Rely Health, Enhancing Care Navigation Through New 2024 HCPCS Codes

This summary of the original white paper explores the strategic expansion of healthcare delivery through the introduction of new Healthcare Common Procedure Coding System (HCPCS) codes in 2024 [1]. These updates signify a pivotal enhancement in structured care coordination, providing health centers with the necessary tools to improve patient outcomes and ensure robust healthcare service delivery. Emphasizing the importance of these new codes, this document outlines the opportunities they present for enhanced reimbursement and the implications for care quality across healthcare systems.

Introduction to Care Coordination and Navigation

Care coordination and patient navigation are critical frameworks within modern healthcare systems, designed to streamline the management of patient care across various settings and services. These methodologies are particularly crucial for patients with complex health needs, such as those with chronic conditions or multiple healthcare requirements. The 2024 updates to HCPCS codes reflect a growing recognition by the Centers for Medicare and Medicaid Services (CMS) of the need for formalized care coordination structures, ensuring that patients receive comprehensive and continuous care.

Understanding the 2024 HCPCS Updates

In 2024, CMS will introduce new HCPCS codes that fall into three primary categories: Community Health Integration (CHI) services, Social Determinants of Health (SDOH) services, and Principal Illness Navigation (PIN) services [1]. Each category is targeted to address specific challenges within healthcare delivery:

• Community Health Integration (CHI) services are designed to enhance the integration of community health resources with traditional healthcare services, facilitating broader patient engagement and support within community settings
• Social Determinants of Health (SDOH) services focus on addressing the external socio-economic factors that significantly impact patient health outcomes, such as housing instability, food insecurity, and lack of transportation.
• Principal Illness Navigation (PIN) services aim to provide targeted support for patients navigating complex health systems, particularly those with severe or multiple illnesses.

Substance Use Navigation through Strategic Code Application

By strategically utilizing the new HCPCS codes for CHI, SDOH, and PIN services, healthcare systems can create robust substance use navigation programs. These programs not only address the immediate needs of patients with SUDs but also justify the allocation of opioid settlement funds by demonstrating improved health outcomes and sustainable, scalable support systems. This alignment with CMS's coding and payment policies ensures that the programs are well-integrated, effectively managed, and financially viable in the long run. These codes can be strategically used to support and sustain substance use navigation programs, justifying the allocation of opioid settlement funds to address the ongoing opioid crisis.

Community Health Integration (CHI) Services

Enhance integration of community health resources with traditional healthcare services. CHI services can be used to connect patients with community-based substance use support services, including counseling, peer support groups, and rehabilitation programs. By integrating these resources, healthcare providers can offer a more comprehensive care plan for individuals struggling with substance use disorders (SUDs).

Social Determinants of Health (SDOH) Services

Address external socio-economic factors impacting health outcomes, such as housing instability, food insecurity, and lack of transportation. SDOH services can identify and mitigate barriers that prevent patients from accessing substance use treatment. For example, securing stable housing and reliable transportation can significantly improve treatment adherence and overall health outcomes for patients with SUDs.

Principal Illness Navigation (PIN) Services

Provide targeted support for patients navigating complex health systems, particularly those with severe or multiple illnesses. PIN services can assist patients with SUDs in navigating the healthcare system to ensure they receive appropriate and timely care. This includes coordinating appointments, managing comorbidities, and providing ongoing support to prevent relapse and promote recovery.

Substance use navigation programs that utilize these HCPCS codes can effectively justify the use of opioid settlement funds by demonstrating:

• Enhanced Patient Engagement and Support: Programs leveraging CHI and SDOH services can show increased patient engagement and support through integrated community resources and addressing socio-economic barriers.
• Improved Health Outcomes: By utilizing PIN services, programs can provide evidence of improved health outcomes through effective navigation and management of patients' healthcare needs, reducing relapse rates and enhancing recovery.
• Sustainability and Scalability: The new HCPCS codes offer a sustainable billing mechanism to support these programs long-term, ensuring continuous funding and scalability of services provided to patients with SUDs.

Preparing for Implementation: A Roadmap for Health Centers

To successfully adopt the new HCPCS codes for Community Health Integration (CHI), Social Determinants of Health (SDOH), and Principal Illness Navigation (PIN) services, health centers must follow a structured implementation roadmap. This guide outlines critical steps to ensure a seamless transition, including staff training, IT system adaptations, and strategies for monitoring and evaluating the impact on care delivery and financial health.

Identify Patient Populations

• Assessment: Conduct a thorough assessment to identify patient populations who will benefit most from CHI, SDOH, and PIN services.
• Criteria Development: Develop criteria to segment patients based on health needs, social determinants of health, and complexity of illnesses.
• Data Analysis: Use existing patient data to identify high-risk individuals who frequently use emergency services, have chronic conditions, or face significant socio-economic challenges.

Setup Care Navigation / Community Health Worker Team

• Team Formation: Establish a dedicated team of Care Navigators and Community Health Workers (CHWs) trained in CHI, SDOH, and PIN services.
• Role Definition: Clearly define roles and responsibilities for each team member, ensuring a focus on patient-centered care and navigation.
• Training Programs: Implement comprehensive training programs on the new HCPCS codes, patient engagement strategies, and effective navigation techniques.

Create Integrations with Data Sources and Identify Triggers

• Data Integration: Integrate electronic health records (EHRs) with community resource databases and other relevant data sources.
• Trigger Identification: Develop algorithms to identify triggers for patient interventions based on data inputs, such as hospital admissions, social risk assessments, and care gaps.
• Real-time Monitoring: Implement systems for real-time monitoring and alert generation to proactively address patient needs.

Create a Technology Environment for Workflow Management

• Technology Selection: Choose a robust technology platform to manage Care Navigation and CHW workflows, incorporating features for task management, communication, and data tracking.'
• VoIP Integration: Integrate VoIP solutions to facilitate seamless communication between care teams and patients.
• User Training: Provide training for staff on using the new technology, ensuring they are comfortable with the workflow management and communication tools.

Create Notification Pathways to Internal Billing Departments

• Notification Systems: Establish automated notification pathways to inform the billing department upon the completion of a Navigation Encounter.
• Documentation Procedures: Develop standardized documentation procedures to ensure accurate and consistent claims submission.
• Billing Team Training: Train the billing team on the new HCPCS codes, emphasizing the importance of timely and accurate claims processing.

Capture Data on Effectiveness and Financial Health

• Performance Metrics: Define key performance indicators (KPIs) to measure the effectiveness of care management teams, such as patient outcomes, service utilization rates, and patient satisfaction.
• Financial Tracking: Track the total dollars captured through billing for CHI, SDOH, and PIN services, and analyze financial performance.
• Failure Rate Analysis: Monitor and analyze the failure rate of claims submissions to identify and address any issues promptly.
• Continuous Improvement: Use data insights to continuously refine care navigation processes, training programs, and billing practices.

By following this detailed roadmap, health centers can effectively implement the new HCPCS codes, enhancing care delivery, improving patient outcomes, and ensuring financial sustainability. This structured approach ensures that all aspects of the transition are meticulously planned and executed, leading to a successful adoption of the new billing codes.

Conclusion

The 2024 HCPCS updates represent a significant advancement in the structuring of care coordination and navigation within healthcare systems. By embracing these changes, health centers can optimize reimbursement opportunities for Care Navigation & Coordination work that already gets done in some capacity. In this White Paper we have reviewed three categories of new billing codes. Community Health Integration (CHI) services, Social Determinants of Health (SDOH) services, and Principal Illness Navigation (PIN) services. Each category is targeted to address specific challenges within healthcare delivery.

About Us

Rely Health: Rely Health is a full-service Care Navigation vendor partnering with various healthcare organizations, from large public counties and health systems like Ascension to individual hospitals and clinics, to design and implement Care Navigation programs. Rely Health manages the personnel, technology, billing integrations, and analytics for healthcare organizations around care coordination and navigation. For sites without personnel, Rely Health hires on-site or virtual care navigators and provides them with a comprehensive technology suite that facilitates patient identification, navigation note capture, billing storage, and analytics generation. For organizations with existing robust case management teams, Rely Health offers its advanced technology suite to help these teams scale 10-15 times more effectively through AI and patient engagement technology.

CEA: Clinical Care Options (CCO) is your undeniable choice for the most cutting-edge medical education available today. Offering meticulously tailored programs and resources that set the gold standard for fulfilling learning requirements, CCO enhances clinical care and improves patient outcomes. With a track record of excellence in 10+ therapeutic areas including oncology, neurology, psychiatry, infectious disease, and more. CCO is committed to providing quality clinical education for physicians, pharmacists, nurses, advanced practice nurses, and physician associates that is innovative in design and that motivates healthcare professionals to adopt safe and appropriate current clinical management strategies.

References and Citations

[1] The official update of the HCPCS code system can be found on FY 2024 IPPS Final Rule Home Page

[2] Community Health Integration - Medicare.gov

[3] IMPROVING THE COLLECTION OF Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes

[4] Top Social Determinant of Health Screening Tools

[5] Detailed information on the new, revised, and discontinued HCPCS codes for April 2024 is available on CGS Medicare and Noridian Healthcare Solutions.

[6] For the latest updates and official guidance, visit the HHS Guidance Portal.