Social determinants of health (SDOH) 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 risks and outcomes. Some examples include income level, transportation, air quality, and access to nutritious food and safe housing. There is emerging awareness that SDOH accounts for 50% of the health factors that ultimately determine health outcomes.
The current Office or Other Outpatient Evaluation and Management (E/M) guidelines allow the E/M of patient SDOH to be captured in the level of the office visit. “Diagnosis or treatment significantly limited by social determinates of health” is noted under the “Moderate Risk” element which correlates to a level 4 visit.
Remember, risk is only one element of medical decision making (MDM) and to support the level of service, two of the three elements must be met (problems, data, risk). The other option to support the level of service for office/clinic visits is to use the total time spent on the date of the encounter.
Let’s look at three examples:
Case Study 1: MDM
A young lady with a hip injury after a fall from a curb presents for initial evaluation. The provider determines that she should have an MRI scan, referral to orthopedics, and remain non-ambulatory. She is a waitress with no healthcare insurance and unable to afford an MRI. In addition, she declines a referral. She is requesting a note for work. The diagnosis is limited to clinical findings, which makes the management decisions more complicated.
- MDM: Moderate
- Problem: 1 undiagnosed new problem with uncertain diagnosis—Moderate
- Data: None
- Risk: Diagnosis significantly limited by SDOH—Moderate
- CPT Codes 99204/99214
Case Study 2: MDM
A 12-year-old young lady presents with her grandmother for anxiety and depression and risk for failing in school due to absences related to her mental health instability. She would benefit from medication management, but the parents are divorced and the mother refuses to allow treatment of the condition with medication.
- MDM: Moderate
- Problem: 1 chronic condition with exacerbation—Moderate
- Data: Assessment requires independent historian—Limited
- Risk: Treatment significantly limited by SDOH—Moderate
- CPT Codes 99204/99214
Case Study 3: Time
A 68-year-old gentleman was recently seen in the emergency department for an uncomplicated laceration to his right hand. He presents for a wound check in which possible infection is noted. No additional testing or treatment is required. The provider learns that the patient cannot cleanse the wound at home because his water has been shut off.
- MDM: Low
- Time is 60 minutes
- Write letter to utilities for medical waiver of shut off
- Discuss case with care manager to enroll patient in meals on wheels
- Document applicable SDOH and related plan in EMR
- CPT Code 99215
There are also ICD-10-CM diagnosis codes that correlate to SDOH. Z codes are a subset of ICD-10-CM diagnosis codes that represent factors influencing health status and contact with health services that may be recorded as diagnoses. ICD-10-CM codes Z55-Z65 identify SDOH. Utilizing these codes allows providers, hospitals, and health systems to better track patient needs and identify solutions to improve health of their communities.
ICD-10-CM SDOH Categories
- Z55 – Problems related to education and literacy
- Z56 – Problems related to employment and unemployment
- Z57 – Occupational exposure to risk factors
- Z58 – Problems related to physical environment (NEW for FY 2022!)
- 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
- Z64 – Problems related to certain psychosocial circumstances
- Z65 – Problems related to other psychosocial circumstances
Shea Lunt, RHIA, CPC, CPMA, PMP
Shea is a consultant for The Haugen Consulting Group with 11 years of health care industry experience. Shea has experience working on the professional fee side of coding, auditing, education and compliance serving coders and physicians.
She earned a bachelor’s degree in health information management and a master’s degree in health services administration from the University of Kansas. Shea is a Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) and a Project Management Professional (PMP).
Shea, her husband, and their daughters, call the wide-open spaces of central Kansas home.