Community Health Worker (CHW) Frequently Asked Questions for HCPCS codes G0019 and G0022
The following FAQs provide additional guidance and clarification to Medi-Cal members and providers regarding CHW services.
General Information
1. What services may be provided with Healthcare Common Procedure Coding System (HCPCS) G0019 and G0022?
Effective for dates of service on or after April 1, 2025, HPCS codes G0019 and G0022 may be used for all CHW services listed in the Medi-Cal Provider Manual: Community Health Worker Preventive Services, including health education, health navigation, screening and assessment, and advocacy.
2. Is an initiating visit required before CHW services can be billed for Healthcare Common Procedure Coding System (HCPCS) G0019 and G0022?
Yes. The initiating visit is part of the HCPCS code description and DHCS does not have the authority to modify the requirements of the HCPCS codes to eliminate the initiating visit without seeking approval from the Centers for Medicare and Medicaid Services (CMS).
3. What type of visits would be considered an initiating visit?
The initiating visit must be billed with one of the following Evaluation and Management codes:
Office or other outpatient services: CPT codes 99203-99205 and 99213-99215
Home or residence services: CPT codes 99342, 99344-99345, and 99348-993450
Preventive medicine services: CPT codes 99381-99387 and 99391-99396
4. Is a treatment plan required for billing for HCPCS codes G0019 and G0022.
Yes. A treatment plan or plan of care is part of the code definition of HCPCS code G0019. It should identify the unmet Social Determinant(s) of Health (SDOH) that significantly limit the ability of the provider of the initiating visit to diagnose or treat problems. It should include goals and steps to achieve those goals, as described below.
5. What is required for the treatment plan?
The treatment plan must include one or more applicable ICD-10 diagnosis code(s) for the unmet SDOH need and outline general goals for the Medi-Cal member. A CHW may assist with development of the treatment plan to identify supports and services to achieve the goals. The final plan of care/treatment plan should be shared with the CHW’s supervising provider and licensed provider of the initiating visit.
6. Does the provider of the initiating visit need to be the same provider who develops the treatment plans?
No. The provider of the initiating visit or another licensed provider who is familiar with the patient may develop the plan of care or treatment plan that outlines general goals that describe the needs for a Medi-Cal member that will be addressed by the CHW as well as other supports and services, if appropriate. CHWs may be part of the team of licensed providers that develops the treatment plan and adds interventions that the CHW will perform to address the SDOH.
Alternatively, a CHW may also draft a plan of care or treatment plan that identifies interventions for CHW services, which is then reviewed and approved by a licensed provider who may be a different licensed provider than the one who performed the initiating visit, as described in this policy, and is also shared with the CHW’s supervising provider and licensed provider of the initiating visit.
For example, if a CHW chooses to draft a treatment plan for a Medi-Cal member following an initiating visit with nurse practitioner (NP) in which unmet SDOH needs are identified that significantly limit the ability of the NP to diagnose or treat problems, it would then be shared with the CHW's licensed clinical social worker or other licensed provider who would review the plan and share as described above.
7. Is there a timeframe for billing HCPCS code G0019?
Yes. A licensed provider must have had an initiating visit with the Medi-Cal member billed with one of the codes identified in Question 2 within the preceding six months prior to billing CHW services with HCPCS code G0019.
8. Does the ICD-10 diagnosis code qualify as documenting SDOH?
Yes, a licensed provider who identifies an unmet SDOH need (or multiple SDOH needs) may document the SDOH by using the appropriate ICD-10 diagnosis code(s).
9. Can the recommending providers for CPT codes 98960-62 conduct the initiating visit?
While DHCS provided great flexibilities for providers who can recommend CHW services billed by CPT codes 98960-98962, only providers who may bill with E&M codes listed in Question 2 may conduct the initiating visit. The flexibilities that DHCS allows for the recommending provider, including out-of-network providers for CPT codes, does not align with the requirement for an initiating visit billed with G0019 prior to billing G0022. Requiring an Evaluation and Management Code for the initiating visit is consistent with CMS' policy guidance and it allows DHCS to confirm that an initiating visit occurred prior to G0019 being billed for a Medi-Cal member.
10. Can the time that CHWs spend working on behalf of a Medi-Cal member that is with the member count toward the total spent billed for the month?
DHCS has adopted the same code description as Medicare that allows for reimbursement for reasonable and necessary services.
11. Can these codes be used for services provided by telehealth?
Yes, if the member consents to receiving services via telehealth and the CHW believes they could appropriately be provided by telehealth, these HCPCS codes may be used for telehealth, subject to the telehealth guidance published in the Medi-Cal Provider Manual: Telehealth.
12. Can the standing recommendation for CHW services by used for HCPCS codes G0019 and G0022?
No. Since HCPCS codes requires an initiating visit and development of a treatment plan/plan of care, the standing recommendation authorizes only up to 12 units if CPT code 98960 is used, per member annually.
13. Can the HCPCS codes G0019 and G0022 be used for Justice Involved Services?
No. Only CPT codes 98960-98962 may be used for CHW services provided for JI services.
14. Did DHCS seek stakeholder input before implementing G codes?
Yes. DHCS sent the proposed policy to 10 organizations and received comments from 14 organizations prior to finalizing the policy.
