There is increasing awareness of the impact of social determinants of health (SDOH) on patient outcomes, as well as a growing desire to incorporate SDOH elements into patient care plans. However, physicians have limited awareness of the existing data infrastructure that supports their practices.
“The clinical care we provide only accounts for about 50% of the health factors that ultimately determine our health outcomes,” said Margie Andrea, M.D., chief medical officer of claims compliance at Michigan Medicine. says. “The other 50% is determined by social determinants of health, so it’s equally important to address them if you want to improve patient health.”
Changes to Evaluation and Management (E/M) ambulatory and consultation documentation and Current Procedural Terminology (CPT®) coding guidelines have made it easier to capture SDOH data related to the level and length of consultation complexity, says Andreae. The doctor said this during his lecture. CPT and RBRVS 2022 Annual Symposium.
“This is important because paying for the visit will incorporate work that many people are already doing and that is currently being encouraged,” said the AMA/Professional Society RVS Renewal Committee (RUC said Dr. Andreae, a member of ).
With the implementation of the 2021 CPT E/M Ambulatory and Ambulatory Visit Coding Guidelines, the level of E/M service is now based on total time on the visit day or level of medical decision making (MDM). ).
For example, using E/M codes 99204 and 99205 for moderate MDM in new patients and MDM levels 99214 and 99215 in established patients may reduce complications, morbidity, and may increase the risk of morbidity and mortality. and diagnostic ability.
As an example, Dr. Andrea described the case of a young man with a knee injury who came in for an initial evaluation. He underwent an MRI and was referred to an orthopedic surgeon who determined he should not walk until the pain subsided. However, he refuses an MRI test and referral because he has a low-wage job with no health insurance.
“Management decisions become more complex and the risk level increases because the necessary additional data cannot be obtained,” Dr. Andrea explained. “This means he has one additional undiagnosed problem with an uncertain diagnosis, and this problem is of medium complexity in terms of medical decision-making.”
Learn how data drives health systems’ efforts on social determinants of health.
SDOH? Has an ICD-10 code
In a related presentation, Nelly Leon-Chisen discussed how an important but rarely used section of the International Classification of Diseases, 10th Revision Codes (ICD-10) addresses SDOH .
ICD-10 Z codes represent a subset of diagnostic codes that describe factors that influence health conditions. Code categories Z55 to Z65 identify SDOH.
These codes allow physicians, hospitals, health systems, and payers to better track patient needs and identify solutions to improve the health of their communities, according to the American Hospital Association Coding and Classification. said Leon Chisen, executive director and coding executive editor for clinic publications.
The most common of these is Z59.0 for people experiencing homelessness, according to claims data from the Centers for Medicare and Medicaid Services (CMS). The use of these codes is voluntary, and while CMS and commercial payers have shown “significant interest” in using his SDOH codes, they have not provided financial incentives to do so, Leon Chisen said. said.
“There’s a lot of interest in addressing some of these social needs, but if you don’t code it, you can’t count it and it won’t be reflected in claims,” she says. “The idea is that if there is enough data on a particular diagnosis code, her SDOH will ultimately be considered to reflect more serious services and intensity, resulting in additional coverage and reimbursement.” .”
The latest Z code statistics are from 2017. Of the 33.7 million Medicare fee-for-service beneficiaries, only about 467,000 (1.4%) filed claims with Z-code data.
According to Leon Chisen, payers are interested in collecting SDOH information in the easiest way possible: claims data.
“What is more important for many of us is being able to advocate for additional funding, compensation or reimbursement to address the social needs that are impacting the health of our patients,” she said.