Capture SDOH Using 2021 E/M Guidelines



EMRs are not the end-all for capturing essential MDM.

As of Jan. 1, 2021, we have been given new evaluation and management (E/M) guidelines for outpatient office and ambulatory services that include specific areas of risk such as social determinants of health (SDOH). I applaud the electronic medical record (EMR) analysts who have proactively added these items, as shown in Figure A. However, to convey the full picture of a patient’s circumstances, the data must be complete. As a pro-fee auditor, I am reviewing records with templates that have no data. Until this is resolved, capturing SDOH will require extra effort on everyone’s part.

Accounting for SDOH

SDOH elements are specifically utilized in accordance with a Level 4 E/M service, as defined in the 2021 CPT® guidelines, and shown in Figure B.

As an auditor, I want to be sure that healthcare providers and facilities are provided with the education to capture these elements. In doing so, this not only impacts the provider’s overall medical decision making (MDM), but also the associated healthcare facility and, ultimately, reimbursement.

For patients living in underserved and impoverished areas of our country, the SDOH factors are significant. They can, in many cases, seriously impact a patient’s treatment, morbidity, and mortality. I have seen many examples of how SDOH factors into a patient’s overall health. However, this data is usually not readily available. It takes Sherlock Holmes’ skills to uncover the data, as it often lies in a random telephone call or a nurse’s follow-up note.

For example, if a patient loses their job, they may have no insurance and will deny treatment due to inability to pay for those services. If they lack transportation, they may not receive their weekly injections for a condition that could either be cured or have a long-term impact on their overall condition and healthcare status. Lack of family support can also affect a patient’s behavioral health and prevent them from getting the treatment they need to gain coping mechanisms, counseling, or other services. We know the costs to the patient’s health, but these missed opportunities also can lead to hospitalizations, extended treatments, and more costs passed on to our already overwhelmed healthcare system.

ICD-10-CM Guidelines Offer Solutions

The new 2021 E/M guidelines do not specify that this information must be captured by the healthcare provider (i.e., physician, nurse practitioner, or physician assistant). We can look to patients to self-report. ICD-10-CM guideline B.14, page 16, states:

“Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off and incorporated into the health record by either a clinician or provider.”

This information can be easily captured by the medical assistant or nurse who rooms the patient. Nonphysician practitioners have been allowed since 2019 to document in the record a patient’s chief complaint, objective elements (vital signs, weight, body mass index, etc.), current medications, and the reason for their visit.

I realize that people are very private and do not want to readily disclose this information. These are difficult questions, but we need to be able to connect with patients in a way that makes them feel comfortable and know we are here to help and not pass judgment. We want to make sure we can provide them with the most proper care and be empathetic to their situation.

I also realize that providers are overwhelmed with documentation requirements. I know that there are 300-plus clicks (as many providers have told me) of the mouse to complete an office visit and charge capture elements before sending it on to the billing system.

Teamwork Makes the Dream Work

As part of the revenue cycle team, I am hoping we can help to find a balance. A way to make sure that these elements are being captured in a workflow that makes the most sense for the providers, staff, and patients. Perhaps our friends in social work or behavioral health can assist us with words or statements that make our patients feel more comfortable.

We are all aware of “not documented, not done.” As health information management professionals, let’s be sure we capture information that, when taken into consideration, leads to additional services available to the patient. Since E/M guidelines now do not require “counting elements,” we can use this data to properly capture the level of MDM more consistent with the patient’s status. We can then provide or refer the patient for additional services that may be helpful in treating and managing their overall condition. The outcome will be better for all.

Evaluation and Management – CEMC

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