Medicare Compliance & Reimbursement

Question: When exactly do we need to perform and report social determinants of health (SDOH) assessments for Medicare beneficiaries?

Kansas Subscriber

Answer: The SDOH risk assessment is an optional element of the Medicare annual wellness visit (AWV) that providers can, as of October 7, 2024, conduct and bill.

Reminder: The AWV should include a clinician establishing or updating the Medicare beneficiary’s: medical and family history, health risk assessment, and personalized preventing plan. Also, the AWV cannot be within 12 months of a previous AWV or initial preventive physical examination (IPPE). Per Centers for Medicare & Medicaid Services (CMS) requirements, the SDOH risk assessment must be optional and at the discretion of both clinician and patient, and separately payable from the AWV with “no applicable patient Part B coinsurance and deductible when part of the same visit with the same date of service (DOS) as the AWV,” and following the same requirements regarding health professional eligibility and encounter frequency as AWVS, CMS says in the revised MLN Matters MM13486.

The health professional must be a physician who is an MD or DO; a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS); or a medical professional working under the direct supervision of an eligible physician, CMS says.

Background: CMS says Medicare didn’t pay for any SDOH risk assessments before January 1, 2024, and established HCPCS code G0136 (Administration of a standardized, evidenced-based SDOH risk assessment tool, 5-15 minutes, not more often than every 6 months) in the calendar year 2024 Medicare Physician Fee Schedule final rule.

Make sure you note this billing clarification from CMS: “When you provide the SDOH risk assessment as an additional element of the AWV, report HCPCS code G0136 for the SDOH risk assessment with Modifier 33, with the same DOS on the same claim as G0438 or G0439. MACs will accept and process HCPCS code G0136 as an additional element of the AWV (HCPCS codes G0438 and G0439) based on the Physician Fee Schedule. You may provide elements of the AWV over a period of multiple days. In these situations, the DOS you report on the claim is the DOS when you complete the entirety of the AWV.”

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC