In the Know
The AMA and UHC Collaborate to Develop Social Determinant Diagnosis Codes
Did you know that United Healthcare (UHC) and the American Medical Association (AMA) are proposing to develop 23 new ICD-10-CM diagnosis codes that address social barriers to care?
Developed by UHC and endorsed by the AMA, they state that while there are several ICD-10-CM codes that identify a variety of social determinants of health (SDOH), there are no unique diagnosis codes that identify social diagnoses or barriers to health care.
This request, following the passing of the Chronic Care Act of 2018 Advancing Care for Adults with Complex Needs, seeks to provide Medicare beneficiaries integrated care by enhancing medical and non-medical care. In addition, several of the Healthcare Effectiveness Data and Information Set (HEDIS) measures require the reporting of outpatient visits that may be difficult to complete due to social barriers that are unrelated to a healthcare consumer’s health. For example, if a patient is not compliant in taking a prescribed medication/therapy because they cannot afford the medication/therapy, the dermatology practice can report ICD-10-CM code Z59.6, Low income.
However, there is virtually no way to assist the patient without asking them for more detail as to what caused the reduction in income that prompted the patient not to not take the medication/therapy as directed by the healthcare provider. Further questions would need to be asked if this was due to loss of health insurance coverage, reduction in income due to loss of employment or underemployment etc. Without the ability to capture this detailed information, the probability is high that the patient’s ability to access the much-needed assistance to alleviate this hardship would be drastically minimized.
UHC believes that focusing on the problems related to housing and economic circumstances code sets could allow for population health improvement. It also provides an opportunity for the National Committee for Quality Assurance (NCQA) to expand HEDIS measurements around social barrier identification and assistance in the future. Today, capturing SDOH barriers appears to vary widely throughout the industry, rendering it a fragmented, inconsistent way of both capturing and using this information.
The existing SDOH code range (Z55-Z65) in the diagnosis code category is entitled “Persons with potential health hazards related to socioeconomics and psychosocial circumstances,” which validates that an expansion of these codes would be warranted within the ICD-10-CM classification. Expanding this code family is a logical choice, as it is the standard language between healthcare providers and payers. UHC hopes to capture further granularity to existing code Z55-Z65 and increase specificity needed to appropriately capture, analyze, and act on SDOH data to improve outcomes for both healthcare consumers and populations.
The expanded ICD-10-CM code recommendations encompass six key areas. These include:
Access to nutritious food
Appropriate housing
Transportation
Expanded payment for medications
Utilities
Caregiver needs
Requesting and getting this SDOH information would present a great advantage to healthcare providers and payers, especially in the advancement for healthcare outcome measures. The information could reduce hospital readmissions while allowing patients to obtain access to psychosocial and socioeconomic assistance. Providers must still hone their documentation skills to assure they are collecting this important information in the patient’s medical record to support measure reporting, this may yield higher bonus payments under the Medicare measures program.
In the meantime, if CMS adopts the expanded ICD-10-CM codes, they may go into effect as early as October 1, 2019. The Fall 2019 issue of the DCC will publish a list of these new codes.
