCM visit, or from CY 2026 a 90791 / HBAI visit — where they determined that an upstream driver significantly limits diagnosis or treatment of a problem addressed. That practitioner is the only one who bills CHI for the patient. The practitioner's documented finding of the need — a social needs screen (AHC-HRSN, PRAPARE and similar) can point to it, but CMS requires no screen or risk assessment for CHI. The staff furnishing CHI hold a state CHW certification or training in the seven CMS competencies, recorded on the Team page. CHI time must be on CHI-specific activities — not duplicative of CCM/PCM clinical staff time. Consent on file: cost sharing applies, and only one practitioner may furnish and bill CHI in a month. Not billable while the patient is under a home health plan of care.

CHI · G0019 · G0022 Period: Calendar month (CHI) Source: CMS-1832-F (CY 2026 PFS Final Rule)

What it is

Community Health Integration (CHI, G0019 / G0022) is a CY 2024+ Medicare benefit for clinical staff time spent actually addressing unmet social drivers of health — food insecurity, housing instability, transportation, utilities, and similar barriers — often billed alongside CCM, PCM or PIN.

SDOH screening — a clinical feature, not a billing program. willowbridge guides the AHC-HRSN screen and records each social needs screen on the care plan: what was asked (and whether it was partial), who asked it and when, the need found in each positive domain, the referral made or declined, and a billable Z-code for the practitioner to sign. The patient can also complete a self-screen in the portal for staff to review. willowbridge offers the screen once a year to care-management patients, and again whenever someone suspects a new need. That is willowbridge's own standard, not a Medicare requirement, and the screen is not billed.

A positive screen may support CHI: the practitioner determines at an initiating visit whether the need significantly limits the patient's care. A positive screen alone does not qualify the patient.

About G0136. willowbridge does not bill G0136. CMS created G0136 in CY 2024 as an SDOH risk-assessment code; for CY 2026 it rewrote the code as a standardized physical-activity and nutrition risk assessment furnished with a visit (CMS-1832-F, 90 FR 49483), so G0136 no longer describes a social needs screen.

Who qualifies

Patient is a Medicare beneficiary.
An initiating visit the billing practitioner personally performed — an E/M other than 99211, an AWV, the TCM visit, or from CY 2026 a 90791 / HBAI visit — where they determined that an upstream driver significantly limits diagnosis or treatment of a problem addressed. That practitioner is the only one who bills CHI for the patient.
The practitioner's documented finding of the need — a social needs screen (AHC-HRSN, PRAPARE and similar) can point to it, but CMS requires no screen or risk assessment for CHI.
The staff furnishing CHI hold a state CHW certification or training in the seven CMS competencies, recorded on the Team page.
CHI time must be on CHI-specific activities — not duplicative of CCM/PCM clinical staff time.
Consent on file: cost sharing applies, and only one practitioner may furnish and bill CHI in a month.
Not billable while the patient is under a home health plan of care.

Codes & when to bill them

How the minutes add upCommunity Health Integration is the program the worklist runs: bill G0019 at 60 minutes of staff and provider time combined, and G0019 + G0022 at 90 minutes — willowbridge bills one G0022 a month. A documented unmet need (a risk-flagged SDOH screening on the care plan, or the clinician's documented finding) plus the practitioner's determination at an initiating visit is what CHI needs. The SDOH screening itself is never billed.

Each billable code, with the requirements that must be on file to bill it.

G0019First 60 minutes of CHI auxiliary-personnel time per calendar month.

RequirementsAn initiating visit by the billing practitioner with their determination of the need; documented unmet need; consent; qualified staff; signed care plan; 60+ min.
G0022Each additional full 30 minutes of CHI time (use with G0019).

RequirementsAdd-on to G0019; one per further full 30 minutes. CMS sets no cap; willowbridge bills up to four a month.

Documentation required every cycle

Each calendar month must show:

The initiating visit (date, type) and the practitioner's determination of the driver(s) — entered at enrollment, re-affirmed at every sign-off.
The need the practitioner determined, and any screening results that point to it.
Time log of CHI activities (person-centered assessment, community-resource connection, health-system navigation, follow-up).
Outcome tracking — did the referral close the gap? Document the disposition.
A signed care plan with at least one active goal.
Patient consent.

What's new in CY 2026

CY 2026 keeps G0019 / G0022 for Community Health Integration. It also redefined G0136 — the CY 2024 SDOH risk-assessment code — as a physical-activity and nutrition risk assessment furnished with a visit, so willowbridge's social needs screening is a clinical feature that is not billed.

Built-in patient consentwillowbridge exclusive

Every program ships with compliant, CY-2026 patient consent language — read verbatim into the in-app consent capture flow, captured with date + modality, and version-pinned to each claim, so the consent on file always matches the consent that was billed. No more chasing signatures or re-papering when the rule changes.

Common questions

Who qualifies for Social & Community Health (CHI · G0019 · G0022)?

Patient is a Medicare beneficiary. An initiating visit the billing practitioner personally performed — an E/M other than 99211, an AWV, the TCM visit, or from CY 2026 a 90791 / HBAI visit — where they determined that an upstream driver significantly limits diagnosis or treatment of a problem addressed. That practitioner is the only one who bills CHI for the patient. The practitioner's documented finding of the need — a social needs screen (AHC-HRSN, PRAPARE and similar) can point to it, but CMS requires no screen or risk assessment for CHI. The staff furnishing CHI hold a state CHW certification or training in the seven CMS competencies, recorded on the Team page. CHI time must be on CHI-specific activities — not duplicative of CCM/PCM clinical staff time. Consent on file: cost sharing applies, and only one practitioner may furnish and bill CHI in a month. Not billable while the patient is under a home health plan of care.

Which codes does willowbridge bill for CHI · G0019 · G0022, and when?

Community Health Integration is the program the worklist runs: bill G0019 at 60 minutes of staff and provider time combined, and G0019 + G0022 at 90 minutes — willowbridge bills one G0022 a month. A documented unmet need (a risk-flagged SDOH screening on the care plan, or the clinician's documented finding) plus the practitioner's determination at an initiating visit is what CHI needs. The SDOH screening itself is never billed.

What changed for CHI · G0019 · G0022 in CY 2026?

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