Social Determinants of Health and Medical Billing: What Healthcare Leaders Need to Know Today

Social determinants of health (SDOH) are an important concept in healthcare and, recently, their role in medical coding has become more important. To keep you up to date, we’d like to help you understand the topic, introduce you to coding concerns, and share what the American Medical Association (AMA) believes SDOH means for medical billing services.

What are Social Determinants of Health for Medical Billing Companies?

According to Health.gov, social determinants of health are the “conditions in the environments where people are born, live, learn, work, play, worship, and age.” These are conditions that affect their health, functioning, quality-of-life, risks, and outcomes [1].

There are many SDOH, but they are divided into five primary domains:

  • Economic stability
  • Education access and quality
  • Healthcare access and quality
  • Neighborhood and built environment
  • Social and community context

These factors can have a major impact on patient health, and of course, in turn, impact medical coding and billing, and possibly even how patients engage with the revenue cycle. Some examples include language and literacy, education and job opportunities, racism, discrimination, violence, safe housing, and transportation.

It’s easy to see how these factors can directly impact experiences like how a patient reads their bills, the conditions they’re seeking treatment for, or even whether or not they’re able to attend appointments. This is because SDOH can contribute to health inequities and disparities. Patients who don’t have access to grocery stores are more likely to have nutrition issues. This means that they become at higher risk for conditions you’re coding and billing for, like diabetes, heart disease, and obesity.

Public health leaders have learned that promoting healthy choices isn’t enough, and that instead, public health organizations and communities have to take action in improving people’s environments and the conditions in which they live, play, and work.

 

What Leaders Responsible for Medical Billing and Coding Services Should Know About SDOH

If you are responsible for medical billing services or navigating medical coding solutions at your organization, you’ll want to keep up with what CMS is saying about Z codes [2].

SDOH-related Z codes range from Z55 to Z65. They are the ICD-10-CM encounter reason codes that should be used to document data around SDOH, including food insecurity, housing, and transportation. CMS recommends 5 steps in using Z code data:

Step 1: Collecting SDOH Data

Any member of a patient’s care team can collect SDOH data. This includes providers, community health workers, social workers, patient navigators, nurses, and case managers. The information can be collected through screening tools, interactions with providers, self-reporting, and risk assessments.

Step 2: Document SDOH Data

This data should be recorded on a person’s paper or electronic health record.

It can be documented in the problem or diagnosis list, provider notes, or patient or client history. Your care teams can collect data beyond current Z codes and this data should be retained. Know that there are ongoing efforts to close the gaps with Z codes and to standardize SDOH data.

Step 3: Map SDOH Data to Z Codes

Be aware that you can get assistance in medical coding solutions with this step from the ICD-10-CM Official Guidelines for Coding and Reporting.

Your coding, billing, and EHR systems should be able to help coders assign the standardized Z codes. They can do this from self-reported data or information in a patient’s health record.

Step 4: Use SDOH Z Code Data

The codes you collect can help with your data analysis. This in turn can improve your care coordination, quality metrics, and the overall care experience.

You will be identifying individuals’ social risk factors and needs that are unmet. You’ll be informing them of multiple elements that impact the revenue cycle, including healthcare services and follow up, as well as discharge planning. You can also trigger referrals to social services, tracking these referrals between providers and social service organizations.

Step 5: Report SDOH Z Code Data Findings

Know that you can add SDOH data to key reports for your leaders and board. These findings can inform value-based care opportunities and decisions.

When addressing your medical billing and coding solutions in light of SDOH, remember to advise your coding professionals to follow ICD-10-CM guidelines. They can use the CDC National Center for Health Statistics ICD-10-CM Browser to find codes and information they need. Also, your team managers should regularly review codes for quality and consistency.

The AMA acknowledges the importance of SDOH, stressing that clinical care only accounts for about 50% of health factors that determine outcomes. It has also stressed the fact that changes to evaluation and management (E/M) outpatient and office-visit and Current Procedural Terminology (CPT®) guidelines do facilitate capturing SDOH data in relation to length of a visit or complexity level. This directly impacts the revenue cycle, since payment now incorporates work that’s being performed by many on the care side [3].

If you are concerned about medical billing services and looking for medical billing companies that can help you navigate SDOH changes, we invite you to contact us to discuss where you can see the most benefit from medical billing and coding services support.

References

[1] U.S. Department of Health and Human Services, “Social Determinants of Health,” 20 June 2022. Available: https://health.gov/healthypeople/priority-areas/social-determinants-health.
[2] U.S. Centers for Medicare & Medicaid Services, “Using Z Codes: The Social Determinants of Health (SDOH) Data Journey to Better Outcomes”. Available: https://www.cms.gov/files/document/zcodes-infographic.pdf.
[3] A. Robeznieks, “Social determinants of health and medical coding: What to know,” American Medical Association, 13 May 2022. Available: https://www.ama-assn.org/practice-management/cpt/social-determinants-health-and-medical-coding-what-know.

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