SDOH - Social Determinants Of Health (CPT G0136)

What is SDOH

The SDOH stands for "Social Determinants of Health" 

CMS has introduced a new stand-alone G code, now assigned as HCPCS code G0136 and effective from Jan 1st 2024, for the administration of a standardized, evidence-based Social Determinants of Health (SDOH) Risk Assessment. 

This assessment takes 5-15 minutes and is performed no more often than every 6 months. 

An SDOH risk assessment involves reviewing an individual’s social determinants or identified social risk factors that influence the diagnosis and treatment of medical conditions. 

HCPCS code G0136 is designed to identify and value the work involved in administering an SDOH risk assessment as part of a comprehensive social history when it is medically reasonable and necessary in relation to an E/M visit.

Why this code has Introduced

Using a standardized, evidence-based tool for SDOH risk assessment can more effectively and consistently identify unmet SDOH needs and enable comparisons across populations. 

For example, during an SDOH risk assessment for a patient presenting for diabetes management, a practitioner might discover that the patient’s living situation does not permit reliable access to electricity, affecting the patient's ability to keep insulin refrigerated. 

The practitioner may then prescribe a type of insulin that remains stable at room temperature or consider oral medication instead. 

In this above scenario, the practitioner can perform an SDOH risk assessment in conjunction with the E/M visit to gain a more thorough understanding of the patient’s full social history and determine whether other SDOH needs are impacting medically necessary care.

A SDOH encompasses economic and social conditions that affect the health of individuals and communities, including food insecurity, transportation issues, housing instability, and unreliable access to public utilities.

SDOH grouped into five key domains,

• Economic Stability: This includes factors such as employment, income, expenses, debt, medical bills, and support.
• Education Access and Quality: This encompasses literacy, language, early childhood education, vocational training, and higher education.
• Health Care Access and Quality: This includes access to health care, health insurance coverage, health literacy, and the quality of health services.
• Neighborhood and Built Environment: This includes housing, transportation, safety, parks, playgrounds, walk-ability, and access to healthy foods.
• Social and Community Context: This involves social integration, support systems, community engagement, discrimination, and community resilience.

CPT Code

G0136 - Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes

Key Note for Billing SDOH Services

• Modifiers 33 required for CPT G0136
• For a provider who spends 5 to 15 minutes time for reviewing an assessment form related to Social Determinants of Health (SDOH) with a patient.
• The beneficiary is eligible for this code every 6 months and this codes can be billed with E/M or Behavioral Health & AWV services.
• SDOH assessments can be done into initial or subsequent wellness visits but not specifically billed as G0136 during the Welcome to Medicare visit.

Cost-sharing

The Coast sharing will apply when performed with E/M or Behavioral Health and "No Coast" sharing will be applied when performed with AWV

Covered ICD Codes 

The SDOH needs identified through the risk assessment must be documented in the medical record. 

These needs can be documented using a set of ICD-10-CM codes known as "Z codes" (Z55-Z65), which are used to capture SDOH data. 

Utilizing these Z codes facilitates high-quality communication between providers, ensuring that SDOH information is accurately and consistently documented.

Z55.0 Illiteracy and low-level literacy
Z55.1 Schooling unavailable and unattainable
Z55.2 Failed school examinations
Z55.3 Underachievement in school
Z55.4 Educational maladjustment and discord with teachers and classmates
Z55.5 Less than a high school diploma
Z55.6 Problems related to health literacy
Z55.8 Other problems related to education and literacy
Z55.9 Problems related to education and literacy, unspecified
Z56.0 Unemployment, unspecified
Z56.1 Change of job
Z56.2 Threat of job loss
Z56.3 Stressful work schedule
Z56.4 Discord with boss and workmates
Z56.5 Uncongenial work environment
Z56.6 Other physical and mental strain related to work
Z56.81 Sexual harassment on the job
Z56.82 Military deployment status
Z56.89 Other problems related to employment
Z56.9 Unspecified problems related to employment
Z57.0 Occupational exposure to noise
Z57.1 Occupational exposure to radiation
Z57.2 Occupational exposure to dust
Z57.31 Occupational exposure to environmental tobacco smoke
Z57.39 Occupational exposure to other air contaminants
Z57.4 Occupational exposure to toxic agents in agriculture
Z57.5 Occupational exposure to toxic agents in other industries
Z57.6 Occupational exposure to extreme temperature
Z57.7 Occupational exposure to vibration
Z57.8 Occupational exposure to other risk factors
Z57.9 Occupational exposure to unspecified risk factor
Z58.6 Inadequate drinking-water supply
Z58.81 Basic services unavailable in physical environment
Z58.89 Other problems related to physical environment
Z59.00 Homelessness unspecified
Z59.01 Sheltered homelessness
Z59.02 Unsheltered homelessness
Z59.10 Inadequate housing unspecified
Z59.11 Inadequate housing environmental temperature
Z59.12 Inadequate housing utilities
Z59.19 Other inadequate housing
Z59.2 Discord with neighbors, lodgers and landlord
Z59.3 Problems related to living in residential institution
Z59.41 Food insecurity
Z59.48 Other specified lack of adequate food
Z59.5 Extreme poverty
Z59.6 Low income
Z59.7 Insufficient social insurance and welfare support
Z59.811 Housing instability, housed, with risk of homelessness
Z59.812 Housing instability, housed, homelessness in past 12 months
Z59.819 Housing instability, housed, unspecified
Z59.82 Transportation insecurity
Z59.86 Financial insecurity
Z59.87 Material hardship due to limited financial resources, not elsewhere classified
Z59.89 Other problems related to housing and economic circumstances
Z59.9 Problem related to housing and economic circumstances, unspecified
Z60.0 Problems of adjustment to life-cycle transitions
Z60.2 Problems related to living alone
Z60.3 Acculturation difficulty
Z60.4 Social exclusion and rejection
Z60.5 Target of (perceived) adverse discrimination and persecution
Z60.8 Other problems related to social environment
Z60.9 Problem related to social environment, unspecified
Z62.0 Inadequate parental supervision and control
Z62.1 Parental overprotection
Z62.21 Child in welfare custody
Z62.22 Institutional upbringing
Z62.23 Child in custody of non-parental relative
Z62.24 Child in custody of non-relative guardian
Z62.29 Other upbringing away from parents
Z62.3 Hostility towards and scapegoating of child
Z62.6 Inappropriate (excessive) parental pressure
Z62.810 Personal history of physical and sexual abuse in childhood
Z62.811 Personal history of psychological abuse in childhood
Z62.812 Personal history of neglect in childhood
Z62.813 Personal history of forced labor or sexual exploitation in childhood
Z62.814 Personal history of child financial abuse
Z62.815 Personal history of intimate partner abuse in childhood
Z62.819 Personal history of unspecified abuse in childhood
Z62.820 Parent-biological child conflict
Z62.821 Parent-adopted child conflict
Z62.822 Parent-foster child conflict
Z62.823 Parent-step child conflict
Z62.831 Non-parental relative-child conflict
Z62.832 Non-relative guardian-child conflict
Z62.833 Group home staff-child conflict
Z62.890 Parent-child estrangement NEC
Z62.891 Sibling rivalry
Z62.892 Runaway [from current living environment]
Z62.898 Other specified problems related to upbringing
Z62.9 Problem related to upbringing, unspecified
Z63.0 Problems in relationship with spouse or partner
Z63.1 Problems in relationship with in-laws
Z63.31 Absence of family member due to military deployment
Z63.32 Other absence of family member
Z63.4 Disappearance and death of family member
Z63.5 Disruption of family by separation and divorce
Z63.6 Dependent relative needing care at home
Z63.71 Stress on family due to return of family member from military deployment
Z63.72 Alcoholism and drug addiction in family
Z63.79 Other stressful life events affecting family and household
Z63.8 Other specified problems related to primary support group
Z63.9 Problem related to primary support group, unspecified
Z64.0 Problems related to unwanted pregnancy
Z64.1 Problems related to multiparity
Z64.4 Discord with counselors
Z65.0 Conviction in civil and criminal proceedings without imprisonment
Z65.1 Imprisonment and other incarceration
Z65.2 Problems related to release from prison
Z65.3 Problems related to other legal circumstances
Z65.4 Victim of crime and terrorism
Z65.5 Exposure to disaster, war and other hostilities
Z65.8 Other specified problems related to psychosocial circumstances
Z65.9 Problem related to unspecified psychosocial circumstances

Example Documentation

SDOH Review Summary

Reviewed the patient's completed SDOH assessment form, which identified issues related to housing instability and transportation insecurity. Discussed the impact of these factors on the patient's health and well-being. Provided information on local resources for housing assistance and transportation services. Referred the patient to the social worker for further support. Spent 10 minutes reviewing the SDOH assessment form with the patient. The patient acknowledged understanding of the discussed information and received contact information for local support resources.

Follow up:

• Follow-up appointment scheduled in 6 months to reassess and address any ongoing SDOH needs.
• Patient encouraged to reach out with any immediate concerns or needs.