Practice Support Update Blog

Social Determinants of Health Risk Assessment: CMS finalizes G code

Feb 27, 2024 8:28:00 AM / by Practice Support Team

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Today we bring you some news from the Center for Medicare and Medicaid Services (CMS) 2024 Physician Fee Schedule Final Rule. CMS has finalized a new stand-alone G Code (G0136) to pay for administering an SDOH risk assessment, no more than once every 6 months:

G0136: Administration of a standardized, evidence-based SDOH assessment, 5-15 minutes, not more often than every 6 months.

You may provide this service with:

  • An evaluation and management (E/M) visit, which can include hospital discharge or transitional care management services
  • Behavioral health office visits, such as psychiatric diagnostic evaluation and health behavior assessment and intervention
  • The Annual Wellness Visit (AWV)

SDOH risk assessments that you furnish as part of an E/M or behavioral health visit isn't a screening.  It may be medically reasonable and necessary as part of a comprehensive social history, when you have reason to believe there are unmet SDOH needs that are interfering with the practitioner's diagnosis and treatment of a condition or illness or will influence choice of treatment or plan of care.  In these circumstances, patient cost sharing will apply, just as it does for any medical service.  The risk assessment wouldn't usually be administered in advance of the visit.

Example: A patient who hasn't been seen recently requests an appointment at a specific time or on a specific date due to limited availability of transportation to or from the visit, or requests a refill of refrigerated medication that went bad when the electricity was terminated at their home.  If the patient hasn't gotten an SDOH risk assessment in the past 6 months, you could have the patient fill out an SDOH risk assessment 7-10 days in advance of an appointment as part of intake to ensure that you have enough information to appropriately treat them.  You may also furnish SDOH risk assessments as an optional element of the AWV, in which case it's a preventive service and cost sharing won't apply.

SDOH risk assessment refers to a review of the individual's SDOH needs or identified social risk factors influencing the diagnosis and treatment of medical conditions.  Use a standardized, evidence-based SDOH risk assessment tool to assess for:

  • Housing insecurity
  • Food insecurity
  • Transportation needs
  • Utility difficulty

You may choose a tool or ask additional questions that also include other areas if prevalent or culturally important to your patient population.  Some tools you may consider that are standardized and evidence-based include the CMS Accountable Health Communities Tool, Protocol for Responding to & Assessing Patients' Assets, Risks & Experiences (PRAPARE), and instruments identified for Medicare Advantage Special Needs Population Health Risk Assessment

Note: G0136 is also added to telehealth services on a permanent basis.

Source: MLN Booklet: Health Equity Services in the 2024 Physician Fee Schedule Final Rule


Interested in learning more about Screening and Intervening for Unmet Social Needs?

NW AHEC has produced a free, online, learning module for practice care teams. Check it out!



Tags: Social Determinants of Health, medicare, health equity

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