Social Determinants of Health Risk Assessment

What is the Social Determinants of Health (SDOH) Risk Assessment?

The Centers for Medicare & Medicaid Services (CMS) began reimbursing for Social Determinants of Health (SDOH) Risk Assessment on January 1, 2024. The SDOH Risk Assessment helps a practitioner understand the unmet social needs of a Traditional Medicare patient that may affect the patient's diagnosis or treatment. The SDOH Risk Assessment must be provided using a standardized, evidence-based tool to assess social needs, such as housing situation, access to food, transportation needs, and difficulty paying utility bills.

Medicare Part B covers one SDOH risk assessment every six months. The SDOH Risk Assessment is not a screening, but rather an assessment administered when the practitioner believes the patient has unmet social needs affecting their diagnosis and treatment. The SDOH Risk Assessment may be provided by telehealth.

The SDOH Risk Assessment is an optional addition to the Annual Wellness Visit (AWV). There is an add-on payment for the SDOH Risk Assessment, but there is no cost sharing when conducted during an AWV.

The SDOH Risk Assessment can be provided during an Evaluation and Management (E/M) visit, with the exception of level 1 visits performed by clinical staff. The SDOH Risk Assessment can also be provided during a behavioral health visit. There is an add-on payment for an SDOH Risk Assessment conducted during an office or behavioral health visit and the usual Medicare Part B cost sharing requirement applies. CMS recommends practitioners notify the patient about cost sharing prior to administering the assessment.

Why conduct a SDOH Risk Assessment?

Providers can use results of the SDOH Risk Assessment to identify and monitor a patient's health-related social needs, inform follow-up, and refer patients to care coordination or community resources. Providers may also review results of the SDOH Risk Assessments for all of their patients in aggregate to understand community needs and inform proactive approaches to addressing these needs.

Who can provide a SDOH Risk Assessment?

The SDOH Risk Assessment can be provided by a:

• Physician
• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Certified nurse midwife
• Medical professional working under the direct supervision of a billing practitioner ”incident to” their professional services

What tools can be used to conduct a SDOH Risk Assessment?

Practitioners need to use a standardized, evidence-based tool to assess housing situation, access to food, transportation needs, and difficulty paying utility bills. Example tools include:

• Accountable Health Communities Health-Related Social Needs Screening Tool
• Protocol for Responding to & Assessing Patients' Assets, Risks & Experiences (PRAPARE)
• Instruments identified for Medicare Advantage Special Needs Population Health Risk Assessment

What is the billing code for the SDOH Risk Assessment?

There is one HCPCS code for the SDOH Risk Assessment:

• G0136: Administration of a standardized, evidence-based SDOH assessment, 5–15 minutes, not more often than every 6 months.

When the SDOH risk assessment is provided as an additional element of the AWV, include G0136 with modifier –33 on the same claim as the AWV (HCPCS codes G0438 or G0439) for the same date of service as the AWV.

G0136 is on the Medicare telehealth list permanently.

How do I document SDOH in my electronic health record (EHR)?

Any social needs identified must be documented in the patient's medical record. The ICD-10-CM Z codes are one way that providers can document health-related social needs in a standard format. Z codes (Z00-Z99) describe factors influencing health status and contact with health services that are not listed elsewhere as diseases, injuries, or external causes.

Are there any special considerations for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) billing for SDOH Risk Assessment?

RHCs and FQHCs can bill for the SDOH Risk Assessment as part of an RHC or FQHC visit, or AWV. The SDOH Risk Assessment is considered part of the RHC or FQHC visit and is not a separately reimbursable code. There is no patient cost sharing for an SDOH Risk Assessment that is conducted during an AWV. Patient cost sharing does apply when the SDOH Risk Assessment is provided with other visits.

Resources

• Care Management, Centers for Medicare & Medicaid Services
• Health Equity Services in the 2024 Physician Fee Schedule Final Rule, Centers for Medicare & Medicaid Services
• Health-Related Social Needs FAQ, Centers for Medicare & Medicaid Services
• Annual Wellness Visit: Social Determinants of Health Risk Assessment, Centers for Medicare & Medicaid Services
• Using HCPCS Code G0136 for Social Determinants of Health Risk Assessment, American Academy of Family Physicians
• Tools to Assess and Measure Social Determinants of Health, Social Determinants of Health in Rural Communities Toolkit, Rural Health Information Hub
• Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes, Centers for Medicare & Medicaid Services
• Using Z Codes: The Social Determinants of Health (SDOH) Data Journey to Better Outcomes, Centers for Medicare & Medicaid Services
• Care Management Services and Patient Navigation Services: A Comparison, American Society of Clinical Oncology

Last Updated: 1/14/2025
Last Reviewed: 1/14/2025