Social determinants of health (SDOH) are the non-medical factors that influence health outcomes.
Providers can receive additional reimbursement when they document and address those SDOH that impact a patient’s treatment.
CMS finalized coverage of HCPCS code G0136 (administration of a standardized, evidence-based SDOH risk assessment tool, 5-15 minutes) beginning January 1, 2024,
In order to report G0136 the provider must use a standardized, evidence based risk assessment tool that includes the SDOH domains of food insecurity , housing insecurity, transportation needs, and utility difficulties.
Examples of standardized tools according to the 2024 MPFS final rule include:
- CMS Accountable Health Communities tool
- Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE)
- Medicare Advantage Special Needs Population Health Risk Assessment
One’s practice should look for and use a tool that fits its patient population, but it must be one that has been tested and validated through independent research. Remind providers to document the tool they used in the patient record. 1
See below for examples of scenarios when it would be appropriate to code a SDOH.
1. The patient is seen and diagnosed with hypothermia. The physician documents that the patient has come from a home that does not have a functioning heater. Z59.11 (Lack of heating)
2. Physician notes in child’s record that she has a history of stealing food from other children. Mother states due to financial issues there have been times when there has been no money for food and child had to go to school hungry. Z59.48 (Lack of food)
3. Patient has missed their appointment several times this month due to lack of transportation. Z59.82 (Lack of transportation)
4. Patient has a history of living on the streets as patient’s home was foreclosed on earlier this year. Z59.819 (Housing instability)