星空入口

Hint: Don鈥檛 forget comorbidities when you鈥檙e coding.

As the first stop in many healthcare situations, family medicine and primary care providers see more patients more frequently than other specialties. While patients may not confide their circumstances fully in their primary care physicians (PCPs), the providers and practices offering primary care services may notice the impact of their patients鈥� social determinants of health (SDOH) on their businesses, including scheduling woes, reimbursement issues, and revenue cycle management complications.

Having a deeper understanding of SDOH can prepare your practice to withstand the pressures of such forces, even though they鈥檙e beyond your control. Keep reading to find out what to fine tune in your primary care practice to better accommodate the impact of your patients鈥� SDOH.

Build and Maintain Trust

Even if PCPs are many patients鈥� first stop when confronting a health problem, not every patient knows or trusts their provider. Concerns about a doctor visit can manifest in many ways, including 鈥渨hite coat syndrome,鈥� where patients feel physical symptoms in their bodies, but also a reticence about speaking openly or even at all about their condition or circumstances.

This can make capturing SDOH difficult. If other qualified healthcare professionals, like nutritionists or therapists or social workers, have access to patient records, then such providers may be able to gather SDOH information more easily.

SDOH can affect many aspects of a patient鈥檚 daily life and opportunities, including:

• Access to healthcare
• Economic stability
• Education
• Housing and environment
• Nutrition and food security
• Social support and networks
• Cultural and social norms
• Occupational and work conditions
• Transportation
• Stress and adverse childhood experiences

鈥淲e want to make sure, when we鈥檙e given that story, we鈥檙e given the complete story, not leaving out any information, because we never know how pertinent that information could be,鈥� said Kimberly Jovilette Williams, CPCO, CPC, CPB, CPMA, CANPC, CCC, CEMC, in the 星空入口REVCON Presentation 鈥淭he Potpourri of Social Determinants of Health: Impact of SDOH on Revenue Cycle Management Reimbursement.鈥�

Use SDOH-Related Codes When Appropriate

Several government departments and agencies, including the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS), are looking to collect more information about populations鈥� well-being, and are using reimbursable codes as one way to encourage providers to assess patients and report their findings.

CMS has introduced an assessment tool for Medicare beneficiaries: The HCPCS code G0136 (Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes) is a standalone code providers can use to report their time spent assessing such patients鈥� SDOH, but other procedure codes may also be appropriate.

When providers document what they and patients discuss about a patient鈥檚 life circumstances, the documentation can give context to the patients鈥� narratives and can help illuminate the how鈥檚 and why鈥檚 of their health conditions, bolstering their medical records. Many of the Z category of ICD-10-CM codes are designed to capture myriad information that influences health and medical services, which provides data useful for many purposes, including the allocation of funds for government-specific disease management programs.

With this in mind, the PCP and their respective medical coder鈥檚 roles are especially important, because the diagnoses they capture and report help paint a picture of a population鈥檚 well-being, and can affect big picture efforts and fund allocation, which can sometimes impact health outcomes. The impact of SDOH data collection may be even bigger for community clinics, but PCPs who see patients within a region or community may also see some of those demographics in play.

As always, only report what the documentation supports. Remember, medical records are legal documents, and accuracy is crucial.

Only document an SDOH diagnosis if the provider has done the work, surveying the patient and specifying the results. Ideally, a provider would have a deep enough discussion with the patient to fully grasp how their situation at home might affect their health and well-being, especially if the patient doesn鈥檛 have anyone to support or check on them day to day. Although data is gleaned from the information that the SDOH procedure and diagnosis codes signify, real lives are in the balance.

This is especially important for hospitalized patients. If you鈥檙e a provider who has an elderly patient who lives alone and receives a hip replacement surgery, and you know they don鈥檛 have family or community support nearby but discharge them to their home without arranging any resources, the patient probably won鈥檛 fare well. It鈥檚 important for providers to acknowledge and lessen those risks as best they can.

Don鈥檛 Neglect Comorbidities

With payers acknowledging that time spent assessing or addressing SDOH should be paid, it鈥檚 important that coders and billers report both the providers鈥� efforts and their findings.

The time a provider spends assessing of SDOH can mean a higher level for evaluation and management (E/M) services. SDOH may be especially relevant for patients whose health insurance won鈥檛 cover services, procedures, or treatments a provider orders. In fact, the American Medical Association CPT^庐 guidance says that 鈥渄iagnosis or treatment significantly limited by social determinants of health鈥� is an example of a 鈥渕oderate鈥� risk of complications and/or morbidity or mortality of patient management.

Time and effort spent assessing SDOH can also be demonstrated via respective work relative value units (RVUs) and the reimbursement values defined by the current Medicare Physician Fee Schedule (MPFS). Some SDOH can be categorized as comorbidities 鈥� the effect of such circumstances has an acknowledged effect on well-being, and coding guidelines recognize that relationship.

While services provided to Medicare beneficiaries can be reported with SDOH assessment-specific codes, coders and billers should be in touch with patients鈥� respective payers to make sure the service codes they report reflect the time and effort the providers spent.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC