How and when to code for social determinants of health
Written by the AOA’s Coding & Reimbursement Committee. Excerpted from page 46 of the March/April 2023 edition of AOA Focus.
At the beginning of the 21st century, the idea that a patient’s environment has a significant influence over their health was a fledgling concept. It was not until the 2010s that “social determinants of health” (SDOH) was granted more than just a cursory mention in medical texts.
Research on the impact of SDOH began to catch up, and more physicians began to realize that their patients would be more likely to experience better health care outcomes and lower health care costs if their physician incorporated a better understanding of their social environs in their treatment.
Coding mechanisms also had to catch up, however.
Created in 2015, ICD-10 Z codes represent subsets of diagnosis codes describing factors influencing health status. Code categories Z55-Z65 identify SDOH. These codes allow physicians, hospitals, health systems and payers to better track patient needs and identify solutions to improve the health of communities. The Centers for Disease Control and Prevention expanded the list of Z codes in 2021 by creating more specific codes for homelessness and housing instability, and by creating new codes for food insecurity and inadequate drinking water.
There can be barriers to the use of Z codes, which might include a lack of understanding on who can document patients’ social needs, a lack of office systems and processes for documenting and coding social needs, unfamiliarity with SDOH-related Z codes and a low priority placed on the collection of this data previously. For 2023, the ICD-10-CM codes for the social determinants of health were revised and expanded (see pages 103-104 of ICD-10-CM Official Guidelines for Coding and Reporting FY 2023). Codes describing problems or risk factors related to SDOH should be assigned when this information is documented. Providers can assign as many SDOH codes as are necessary to describe all the problems or risk factors when chart documentation indicates that these factors are associated with patient problems and/or risk factors. For example, not every individual living alone would be assigned code Z60.2 (problems related to living alone). But a patient who is not taking their glaucoma medication due to lack of permanent housing or because they could not afford the copay for the medication should be assigned the appropriate SDOH code (i.e., Z59.0 homelessness or Z59.6 low income).
Additional barriers include the limited number of Z codes, the limited or lack of training regarding Z codes, and physicians feeling limited in what they can do and/or how to provide guidance in assisting patients once nonmedical needs have been identified. The notation of adverse SDOH in the clinical record also can raise the level of complexity of care for some patients, leading to a higher level of medical decision making (MDM) and reportable evaluation and management (E/M) service. The 2021 CPT® E/M guidelines for Office and Other Outpatient E/M Services (99202-99215) now includes SDOH in the MDM scoring process for 99204/99214.
With these barriers in mind, what should doctors of optometry do to gain a better understanding of how and when to code for SDOH?
- Doctors of optometry should read and follow the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023.
- Doctors should train themselves and their staff members on the Department of Health and Human Service Using Z Codes: The Social Determinants of Health, Data Journey to Better Outcomes. It is a regularly updated, step-based guide that is easy to read, illustrative and provides links for questions regarding coding for SDOH.
- Doctors of optometry and their staff members should be trained in the collection and reporting of SDOH-related data. The AOA has developed a screening tool to help practices assess the health-related social needs of patients. Upcoming EyeLearn and Optometry’s Meeting® courses will provide further information on best practices.
- Doctors of optometry should put systems into place to connect their patients with the appropriate services to address their unmet social needs.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.