Step Three: Coding & Reimbursement for SDOH

What to Know About Getting Reimbursed for Your Screening Efforts

Recognition of the impact social determinants of health have on patient outcomes is growing, as is the desire to incorporate these factors into patient-care plans. Despite growing awareness, there is limited knowledge of the existing data infrastructures designed to help patient practices screen for SDOH.

ArMA’s SDOH Center of Excellence compiles the latest information on SDOH coding, data reporting, and reimbursement to help your practice sustainably screen.

Benefits of SDOH Coding

Coding your SDOH screening efforts has a positive impact on healthcare broadly by improving patient outcomes, supporting health equity, and informing future healthcare policies.

• Improving Patient Outcomes: Recognizing and addressing social factors helps in developing comprehensive care plans that address barriers to health
• Supporting Health Equity: Documenting SDOH helps in identifying disparities in care and supporting efforts to reduce them
• Informing Policy: Data from SDOH coding can inform healthcare policy and initiatives aimed at addressing social factors that impact health

By integrating SDOH ICD-10 codes into clinical practice, healthcare providers can contribute to a holistic approach to patient care, improving individual outcomes and broader population health.

ICD-10 Codes for SDOH

International Classification of Diseases 10th Revision codes (ICD-10) address SDOH. ICD-10 Z codes represent subsets of diagnosis codes describing factors influencing health status. Code categories Z55 through Z65 identify SDOH.  

Key ICD-10 Codes Resources:

• The Social Determinants of Health ICD-10 Codes List is your resource for bettering track patient needs and identify solutions to improve the health of communities.
• The National Center for Health Statistics ICD-10-CM Browser Tool is a user-friendly web-based query application that allows users to search for codes from the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and provides instructional information needed to understand the usage of ICD-10-CM codes.  

New Coding Guidelines and Their Impact

With the implementation of 2021 CPT E/M outpatient- and office-visit coding guidelines, the level of the E/M service is now based on either the total time on the date of the encounter or the level of medical decision-making (MDM). 

The 2021 CPT E/M coding guidelines enhance the ability of healthcare providers to document and be reimbursed for the time and complexity involved in addressing Social Determinants of Health. By allowing billing based on total time or MDM, the guidelines make it easier to reflect the real-world challenges and complexities introduced by SDoH, encouraging more comprehensive and patient-centered care. This can lead to better health outcomes by recognizing and addressing the social factors that significantly impact patient health. 

Financial Incentives for SDOH Screening Under New Guidelines

In addition to contributing to improved patient outcomes nationally, your practice can be reimbursed for SDOH screening, coding, and reporting.

Key Ways to Be Reimbursed:

• Total Time Documentation: Under the new guidelines, physicians can bill based on the total time spent on the day of the encounter. This includes time spent addressing SDOH-related issues, such as:
  • Reviewing community resources for housing or food insecurity
  • Coordinating care with social workers or other healthcare professionals to address a patient’s social needs
  • Counseling patients on how their social conditions affect their health and discussing strategies to mitigate these impacts
• MDM and SDOH Complexity: SDOH factors can significantly impact the complexity of decision-making during a patient encounter
  • For example, a patient with multiple chronic conditions who is also dealing with homelessness may present a higher level of risk and require more complex decision-making
  • When SDOH issues such as transportation challenges or financial constraints limit treatment options, the physician must navigate these complexities in their decision-making process, which can contribute to a higher level of MDM.
  • Appropriate E/M Level: The complexity added by SDOH considerations can justify a higher E/M level under the MDM criteria, ensuring that the provider’s efforts are appropriately recognized and reimbursed.

Using G-codes for Reimbursement by Federal Programs

G-codes are Healthcare Common Procedure Coding System Level II codes used primarily for reporting specific procedures, services, and other medical items that are not covered by standard CPT codes. They are often used for billing purposes in Medicare and other insurance programs, especially for preventive services, screenings, and other services related to federal healthcare programs. 

For more information on using G codes, see the Health Equity Services in the 2024 Physician Fee Schedule Final Rule booklet provided. 

Start Step Four of SDOH Screening

With an understanding of how to code for SDOH screening, you’re ready to deepen your understanding of SDOH beyond the basics.