Primary Care Coding Alert

And learn how to factor it in to your 2021 office/outpatient E/M MDM decisions.

While you have always been able to document the impact social determinants of health, or SDoH, have on a patient’s wellbeing using ICD-10 coding and other means, the 2021 changes to the office/outpatient evaluation and management (E/M) codes now allow your provider to get credit for SDoH when determining the level of medical decision making (MDM) for an E/M.

But how, specifically, does SDoH factor into an MDM determination? More, what constitutes SDoH, and how and why do you need to report these less visible influences on your patient’s wellbeing?

To answer these questions, here are some insights from two experienced coders.

SDoH Defined

In the 2021 E/M services guidelines, CPT^® provides a very broad definition of SDoH, calling them the “economic and social conditions that influence the health of people and communities,” and adding examples such as “food or housing insecurity.”

In fact, some organizations, such as the Office of Disease Prevention and Health Promotion (ODPHP), go much further, calling SDoH “conditions in the environments in which 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.” Examples of those conditions include such factors as the “availability of resources to meet daily needs (e.g., safe housing and local food markets), access to educational, economic, and job opportunities, exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community), [and] socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)” (Source: www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health).

SDoH As MDM Element … and Problem

Per the 2021 table of MDM elements, when it “significantly limits” a patient’s diagnosis or treatment, SDoH is an example of a moderate-level risk of complication/ morbidity. Should your provider document any of the above factors in a patient evaluation, then you can use the information to assign a moderate risk of morbidity to the encounter.

Then, providing one of the other two MDM elements (the number and complexity of problems addressed and/or the amount or complexity of data to be reviewed and analyzed) meets or exceeds the moderate level, you can document a minimum office/ outpatient E/M level of 99204 or 99214 (Office or other outpatient visit for the evaluation and management of a new/established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making …).

This addition of SDoH as an MDM element is generally a positive thing, as “it provides us with yet another good reason to assess and document the SDoH status of our patients,” according to JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis. However, the addition “sets up a possible contradiction between ICD-10 and CPT^® guidelines,” because “ICD-10 guideline IV.J. states that we should ‘Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.’ But with the new E/M documentation guidelines for MDM, the diagnosis or treatment must be ‘significantly limited’ by SDoH in order for SDoH to be considered,” Wolf notes.

So, when SDoH affects a patient, your provider will have to document if the conditions will significantly limit the patient’s diagnosis or treatment before counting the SDoH toward the risk of complications/morbidity MDM element.

But, whether or not SDoH does count toward the element, you will still need to use an ICD-10 code to document it on the claim if it coexists at the time of encounter/ visit and requires or affects patient care treatment or management.

How to Document SDoH

You can document most SDoH conditions using a code from the following:

• Z55.- (Problems related to education and literacy)
• Z56.- (Problems related to employment and unemployment)
• Z59.- (Problems related to housing and economic circumstances)
• Z60.- (Problems related to social environment)
• Z62.- (Problems related to upbringing)
• Z63.- (Other problems related to primary support group, including family circumstances)

Importantly, unlike most diagnosis codes, you do not have to report codes from Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) based only on your provider’s documentation. That’s because ICD-10 guidelines tell you that “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.”

Additionally, guideline I.B.14 goes on to note that “patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”

Coding alert: Per that same guideline, remember that codes in categories Z55-Z65 “should only be reported as secondary diagnoses.”

When to Document SDoH

No legal mandates exist for reporting SDoH. But that doesn’t mean you shouldn’t use the ICD-10 codes for data-gathering purposes. “These status codes can better show the complexity of the patient population they serve,” Wolf notes.

Consider, for example, that “for children and adolescents, poverty correlates with high rates of ‘infant mortality, developmental delays, asthma, ear infections, obesity, and child abuse and neglect,’ according to the American Academy of Pediatrics [AAP] Bright Futures,” says Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC.

That’s why the AAP “prioritizes SDoH at the very top of health supervision visits at every age and makes recommendations for managing adult diseases by acknowledging their developmental nature as disorders that begin early in life,” Blanchard adds.