New SDoH assessment code requires attention to compliance details

As the Centers for Medicare and Medicaid Services (CMS) broadens its whole-person health initiative, we’re seeing new payment policies for behavioral health services addressing Health Related Social Needs (HRSN).

Care planning, case management, and clinical documentation are integral to the effective use of these new HRSN payment policies, including a new G code which took effect on Jan. 1, 2024.

HCPCS Code G0136 allows providers to bill Medicare for the administration of a standardized, evidence-based assessment of Social Determinants of Health (SDoH) which could impact or interfere with the diagnosis and treatment of the beneficiary.

G0136 was added to the Medicare Telehealth List as a permanent code under the final rule establishing the 2024 CY Physician Fee Schedule. For 2024, the assessment pays a national facility rate payment of $8.84 or a non-facility rate of $18.66.

When to assess for SDoH

CMS allows HCPCS Code G0136 to be billed when the practitioner administers a standardized, evidence-based SDoH risk assessment of 5-15 minutes (per practitioner, per beneficiary.)

It’s important to note that the assessment is not meant to be a routine screening used at every visit or even at standard intervals.

Instead, it is intended to be used when a practitioner has reason to believe there are unmet SDoH needs that may be interfering with the diagnosis and treatment of the patient’s condition or illness.

Use an evidence-based assessment

Although no specific assessment tool has been singled out for G0136, CMS expects behavioral health providers to conduct the assessment using a standardized and evidence-based tool. In the final rule, CMS explains that an acceptable SDoH risk assessment tool will be one “that has been tested and validated through research.”

The assessment may look at additional risks, but CMS expects the assessment to include, at a minimum, the domains of:

Food insecurity
Housing insecurity
Transportation needs
Utility difficulties

Three examples of evidence-based tools mentioned by CMS are the CMS Accountable Health Communities (AHC) tool, the Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) tool, and the Medicare Advantage Special Needs Population Health Risk Assessment.

Clinical documentation

Because the SDoH assessment is not a routine screening, is it is important for the patient’s medical record to support its use.

During review, Medicare contractors likely will check the medical record to make certain it indicates the assessment was conducted because the practitioner believed unmet needs were interfering with treatment.

They will also expect to see the findings of the assessment and what action was taken by the provider based on those findings.

The final rule encourages providers to use standardized Z codes to document SDoH findings. Z codes are a subset of the International Classification of Diseases (ICD-10-CM). Currently, the Z codes which would be used to report SDoH are found in categories Z55-65. However, CMS makes frequent coding updates and providers should always check the CMS website to report current coding on claims.

Follow-up is essential

There is an expectation that all HRSN interventions such as an SDoH assessment will be fully integrated into the patient’s care plan.

In the final rule, CMS said: “We continue to believe that follow-up or referral is an important aspect of following up on findings from an SDoH risk assessment.”

This is why it is essential for providers administering an SDoH assessment to take necessary action follow up on its findings and include the follow-up actions in the medical record.

At a minimum, the patient’s care plan should indicate that results of the assessment were considered in medical decision making, and the provider will refer the patient to relevant resources in the community.

SimiTree can help

SimiTree’s certified healthcare compliance experts have a comprehensive understanding of Medicare methodology and medical review requirements. We help clients identify potential Medicare program integrity risks and set in place the processes, procedures and policies needed to mitigate risk. We can assist your organization in meeting all clinical documentation requirements and establishing billing practices designed to stand up to audit scrutiny.

Next week: Telehealth creates additional compliance risk for healthcare providers.

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J’non Griffin serves as Senior Vice President for the Compliance as well as Coding divisions at SimiTree. With a healthcare career that spans three decades, she has a track record of helping many provider types implement effective compliance programs. She has worked with organizations nationwide to develop compliant emergency preparedness and operation plans, implement fully compliant plans of care, and meet regulatory demands. As an AHIMA ambassador, Griffin was instrumental in preparing the coding community for the launch of ICD-10.