Coding Tip Corner – March 2025

It is now March, so we are almost a quarter of the way through the year. Have you started a collection of the Social Determinants of Health (SDOH) that CMS will be collecting in 2025? The Centers for Medicare and Medicaid Services (CMS) is requiring healthcare providers to collect data on for your patients for the following SDOH: 

• Food insecurity 
• Housing instability 
• Interpersonal safety (Domestic violence) 
• Transportation insecurity 
• Any difficulty with utility payments 

What does this mean to you as a healthcare provider? 

• Healthcare providers must routinely screen patients for SDOH factors. 
• They must document and report SDOH factors in the Electronic Health Record (EHR). 
• They must incorporate SDOH information into care plans and consider these when making healthcare decisions. 
• Track the outcomes: Measure and track how addressing SDOH impacts patient health outcomes, including both clinical and quality measures (you are already doing this through follow-up appointments and making adjustment to their care plan). Remember: Document it in the patient’s record. 

Below is a summary of places that can aid patients that have a positive screening for SDOH in the state of North Carolina. Key resources include:  

• NCCARE360 is a statewide coordinated care network connecting people to community resources. 
• Findhelp.org is a platform to search and connect with social care. Local health departments and the Healthy Opportunities program within the North Carolina Department of Health and Human Services can help with needs related to housing, food transportation, and more (depending on the specific SDOH concern). 
• There is also a Member Services number on the back of the member’s HealthTeam Advantage ID card for insurance questions. 

Last but not least, document the work code addressing SDOH during the visit, using a Z code from Z55-Z65! 

Coding Tips 

There is a new HCPCS code (G0136) to help capture the following: 

1. Annual Wellness Visit (AWV) 

Can be provided during the visit or prior to the appointment. 

Documentation: 

• Should indicate what date the assessment was completed and that was reviewed.  

• Should document the issues the patient is facing and referrals made, or recommendations made.  

• If no condition was found, please have the clinician make a notation of this.   
• If an SDOH condition is identified, please bill the service with the appropriate SDOH Z code (Z55-Z65). If no condition is evident, please bill with the appropriate diagnosis code.  

2. E/M or other code such as Behavioral Health, etc.  

Not to be used as a screening but as part of a “medically necessary and reasonable service to include a comprehensive history.” 

Limitations and Cost-Sharing: 

• Code can be only processed not more than once every 6 months, outside of an AWV.  If the service is provided as part of an AWV, it is subject to those frequency limitations.    

• Bill with modifier 33 when the tool was administered during an AWV to avoid assessing a copay or any cost sharing.  

​​References 

​​CMS. (2024, October). Annual Wellness Visit: Social Determinants of Health Risk Assessment. Retrieved from MLN Matters: https://www.cms.gov/files/document/mm13486-annual-wellness-visit-social-determinants-health-risk-assessment.pdf 

​CMS. (2024, October). Chapter 15 – Covered Medical and Other Health Services. Retrieved from Medicare Benefit Policy Manual: https://www.cms.gov/files/document/r12865BP.pdf 

​CMS. (2023, November). CMS Finalizes Physician Payment Rule that Advances Health Equity. Retrieved from Press Releases: https://www.cms.gov/newsroom/press-releases/cms-finalizes-physician-payment-rule-advances-health-equity

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