March 26, 2021 | By Jamee Black, CPC, COC, CPMA
The American Medical Association (AMA) recently released changes to the current Evaluation and Management (E/M) documentation guidelines for the Office and Other Outpatient Visit code range (99202–99215). The new guidelines focus on medical decision making (MDM), and are intended to more closely reflect the provider’s actual work performed in treating a patient’s conditions. Depending on the significance of the impact of a patient’s socioeconomic situation on his or her diagnostic or treatment options, the encounter may be considered moderate risk.
CMS defines social determinants of health as “the range of social, environmental, and economic factors that can influence health status—conditions that can often have a greater impact on health outcomes than the actual delivery of health services.”[1] The acknowledgment of these social, economic, and environmental issues is integral to providing value-based care. Some examples of social determinants of health include, but are not limited to:
- Availability of resources to meet daily needs (e.g., safe housing and local food markets)
- Access to educational, economic, and job opportunities
- Access to health care services
- Quality of education and job training
- Transportation options
- Public safety
- Social support
- Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
- Language/Literacy
- Access to emerging technologies (e.g., cell phones)
- Availability of community-based resources
When the assessment and plan is developed with consideration of these social determinants of health, the documentation should clearly describe the circumstances and how they affect the patient’s treatment or management.
Example: A patient requiring dialysis treatments has no transportation and no access to public transportation. Therefore, her circumstance require discussions with home health for home treatments and/or researching community service options for help with transportation for those in need.
Example: A patient requiring a specific drug that is very expensive, was recently laid off and has no income or prescription benefits. The decision might be made to try a different drug to ease the cost burden for the patient.
Example: A patient with a complicated medical history that includes multiple medications reports having trouble reading the prescription labels and remembering the medication schedule. He lives alone and currently has no support for these types of situations. This might require initiation of home health or some type of elderly assistance service.
ICD-10-CM code range Z55-Z65 should be used for to indicate these socioeconomic issues are being addressed and/or considered in the management plan. These codes are always listed secondary to other conditions addressed during the same encounter.
Z55 – Problems related to education and literacy
Z56 – Problems related to employment and unemployment
Z57 – Occupational exposure to risk factors
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
*Refer to the ICD-10-CM book for additional diagnosis coding guidelines.
[1] https://www.cms.gov/newsroom/press-releases/cms-issues-new-roadmap-states-address-social-determinants-health-improve-outcomes-lower-costs
