Healthcare is evolving, and as we move forward with quality care and compassion, it’s crucial to address the factors that significantly impact patient outcomes beyond traditional medical care. Social determinants of health (SDoH) are these non-medical factors—such as access to food, stable housing, transportation, and utility services—that influence a person's overall health and treatment outcomes. By effectively addressing and coding these determinants, providers can enhance care while also accessing additional reimbursement opportunities. 

CMS Strategic Plan 

“The Centers for Medicare & Medicaid Services (CMS) infuses health equity in everything it does. CMS is working to advance health equity so that each person has a fair and just opportunity to attain their highest level of health regardless of their age, race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.” CMS wants to make sure that all individuals and families have access to quality healthcare. To do this CMS has to remove the barriers to healthcare and support and partner with providers to ensure that every person and family can access care they need. 

Starting in January 2024, CMS began offering coverage for HCPCS code G0136. This coverage allows providers to be reimbursed when they use a standardized, evidence-based SDoH risk assessment tool that evaluates crucial areas such as food insecurity, housing instability, transportation needs, and utility difficulties. 

To comply with G0136, providers must use validated tools that have been independently tested. The 2024 MPFS final rule specifies some approved tools, including: 

• CMS Accountable Health Communities Tool 

• Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) 

• Medicare Advantage Special Needs Population Health Risk Assessment 

The key is to find a tool suitable for your practice’s patient population while ensuring it meets CMS requirements. Documentation of the tool used in the patient record is also critical. 

Hospital Outpatient Quality Reporting Program (OQR) 

CMS is expanding its focus on SDoH beyond inpatient settings. The Hospital Outpatient Quality Reporting Program (OQR), a pay-for-reporting quality program, requires hospital outpatient departments to meet specific quality reporting requirements. Failure to do so results in a 2% reduction in their annual payment update. CMS is proposing to adopt the screening of Social Drivers of Health measure, with voluntary reporting starting in CY 2025, followed by mandatory reporting beginning in CY 2026. 

This expansion reflects CMS’s recognition of the importance of social factors in shaping health outcomes. It provides healthcare providers with the tools to identify at-risk populations and develop targeted interventions. The Commitment to Health Equity measure further encourages healthcare organizations to integrate equity into their strategic and operational goals, fostering a culture of accountability and continuous improvement. 

Expanded Reimbursement Opportunities 

CMS is committed to advancing health equity and has included measures to support providers and hospitals in addressing social drivers of health. For example, the new policy finalized for FY 2024 recognizes the higher costs that hospitals face when treating patients experiencing homelessness or housing insecurity. This policy introduces new codes effective from October 1, 2024, which will be classified as complications or comorbidities (CCs), thus increasing reimbursement for specific diagnosis-related groups (DRGs). These codes include: 

• Z59.10 (Inadequate housing, unspecified) 

• Z59.11 (Inadequate housing, environmental temperature) 

• Z59.12 (Inadequate housing, utilities) 

• Z59.19 (Other inadequate housing) 

• Z59.811 (Housing instability, housed with risk of homelessness) 

• Z59.812 (Housing instability, housed, homelessness in past 12 months) 

• Z59.819 (Housing instability, housed, unspecified) 

Real-World Scenarios: How SDoH Coding Can Make a Difference 

Here are some examples where documenting SDoH impacts patient care and enhances reimbursement: 

1. A patient is diagnosed with hypothermia, and the physician documents that their home does not have heating. Code: Z59.11 (Lack of heating). 
2. A child’s record shows a history of food insecurity due to financial difficulties at home, leading to hunger. Code: Z59.48 (Lack of food). 
3. A patient misses multiple appointments due to transportation issues. Code: Z59.82 (Lack of transportation). 
4. A patient becomes homeless following the foreclosure of their home. Code: Z59.819 (Housing instability). 

Why This Matters for Your Practice 

Incorporating SDoH documentation not only improves patient care but also opens up significant reimbursement opportunities. UASI is here to guide you through these changes and help your practice implement these assessments seamlessly. Our expertise ensures your compliance with the latest CMS guidelines, helping you maximize reimbursement potential while enhancing patient outcomes. 



Take Action Today 

Don’t let your practice fall behind in leveraging these opportunities. Contact UASI to learn how our clinical documentation and coding solutions can empower your practice to succeed. Together, we’ll build a more equitable, efficient, and effective healthcare environment for your patients.