This is information from the 2024 Physician Fee Schedule Final Rule, released Nov. 2, 2023. New CPT and HCPCS codes, and CMS policy changes are effective 1-1-2024.
CMS established a standalone code G0136 (a HCPCS code) for the assessment of SDoH. They define SDoH into broad groups: “economic stability, education access and quality, neighborhood and built environment, and social and community context, which include factors like how soon, food and nutrition access, and transportation needs.” p 345. CodingIntel addressed the question of what conditions are included in SDoH in a recent Q&A.
G0136 defined as “Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.” The risk assessment is in relation to the patient’s social risk factors that influence the diagnosis and treatment of medical conditions. This is a service that can be performed in outpatient settings, with the exception of discharge visits, discussed below.
Table of Contents
- When to report G0136
- Diagnosis coding for SDoH
- Other issues for practices reporting HCPCS Code G0136
- HCPCS Code G0136 Q&A
When to report G0136
This assessment can be done on the day of an E/M service, not including code 99211. During the 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. They believe this is not a screening but an assessment, and it is to be used when the practitioner believes that the patient has unmet SDoH needs that are interfering with the the diagnosis or treatment of an illness.
G0136 may be billed with discharge visits from the hospital. However, it is CMS’s expectation that for patients with unmet needs, there will be follow up visits either as outpatients or a transitional care management visit to try and meet those needs.
G0136 will be subject to cost sharing, (co-pay and deductible) unless it is done at an Annual Wellness Visit (AWV).
CMS is also allowing G0316 to be furnished on the same day as 90791 (psychiatric diagnostic evaluation) and with Health Behavior Assessment and Intervention codes 96156, 96158, 96159,96164, 96165, 96167, and 96168, when performed by a clinical psychologist, not a social worker.
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.
CMS is allowing the SDoH assessment at the time of the initial or subsequent wellness visits. The Final Rule doesn’t mention the Welcome to Medicare visit, so it seems that G0136 may not be performed on the day of that service. If performed on the day of a wellness visit, Medicare will pay 100% of the allowance, with no beneficiary cost sharing.
Assessment tools (links below)
The Final Rule describes the service and possible assessment instruments that may be used:
● Administration of a standardized, evidence-based SDOH risk assessment tool that has been tested and validated through research, and includes the domains of food insecurity, housing insecurity, transportation needs, and utility difficulties.
++ Billing practitioners may choose to assess for additional domains beyond those listed above if there are other prevalent or culturally salient social determinants in the community being treated by the practitioner.
Possible evidence-based tools include the CMS Accountable Health Communities (AHC) tool, the Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) tool, and instruments identified for Medicare Advantage Special Needs Population Health Risk Assessment.” p. 346
The code would have wRVU of .18.
It has a national facility rate payment of $8.84, and non-facility rate of $18.66 in 2024.
Diagnosis coding for SDoH
CMS is requiring that the SDoH needs that are identified during the assessment be documented in the medical record and “actively encouraging Z-code reporting to improve our data…” p. 357 The Z codes in question are in categories Z55-65. That is, you must document the SD0H condition in the record and you are encouraged to add that to the claim form. If you are part of an ACO or have risk based contracts, report these codes on a claim form!
Other issues for practices reporting HCPCS Code G0136
CMS is not requiring that if a practice reports G0136 that they also must have the capacity to furnish Community Health Integration (CHI) services, Principal Illness Navigation (PIN) or other care management services. However, 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
It’s not a screening, and it requires 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.”
“An SDOH risk assessment without appropriate follow-up for identified needs would serve little purpose.” CMS Final Rule, p. 346
“We continue to believe that follow-up or referral is an important aspect of following up on findings from an SDoH risk assessment.”
HCPCS Code G0136 Q&A
Is G0136 a screening tool that we should use on all of our Medicare patients at office visits and annual wellness visits?
No. It is an assessment, not a screening. The assessment is performed at a visit after the physician/NPP has seen the patient, and decides the it is necessary. And, if problems are found, follow up is required. See CMS Final Rule citations above.
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