Incorporating Social Determinants of Health into Medicare Annual Wellness Visits

🏥 What Is G0136?

G0136 was introduced by CMS in 2024 and allows billing for:

• Administration of a standardized, evidence-based SDOH risk assessment tool
  
• Duration: 5–15 minutes
  
• Frequency: No more than once every 6 months
  

This assessment must go beyond routine screening—it’s only reportable when unmet social needs may interfere with diagnosis or treatment 

💵 Reimbursement: What You’ll Earn

• Average non-facility rate: $18.97, varying by MAC locality (range: $17.02–$24.93)
  
• Average facility payment: About $5.99, compared to ~$18 non‑facility
  
• RVUs: ~0.18 work RVU; total ~0.57 RVU in non-facility settings
  

Note: This service is subject to Medicare deductible & coinsurance, unless performed during an AWV—then it's fully covered for patients 

✍️ Billing G0136 with an AWV

1. Perform the SDOH Assessment

Use a validated tool, such as:

• Accountable Health Communities (AHC)
• PRAPARE
• AAFP Social Needs
• HealthBegins
  

2. Time Requirements

Spend 5–15 minutes on the assessment. Document start and stop times to support billing.

3. Document Social Needs

Record specific SDOH findings using ICD-10 Z codes (Z55–Z65), and explain how they influence clinical decisions.

4. File the Claim

• Include G0438 (initial AWV) or G0439 (subsequent AWV)
  
• Append G0136-33 modifier on the same date to indicate preventive service and waive cost-sharing.
  
• Document relevant Z codes as secondary diagnoses.
  

5. Follow-Up Required

CMS expects providers to address identified needs—e.g., referrals or care planning—with documentation showing how the assessment informed care.

📅 Summary

How often
➔ Every 6 months per provider–patient

Time
➔ 5–15 minutes total time spent on tool

Who can perform
➔ Providers or supervised auxiliary staff 

Code/Base reimbursement
➔ G0136 non-facility: $18.97; facility: ~$5.99

AWV cost-share
➔ Waived with -33 modifier during AWV

Z codes required
➔ Z55–Z65 to explain found social needs

Follow-up required
➔ Referral or care action must be documented

✅ Best Practices

1. Pre-screening workflow
   Use patient questionnaires at check‑in or rooming to flag SDOH needs.
   
2. Integrate with AWV
   Schedule an extra 5–15 minutes for SDOH during AWV check-ins—capturing the tool, Z codes, time, and follow-up actions.
   
3. Staff training
   Teach clinical teams about the code’s purpose, time criteria, and documentation expectations.
   
4. Monitor reimbursement
   Keep an eye on MAC-specific rates and local updates.
   
   

🧠 Why It Matters

• Enhances patient care: Identifying barriers leads to better chronic disease control, reduced hospitalizations, and improved health equity.
  
• Reimburses care coordination: Practices are rewarded ~$19 for valuable social risk screening, with no patient cost during AWV.
  
• Prepares for value-based care: Documented SDOH and interventions support quality metrics and risk adjustment programs.
  
  

✅ Bottom Line

G0136 empowers primary care to bill appropriately for meaningful SDOH assessments—when performed thoughtfully, documented well, and integrated into AWVs. The non‑facility reimbursement (~$19), plus waived cost-sharing during AWVs, makes this a practical and impactful addition to your preventive care toolkit.

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