Originally posted in AAPC's Healthcare Business Monthly, January 2020 Edition
Written By: Toni Elhoms, CPC, CRC, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer
There is a lot of buzz in the healthcare industry recently about social determinants of health (SDOH) and their impact on society at large . With the expansion and updates to ICD-10-CM and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the new approach is to medicalize social problems. National claims data shows us that most healthcare providers don’t code for SDOH.
What Are Social Determinants of Health?
The Centers for Disease Control and Prevention (CDC) defines SDOH as “societal and environmental conditions such as food, housing, transportation, education, experiences, social support and employment that can affect a person’s health. Numerous studies have demonstrated a link between economic status, social factors and physical environment as key influencers in health outcomes.”
Hospitals across the United States are filled with SDOH patients. For example, a homeless man is admitted to the observation unit for chest pain of unknown origin. After a comprehensive workup, there is no medical diagnosis concluded, and the patient is discharged. How do you code for this encounter and get reimbursed?
SDOH codes are represented in ICD-10-CM code categories Z55-Z65 to describe conditions such as poverty, homelessness, abuse, neglect, etc. Payers often deny the SDOH codes as primary diagnoses because they are classified in ICD-10-CM as “Unacceptable Principal Diagnosis” codes. This designation has historically been exclusive to facility billing, but many outpatient claims are denied every year for the same reason.
There has also been a lot of controversy surrounding who can capture SDOH data and the context for which it can be used for coding and reporting purposes. These additional hassles tend to disincentivize providers from assigning diagnosis codes to patients with SDOH factors.
Official Guidelines Change Things Up
According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2019, “For social determinants of health, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.” This update is a game-changer, as most of the patient-specific SDOH information is captured by ancillary staff supporting the physicians.
SDOH Affect Everyone
The SDOH codes are very powerful tools in capturing the complexity of patient populations. These additional factors affecting a patient’s health can justify higher levels of evaluation and management services, risk adjustment payment methodologies, prolonged services, extended monitoring, etc. An additional consideration is the lack of continuity of care for SDOH patients because their access to stable phone and mailing resources are often limited.
SDOH diagnosis codes are one of the few tools we share collectively to measure and evaluate SDOH on a national scale. Medical coders across the country can have a huge impact on this public health issue by aligning their training efforts to educate healthcare providers about the importance of comprehensive clinical documentation and capturing accurate code assignment for SDOH.