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.

Rachel Yates, B.S.N., RN, is the founder and CEO of Premier Care Coordination, a nurse-led virtual care coordination company serving Medicare primary care practices nationwide.