The healthcare landscape is increasingly recognizing the profound influence of Social Determinants of Health (SDOH) on patient outcomes. Beyond clinical care, factors like socioeconomic status, housing, and access to resources significantly shape an individual’s health journey. Physician practices are striving to integrate these SDOH factors into patient care plans, and the existing data infrastructure, particularly Evaluation and Management (E/M) coding, is emerging as a crucial tool. This article delves into how recent changes in E/M coding guidelines can facilitate the capture of SDOH data and explores the ethical considerations that arise as we navigate this evolving intersection of coding practices and patient well-being.
Dr. Margie Andreae, chief medical officer of billing compliance at Michigan Medicine, emphasizes the critical role of SDOH, stating, “The clinical care we provide only accounts for about 50% of the health factors that ultimately determine our health outcomes. The other 50% are determined by social determinants of health, making them just as important to address if we want to improve the health of our patients.” This perspective underscores the necessity of a holistic approach to healthcare that acknowledges and addresses SDOH.
Recent updates to E/M outpatient and office-visit documentation and Current Procedural Terminology (CPT®) coding guidelines are pivotal in this shift. These changes now enable the incorporation of SDOH data when determining the complexity level or duration of an office visit. Speaking at the CPT and RBRVS 2022 Annual Symposium, Dr. Andreae highlighted the significance of this integration: “This is important because payment for the visits will now incorporate the work that is already being performed by many and is now encouraged.” This evolution in coding acknowledges the additional effort involved in addressing SDOH during patient encounters and potentially paves the way for better reimbursement models that support comprehensive care.
With the implementation of the 2021 CPT E/M outpatient and office-visit coding guidelines, the level of E/M service is now determined by either the total time spent on the date of the encounter or the complexity of medical decision-making (MDM). For instance, E/M codes 99204 and 99205 (moderate MDM for new patients) and 99214 and 99215 (established patients) can be significantly influenced by SDOH factors. These factors can escalate the risk of complications, morbidity, or mortality by limiting treatment options and diagnostic capabilities.
Consider the example provided by Dr. Andreae: a young man presenting with a knee injury requires an MRI and orthopedic referral, needing to remain non-ambulatory. However, due to his low-paying job and lack of health insurance, he declines both the MRI and the referral. This SDOH barrier directly impacts the physician’s ability to provide optimal care. Dr. Andreae explains, “Because you’re not able to get the additional data that you would like, this makes your management decisions more complicated and a higher level of risk. So now you have in your medical decision-making: one undiagnosed new problem with an uncertain diagnosis, which makes this a moderate-level problem complexity.” This scenario vividly illustrates how SDOH factors can increase the complexity of medical decision-making and, consequently, influence E/M coding levels.
Beyond E/M coding, the International Classification of Diseases 10th Revision codes (ICD-10) also offer a valuable, though underutilized, resource for capturing SDOH data. Nelly Leon-Chisen highlighted in a related presentation that ICD-10 Z codes, specifically categories Z55-Z65, are designed to identify SDOH. These Z codes allow for a more granular tracking of patient needs and can empower physicians, hospitals, health systems, and payers to develop targeted solutions for community health improvement. The most frequently used SDOH code, according to Centers for Medicare & Medicaid Services (CMS) data, is Z59.0 for homelessness.
While the use of ICD-10 Z codes for SDOH is currently voluntary, both CMS and commercial payers have expressed considerable interest in leveraging this data. Leon-Chisen, executive director of coding and classification at the American Hospital Association, points out, “There is a great interest on addressing some of these social needs, but—if you don’t code it, you can’t count it—and it’s not showing up in the claims. The idea is that, with enough data on specific diagnosis codes, SDOH can eventually be considered to reflect higher severity and intensity of services that will result in additional coverage and reimbursement.” Currently, Z-code utilization remains low; 2017 statistics show only 1.4% of Medicare fee-for-service beneficiaries had claims with Z-code data out of 33.7 million.
The drive to incorporate SDOH into coding and claims data is largely motivated by the potential to advocate for enhanced funding, coverage, and reimbursement to address the social needs impacting patient health. Payers are keen on collecting SDOH information via claims data as it offers a straightforward method for population-level analysis.
However, the integration of SDOH into E/M coding and healthcare practices raises significant ethical considerations. While acknowledging SDOH is a crucial step towards equitable patient care, ethical issues can emerge in several areas:
- Data Privacy and Confidentiality: Collecting and utilizing sensitive SDOH data requires robust privacy safeguards to protect patient confidentiality. Ethical guidelines and regulations must be strictly adhered to prevent misuse or breaches of this information.
- Potential for Bias and Stigmatization: SDOH data, if not handled carefully, could inadvertently lead to bias or stigmatization of certain patient populations. It’s crucial to ensure that coding practices do not reinforce existing health disparities or contribute to discriminatory practices.
- Resource Allocation and Equity: While SDOH-informed coding can advocate for better resource allocation, ethical concerns arise if this leads to disproportionate focus or funding on certain SDOH factors over others. Fair and equitable distribution of resources based on comprehensive needs assessment is paramount.
- Patient Autonomy and Informed Consent: Patients should be informed about how their SDOH data is being collected, used, and its potential impact on their care and billing. Obtaining informed consent and respecting patient autonomy in data sharing is ethically essential.
- The Risk of Over-Coding or Misrepresentation: The financial incentives associated with incorporating SDOH into E/M coding could create a risk of over-coding or misrepresentation. Maintaining ethical coding practices and ensuring accurate and honest documentation is vital.
In conclusion, the evolving landscape of E/M coding and the incorporation of SDOH data present both opportunities and ethical challenges. By thoughtfully integrating SDOH into coding practices, healthcare systems can move towards a more holistic and equitable approach to patient care. However, it is imperative to proactively address the ethical considerations surrounding data privacy, bias, resource allocation, patient autonomy, and coding integrity to ensure that these advancements truly benefit all patients and promote health equity without unintended negative consequences. As we move forward, ongoing dialogue and ethical reflection are crucial to navigate this complex intersection of coding, SDOH, and patient care, ensuring that ethical principles remain at the heart of these developments.
