Account for Social Determinants of Health When Coding Office Visits
In 2021, external factors affecting patient health weigh in on medical decision making.
The American Medical Association’s 2021 medical decision making (MDM) grid for outpatient/office evaluation and management (E/M) services is particularly innovative because it recognizes social determinants of health (SDOH) as a factor for determining level of MDM. Specifically, “Diagnosis or treatment significantly limited by social determinants of health” is an example of “Moderate risk of morbidity from additional diagnostic testing or treatment.”
Providers should work with medical coders and auditors to ensure clear communication when it comes to SDOH that significantly limit diagnosis or treatment. Such discussions should be documented and entered in the practice’s compliance manual as a reference to how the new MDM grid is accommodated.
Commenting on the implementation of curriculum on structural competency and health disparities for first- and second-year osteopathic medical students, Jordan Keys, DO, MS, interim chair of the Osteopathic Manipulative Medicine Department, Touro University California (TUC), says, “These are critical issues to address with our patients. Structural vulnerabilities and SDOH play a huge role in our patient’s overall health and ability to attain proper treatment. In addition, this new policy change is important for changing the mindset of clinicians to be aware of the impact of SDOH on their patients. This is a starting point to raise awareness of our patient’s needs. With the implementation of this curriculum, feedback from our students is overwhelmingly supportive and meaningful. I am glad new E/M policies are starting to match the needs of our patients and the education of current medical students.”
What Are SDOH?
According to Healthy People 2020, SDOH are “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.”
Healthy People 2020 describes five SDOH domains:
- Economic stability
- Health and healthcare
- Neighborhood and built environment
- Social and community context
Each of these domains is further described with objectives. For example:
- Economic stability objective SDOH-4.2 is the proportion of all households that spend more than 50 percent of income on housing.
- Health and healthcare objective HC/HIT-1.2 is the proportion of persons who report their healthcare provider always asked them to describe how they will follow the instructions.
- Social and community context objective AH-3.1 is the proportion of adolescents who have an adult in their lives with whom they can talk to about serious problems.
Michael Clearfield, DO, MACOI, FACP, dean of the College of Osteopathic Medicine at TUC, says he is pleased to see 2021 MDM methodology affirm the importance of SDOH. “We’ve embraced the importance of SDOH into our curricula and established it as part of our medical school culture for years,” Clearfield said. “To be effective as a practicing clinician, you need to know your patients and what potential barriers exist to making an accurate diagnosis and delivering effective care. I believe including SDOH reveals a change in healthcare delivery that will benefit patients.”
Case in Point
A patient with chronic knee pain and a positive anterior drawer test may need imaging of the knee, a consult with an orthopedic surgeon, and a referral to physical therapy. This patient, however, may not have the means to access or afford this care. In this situation, it is important to consider how SDOH may significantly limit the patient’s ability to attain appropriate diagnosis and treatment.
A clinician may, for example, document: “Patient cannot afford to obtain an MRI of the knee at this time because of the cost. This significantly limits my ability to confirm the diagnosis beyond physical examination findings and presenting symptoms.”
In 2021, this documentation may be the deciding factor for whether an E/M service’s level of MDM is low or moderate. Proper ICD-10-CM coding of external factors (Z codes) is also key in meeting Merit-Based Incentive Payment Program (MIPS) reporting requirements.
Get the Full Picture
AMA’s 2021 MDM grid gives clinicians an opportunity to expand their knowledge of patients and their environments and use this information to enhance their ability to determine, document, and understand the root cause of a patient’s complaint. In turn, clinicians will be able to ultimately better serve their patients, and coders will be able to capture patient encounters more fully.
Warner, M, Penkala, C. “Evaluation and Management (E/M) Documentation and Scoring,” 32-min AOA webinar posted on YouTube Oct. 12, 2018: www.youtube.com/watch?v=-CjJ4MZtBec&feature=youtu.be
CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202–99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guidelines Changes – effective Jan. 1, 2021, AMA, ©2019: www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
Social Determinants of Health, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Aug. 18, 2020: www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
CPT® E/M Office Revisions Level of Medical Decision Making (MDM): www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
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