Medicare's new code for assessing cardiovascular disease risk
Editor's note: This post was edited to clarify that code G0537 can be used with code G2211 for Medicare patients.
The final Medicare rules for 2025 include a number of codes that support primary care, including a new one for assessing cardiovascular disease risk:
G0537 — “Administration of a standardized, evidence-based atherosclerotic cardiovascular disease risk (ASCVD) assessment for patients with ASCVD risk factors, 5-15 minutes, not more often than every 12 months per practitioner.”
What that means:
You can report code G0537 to Medicare after you calculate the patient’s risk for ASCVD using a validated assessment tool, such as this one from the American College of Cardiology.
You can submit the code for eligible Medicare patients once per 12 months.
Who is eligible:
Medicare does not intend the assessment to be a general screening. It is reserved for patients who do not currently have a cardiovascular disease diagnosis or history of heart attack or stroke, but have at least one condition that would put them at risk for ASCVD. Such conditions include obesity, family history of cardiovascular disease, history of high blood pressure, history of high cholesterol, history of smoking/alcohol/drug use, pre-diabetes, or diabetes.
When you should do the assessment:
The Centers for Medicare & Medicaid Services (CMS) initially proposed to require clinicians to perform the assessment on the date of a visit. CMS ultimately did not finalize that requirement, but it did stipulate that the code must be "associated" with an E/M visit. For example, you saw the patient, drew labs, and did the assessment later in the week after lab results were in. This can get complicated, so I recommend just doing the assessment on the E/M visit day.
Payment, coding, and documentation:
Average Medicare reimbursement for code G0537 is $18.44 based on 0.18 relative value units. Although there are preventive features to this work, the final rules did not indicate this is a “preventive service” under Medicare rules. Therefore, there may be a co-pay with code G0537, and you should inform patients of that.
There is currently no Medicare requirement to add modifier 25 to the E/M visit code when you’re also reporting G0537. But other payers who adopt the code may require it, or National Correct Coding Initiative (NCCI) edits related to this code combination may change. If modifier 25 at some point becomes a requirement, then G0537 couldn't be used at the same time as G2211 unless it is reclassified as a preventive service. For now, however, G0537 is to be used in connection with an office visit and does not require modifier 25, so you can use both G0537 and G2211 at the same visit for Medicare patients.
In your documentation, write something like, "Patient's 10-year ASCVD risk score calculated at X% using the ASCVD Risk Estimator from the American College of Cardiology using current lipid data (less than 12 months old). This assessment was performed due to the predisposing cardiovascular risk factor of X."
This assessment may already be part of your normal workflow to formalize ASCVD risk for your patients — now you can get paid for it.
— Samuel L. Church, MD, MPH, CPC, FAAFP
Posted on Feb. 7, 2025.