Walk into any independent primary care practice and ask the nurse what she did on her lunch break. There’s a good chance she’ll tell you she was on the phone with the daughter of a dementia patient, calling the dialysis center to sort out a transportation problem, or following up on the discharge med rec for the COPD patient who landed in the ED again last week. None of it was billed and most of it never will be.
That work has a name in the Medicare Physician Fee Schedule. Since January 2024, CMS has reimbursed for it under two new sets of codes: Community Health Integration for addressing health-related social needs, and Principal Illness Navigation for patients with serious, high-risk conditions. Add Chronic Care Management to the mix and a practice’s care coordination work has a clear path to reimbursement.
The codes have been live for over two years, the patients these codes were designed for are already sitting in your panel, and the federal reimbursement is authorized and waiting. So why aren’t more independent practices billing them? Every practice I talk to gives me a version of the same answer. They want to bill these codes but they just can’t pull it off operationally. The number one reason is staff burden, and it shows up in three layers.
The first layer is training. Three different code sets, each with its own qualifying conditions, time thresholds, documentation requirements, and billing rules. Someone on staff has to learn all of it, keep up with CMS rule changes, and translate it into a workflow the rest of the team can actually follow. In a practice already short-staffed, that someone usually doesn’t exist.
The second layer is the documentation itself. CHI requires that a social need be identified, that the intervention be tied to a clinical concern, and that the time spent be tracked under the right code. PIN requires documentation of the high-risk condition, the navigation activities performed, and the time spent on each. CCM has its own care plan and consent requirements. The clinical work is the easy part, but the paperwork that proves the clinical work happened is what eats hours.
The third layer is the one practices don’t see until they’re six months in. The codes require ongoing monthly time tracking, audit-ready logs, and a documentation trail that holds up if CMS comes asking. That’s not a project you complete, it’s a function you staff. And the staff member running it can’t also be the staff member running rooming, triage, refills, and prior auths.
So the work happens informally. The nurse coordinates the transportation while she’s between patients, the MA follows up on the discharge during her charting time, and the physician calls the daughter of the dementia patient on his lunch break. The coordination is real, but the reimbursement isn’t.
There’s another path, and it’s the one CMS built into these codes intentionally. CHI and PIN can be delivered by auxiliary personnel under general supervision of the billing physician. That means a practice doesn’t have to hire a full-time care coordinator, build the documentation infrastructure, or rework their EHR to start capturing this revenue. They can contract with a nurse-led care coordination team that operates as auxiliary personnel, runs the program under the billing physician’s supervision, and produces the audit-ready documentation that ties the work to the billing. The practice bills Medicare, the contracted team does the coordination work, and the in-house staff gets their evenings back.
I have watched too many nurses do exactly the work I described in the opening paragraph, unpaid and unrecognized, while their practices left federal reimbursement on the table. The clinical work was already happening, but what was missing was the operational layer that connected it to the billing. For physicians reading this who run or work in independent practices, the question isn’t whether your team is doing this work. The question is whether you’re going to keep absorbing the cost of it, or whether you’re going to let someone else carry the operational weight while you stay focused on the patient in front of you.
Rachel Yates is a registered nurse with nearly a decade of clinical experience, including trauma surgical ICU and virtual nursing. She earned her Bachelor of Science in Nursing from Purdue University Northwest and is completing her Master of Science in Nursing in executive nurse leadership at Purdue University Global, where she was inducted into Alpha Alpha Alpha, the national honor society for first-generation college students.
She is the founder and chief executive officer of Premier Care Coordination, a nurse-led virtual care coordination company. The company partners with primary care practices to deliver Medicare community health integration, principal illness navigation services, and chronic care management.
Rachel has written in Medical Economics on how new Medicare care coordination codes could transform care for vulnerable patients and is a recognized voice on the gap between federal health care policy and practice-level implementation. She shares professional updates on LinkedIn, with company updates available through Premier Care Coordination on LinkedIn.
