November 6, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O
Pumpkin spiced lattes are back at Starbucks, the days are getting shorter, there is a crispness in the air (in some parts of the country, anyway), and the 2021 ICD-10-CM guidelines have gone into effect. These are all signs we are heading into the holiday season and the final countdown to the new year. As you are making plans for celebrating the holidays this year, keep in mind that when the fireworks go off at midnight on December 31st, we will be ringing in more than just a new year. We will also ring in the most significant changes to E/M documentation guidelines in 25 years.
There have been many webinars and articles published to help us prepare ourselves and our providers for these changes. We have learned these changes:
- Only effect the Office and Other Outpatient E/M code set, 99202-99215
- Eliminate the “bean counting” of history and exam
- Assign the level of visit based on either MDM or time
- Change the definition of time
- Provide us with a new MDM table for codes 99202-99215
In addition, definitions are provided in the new CPT guidelines to help us (isn’t that what guidelines are meant to do after all?). While many of the definitions will hopefully give us clarity for many gray areas that we have struggled with, we also see inclusion of a newer term we will need to consider, “social determinants of health (SDoH).” CPT 2021 defines this as “Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.” Why has this definition been included? Let’s look at the examples provided under the moderate level in the risk column of the new MDM table:
|Moderate risk of morbidity from additional diagnostic testing or treatment|
|• Prescription drug management|
|• Decision regarding minor surgery with identified patient or procedure risk factors|
|• Decision regarding elective major surgery without identified patient or procedure risk factors|
|• Diagnosis or treatment significantly limited by social determinants of health|
As noted above, we have been provided with a couple of examples of SDoH, but what besides food or housing insecurity is considered a SDoH? Google to the rescue! The first reliable link Google provided was to the CDC, so off I went down the rabbit hole to learn more about this concept we will have to consider. CDC defines SDoH as “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.” They identify five key areas of SDoH: healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment. After defining each of these areas in more detail, CDC provided a link to the World Health Organization (WHO).
WHO defines SDoH as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”
It was quickly becoming apparent there is much more to SDoH we will need to look for in documentation than just food and housing insecurities. That led to the next thought, if we see information about SDoH in the documentation, how would we report it? So, the Google search was refined to SDoH ICD-10-CM.
Jackpot! There is an entire section of ICD-10-CM for “Persons with potential health hazards related to socioeconomic and psychosocial circumstances (Z55-Z65). Upon review of the categories in this section of ICD-10-CM, it is clear they align with the information found on the CDC and WHO websites.
Why is it this section of ICD-10-CM didn’t immediately jump to mind when thinking about the inclusion of SDoH in MDM for 2021? Maybe, just maybe, it is because we would only be looking for these diagnoses codes if the documentation tells us SDoH is affecting the care of the patient. Thinking back on documentation audits done this year, I can recall only one encounter in which a provider identified a patient’s inability to afford medications as a factor that increased complexity during the visit.
Considering all we have learned from this trip down the rabbit hole, I believe it is fair to say that in addition to socially distanced holiday planning, we have some work to do. Each of us needs to be familiar with SDoH so we can begin educating our providers about the importance of capturing information about the complexity of SDoH in their documentation for 2021.
Follow the links below for your own trip down the SDoH rabbit hole. Enjoy your end-of-year prep!