CMS Announces: Social Determinations and Equality a Focus for Medicare Part C

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Medical Coding Leave a Comment

CMS Announces: Social Determinations and Equality a Focus for Medicare Part C

Over the past 20 years, Healthcare has seen an increased interest in the impact and influence of “Social Determinants of Health” or SDOH. Recent the Centers for Medicare and Medicaid Services (CMS). Health plans themselves have become more interested in SDOH and the associated cost of care present and future. Now we have CMS Medicare Part C raised attention to SDOH also. 

Social determinants of Health are defined by the Centers for Disease Control and Prevention (CDC) as: Conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes. These conditions are known as social determinants of health (SDOH). are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.

The CMS February 2022 “Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies”, states that “CMS is committed to advancing equity in health and healthcare for all individuals and addressing inequities that exist in our policies and programs that serve as barriers to equal opportunity.” This advance notice can be accessed at: https://www.cms.gov/files/document/2023-advance-notice.pdf

In addition, CMS has a 26 page booklet on SDOH, which was published in 2020, titled, “Addressing Social Determinants of Health in Demonstrations Under the Financial Alignment Initiative”, that contains some great information.

Within the ICD-10-CM classification system, the SDOH are divided into several specific categories and subcategories. Social determinants of health codes are located primarily in these Z code categories of ICD-10-CM:

  • Z55 Problems related to education and literacy
  • Z56 Problems related to employment and unemployment
  • Z57 Occupational exposure to risk factors
  • Z58 Problems related to physical environment
  • 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

The Official Guidelines for Coding and Reporting 2022 contain details of the proper coding for SDOH. See the Official Guidelines, Section I.C.21.c.17 and See Section I.B.14 for Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances, documentation by clinicians other than the patient’s provider, for additional information regarding coding social determinants of health. The Official Guidelines are located and available at: https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2022-7-2022-508.pdf

Documentation and coding for SDOH requires attention to detail, and also knowing where information is located so they can be coded. The data these codes create is vital for SDOH to be available across the healthcare spectrum. There is a growing interest and research is being conducted on this specific area of healthcare, which will require healthcare settings to take a look at their documentation practices as well as ensuring that coding professionals know when and where to capture this data.

Some initial steps to take in helping with the capture of these important aspects of healthcare are:

  • Awareness and education to providers and coding professionals
  • Audit encounters from the past year and determine corrective action
  • Include SDOH in future audits
  • Follow regulatory changes and Official Guidelines for Coding & Reporting

Having SDOH data will have a powerful impact on the future of healthcare which is important to all of us.

References: Social Determinations and Equality a focus for Medicare Part C; https://innovation.cms.gov/data-and-reports/2021/fai-sdoh-issue-brief

MRA is available to provide assistance for auditing and education. Visit: https://www.mrahis.com

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