CMS clarifies SDOH risk assessment coding

Wednesday, May 22, 2024

CMS recently published MLN Matters 13486 to clarify the use of social determinants of health (SDOH) risk assessments during Medicare annual wellness visits (AWV).

The agency specified that when an SDOH risk assessment is given in conjunction with an AWV, it is to be claimed with the appropriate AWV code (G0438 for initial, G0439 for subsequent) and the add-on code G0136, plus modifier 33 (preventive services).

Note that in this situation, the assessment requires neither coinsurance nor deductible on the patient’s part. This is different from when it’s provided with an evaluation and management office visit or other non-preventive visit. But the provider must remember to add modifier 33 or the patient will be billed.

The SDOH risk assessment may be given on a separate occasion, and even a separate day, from the face-to-face or telehealth AWV encounter.  

CMS also clarified that when the SDOH/AWV combination goes past one day, the billing date should be the date on which the entire service is accomplished (presumably the encounter date), and that the multiple performance dates should be noted in the medical records. Also, watch out for other time-based billing issues — for example, the frequency restriction on AWVs that prevents reimbursement when the date of service occurs within a year of a previous claim for the same code.

Editor’s note: A version of this article was originally published on Part B News.