Reporting SDoH G0136 in compliance

(updated 4/6/2024) – This is also posted on the NAMAS.co website

2024 brought new HCPCS codes that Medicare, Medicare Advantage and some 3^rd-party Commercial plans that they will now pay for. One of those codes is the G0136; that is the Social Determinate of Health (SDoH) assessment. It is not an add on code, but a stand-alone assessment.

G0136 is defined as “Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.”

G0136 is not a screening tool that should be used on all Medicare patients at office visits or annual wellness visits.

It is an assessment, not a screening. The assessment is performed at a visit after the physician/NPP has seen the patient and decides that it is necessary. And, if problems are found, follow-up is required. See CMS 2024 Final Rule citations below.

From the Final Rule, they do expect that a practitioner who furnishes the risk assessment would “… at a minimum, refer the patient to relevant resources and take into account the results of the assessment in their medical decision making, or diagnosis and treatment plan for the visit.” p.358 Final Rule.

CMS also, was clear that this is not a screening, and it 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, goes on to say, “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.

Here is my professional advice on reporting this new code

The only time you would bill Traditional Medicare and/or Medicare Advantage Plans for the SDoH assessment, G1036, is when an SDoH need is suspected, identified, and a plan of care is needed to address these concerns, and at least 5 minutes or greater is documented, as described in the code. Remember, the AWV guidelines were updated this year to include the SDoH considerations, so if there are “unmet needs” that need to be addressed, report it. The appropriate SDoH needs to be identified in the medical record documentation and reported with appropriate diagnosis codes from the ICD-10-CM categories, Z55-Z65. (linking Z13.9 encounter for screening would not be appropriate)

When the patient is presenting for a problem-oriented encounter, this assessment can be done on the day of an E/M service (99202-99215), not including code 99211. Since the patient is there for a problem-oriented visit, I would want to see that there is a reason linked to the problems addressed and the SDoH that needs attention. It would not be reported for every patient, as some just come in for that 3-6 month checkup, or annual medicine reconciliation, etc, and there are no SDoH factors to consider on that DOS. As with all medical services, it has to be medically necessary to capture it.

According to CodingIntel.com, during the Final Rule CY 2024 comment period, CMS was asked about the patient using an on-line portal rather an having the service done on the day of an E/M service and can that be considered the assessment. The short answer is No. Again, CMS believes that this is not a screening, but an assessment, and is to be used when the practitioner believes that the patient has unmet SDoH needs that are interfering with the diagnosis or treatment of an illness, so this needs to be an in-person assessment.

(source: https://codingintel.com/screening-for-social-determinants-of-health-sdoh/ )

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. The published guidance, when performed on the same date as the AWV, states, that the G0136 will need a -33 modifier to waive the out of pocket for the patient.

Here is the reimbursement breakdown

Non-Facility total RVU is 0.57 = $18.39 (office)*
Facility total RVU is 0.18 = $5.99 (hospital, SNF, CAH, etc..)*

(* For services after 3/9/2024 the adjusted CY CF is $33.2875)

Some examples of SDoH factors (diagnoses) per NIH.gov

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.

References and Cited Resources

Joe Kuzma