By Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI
Welcome to Compliance Corner, a department dedicated to providing information and tools to help keep your healthcare documentation for coding and billing compliant. This resource aims to help you navigate recent changes to Current Procedural Terminology® (CPT®) Evaluation and Management (E/M) guidelines for office visits, which became effective January 1, 2021. Written by the American Medical Association (AMA), these guidelines contain new methodology and new definitions, both of which affect the way you as providers document the account of the patient visit.
Typically, our articles address coding situations or scenarios that are very common to most dermatology practices. This article and this topic may not apply to every practice. This article is going to address social determinants of health. It is an important topic and one that should be considered when you are evaluating all your patients.
When the AMA created the 2021 documentation guidelines, part of their intent was to create an atmosphere where providers and patients had a collaborative effort in determining the best treatment options for the patient based on the patient’s needs and ability. Some of you may remember that the phrase “social determinates of health (SDOH)” is found in the 2021 guidelines under the definitions of risk. The documentation of a SDOH that affects patient care is considered moderate risk. So, why is SDOH considered under “risk” and how are these documented and coded?
The International Classification of Diseases Tenth Revision, Clinical Modification (ICD-10-CM) codes that reflect SDOH are in the Z55 to Z65 range. We will examine a few of the codes in that range further in this article. It may be best to start with some definitions and explanation of the importance of these codes and begin to raise awareness of the opportunities to better reflect the whole patient.
According to the United States Department of Health and Human Services (HHS), social determinants of health are the environmental conditions where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning and quality-of-life outcomes and risks. The HHS has grouped SDOH into five key domains.
The 5 Key Domains of Social Determinants of Health
1. Economic Stability
3. Health and Health Care
4. Neighborhood and Built Environment
5. Social and Community Context
Based on various studies, the AMA has concluded that there is an emerging awareness that clinical care and health behaviors only account for 50 percent of the health factors that ultimately determine health outcomes. The other 50 percent are determined by SDOH. It is believed that SDOH information improves whole person care and lowers cost. Unmet social needs negatively impact health outcomes. A few examples of “unmet social needs” from the Centers for Disease Control and Prevention (CDC) are as follows:
1. Food insecurity correlates to higher levels of diabetes, hypertension, and heart failure.
2. Housing instability factors into lower treatment adherence.
3. Transportation barriers result in missed appointments, delayed care, and lower medication compliance.
When the ICD-10-CM codes that represent SDOH are used appropriately, that data can be used in the following ways within your practice:
1. Population health management
2. Social risk interventions
3. Medical care
5. Community health improvement
6. Risk adjustment
The AMA also recognizes a growing number of initiatives that are emerging to address social and environmental factors that influence health within the context of the healthcare delivery system. Three of these initiatives are:
1. Multi-payer, federal, state, and local initiatives
2. Medicare and Medicaid initiatives
3. Provider-level activities
The primary intent remains focusing on identifying patients with health-related social needs and connecting them with community services. This intent can be found in two areas within the 2021 documentation guidelines. Within the definition of activities that count towards time, the AMA was very careful to include coordination of care. The other place would be under the definitions of risk.
Everyone must remember that identifying a patient with social needs may be difficult. Some patients may have fallen on harder times during the public health emergency and are not willing to discuss their current situation. Here is a scenario to consider; this situation could happen to anyone.
Elderly patient who is having difficulty living alone since their spouse recently passed away. Patient is confused with dosing and co-pays and getting their medication. Patient has been skipping doses of medication.
a. T36-T50—Codes for underdosing of certain medications
b. Z60.2—Problems related to living alone
c. Z63.4—Disappearance or death of family member
The following is a sample of some other Z codes that represent SDOH:
• Z55.0—Illiteracy and low-level literacy
• Z85.6—Inadequate drinking water supply
• Z60.0—Problems of adjustment to life cycle transitions (retirement, empty nester)
• Z63.5—Disruption of family by separation and divorce
These codes may not represent many of your patients, and hopefully, the codes do not represent a large percent at all. However, it has become more important now to take a moment and think about the whole patient. The AMA placed this additional language into the guidelines for a reason. The CDC and the WHO are updating the list of SDOH ICD-10-CM codes for a reason. Will there be financial rewards for using these codes? Probably not unless it is needed to help get to that level 4 encounter. The biggest push to using these codes correctly is to obtain the data that are needed to help patients get the help they need.
As stated at the beginning of this article, you may not believe these codes apply to your patients; however, if you do not take the time to ask a few more questions about the social health of your patient, you may never know.
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Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI has been working in the field of medical coding and auditing for over 30 years. She has been a Certified Professional Coder (CPC) since 1994, attained her Certified Outpatient Coder (COC) for facility-based coding in 2005, and is a Certified Professional Medical Auditor specializing in Evaluation and Management (E/M) Coding. She has expertise in coding for family practice, urgent care, obstetrics and gynecology, general surgery, and Medicare’s Teaching Physician Guidelines, with a particular emphasis on E/M guideline compliance. She has served on the American Academy of Professional Coders (AAPC) National Advisory Board and is past president of AAPC’s Richmond and Charlottesville, Virginia, local chapters. Kipreos is president of Practice Integrity, LLC, where she manages a national client list and provides compliance monitoring for provider documentation. She currently resides in San Diego, California.
Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.
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