SDoH Improves Reimbursement and Risk Scores

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Feb 10th, 2022

Social Determinants of Health (SDoH) refers to the conditions in which people are born, live, and work that continuously shape their specific health outcomes. Patients without housing, or food security are less likely to be able to concern themselves with healthcare and preventive care. Over time, these  circumstances can lead to serious and even life-threatening conditions. SDoH has always impacted quality of care and patient compliance, but most payers were not tracking this information with the codes that were available until recently. With the focus on identifying a patient’s risk adjustment factor, improving quality of care, and reducing risk, the section of ICD-10-CM codes for reporting SDoH has consistently been expanded, including for 2021. Identifying and monitoring SDoH is beneficial to not only ensuring the patient has the ability to receive the care needed to improve health conditions, but also to ensure there is enough funding available to secure that care. 

New ICD-10-CM codes have been added annually to the category Z55-Z65 “Persons with potential health hazards related to socioeconomic and psychosocial circumstances”, also referred to as social determinants of health (SDoH). As of October 1, 2021, the following SDoH codes were added:

• Z55.5 Less than a high school diploma
• Z58.6 Inadequate drinking-water supply
• Z59.00 Homelessness unspecified
• Z59.01 Sheltered homelessness
• Z59.02 Unsheltered homelessness
• Z59.41 Food insecurity
• Z59.48  Other specified lack of adequate food
• Z59.811 Housing instability, housed with risk of homelessness
• Z59.812 Housing instability, housed, homelessness in past 12 months
• Z59.819 Housing instability, housed unspecified
• Z59.89 Other problems related to housing and economic circumstances

SDoH identifies patient life issues, other than chronic conditions, that may impact patient outcomes. Identifying and documenting these patient life circumstances can help providers ensure quality care and promote healthier outcomes as they identify services and resources available to their patients that will allow them to remain compliant with recommended diagnostic and treatment plans. 

SDoH Can Increase the Level of E/M Service

While SDoH codes may not raise the risk score, they do have the ability to raise the level of complexity of care for some patients leading to a higher level of medical decision making (MDM) and reportable evaluation and management (E/M) service. The 2021 CPT® E/M guidelines for Office and Other Outpatient E/M Services (99202-99215) now includes SDoH in the MDM scoring process for 99204/99214. The following statement describes a moderate level of risk (99204/99214): 

Diagnosis or treatment significantly limited by social determinants of health

With this new risk point under MDM, an otherwise low level E/M service (99203/99213) may increase to 99204/99214 when the documentation includes patient SDoH that increases patient risk of compliance with the treatment plan. Organizations need to review and update patient questionnaires (as applicable) to include SDoH questions that may affect diagnosis and treatment. This will enable them to identify and prepare a list of resources for patient assistance, and educate their staff on to identify patients who are negatively impacted by SDoH and bring awareness to the provider who can then in order to better interact with them appropriately, improving quality of care and potential outcomes while at the same time ensuring proper reimbursement for the level of complexity identified by this  information. Patients properly evaluated for chronic conditions who have the coverage and resources needed are likely to result in a more detailed and higher specificity ICD-10-CM code assignment leading to a more accurate risk adjustment factor.

About the Author: Aimee Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. She believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.