Q&A: Reporting SDOH with E/M codes based on MDM
Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an evaluation and management (E/M) service level is based on medical decision-making (MDM)?
A: When determining the E/M level based on MDM, there are no official requirements for reporting a SDOH ICD-10-CM diagnosis code for a moderate or highly complex E/M service. However, it is helpful for support of that level selection.
In recent years, there has been an increased focus in healthcare on SDOH, or non-medical factors that impact one’s overall health. There are five classifications of SDOH, according to the United States Office of Disease Prevention and Health Promotion:
- Economic stability
- Education
- Health and healthcare
- Neighborhood and built environment
- Social and community context
The codes for reporting SDOH range from ICD-10-CM code categories Z55-Z65.
Documentation and capture of SDOH can support more complex E/M levels for professional billing. However, as with documentation of any service, it should clearly support the level of service that's being reported. So, while it's not required, I highly encourage coders to include the diagnosis reporting if they are basing part of their level of complexity on a SDOH condition.
Editor’s note: This question was republished from Revenue Cycle Advisor and answered by Kimberly Cunningham, CCS, CPC, CCDS-O, instructor for HCPro’s Certified Coder Boot Camps in Chicago, during the webinar, “Solidify ICD-10-CM Coding for Social Determinants of Health.”