Using HCPCS Code G0136 for Social Determinants of Health Risk Assessment

The SDOH Risk Assessment must be reported in conjunction with:

• An office/outpatient or a home or residence evaluation and management (E/M) visit, which can include hospital discharge or transitional care management services. It is not expected that the SDOH Risk Assessment would be provided with a low-level office visit E/M (i.e., 99211).

• Behavioral health visits, such as a psychiatric diagnostic evaluation (CPT code 90791) and health behavior assessment and intervention services (CPT codes 96156, 96158, 96159, 96164, 96165, 96167, 96168).

• As an optional element of the annual wellness visit (AWV).

What SDOH Risk Assessment tools can I use?

Practices can use any standardized, evidence-based assessment tool that has been tested and validated through research. The tool must contain, at minimum, the domains of food insecurity, housing insecurity, transportation needs, and utility difficulties. Practices may ask additional questions to assess other areas of SDOH risk as well as tools that combine questions from multiple standardized, validated tools.

Example tools include:

• AAFP Social Needs Screening Tool
• CMS’ Accountable Health Communities Health-related Social Needs Screening Tool
• Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) Screening Tool

Can the SDOH Risk Assessment be administered before the visit?

The SDOH Risk Assessment is not required to be provided on the same date as the E/M or behavioral health visit. However, CMS does not believe it would be frequently provided on a separate date.

The SDOH Risk Assessment is not intended to be a routine screening, but rather is to be administered when the physician believes there is an unmet SDOH need that may interfere with their ability to diagnose and treat the patient.

How often can the SDOH Risk Assessment be provided?

The SDOH Risk Assessment may be provided once every six months per beneficiary per physician, when appropriate. 

Is the SDOH Risk Assessment subject to deductible and coinsurance?

Yes, the SDOH Risk Assessment is subject to deductible and coinsurance unless it is provided as an optional element of the AWV. When reported with the AWV, append modifier -33 to the SDOH Risk Assessment to indicate that it is a preventive service.

What are the documentation requirements for the SDOH Risk Assessment?

Documentation must include any SDOH needs identified by the assessment. CMS encourages practices to document “Z codes,” when applicable.

Who can administer the SDOH Risk Assessment?

The SDOH Risk Assessment may be performed by physicians and other practitioners (nurse practitioners, clinical nurse specialists, certified nurse-midwives, physician assistants) and auxiliary staff under the general supervision of the billing practitioner incident to their professional services.