How to report social determinants of health risk assessment in conjunction with psychological services

The goal of an SDOH assessment is to identify unmet social needs that may affect the patient’s health outcomes. The Healthcare Common Procedure Coding System (HCPCS) code G0136 is used for the assessment of social determinants of health and is defined as the “administration of a standardized, evidence-based SDOH assessment, 5–15 minutes, not more often than every 6 months.” The purpose of this assessment is to evaluate the patient’s social risk factors that influence the diagnosis and treatment of mental and behavioral health conditions.

Assessment for SDOH is crucial because it helps identify and address factors beyond physical and behavioral health that significantly impact patient outcomes.

SDOH Z code categories include:

• Z55 – Problems related to education and literacy
• Z56 – Problems related to employment and unemployment
• Z57 – Occupational exposure to risk factors
• Z58 – Problems related to physical environment
• Z59 – Problems related to housing and economic circumstances
• Z60 – Problems related to social environment
• Z62 – Problems related to upbringing
• Z63 – Other problems related to primary support group, including family circumstances
• Z64 – Problems related to certain psychosocial circumstances (e.g., problems related to unwanted pregnancy, discord with counselors)
• Z65 – Problems related to other psychosocial circumstances

Here are some key points about why SDOH assessment matters:

• Patients’ social needs: Social determinants of health refer to nonmedical factors that influence health outcomes, such as food security, housing stability, transportation access, and employment. Patients facing challenges in these areas may struggle with managing their health conditions effectively.
• Obstacles to high-quality care: When patients lack safe housing, reliable transportation, or adequate food resources, it can create significant barriers to receiving high-quality care.

In summary, SDOH assessment helps clinicians understand patients’ social context and enables them to address barriers beyond physical and behavioral health treatment, ultimately improving overall health outcomes.

The core components of social determinants of health risk (SDOH) assessment related to HCPCS Code G0136:

Standardized, evidence-based risk assessment tool, 5–15 minutes, not more often than every 6 months.

• To report G0136, health care providers must use a standardized, evidence-based risk assessment tool.
• This tool includes the following SDOH domains:
  Food insecurity: Assessing whether the patient has reliable access to nutritious food
  Housing insecurity: Evaluating housing stability and safety
  Transportation needs: Identifying transportation barriers that may affect health care access
  Utility difficulties: Examining challenges related to utilities (e.g., electricity, water) and their impact on health

Individual-level assessment:

• The assessment focuses on individual social risk factors that influence health outcomes.
• It goes beyond medical conditions and considers broader social determinants.
• Providers use the assessment tool to identify unmet needs and tailor care accordingly.

When to report G0136:

• Behavioral health office visits, such as psychiatric diagnostic evaluation (CPT^® code 90791) and health behavior assessment or re-assessment (CPT code 96156)
• It is not a screening but an assessment, meant to identify unmet SDOH needs that may impact the patient’s health.
• Cost-sharing (co-pay and deductible) applies unless it is done during an annual wellness visit.

It is important to note that HCPCS code G0136 is not intended to be utilized as a screening tool that should be used at office visits for all patients. CMS made it very clear in the CY2024 Physician Fee Schedule Final Rule that this service is an assessment performed at a visit after the physician/NPP has seen the patient and decides that it is necessary. And, if problems are found, follow-up is required.

“We reiterate that the SDoH risk assessment code, HCPCS code G0136, when performed in conjunction with an E/M or behavioral health visit is not designed to be a screening, but rather tied to one or more known or suspected SDoH needs that may interfere with the practitioners’ diagnosis or treatment of the patient… An SDOH risk assessment without appropriate follow-up for identified needs would serve little purpose and we continue to believe that follow-up or referral is an important aspect of following up on findings from an SDoH risk assessment.” p.346 CY2024 PFS Final Rule.

Possible evidence-based tools for SDOH assessment include:

1. CMS Accountable Health Communities (AHC) Tool: This tool is recommended by CMS. It assesses various social determinants, including economic stability, education access, neighborhood environment, and community context. Additional information regarding this tool can be found on the CMS website (PDF, 328KB)opens in new window.
2. Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) Tool: PRAPARE is widely used in health care settings. It covers a comprehensive range of social determinants, allowing providers to identify patients’ needs related to housing, food security, transportation, and more. Additional information regarding this tool can be found on the PRAPARE websiteopens in new window.
3. Instruments Identified for Medicare Advantage Special Needs Population Health Risk Assessment: These instruments are specifically designed for assessing social determinants in Medicare Advantage populations. They focus on risk assessment and tailored interventions based on individual needs.

APA is dedicated to improving population health, along with advocating for financial incentives that support psychologists’ involvement in these efforts. A population health approach, or preventive health approach, focuses on improving the health, health equity, safety, and well-being of entire populations, including individuals within those populations. Providing SDOH assessments plays a crucial role in population health and prevention. SDOH assessments are essential for understanding and addressing the underlying social factors that impact population health. By recognizing and acting on these determinants, clinicians can provide effective prevention and promote health equity. Providing SDOH assessments is an important part of addressing population health, and the SDOH assessment code allows psychologists to be reimbursed for this service.

G0136 can only be reported in conjunction with:

• CPT code 90791; Psychiatric diagnostic evaluation or
• CPT code 96156; Health behavior assessment, or re-assessment (i.e., health-focused clinical interview, behavioral observations, clinical decision making)
• Note: APA Services is continuing efforts with the agency to advocate for clinical psychologists to have the ability to utilize SDOH assessment in conjunction with the neurobehavioral status exam (codes 96112/96121).

Do not report the SDOH assessment more often than every 6 months.

The appropriate SDOH needs to be identified in the medical record documentation and reported with appropriate diagnosis codes from the ICD-10-CM categories, Z55-Z65. For example, Z59.41, specifically represents food insecurity; Z59.82, represents transportation insecurity. Reporting Z13.9 encounter for screening would not be appropriate.

Currently there are no Practitioner-to-Practitioner (PTP) or Medically Unlikely Edits (MUE) NCCI edits for reporting HCPCS code G0136 in conjunction with CPT codes 90791 or 96156. APA will update this section in the future if PTP and/or MUE edits are implemented.

Example one

The following example depicts a patient who was diagnosed with depression during a psychiatric diagnostic interview and was also assessed and found to have food (Z59.41) and transportation (Z59.82) insecurities:

Example two

The following example depicts a patient who has been diagnosed with diabetes mellitus due to underlying condition with hyperglycemia (ICD-10 code E0865) who was seen for a health behavior assessment and was assessed and found to have food insecurities (ICD-10 code Z59.41):

• CMS Using Z Codes: The Social Determinants of Health (SDOH) Data Journey to Better Outcomes (PDF, 2MB)opens in new window
• CMS Health Equity Services in the 2024 Physician Fee Schedule Final Rule (MLN9201074) (PDF, 1MB)opens in new window
• CMS Accountable Health Communities (AHC) Tool (PDF, 328KB)opens in new window
• Protocol for Responding to and Assessing Patients’ Assets, Risks & Experiences (PRAPARE)opens in new window
• Medicare Managed Care Manual, Chapter 16-B: Special Needs Plans (PDF, 2MB)opens in new window
• CMS Health Equity Fact Sheet (PDF, 650KB)opens in new window
• HHS Office of Disease Prevention and Health Promotion (OASH) SDOH webpageopens in new window
• Healthy People 2030 SDOH webpageopens in new window
• CY2024 Physician Fee Schedule Final Ruleopens in new window