How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment

March 31st, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Categories:   Reimbursement   Compliance  
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Over the last several years, there has been an increased interest in understanding how social factors affect health outcomes. A recent CMS Data Highlight discussing the use of social determinants of health (SDOH) ICD-10-CM codes in the Medicare FFS population described SDOH as: 

"...the conditions of an individual's living, learning and working environments that affect one's health risks and outcomes." 

The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. 

Will the 2021 E/M Changes Help or Impede Collection of Social Determinants of Health (SDOH)?

As part of the 2021 E/M changes to 99202-99215 (office/other outpatient services), providers may determine what is considered a medically appropriate history and examination instead of following a template that may or may not be appropriate for the patient's individual situation. While the history and examination are no longer part of the scoring process of these specific E/M codes, they contain important information, including SDOH, that may lead to better patient care and management, especially for identifying at-risk patients and those with chronic conditions that may lead to greater needs for medical services. 

Additional changes to the 2021 E/M guidelines allows for ancillary staff to assist in the gathering and documentation of a patient's history. Of course, historical information documented by ancillary staff must be reviewed by the service provider prior to signing the encounter note; however, this provides an option for providers to use ancillary staff to obtain a rich patient history as long as it is done appropriately. Patient questionnaires can be more fully developed in order to identify situations that may interfere with positive patient outcomes or lead to exacerbated chronic conditions which could place the patient at greater risk.

Identifying SDOH in Your Organizations

How is your organization identifying SDOH? Are questionnaires updated annually or even midyear? Is clinical staff actively engaged in the process of patient interviews? Are patients hesitant to provide such sensitive information? Do staff have enough time to establish a connection with the patient or are they simply going through the motions to quickly prepare the patient for the provider? Connections are critical because they help to establish trust, and once trust is present, patients may be more willing to share the SDOH issues they are dealing with. 

Reporting SDOH codes may be done using ICD-10-CM codes found in categories Z55-Z65 as shown in the following table:

Category Description
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

Note: Additional SDOH codes are currently being considered for implementation on October 1, 2021. Watch for further announcements about ICD-10-CM code changes regarding SDOH.

Social Determinants of Health Example

The following is an example of a finding noted in the CMS Data Highlight:

"Of the 467,136 Medicare FFS beneficiaries with Z code claims, 334,373 individuals (72%) had hypertension and 248,726 individuals (53%) had depression."

Using this information can help providers identify SDOH issues among their own patient populations. Consider running billing reports to identify the most commonly reported ICD-10-CM codes. Look through the CMS Data Highlight information (see References) to identify the top 10 chronic conditions among Medicare’s FFS Beneficiaries with Z codes in 2017, which include depression and hypertension among the Medicare-aged patient population. Once identified, assemble a team to determine how to best address these patients’ needs and identify whether SDOH issues are making it difficult for them to remain compliant with treatment plans. Clinical staff and providers can review the current method of history gathering and determine if there is a way to enhance patient questionnaires, identify additional opportunities to connect and gain patient trust, and establish documentation practices that can increase SDOH data collection for those patients. 

Coding staff should be included in the planning and training as well. While most of the heavy lifting is done in the patient room and during provider interaction, if coding personnel are not made aware of the goal to increase recognition and reporting of SDOH, they may not specifically look for those SDOH statements to code and report them, as they are specifically looking to match the procedure with a documented and supported diagnosis code that will facilitate payment. 

This is a great example of using data collected during the E/M encounter to identify at-risk patients in provider organizations. If your patient demographics include Medicare FFS beneficiaries with hypertension or depression, you might consider beginning there to employ some of the suggestions of collecting more detailed patient questionnaires, ensuring they are completely filled out, involving ancillary staff in reviewing these questionnaires, and asking key questions while documenting a patient's history on the medical record. 

Working as a team with the goal of improved patient outcomes and quality of care will help patients feel supported and secure in the care they are receiving, which is the overall goal of all providers and payers alike. 

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