Compliance
Health Equity And Collection Of Social Determinants Of Health (SDoH)
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Health Equity has become embedded in CMS’s goal of reducing disparities in health. It is defined as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of health race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, and other factors that affect access to care and health outcomes.” One of the priorities CMS identified in its framework to better serve underserved and disadvantaged communities is the collection, reporting, and analysis of SDoH data.
To enhance collection efforts of SDoH, CMS has made the collection of this data from patients an optional Annual Wellness Visit (AWV) element. The AWV includes the establishment, or update, of:
• The patient’s medical and family history
• A health risk assessment
• A personalized prevention plan.
The AWV includes the initial visit (HCPCS code G0438) and the subsequent visit (HCPCS code G0439).
Starting October 7, 2024, Eligible Health Professionals will be able to bill HCPCS Code G0136, Administration of a standardized, evidence-based SDoH risk assessment tool, 5-15 minutes, not more often than every 6 months.
When you provide in conjunction with certain evaluation and management or behavioral health services, CMS requires that the SDoH risk assessment is standardized, evidence based, and that any documented health related social need is identified in the medical record.
SDoH risk assessment refers to a review of the individual’s SDoH needs or identified social risk factors influencing the diagnosis and treatment of medical conditions.
Use a standardized, evidence-based SDoH risk assessment tool to assess for:
• Housing insecurity
• Food insecurity
• Transportation needs
• Utility difficulty
When you provide the SDoH as an additional element of the AWV, CMS also requires that the SDOH risk assessment is:
• Optional at the discretion of the clinician and patient,
• Separately payable from the AWV with no applicable patient Part B coinsurance and deductible when part of the same visit with the same date of service (DOS) as the AWV, and
• Subject to the same health professional eligibility and frequency limitations as the AWV.
Eligible Health Professionals include:
• Physician who’s a doctor of medicine or osteopathy
• Physician assistant, nurse practitioner, or clinical nurse specialist
• Medical professional or a team of such medical professionals, working under the direct supervision of a physician
Patient cost sharing, Part B coinsurance, and deductible isn’t applicable to the AWV, and doesn’t apply to the SDOH risk assessment when you provide as an additional element of the AWV.
For more information on SDoH billing requirements and Health Equity Services, see
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