Coding for SDOH

Coding for social determinants of health

In January 2021, several changes were made to the descriptions of the outpatient Evaluation and Management (E&M) codes. Level of service can now be determined by either total time spent on patient care on the calendar day of service, or by the level of Medical Decision Making (MDM). Diagnosis or treatment limited by Social Determinants of Health (SDOH) is an element in either the Moderate (99204 / 99214) or the High (99205 / 99215) levels of MDM.

Documentation of SDOH elements in the medical record increase the correct level of coding and should be considered carefully. The Z-codes are not presently included in many electronic medical record systems for explicit entry, but the appropriate documentation should be entered in the chart and the level of billing adjusted accordingly.

Examples of patient experiences related to SDOH:

• Patient returns to the office today having missed the last two scheduled appointments due to difficulties with transportation. Patient has been out of medications for several weeks and has presented to a local Emergency Department at least once for associated symptoms.
• Patient has recently been evaluated by orthopedics for bilateral knee pain. Found with severe tricompartmental degenerative disease, total knee replacements were advised. Scheduling surgery is delayed due to patient’s morbid obesity and continued daily tobacco use.
• Patient was prescribed additional anti-hypertensive agents on the last visit, however was unable to afford them and has continued taking prior medications. Blood pressure has been very high when checked at the local fire station.