How to Properly Interpret the SDoH Assessment
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How to Properly Interpret the SDoH Assessment

In 2024, new HCPCS codes were introduced, which Medicare, Medicare Advantage, and some third-party commercial plans will now cover. One of these codes is G0136, which pertains to the Social Determinants of Health (SDoH) assessment. This code is not an add-on but a standalone assessment.

G0136 is defined as the “Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.” It is important to note that G0136 is not a screening tool to be used for all Medicare patients during office visits or annual wellness visits. It is an assessment, not a screening. The assessment is conducted during a visit after the physician or NPP has seen the patient and determined it is necessary. If issues are identified, follow-up is required. Refer to the CMS 2024 Final Rule citations below.

According to the Final Rule, practitioners who perform the risk assessment should “… at a minimum, refer the patient to relevant resources and consider the results of the assessment in their medical decision-making, or diagnosis and treatment plan for the visit.” p.358 Final Rule. CMS also emphasized that this is not a screening and requires physician follow-up. “We reiterate that the SDoH risk assessment code, HCPCS code G0136, when performed in conjunction with an E/M or behavioral health visit is not designed to be a screening, but rather tied to one or more known or suspected SDoH needs that may interfere with the practitioners’ diagnosis or treatment of the patient.” CMS Final Rule further states, “An SDOH risk assessment without appropriate follow-up for identified needs would serve little purpose and we continue to believe that follow-up or referral is an important aspect of following up on findings from an SDoH risk assessment.” p.346 Final Rule.

Professional Advice on Reporting the New Code

You should only bill Traditional Medicare and/or Medicare Advantage Plans for the SDoH assessment, G1036, when an SDoH need is suspected, identified, and a care plan is required to address these concerns. Documentation must show at least 5 minutes or more, as specified in the code. The relevant SDoH must be identified in the medical record and reported with appropriate diagnosis codes from the ICD-10-CM categories, Z55-Z65. (Linking Z13.9 encounter for screening is not appropriate.)

This assessment can be performed on the same day as an E/M service (99202-99215), excluding code 99211. During the comment period, CMS was asked about patients using an online portal instead of having the service done on the day of an E/M service. Since CMS views this as an assessment rather than a screening, it should be used when the practitioner believes the patient has unmet SDoH needs that interfere with the diagnosis or treatment of an illness, necessitating an in-person assessment. CMS did not finalize the requirement that.the assessment must be done on the same day as one of these visits, but it seems likely that is when it will be done. They do not believe it will be performed in advance, via a portal, because it is not a screening. It is performed as an assessment based on the practitioner’s evaluation of the patient’s situation. Also, it is important to remember that G0136 will be subject to cost sharing, (co-pay and deductible) unless it is done at an Annual Wellness Visit (AWV), codes G0438-G0439.

Here is the reimbursement breakdown:

  • Non-Facility total RVU is 0.57 = $19.80 (office)
  • Facility total RVU is 0.27 = $8.84 (hospital, SNF, CAH, etc..)

Some examples of SDoH factors (diagnoses):

  • Illiteracy and low-level literacy —> Low health literacy may require different or more extensive efforts with patient education (i.e. all verbal instruction because patient can’t read written instructions)
  • Inadequate housing —> Patient may lack refrigeration in their home so can’t be prescribed cold storage medications, so you have to prescribe something else. May have mold infestation so have to intensify management of their asthma.
  • Extreme poverty or Low income —> May not be able to afford medications or other over-the-counter type therapies/devices.
  • Disappearance and death of family member —> May decide to defer addressing some medical issues to prioritize providing emotional support for bereavement.
  • Child in welfare custody. —> May have to spend extra time educating new foster parent on medical management or on how to provide support care for medical condition

Even though CMS does not require a specific form or tool, a link was offered on page 346 of the Final Rule. This link was offered for CMS’ Accountable Health Communities tool and is below in references and resources.

Resources

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