New Billing Codes for Social Drivers of Health

Effective September 2022, North Carolina Medicaid will be implementing a set of new billable codes that capture primary care provider activities to address social drivers of health for their Medicaid members. While all Medicaid providers are encouraged to provide these interventions and screenings, these activities are a key part of the North Carolina Integrated Care for Kids Alternative Payment Model (NC InCK APM). The new codes are related to: 

1. interventions to promote Kindergarten Readiness, and 
2. screening for and addressing food- and housing-related needs. 

These codes will be used to capture data but will reimburse at zero dollars. This data will be used to measure performance for the NC InCK APM. In addition, all providers are encouraged to begin using these codes to capture and report on relevant activities, as Medicaid is considering use of these measures in other Medicaid programs and for other Medicaid Alternative Payment Models (APMs).  

Providers can begin to bill these codes to both NC Medicaid Direct (NCTracks) and to Standard Plans beginning on Sept. 1, 2022. The quality measurement period for the InCK APM begins Jan. 1, 2023, and runs through Dec. 31, 2023 (Calendar Year 2023).  

Webinar May 24, 2022

NC Medicaid, NC InCK and NC Area Health Education Centers (AHEC) will host a webinar on May 24, 2022, at 5:30 p.m. to provide an overview of the new billing codes for Kindergarten Readiness and Food/Housing measures and answer questions.  

The InCK Alternative Payment Model (APM), which will be available to many providers in Alamance, Orange, Durham, Granville and Vance counties, will include financial incentives to use these new codes beginning in January 2023. While only providers in these counties are eligible to participate in the APM, all NC Medicaid providers are encouraged to use the new billing codes. Please register in advance.

Primary Care Kindergarten Readiness Promotion Bundle: Adding CPT Category II Code 1003F 

The Kindergarten Readiness Promotion Bundle (KRPB) is a set of interventions that primary care practices can provide or connect children and families to in the community. Activities in the bundle can be delivered at well-child visits from birth to age 6. 

Billing CPT code 1003F (described below), will indicate that a provider has completed at least five of the actions included in the bundle. CPT Code 1003F should be added to the usual CPT and diagnosis codes for well visits. Reimbursement is not provided for CPT code 1003F. 

The bundle includes universal interventions that are applicable to all children at specific ages and flexible need-based interventions for children with specific needs. Components of the bundle promote the five domains recognized in North Carolina’s definition of kindergarten readiness: health and physical development, social and emotional development, language and communication development, cognition and general knowledge, and approaches toward learning. 

Universal interventions that count toward the five required activities are: 

Need-Based interventions that count toward the five required activities are:

More information on the Kindergarten Readiness Promotion Bundle is available in this presentation.

Providers should utilize the following billing guidance to document the receipt of the Kindergarten Readiness Promotion Bundle. The bundle is considered to be received when any five or more of the bundle components are provided.

Food and Housing Measures: Adding HCPCS and ICD-10 Codes

NC Medicaid will be implementing a new set of billable HCPCS codes (G codes) and ICD-10 diagnosis (Z codes) to capture actions that primary care providers take to address food- and housing-related needs for their Medicaid members. The new food and housing measures are based on screenings for food- and housing-related needs that may be conducted at primary care visits for all members. NC Medicaid recommends that providers use the screening tool provided below.

HCPCS G Codes

The following non-reimbursable HCPCS codes should be used to document a food- and housing-related screening:

G9920: Screening Performed and Negative

When the provider has screened for both housing and food-related needs, and no needs are identified.

G9919: Screening Performed and Positive and Provision of Recommendations

When the provider has screened for both housing and food-related needs, at least one need is identified, and referrals have been provided. To meet this requirement, provider must refer patients on to human service organization(s) for service delivery.

Providers are highly encouraged to refer patients via NCCARE360 to find resources available in their area. The NCCARE360 platform aims to refer, intervene, and perform closed-loop referrals to address social needs. Any beneficiary referred via NCCARE360 meets the requirements of G9919.

Some beneficiaries may have multiple needs identified through a screening (i.e., both food and housing needs). Providers may code G9919 only when referrals are provided to address all identified needs.

G9921: Positive Screening Without Recommendations

When the provider has screened for both housing and food-related needs, and at least one need is identified, but the provider has NOT provided referrals for all identified needs.

ICD-10 Z Codes

In addition to the G codes described above, the following ICD-10 codes should be used to describe a positive screen. These Z codes cannot be used as a primary diagnosis code; they must be added to the claim after a primary diagnosis code.

For more information, please see the NC Medicaid InCK webpage.

Contact

NC Medicaid Contact Center, 888-245-0179