How Will Severity of Illness Intersect with SDoH?

CMS is seeking public comment on how SDoH would improve severity of illness under the MS-DRGs.

In the Inpatient Prospective Payment System (IPPS) Proposed Rule FY23, there was solicitation for public comment on social determinants of health (SDOH). The Centers for Medicare and Medicaid Services (CMS) wants opinions on how the SDOH would improve the recognition of severity of illness, complexity of illness, and/or utilization of resources under the Medicare Severity Diagnosis Related Groups (MS-DRGs).

The definition of SDOH is conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, quality of life outcomes, and risks. These conditions may be predictors for risk of developing medical conditions such as heart disease, diabetes, and obesity.

The ICD-10-CM codes that capture SDOH fall in the range of Z55 – Z65 (Persons with Potential Health Hazards Related to Socioeconomic and Psychosocial Circumstances). These codes are not complications/comorbid conditions (CCs), major complications/comorbid conditions (MCCs), or hierarchical condition categories (HCCs).

The SDOH data is important to report and include in the claims database. Here are several considerations as you think about reporting this data. These include the following:

1. Research high-volume payers for social program offerings.
2. Discuss the facility’s interest in SDOH with leadership.
3. Determine the facility’s need for specific SDOH data.

Here are action steps as you investigate SDOH data:

• Generate a frequency report for SDOH data for your facility. Are you currently reporting SDOH data? What is your frequency?

• Determine which documentation in the electronic health record will be the “source of truth” for the data. Remember that the Official Coding and Reporting Guidelines have been revised under I.B.14 which permits the use of other “clinician” documentation. This guideline now includes SDOH.

• Identify the specific topics of SDOH on which your facility is focused. Social Services Department may be helpful. These areas may be identified by payer social programs; facility leadership interests; state concerns; etc.

• Discuss the topic of SDOH with the coding and clinical documentation integrity staff. Identify their struggles in capturing documentation or codes on this topic.

• Update the facility-specific coding guidelines to include SDOH

Social programs need this data to provide the right resources in the right geographic areas. Go ahead and report SDOH codes. Provide feedback to CMS regarding how the SDOH data can assist in identifying patients with additional needs. Give suggestions regarding how CMS may provide incentives for SDOH cases. We may find that the SDOH codes will provide additional incentives in the future.

NOTE: The Official Coding and Reporting Guidelines for ICD-10-CM FY 23 are effective with discharges/visits on October 1, 2022.

Programming Note: Listen to Laurie Johnson’s live Coding Report every Tuesday on Talk Ten Tuesdays with Chuck Buck and Erica Remer, MD.

Resources:

Official Coding and Reporting Guidelines ICD-10-CM FY23

FY23 Inpatient Prospective Payment System Proposed Rule