This article covers the definition and examples of social determinants of health (SDOH) and secondary ICD-10-CM codes that may be reported. For more information, contact Lori Carlin, Director of Professional Coding Services at Pinnacle Integrated Coding Solutions or Mary Hurley, Staff Coder at Pinnacle Integrated Coding Solutions .
In a speech to the American Medical Association Annual Meeting of the House of Delegates in June 2019, Seema Verma, the CMS Administrator was quoted as saying, “The practice of medicine has greatly changed over time. Physicians must now spend time managing patients with multiple co-morbidities while assessing genetic information, evaluating the social determinants of health, and coordinating care.”
Effective January 1, 2021, The Centers for Medicare and Medicaid Services’ (CMS) 2021 Evaluation and Management (E/M) guidelines went into effect which include office and other outpatient CPT codes for new patients (99202-99205) and established patients (99212-99215). Assignment of these codes will be determined based on medical decision making (MDM) or time, removing history and exam as key components. Keep in mind that a medically necessary History and Exam should still be performed and documented. Providers may now select their level of service based on the complexity of the patient’s overall condition. Under Moderate Risk of Morbidity, CPT codes 99204 and 99214, CMS has included “Diagnosis or treatment significantly limited by Social Determinants of Health for Medical Decision Making”. Per ICD -10-CM Guideline I.B.14, Documentation by Clinicians Other than the Patient’s Provider. Code assignment is based on the documentation by the patient’s provider such as a physician or other qualified healthcare practitioner legally accountable for establishing the patients’ diagnosis. The code assignment may be for potential health hazards related to socioeconomic and psychosocial circumstances documented by clinicians involved in the care of the patient and may represent social information rather than medical diagnoses. After the patient’s Social Determinants of Health (SDOH) has been assessed and documented the Social Determinant of Health (SDOH) should be tied to the status of the patient’s current health condition. In addition, ICD-10-CM code assignment may be allowed if the patient self-reports a SDOH and it is signed-off by and incorporated into the health record by either a clinician or provider.
The Center for Disease Control and Prevention (CDC) defines SDOH as:
“…conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes.”
|INCOME LEVEL||EDUCATIONAL OPPORTUNITIES||OCCUPATION||EMPLOYMENT STATUS|
|WORKPLACE SAFETY||GENDER INEQUALITY||RACIAL SEGREGATION||FOOD INSECURITY|
|INACCESSIBILITY OF NUTRITIOUS FOOD CHOICES||ACCESS TO HOUSING AND UTILITY SERVICES||EARLY CHILDHOOD EXPERIENCES||EARLY CHILDHOOD DEVELOPMENT|
|SOCIAL SUPPORT||CRIME RATES||EXPOSURE TO VIOLENT BEHAVIOR||AVAILABILITY OF TRANSPORTATION|
|NEIGHBORHOOD CONDITIONS||PHYSICAL ENVIRONMENT||ACCESS TO SAFE DRINKING WATER AND CLEAN AIR||RECREATIONAL AND LEISURE OPPORTUNITIES|
It is believed that the SDOH’s influence over half of health outcomes by 80%. In 2010 an initiative called Healthy People 2020 was launched by the Office of Disease Prevention and Health Promotion (ODPHP). It was a 10-year agenda for improving health in the United States, designed to identify ways to create social and physical environments that promote good health for all. Healthy People 2020 categorized all the determinants into five key areas: Economic Stability, Education, Social and Community Context, Health/Healthcare and Neighborhood and Built Environment.
Economic stability are the financial resources people have access to as it relates to their health (i.e., income, cost of living and socioeconomic status) and includes:
- Food security
- Housing stability
- ICD-10-CM Z56.9 – Z59.4
The relationship between education and a person’s health and wellbeing can be affected by:
- High school graduation
- Higher education enrollment
- Educational attainment
- Language and literacy
- Early childhood education
- Early childhood development
- ICD-10-CM Z55.0 – Z55.9
Social and Community Context is the relationship between the characteristics and the contexts in which people live, learn, work and play including their health and well-being:
- Community cohesion
- Civic participation
- Workplace conditions
- ICD-10-CM Z60.2 – Z63.8
Health and Healthcare involves peoples’ access to, and the understanding of health services connected to their own health:
- Access to primary care
- Health insurance coverage
- Health literacy
- ICD-10-CM Z75.3 – Z77.090
Neighborhood and Built Environment is where a person lives (i.e., housing, neighborhood, and environment) and the effect it has on their health and wellbeing:
- Quality of housing
- Access to transportation
- Availability of healthy foods
- Air and water quality
- Neighborhood crime and violence
- 0 – Z91.82
Now to identify the SDOH. We have already established this does not have to be performed solely by the provider. It may be the patient, RN/MA, Social Worker, Therapist, or other clinician. It can be performed Online, via patient web portal, by telephone, at check-in or during the rooming of the patient and individuals may be more likely to disclose sensitive information when self-reported.
There are separate barriers to identifying SDOH as well. They may stem from the Providers due to the lack of a standardized SDOH screening tool, company policy, staff issues, implicit bias, or the inability to follow up.
The patients may cause barriers due to their reluctance to share their personal information which may be due to social stigma, pride or embarrassment, safety concerns, fear of law enforcement, unable to read or interpret.
Providers can be pro-active and have the receptionist or MA distribute the SDOH screening tool to the patient upon arrival. Leave education materials and resources in the waiting areas and exam rooms. Administrators should ensure there are adequate resources and staffing to screen and provide an action plan. Ensure the staff knows what their responsibilities are and provide training and education. Social workers/community health care workers should determine what resources are available in the community. Facilitate referrals with case management and follow up between patient visits.
Some examples of how SDOH may impact the treatment of patients.
A middle-aged male goes to his provider with the signs and symptoms that appear to be a bladder infection. The provider submits an order for a prostate ultrasound, but his Medicaid plan denies the test. The provider cannot definitively diagnosis the patient’s illness. The provider ends up treating him with antibiotics for what appears to be an enlarged prostate. Code as ICD-10-CM N40, Z59.7.
A young mother brings her toddler to the pediatrician for breathing problems. The pediatrician diagnoses the toddler with asthma. After talking to the mother, the pediatrician ascertains the family lives in extreme poverty which can be contributing to the toddler’s asthma. If they continue to live under these conditions the toddler will probably continue to suffer from breathing problems. Code as ICD-10-CM J45.901, Z59.1.
A man is seen in the office of a new PCP with type II diabetes and hypertension. He had been incarcerated for the last ten years and was provided with insulin and Lisinopril while in prison. He is homeless and no longer has access to these medicines. The provider will need to obtain his previous medical records from the prison to treat him. ICD-10-CM E11.9, I10, Z65.2, Z59.0.