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25-1167m Integrating Social Determinants of Health Into Clinical Practice

Date: 11/14/25

Support care teams in recognizing and responding to social needs that shape health outcomes

Social Determinants of Health (SDOH) influence up to 80% of health outcomes. By identifying and documenting these factors, physicians and other providers can deliver more personalized care, reduce disparities and support value-based care initiatives.

Recognize the impact of SDOH

SDOH are non-medical factors that shape health outcomes. Key factors include:

  • Economic stability (e.g., income, employment).
  • Education access and literacy.
  • Housing and environmental safety (e.g., homelessness,
    unsafe conditions).
  • Food security.
  • Social support and experiences of discrimination.
  • Access to transportation and health care services.

Know when to screen for SDOH

Incorporate screening during:

  • Annual wellness visits (AWV).
  • Chronic care management.
  • Behavioral health assessments.
  • Hospital discharge planning.
  • Any encounter where social needs may impact care.

Where to document SDOH

Use your electronic health record’s designated fields for SDOH, such as:

  • Problem list.
  • Encounter notes.
  • Diagnosis codes.

Ensure documentation includes:

  • Screening tool used.
  • Source of information (e.g., patient, caregiver, social worker, nurse).
  • Provider sign-off.
  • Clear linkage to health impact (e.g., asthma exacerbated by poor housing).

Take action – a five-step approach

  1. Screen using tools like PRAPARE® or AHC-HRSN (PDF).
  2. Document findings in the medical record.
  3. Code using ICD-10-CM Z codes (Z55–Z65) to reflect SDOH factors.
  4. Refer to social services or care coordination teams.
  5. Follow up assessing impact and adjust care plans.

Use the right codes for SDOH

Use ICD-10-CM Z codes to document SDOH-related issues. These codes are not primary diagnoses, but they support care planning and reimbursement.

Common Z code categories:

  • Z55 – Problems related to education and literacy.
  • Z56 – Employment and unemployment issues.
  • Z57 – Occupational exposure to risk factors.
  • Z58 – Physical environment concerns.
  • Z59 – Housing and economic circumstances (e.g., Z59.0 for homelessness).
  • Z60–Z65 – Social environment, upbringing, psychosocial circumstances.

Use HCPCS code G0136

G0136 supports reimbursement for a standardized SDOH risk assessment (5–15 minutes).1

  • Billable when performed during eligible visits (e.g., AWVs, behavioral health or evaluation and
    management services).
  • Use only when social barriers impact clinical decision making.
  • Clearly document relevance and rationale in the medical record.

Top provider resources for SDOH

Need help or have questions?

If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral Health providers can call 844-966-0298.

 
1American Academy of Professional Coders: CMS finalizes G0136 for conducting an SDOH risk assessment and assigned it a payment value.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Imperial County.
 



Last Updated: 11/14/2025