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Question: What鈥檚 the difference between codes G0537 and G0538? I think they became billable in early 2025.

Texas Subscriber

Answer: The U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) published information on newly proposed codes that could be used to report the assessment and management of atherosclerotic cardiovascular disease (ASCVD) in the final rule 鈥�,鈥� which went into effect in January 2025.

Both of the following codes can be used to report the evaluation of an ASCVD, but they should be used in different ways.

Code G0537 (Administration of a standardized, evidence-based atherosclerotic cardiovascular disease (ascvd) risk assessment, 5-15 minutes, not more often than every 12 months) should be used when a provider assesses a Medicare beneficiary鈥檚 risk of developing ASCVD if they have at least one predisposing condition. Conditions may include a history of high blood pressure, high cholesterol, history of smoking or use of drugs or alcohol, prediabetes, or diabetes. There is no specific assessment tool that must be used, but whatever the provider chooses must be standardized and evidence based.

CMS says: 鈥淲e further proposed that the ASCVD risk assessment must be furnished by the practitioner on the same date they furnish an E/M visit, as the ASCVD risk assessment will be reasonable and necessary when used to inform the patient's diagnosis, and treatment plan established during the visit 鈥� We further proposed that the ASCVD risk assessment will not be separately billable for patients with a cardiovascular disease diagnosis or those who have history of a heart attack or stroke.鈥�

Code G0538 (Atherosclerotic cardiovascular disease (ascvd) risk management services; clinical staff time; per calendar month) should be used to report the management of a Medicare beneficiary鈥檚 diagnosed ASCVD, including services such as medication management, blood pressure management, cholesterol management, and smoking cessation.

CMS says: 鈥淲e proposed that ASCVD risk management services can be billed no more often than once per calendar month, and that payment is limited to one practitioner per beneficiary per month. Patients must be determined to be at medium or high risk for CVD (>15 percent in the next 10 years) as previously determined by the ASCVD risk assessment and must not have a current diagnosis of cardiovascular disease or have a history of heart attack or stroke.鈥� The agency finalized this proposal for code G0538, and providers should bill accordingly.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC