Well, here we are into the third quarter of 2024 and by now, if you’re a provider in private practice, you (and any other providers that may be working for you/with you), should have performed an Annual Wellness Visit (AWV), on most, if not all your active patients and hopefully, have included a Social Determinants of Health screening (SDOH). CMS implemented changes to the Annual Wellness Visit (AWV), and the Health Risk Assessment (HRA) as of January 1st, 2024, which now includes an optional SDOH Risk Assessment for office-based providers and a mandatory directive to provide the SDOH for inpatient providers.
This new optional 13th component, of what was always a twelve (12), component AWV, applies to both office-based and inpatient facilities, but as I stated above, is “optional” for office-based and “requires” it for Hospitals and other inpatient type facilities as of January 1st, 2024. The good news for all providers and facilities is CMS will allow for additional payment on top of the reimbursement for the standard AWV.
If you want to view the updated HRA with SDOH minimum elements, you can click on the link for “A Framework for Patient-Centered Health Risk Assessments”
(https://www.cdc.gov/policy/paeo/hra/frameworkforhra.pdf) Providers will be able to see more details, including a sample HRA with the SDOH data that CMS is requesting when provided.
Of note from the Federal Register, the new SDOH assessment must adhere with a set of uniform, proven practices, and ensure that all modes of communication, align and sync with the patient’s demographic for all areas of education, development, healthcare comprehension and must be socially and verbally appropriate. The rationale for the SDOH is to boost patient-centered care and ensure efficacy for the administration providing an AWV. The good news for patients – they will not be subject to a deductible or Part B coinsurance by partaking in an annual AWV.
For more information: (https://www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other#h-512)
Coding for the SDOH:
To better track and assist providers and facilities as they provide the new SDOH component, CMS has created a new HCPCS code, G0136 – administration of a standardized, evidence-based SDOH assessment, 5–15 minutes. This new HCPCS code for the SDOH, is not to be performed or reported, more than 1-2 times a year.
CMS has stated that the SDOH may be provided with the following:
- An evaluation and management (E&M) encounter, which can include office-based, inpatient, hospital discharge or transitional care management services.
- Behavioral health encounters, which can include psychiatric diagnostic evaluation and/or a health behavior assessment and intervention.
Breakdown:
When a provider furnishes an AWV, any SDOH risk assessments that are provided as part of an E&M encounter or Behavioral health encounter, isn’t considered a screening, although it may be medically necessary as part the data elements of a social history (PFSH). It is only when a provider feels there is adequate reason to support SDOH needs are not being met, which hinder the providers ability to diagnose and treat a specific illness and/or chronic condition that negatively impacts the plan of care (POC). In this instance, the patient will be responsible for their cost share, just as they would with any regular encounter/visit. In this scenario, the SDOH assessment wouldn’t normally be provided ahead of the encounter.
Example:
John Smith, a patient of Dr Jones, and a Type 2 Diabetic, has not had an office visit in six months, requests an appointment for 10-days from today at 1pm to refill refrigerated medication that went bad from a power outage when his electricity was shut off for non-payment. Mr. Smith must use public transportation which has limited availability in his area. If Mr. Smith has not received an SDOH assessment in the past 6 months, then the office of Dr Jones can have Mr. Smith complete an SDOH risk assessment 7–10 days in advance of his appointment which will be part of his intake information and it ensures that Dr Jones will have adequate information to treat and provide an appropriate plan of care (POC).
Providers can provide an SDOH risk assessment as an elective component of an AWV. In this scenario, CMS looks at as a preventive service, which removes the patient cost sharing responsibility, when done once a year and billed in conjunction with the AWV. To be clear, the SDOH risk assessment applies to a thorough look at the patients SDOH needs, along with any detected community risk factors affecting diagnosis and plan of care (POC) for any and all current medical conditions. Providers should use a recognized SDOH risk assessment tool which will allow them to identify the following as it pertains to their patients:
- Lodging/shelter/home uncertainty /anxiety
- Nutrition/dietary/food uncertainty /anxiety
- Public or personal modes of transportation accessibility
- Utility obstacles/accessibility
Diagnosis Code Selection:
Providers should report diagnosis codes that are congruent and relative to a patient’s current health status on exam. CMS does not require a specific diagnoses code(s), in order to submit either an optional or mandatory SDOH Risk Assessment claim as a component of an AWV.
Billing
The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when the following applies:
- Provided on the same day as the covered AWV
- Provided by the same provider as the covered AWV
- Billed with modifier 33 (Preventive Service)
- Billed on the same claim as the AWV
TIP: CMS has added G0136 to telehealth services permanently
TIP: When a provider feels it is appropriate to do an SDOH risk assessment as an optional or mandatory additional element of an AWV, it should be reported with the same DOS on the same claim as G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit), or G0439 (Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit). Providers can also document and provide various components of the AWV over a course of several days and then would report the HCPCS codes for everything on the actual date of completion for all components of the AWV, which includes the SDOH.
CONCLUSION:
Providers in office based practices should seriously consider the benefits of providing the SDOH for both their patients and the business side of the practice. Adding the SDOH is important when assessing patient histories, medical decision making, diagnosis, treatment, and plan of care. CMS and Healthy People 2030,
(https://health.gov/healthypeople), has estimated that roughly close to fifty percent of an individual’s healthcare comes from a direct correlation with the SDOH. From Healthy People 2030, they stated the following “The conditions in the environment where people are born, live, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
AWV Resources:
- https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-410/subpart-B/section-410.15
- https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf#page=30
- https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c18pdf.pdf#page=161
- https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html
- https://www.cdc.gov/policy/paeo/hra/frameworkforhra.pdf
- Comprehensive Review of Medicare Preventive Screening Services
- Annual Wellness Visit: Social Determinants of Health Risk Assessment
MBR AAPC/NAMAS
Director of Compliance and Education, ZENMED Solutions INC.
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