Has a payer placed your facility on pre-payment review for certain services, such as emergency room visits for specific levels of care?

Pre-payment review means your facility must submit medical records with each affected claim before the payer will agree to pay or otherwise adjudicate the claim. This process:

• Increases administrative costs in the form of developing alternate workflows to submit medical records with affected claims
• Delays payment and increases days in accounts receivable
• Insinuates there are concerns with a provider’s billing practices

The latter observation is critically important; however, despite the serious nature of what pre-payment review suggests, payers often provide little to no explanation or basis for placing a provider on pre-payment review.

There’s often no transparency as to why it happened or what’s needed to end it. Providers have engaged neutral third parties to evaluate their billing practices, and these reviews find them to be compliant and consistent with Medicare and industry requirements. Providers are left to wonder what’s going on, how to move forward, and how to avoid this situation in the future.

Pre-payment review can be a worrisome status for a provider to have. Here are some key steps to consider if your facility is facing pre-payment review:

On January 1, 2024, Centers for Medicare and Medicaid Services (CMS) introduced the new HCPCS code G0136 – administration of a standardized, evidence based social determinants of health risk assessment tool, 5 to 15 minutes, referred to below as the Social Determinants of Health (SDoH) risk assessment.

This code is meant to reimburse a physician or other qualified healthcare professional for administration of an assessment of an individual’s social needs or identified social risk factors that may influence the diagnosis and treatment of their medical conditions.

The assessment may be rendered as a standalone service or in conjunction with another evaluation and management service. It is subject to a limitation of once every six months per provider per patient. The service will be subject to cost sharing (co-pay and deductible) unless it is performed at the same encounter as an Annual Wellness Visit.

The SDoH risk assessment can be performed by the treating physician or other practitioner (NPs, CNSs, CNMs, PAs), or by auxiliary personnel under the general supervision of the billing practitioner incident to their professional services.

The SDoH risk assessment refers to a review of the individual’s SDoH needs or identified social risk factors influencing the diagnosis and treatment of medical conditions. Use of a standardized, evidence-based SDoH risk assessment tool helps to assess for:

• Housing insecurity
• Food insecurity
• Transportation needs
• Utility difficulty

Any SDoH needs identified through the risk assessment (HCPCS Level II code G0136) must be documented in the patient’s medical record and may be documented using one of the ICD-10-CM, “Z codes” (Z55–Z65) which are used to document SDoH data to facilitate high-quality communication between providers.

It is important to note that this is not a screening service that would be performed on every patient. This is an assessment service to be performed when the provider has reason to believe that there are unmet SDoH needs that are interfering with the diagnosis and treatment of a condition or illness or will influence choice of treatment plan or plan of care.

There is some confusion with providers that G0136 can be reported with most Medicare patients. However, the assessment is only to be completed when the provider has reason to believe there are SDOH needs. Medicare has provided limited information on this new code and we may expect additional information as the year progresses and usage increases.

Provider reimbursement for G0136 is $18.97 nationally and can be negotiated into commercial contracts.

Our recommendation for operationalizing this new code is for providers to understand what the potential health hazards related to socioeconomic and psychosocial circumstances are, and to make sure they are aware this new code is available when an assessment is required.

Reference: Detailed information on the use of this code can be found in the CMS publication MLN booklet Health Equity Services in the 2024 Physician Fee Schedule Final Rule.