Q&A: Setting, timing on SDOH risk assessments

CDI Strategies - Volume 18, Issue 13

Q: Should coders report HCPCS code G0136 (administration of a standardized, evidence-based social determinants of health [SDOH] risk assessment, 5-15 minutes, not more often than every 6 months) when the service is performed by a provider in the patient’s home? And does the provider have to perform the assessment on the same day as the E/M visit (CPT codes 99341-99345 and 99347-99350), or can they perform the assessment on a different day?

A: You can report G0136 in a wide range of settings, including place of service 12 (Home). In the 2024 Medicare Physician Fee Schedule final rule, CMS stated that the service can be reported with an outpatient E/M visit “other than a level 1 visit by clinical staff” and hospital discharge services. And CMS will continue to assess where the service can be performed.

“We are interested in learning more about the ideal settings for HCPCS code G0136 as we work with interested parties about how HCPCS code G0136 is used, and we will continue to examine this issue in future rulemaking,” the agency states in the final rule.

Remind your staff that setting is only one factor for the service. The physician or qualified healthcare professional (QHP) must perform and document all four parts of the risk assessment, which requires that the provider:

  1. Determine that the patient has an unmet SDOH that affects their treatment
  2. Administer risk assessment with the appropriate tool
  3. Take steps to address the SDOH, such as referring the patient to relevant resources
  4. Indicate how the assessment results affected their medical decision-making (MDM) or treatment plan

CMS does not require the provider to perform the risk assessment on the same day as the patient encounter. “We are not finalizing the requirement that the SDOH risk assessment must be performed on the same date as the associated E/M or behavioral health visit, for the operational ease of practitioners,” the agency explained in the final rule.

However, CMS indicated that risk assessments performed before the encounter should be rare. “We continue to believe that in most cases, HCPCS code G0136 would not be performed in advance of the associated E/M or behavioral health visit,” CMS says.

Remember that the provider must document “one or more known or suspected SDOH needs that may interfere with the practitioners’ diagnosis or treatment of the patient” before they can perform the assessment, according to CMS. Your practice must collect that information and communicate it to the treating provider to support the medical necessity of the assessment.

Assessments performed after the encounter could also run into problems because the provider must connect the assessment results to their MDM or treatment plan. In addition, the separate assessment could create additional burden for the patient, the provider, or both.

Editor’s note: This article was originally published in JustCoding. This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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