Watch for opportunities to bill for an SDOH assessment during the Annual Wellness Visit
During a typical Medicare Annual Wellness Visit (AWV), there are a lot of bases to cover: Preventive care, health screenings, wellness planning, and more. However, what you might not know is that screening patients for social determinants of health (SDOH) is an optional element that may warrant separate payment. Here are seven things you need to know about performing and billing for SDOH assessments in your medical practice.
1. SDOH assessments are important because they help promote health equity. An SDOH assessment is a structured evaluation of the non-medical factors that impact health and quality of life, such as living environment, access to food, employment status, education and literacy levels, family circumstances, and more. It promotes health equity because it helps you identify and understand the types of social support patients might need to achieve positive health outcomes.
2. G0136 is the medical code necessary to bill for an SDOH assessment. What is the code G0136 description? HCPCS code G0136 denotes the administration of a standardized, evidence-based SDOH risk assessment tool for 5-10 minutes not more often than every six months. Examples of evidence-based tools include—but are not limited to—the CMS Accountable Health Communities (AHC) tool, the Protocol for Responding to & Assessing Patients' Assets, Risks & Experiences (PREP ARE) tool, and instruments identified for Medicare Advantage Special Needs Population Health Risk Assessment. However, you may want to ask additional questions not included in these tools, depending on the needs of your patient population. You and your clinical team should collaborate to identify any additional questions that may be relevant and informative.
3. HCPCS code G0136 yields separate payment. What is the G0136 reimbursement rate? HCPCS code G0136 pays between $17.02 and $24.93, depending on your Medicare Administrative Contractor locality. The national average G0136 reimbursement rate is $18.97.
4. HCPCS code G0136 is not meant for routine SDOH screenings. HCPCS code G0136 billing guidelines state this code is meant to capture cases for which you suspect a patient’s unmet social needs might interfere with your diagnosis and treatment of a condition or illness. If you routinely screen patients for SDOH, don’t report it unless there is an actual finding that impacts diagnosis and treatment. The Annual Wellness Visit is an opportune time to perform the SDOH assessment; however, you may also do it during an outpatient evaluation and management (E/M) visit (excluding level 1 E/M visits) or certain behavioral health visits.
5. Report one or more Z codes with G0136. HCPCS code G0136 billing guidelines require providers to report one or more corresponding ICD-10-CM Z codes (Z55-Z65) to explain why separate payment for the SDOH assessment is warranted.
6. Treating physicians aren’t the only ones who can administer the SDOH assessment. Nurse practitioners, clinical nurse specialists, certified nurse midwives, physician assistants, or auxiliary personnel may also perform the SDOH assessment under the general supervision of the billing practitioner incident to their professional services.
7. You can furnish the SDOH assessment via telehealth. HCPCS code G0136 was added to the Medicare Telehealth Services List on a permanent basis.
Performing the SDOH assessment as an optional element during the AWV
If you intend to bill HCPCS code G0136 for an SDOH assessment during the AWV, here are three important considerations:
Patients won’t incur a cost. However, if you perform the SDOH assessment as part of an E/M visit or behavioral health visit, the usual Part B deductible and coinsurance apply.
How you communicate with patients is important. You must provide the SDOH assessment in a manner that’s appropriate for the patient’s educational, developmental, and health literacy level. The assessment must also be culturally and linguistically appropriate.
You’ll need to report a billing modifier. 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 date of service on the same claim as G0438 or G0439 to ensure separate payment. Be sure to document how the SDOH impacts your diagnosis and treatment.
Looking ahead
In today’s healthcare environment, it’s important to capture additional revenue wherever possible, and HCPCS code G0136 enables you to do that. Leveraging the right revenue cycle technology can also make a difference. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
