How often do you get a chance to improve the quality of care for your patients and get paid for it? Screening for Social Determinants of Health (SDOH) is one such opportunity! SDOH issues impact asthma disparities, childhood risk of asthma and asthma morbidity, among other things.1 As a result, CMS encourages physicians to incorporate SDOH risk assessment into your practices – and now they are paying you to do it.
“It is not always apparent to physicians when a patient has social determinants of health that may impact their treatment,” said Gary Gross, MD, FACAAI, coding consultant for the Advocacy Council. “I believe we should all get a ‘read’ on our patients at least once, and certainly if we suspect situations have changed (like the real estate or oil crash in Texas earlier in my career when many of my patients were out of work).”
Beginning in January, CMS started reimbursing stand-alone code G0136 for the administration of a patient SDOH Risk Assessment. Here are the facts:
- G0136 can be billed once every six months, with a duration of 5-15 minutes.
- The CMS national payment amount for nonfacility reimbursement of this code is $18.97.
- Any standardized, evidence-based SDOH risk assessment tool that has been tested and validated through research may be used. The tool must include the domains of food insecurity, housing insecurity, transportation needs and utility difficulties. Google some of the tools below or find most of them in the Health Equity Services in the 2024 Physician Fee Schedule Final Rule.2
- Accountable Health Communities Health-Related Social Needs Screening Tool
- American Academy of Family Physicians Social Needs Screening Tool
- HealthBegins Screening Tools
- Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)
- G0136 can be billed with an outpatient E/M visit and can be provided via telehealth.
- Physicians are not required to have the capacity to furnish care management services or have partnerships with community-based organizations to bill this code. However, CMS does expect physicians to consider the results of the assessment in their medical decision-making or diagnosis and treatment plan for the visit. In addition, CMS encourages follow-up or referral to appropriate resources where available.
- Medicare covers this code, but allergists should check to see if their Medicaid and commercial plans cover it as well.
- G0136 is subject to cost sharing (co-pay and deductible).
There are several ways to incorporate SDOH screening into your workflow:
- Have patients complete SDOH risk assessment questions at check-in.
- Make SDOH risk assessment questions part of the rooming process for medical assistants or nurses.
- Once you’ve collected the results, use them to have a focused conversation with the patient about SDOH needs.
- Document how the SDOH is interfering with patient care.
Following are common SDOH Z Codes:3
| SDOH Code | Description |
|---|---|
| Z55 | Problems related to education and literacy |
| Z56 | Problems related to employment and unemployment |
| Z57 | Occupational exposure to risk factors |
| Z58 | Problems related to physical environment |
| Z59 | Problems related to housing and economic circumstances |
| Z60 | Problems related to social environment |
| Z62 | Problems related to upbringing |
| Z63 | Other problems related to primary support group, including family circumstances |
| Z64 | Problems related to certain psychosocial circumstances |
| Z65 | Problems related to other psychosocial circumstances |
Let’s walk through a sample visit with SDOH codes.
How would you code SDOH for this patient?
- Single mother of three school-aged children in her mid-20’s.
- Children’s father was incarcerated, resulting in loss of public housing.
- Works two part-time jobs and does not have health insurance.
- Cannot always afford to fill prescriptions and misses appointments.
Here are the relevant SDOH codes for this patient:
- 7, Insufficient social insurance and welfare support
- 0, Unemployment, unspecified
- 120, Patient’s intentional underdosing of medication regimen due to financial hardship
When the effects of a patient’s SDOH are significant, like the patient above, it can also increase the level of the patient’s office visit due to increased risk. When using MDM to determine the E/M level, risk may increase due to a diagnosis or treatment significantly limited by SDOH.
Screening for SDOH can also help you with MIPS. There is a new MIPS Quality Measure 487: Screening for Social Drivers of Health.
Screening patients for SDOH can be a win-win for you and your patients. It’s an opportunity to improve both the health of your patient and the financial health of your practice.
1 “Asthma and Social Determinants of Health,” Ann Allergy Asthma Immunol, 128 (2022) 5−11.
2 MLN9201074 – Health Equity Services in the 2024 Physician Fee Schedule Final Rule (cms.gov)
