Social & Community Health

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.

The need CHI addresses is identified with a validated SDOH screening: willowbridge guides the AHC-HRSN core questions and records the result on the care plan; a risk-flagged screening lets a patient enroll in CHI, and without one the clinician can attest a documented unmet need instead.

About G0136. willowbridge does not offer G0136 enrollment in the app today — CHI is the program your team runs from the worklist. 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), so G0136 no longer describes the social-needs screening CHI relies on.

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.
• At least one documented unmet need, identified with a validated screening tool (PRAPARE, AHC-HRSN, etc.) — or the clinician's documented finding.
• 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

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:

1. The initiating visit (date, type) and the practitioner's determination of the driver(s) — entered at enrollment, re-affirmed at every sign-off.
2. Screening tool results documenting the unmet need.
3. Time log of CHI activities (person-centered assessment, community-resource connection, health-system navigation, follow-up).
4. Outcome tracking — did the referral close the gap? Document the disposition.
5. A signed care plan with at least one active goal.
6. 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.

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.