The current pandemic has prompted the World Health Organization (WHO) to take the unusual step of establishing a unique ICD-10 code for COVID-19 cases, U07.1 five months prior to the traditional U.S. implementation date for new codes. The use of the code became effective with April 1, 2020 discharges and was accompanied by updated coding guidance to the ICD-10-CM Official Guidelines for Coding and Reporting.1
Currently healthcare, the private sector, and the government are overwhelming concentrating on “flattening the curve” and saving lives but when the dust settles there will be a focus on data analysis and research to establish future treatment and prevention. One early finding demonstrates the disproportionate impact of the coronavirus infection in minorities with higher rates of sickness and death. Lack of adequate COVID-19 testing in the minority population has also been identified.
Prior to this global crisis and its inevitable concentrated attention, the landscape for coder challenges in 2020 looked quite different. Despite being overshadowed by COVID-19 priorities, two of those original areas of focus pre-pandemic still have relevance in 2020, social determinants of health (SDOH) and the opioid crisis. The social and economic elements at play can help identify resources needed in certain communities to improve the healthcare outcomes of the most vulnerable populations. Though opioid overdoses in America has been critical over recent years, the stress and mental health effect of COVID-19 may impact the crisis further.
Not only will the coronavirus pandemic have added focus for coders in 2020 but so will SDOH and the opioid epidemic. Certainly, SDOH and opioid abuse will require increased frequency in accurate code capture. It would be imperative for coders to be cognizant of the background, implications and coding guidelines related to these topics. Appropriate coding now also may have future implications for risk-adjustment value-based payment initiatives such as hierarchical condition categories (HCC).
Social Determinants of Health (SDOH)
The FY 2019 changes to the ICD-10-CM Official Guidelines for Coding and Reporting in Section I.B.14 may have been a foreshadowing of the increasing importance of social determinants of health (SDOH). The guideline addresses the use of medical record documentation from clinicians involved in the patient’s care who are not the patient’s provider in coding for certain circumstances. The guideline was updated to include social determinants of health (SDOH) code categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychological circumstances.
SDOH codes include problems related to education, employment, occupational risk factors, housing/economic circumstances, social environment, upbringing, primary support group, and psychosocial circumstances. It is being recognized that the non-medical needs of patients can also influence the patients’ health outcomes. One obvious (and prevalent in some areas) social determinant of health is homelessness. The lack of housing and food insecurity can have a significant impact on the physical and mental health of patients. Improving socioeconomic factors can enhance patient outcomes and potentially provide a positive financial impact. Organizations are focusing on the relevance of SDOH in improving patient outcomes and ultimately enhancing the bottom fiscal line.
Some data analytic firms are focusing on social determinant factors in providing information to better health outcomes for clients and their patients. One example is City Health Dashboard (https://www.cityhealthdashboard.com/metrics) which provides metrics on 500 of the largest U.S. cities and where they fall on 37 key measures including socioeconomic factors, physical environment and health outcomes. Another analytic firm, Socially Determined (https://www.sociallydetermined.com/) measures the impact of SDOH to provide clients with solutions to change the health of the population.
The government is getting in the game as well with the Centers for Disease Control and Prevention dedicating a web portal to SDOH (https://www.cdc.gov/socialdeterminants/tools/index.htm). Last year, the Social Determinants Accelerator Act of 2019 (H.R. 4004) was introduced in Congress to establish federal government assistance in improving health outcomes and cost effectiveness in using SDOH.
Healthcare institutions are using SDOH to develop programs in the community to improve health outcomes. The Henry Ford Health System in Detroit, Michigan has been recognized nationally for its Women-Inspired Neighborhood Network program. The initiative of the program was to reduce the infant mortality rate in the area which was more than two times the rate for the state in 2017. Henry Ford and other local healthcare systems developed a program that connected at-risk mothers with community health workers to access maternity care which has improved the health care outcomes for this population as a result.
Risk-adjustment payment models such as hierarchical condition category (HCC) take into consideration SDOH. In April 2019 UnitedHealthcare and the American Medical Association (AMA) announced a collaboration to use SDOH in improving access to health care and patient outcomes. They are also supporting the creation of more ICD-10-CM codes related to social determinants of health including those for a patient’s inability to pay for prescriptions and fears about losing housing. The American Academy of Pediatrics (AAP) requested an expansion of category Z62 at the September 2019 ICD-10 Coordination and Maintenance Committee to better identify the variety of family dynamics in upbringing.
With the increasing focus of social determinants of health across the healthcare spectrum, the coding of code categories for SDOH (Z55-Z65) will become even more relevant. The impact will likely encourage more facilities to capture these codes more frequently than ever before especially in light of COVID-19.
The National Safety Council (NSC) collects, analyzes and reports on preventable injuries and fatalities and has been doing so since 1913.2 The NSC reported that there was a record high number of preventable deaths (169,936) in 2017 with the dramatic increase attributed in part due to poisoning deaths related to the opioid epidemic. Unintentional poisonings were the leading cause of death for the 25-64 years age group in 2017, surpassing deaths due to unintentional more vehicle traffic accidents.3 The Centers for Disease Control and Prevention (CDC) reports that there were 70,237 drug overdose deaths that occurred in the U.S. in 2017.4 Opioids were the primary substance involved in the drug overdose deaths with 47,600 attributed to opioids. The CDC reports that there are 192 drug overdose deaths every day.
The CDC injury center analyzes deaths and nonfatal overdoses for four categories of opioids:
- Natural opioids (e.g. morphine, codeine) and semi-synthetic opioids (e.g. oxycodone, hydrocodone)
- Synthetic opioids other than methadone (e.g. tramadol, fentanyl)
Breaking down the overdoses within these categories helps to classify the drugs to better understand the morbidity and mortality involved in order to identify targeted preventative, intervention and treatment measures and programs. As such, the data collected in coding can be vital in this effort.
At the ICD-10-CM Coordination and Maintenance Committee Meeting in September 2019, a proposal to expand category T40-4 (Poisoning by, adverse effect of and underdosing of other synthetic narcotics) was submitted by the Pacific Institute for Research and Evaluation, Children’s Safety Network. The proposal seeks to provide codes differentiating fentanyl or fentanyl analogs from tramadol codes for providing more detailed surveillance/analytic data in reducing opiate-related poisonings. The two drugs require different preventative responses.
While today’s coder already codes drug overdoses, it is imperative in this critical opioid crisis sweeping the nation that poisonings are distinctly identified, captured accurately and thoroughly for specific type of drug, the intent and other pertinent circumstances. Having the granular detail will be vital for data analysis and stakeholders attempting to curb the rise of opioid overdoses and establish preventative and treatment programs.