Social & Community Health

What it is

Two related CY-2024+ Medicare benefits that pay for identifying and actually addressing social drivers of health — housing, food, transportation, and similar barriers.

• SDOH Risk Assessment (G0136) — a per-event benefit for administering a standardized SDOH risk assessment to a patient.
• Community Health Integration (CHI, G0019 / G0022) — clinical staff time addressing the unmet social needs the assessment surfaces, often billed alongside CCM/PCM/PIN.

Who qualifies

• Patient is a Medicare beneficiary.
• SDOH-RA: a validated risk-assessment tool (PRAPARE, AHC-HRSN, etc.) is administered and the results documented. Maximum 2 events per patient per year.
• CHI: at least one documented unmet SDOH need identified via a validated tool, and the care team has the community-resource navigation capability to address it.
• CHI time must be on CHI-specific activities — not duplicative of CCM/PCM clinical staff time.
• Consent on file.

Codes & when to bill them

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

• G0136Administration of a standardized, evidence-based SDOH risk assessment, per event.
  RequirementsValidated tool; results documented; max 2 per patient per year.
• G0019First 60 minutes of CHI clinical-staff time per calendar month.
  RequirementsDocumented unmet SDOH need; consent; 60+ min.
• G0022Each additional 30 minutes of CHI time (use with G0019). Max 2 add-ons.
  RequirementsAdd-on to G0019.

Documentation required every cycle

SDOH risk assessment (G0136):

1. Name of the validated tool used.
2. Date administered.
3. Results / risk flags identified.
4. Any actions taken or referrals made.

Community Health Integration (G0019 / G0022):

1. Screening tool results documenting the unmet SDOH need.
2. Time log for community-resource activities (referrals, follow-up, navigation).
3. Outcome tracking — did the referral close the gap? Document the disposition.
4. Patient consent.

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.