News: Commenters ask CMS to expand the SDOH risk assessment

CMS issued a broad request for information on the new codes that it created this year to address social needs. This includes HCPCCS code G0136, or Administration of a standardized, evidence-based social determinants of health risk assessment (SDOHRA) tool, 5-15 minutes, no more than once every 6 months, which is an option for a wide range of providers and is performed in a variety of settings in association with several evaluation and management and behavioral health visits. When the social determinants of health (SDOH) risk assessment is performed with an annual wellness visit, the patient does not have a copay or deductible for the service, JustCoding reported.

CMS sought feedback on several aspects of the code, such as:

• Barriers to providing the service.
• Whether the codes improve the provider’s ability to address unmet social needs that interfere with diagnosing and treating the patient.
• The use of ICD-10-CM codes Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances. CMS wanted to know “whether practitioners are also capturing unmet social needs on claims using Z codes for social risk factors or in some other way, and any barriers or opportunities to increase coding of Z codes when social risk factors screen positive,” they wrote in the proposed rule.

Commenters had suggestions for improving the risk assessment, which ranged from giving registered nurses (RN) more autonomy, to using artificial intelligence (AI) to speed the process of collecting and using information. Here are four comments that could shape the SDOH risk assessment in the future:

1. Make the assessment a standalone nurse visit: Auxiliary staff can perform the SDOHRA incident-to the treating practitioner’s services, and in certain cases the assessment can be performed before the associated visit. But an RN in Wyoming thinks CMS should go further to integrate the work performed by the nursing staff into team-based care. The RN wrote that conducting the risk assessment is within an RN’s scope of practice and observed that “the requirement to bill it with a visit can be onerous.” The RN strongly encouraged CMS to allow practices to bill G0136 without a companion visit and also to allow practices to report the visit when performed by an RN who is working under the general supervision of the treating physician or qualified health care professional.
    
2. Add AI tools: Explore ways to leverage health data, including SDOH, with AI tools, suggested Brian Scarpelli, executive director, and Chapin Gregor, policy counsel for Washington, D.C.-based Connected Health Initiative. “AI can dramatically reduce administrative burdens, improve physicians’ ability to care for their patients, and permit resource redeployment within Medicare to better serve the most vulnerable populations,” they explained in a co-written comment.
    
3. Include pediatric patients: Two pediatric groups expressed their support for payment of the SDOHRA, but urged CMS to make changes that would allow pediatricians to report the service. Sunrise, Florida-based Pediatrix Medical Group suggested that CMS work with the AMA CPT Committee and Specialty Society RVS Update Committee to create social needs codes that apply to more patients and might be adopted by more payers, including Medicaid. “We encourage CMS to consider how to support other payors, particularly Medicaid, with respect to coverage and payment for these services to enhance care navigation and care coordination across different settings,” wrote David M. Kanter, M.D., MBA, CPC, senior vice president, medical administrative services for Pediatrix. The American Society of Pediatric Nephrology in McLean, Virginia also noted that there isn’t a validated SDOH tool for children and that “there must be a validated tool available for children and their caregivers so that G0136 can be used in a meaningful fashion when providing pediatric care,” wrote society president Meredith Atkinson, MD.
    
4. Add more behavioral health services. CMS allows providers to report the SDOHRA with a psychiatric diagnostic evaluation (CPT code 90791) and all health behavior assessment and intervention services (CPT codes 96156-96168). In response to CMS’ request for information, several state psychological associations, including the Nebraska Psychological Association and the South Carolina Psychological Association, stated that this creates a barrier to access and utilization of the code. The associations asked CMS to increase the list of companion services to include the second psychiatric diagnostic and all psychotherapy codes (CPT codes 90792 and 90832-90853) and neurobehavioral status exam codes (CPT codes 96116 and 96121). Integrating the SDOHRA “into the neuropsychological assessment report will allow neuropsychologists to identify social needs that are negatively affecting health outcomes, utilize that information to provide more comprehensive care, develop more informed treatment recommendations to achieve improved treatment outcomes, as well as provide better coordination of care across the health care team,” the associations wrote.

While CMS did not indicate if or when it would make changes to any of the social needs codes, practices that report G0136 should stay alert to changes and clarifications that CMS might issue between rulemaking periods. For example, CMS clarified its policy for reporting the risk assessment in conjunction with an annual wellness visit in a change request that it published on May 2.

Editor’s note: This article first appeared in JustCoding. To view the CMS request for comments, click here.