The Centers for Medicare and Medicaid Services (CMS) created two new G codes in the 2025 Medicare Physician Fee Schedule final rule that will provide reimbursement for atherosclerotic cardiovascular disease (ASCVD) risk assessment and risk management services. The codes were inspired by the success of the CMS Innovation Center’s Million Hearts® Cardiovascular Disease Risk Reduction model, which reduced the rate of death from any cause for medium and high risk patients by 4% and reduced risk of death from a cardiovascular event by 11%. 

The ASCVD risk assessment code, G0537, is defined as “Administration of a standardized, evidence-based Atherosclerotic Cardiovascular Disease Risk Assessment for patients with ASCVD risk factors, 5-15 minutes, not more often than every 12 months per practitioner.”

The service is billable for a patient that does not currently have a cardiovascular disease diagnosis or history of heart attack or stroke but does have at least one predisposing condition that may put them at increased risk for future ASCVD diagnosis. Qualifying conditions include, but are not limited to: obesity, family history of cardiovascular disease, high blood pressure, high cholesterol, smoking/alcohol/drug use, prediabetes or diabetes.

There is not a specified tool that must be used for this risk assessment; however, there are specific components that must be present, including:

• Current (from the last 12 months) laboratory data (lipid panel) for inputs for the risk assessment tool.
• Administration of a standardized, evidence-based ASCVD risk assessment tool that has been tested and validated through research, and includes the following domains:
• The output of the tool must include a 10-year estimate of the patient’s ASCVD risk. This output must be documented in the patient’s medical record.
• Demographic factors (such as age, sex).
• Modifiable risk factors for cardiovascular disease (such as blood pressure and cholesterol control, smoking status/history, alcohol and other drug use, physical activity and nutrition, obesity).
• Possible risk enhancers (such as preeclampsia, prediabetes, family history of cardiovascular disease).
• Billing practitioners may choose to assess for additional domains beyond those listed above if the tool used requires additional domains.

The ACC ASCVD Risk Estimator is one example of an acceptable tool to use for this risk assessment. The G0537 ASCVD risk assessment code has been assigned a work relative value unit (RVU) of 0.18. G0537 may be billed once every 12 months per practitioner per patient.

The ASCVD risk management code, G0538, is defined as “Atherosclerotic Cardiovascular Disease risk management services with the following required elements: patient is without a current diagnosis of ASCVD, but is determined to be at intermediate, medium or high-risk for cardiovascular disease as previously determined by the ASCVD risk assessment; ASCVD-specific care plan established, implemented, revised or monitored that addresses risk factors and risk enhancers and must incorporate shared decision-making between practitioner and patient; clinical staff time directed by physician or other qualified health care professional; per calendar month.”

The ASCVD risk management code will be billable when performed on a patient that was found to have intermediate, medium or high risk of cardiovascular disease over the next 10 years per the ASCVD risk assessment.

The risk management services should address the “ABCS” of cardiovascular risk reduction, referring to aspirin (along with statins and other appropriate medications), blood pressure control, cholesterol control and smoking cessation. Specifically, the ASCVD risk management services include:

• ASCVD Specific Risk Management, which may include:
• Promoting receipt of preventive services (including tobacco cessation counseling, diabetes screening, diabetes self-management training).
• Medication management (including aspirin or statins to maintain or decrease risk of cardiovascular disease).
• Ongoing communication and care coordination via certified electronic health record technology.
• Synchronous, non-face-to-face communication methods must be offered.
• ASCVD-Specific, Individualized, Electronic Care Plan:
• Must address modifiable risk factors and risk enhancers specific to cardiovascular disease, as applicable, such as blood pressure and cholesterol control, smoking/alcohol/drug use status, history and cessation, physical activity and nutrition, and obesity.
• Plan must be established, implemented, and monitored and must incorporate shared decision-making between the practitioner and patient.

The ASCVD risk management services can be performed by a physician or a qualified health professional who may furnish evaluation and management services under Medicare. CMS emphasizes that patient consent must be obtained for these services. As risk management is not considered a preventative service, cost-sharing may apply. The G0538 code has been assigned a work RVU of 0.18.

The ACC will share any additional guidance or resources provided by CMS for use of these codes in the coming weeks.

Keywords: ACC Advocacy, Heart Disease Risk Factors, Risk Assessment, Risk Management, Centers for Medicare and Medicaid Services, U.S.