When Your Patient Is Poor: Dx Coding for Financial Hardship

Betsy Nicoletti, MS


August 25, 2020

Physicians have become much more aware of how social and environmental factors, such as poverty or lack of housing or food, affect a person's health and medical outcomes. You may be surprised to know that when billing, you can code for some of these factors, to the extent that they affect a patient's health and potential outcome.

In fact, the office or hospital visit note frequently describes the effects of social determinants of health on the patient's treatment. There are diagnosis codes that describe these factors, but they are not uniformly reported to payers on a claim form, even when they're well documented in the note.

Here's an example. A physician looks at a patient's reason for a visit in her appointment schedule: sore on foot. The patient tells the medical assistant that the sore won't heal and keeps getting worse. The physician reviews the patient's problem and medication list and sees that the patient was prescribed insulin for his diabetes and has peripheral vascular disease, among many other problems. His most recent documented A1c was over a year old and was 14.3, and the patient missed his follow-up appointment and could not be reached to reschedule.

During the patient visit, the physician learns that in the past year, the patient has been in homeless shelters, stayed on the couch of a family member, and sometimes even slept on the street. He had no regular access to a refrigerator in which to keep his insulin, and was not able to shop and cook in a kitchen. He doesn't always have access to laundry and clean socks. He hasn't had the money to buy his medicines.

Arranging care and social services for this patient takes the physician three times the scheduled office visit time. But there is a way to code for it: The physician can look up ICD-10-CM codes for homelessness and food insecurity.

According to the Centers for Disease Control and Prevention, social determinants of health include economic and social conditions that influence the health of people and communities. These include food and housing insecurity, access to clean water and a safe environment, and poverty. Food insecurity is defined as the disruption of food intake or eating patterns because of lack of money and other resources.

There are diagnosis codes for problems related to education and literacy, employment, housing and economic conditions, and other psychosocial circumstances. These codes do not describe a specific disease or injury; instead, they describe external factors that may affect a person's health and create challenges in treatment.

Adding these informational diagnosis codes to the claim form submitted to the insurance company doesn't result in increased payment to the practice on the individual claim, unfortunately. But depending on the types of contracts the practice has with the payer, there may be additional reimbursement at the end of a contract year. Contracts that include accounting for quality measure or the acuity of a panel of patients may provide additional reimbursement at the end of a contract year.

The last chapter of ICD-10-CM is "factors influencing health status and contact with health services," which includes categories Z55-Z65: "persons with potential health hazards related to socioeconomic and psychosocial circumstances." These describe problems and risk factors that are not considered a specific disease or injury but which affect individual patients' health and health outcomes for a population of patients.

Let's go back to our physician, who is seeing a diabetic patient with peripheral vascular disease and who presents with a nonhealing foot ulcer. In addition to the medical diagnoses she is treating that day, why should our physician, who is already running behind in her schedule, take the time to find codes Z59.1, homelessness; Z59.4, lack of adequate food and safe drinking water; and Z91.12, patient's intentional underdosing of medication regimen due to financial hardship?

How Does It Help to Use These Codes?

Do these codes provide additional reimbursement? Why should you use them? In fee-for-service medicine, there isn't an economic incentive. Medical practice claims are paid on the basis of the fee associated with the CPT codes submitted on the claim form. The diagnosis code establishes the medical necessity for the service, but it doesn't change the payment amount for the visit.

Adding more ICD-10-CM status codes may support a higher-complexity visit, but the diagnosis codes themselves don't make a difference in how much the practice is paid when the claim processes. The payment is tied to the visit level. There isn't an economic incentive in fee-for-service reimbursement to spend the extra time.

Is it worth using these codes? There are two reasons why a physician might take the extra time to add homelessness and food insecurity to the claim form. First, if the practice or health system is part of an accountable care organization (ACO) or has risk-based contracts, describing the non–disease-related factors that influence the patient's health status can make a difference in future payments. Second, it allows the practice to easily identify patients in the practice with psychosocial issues.

These codes can help you track patients in need. If these codes are added to the patient's medical records, the practice or healthcare organization can easily find patients with social needs by searching for those diagnosis codes. In a prepublication article in Health Affairs, "The COVID-19 Shadow Pandemic: Meeting Social Needs for a City in Lockdown," Clapp and colleagues describe addressing the nonmedical needs of the patients they discharged. Their team was concerned about patients' access to food, secure housing, and money.

One way to identify patients who have these nonmedical needs is to add the ICD-10-CM code that describes these needs into those patients' medical records. For patients discharged from a hospital stay, a coder can add these social determinants of health codes based on the documentation of any clinician who can enter notes in the chart. It does not need to be a physician, nurse practitioner, or physician assistant; it could be documented by a social worker, physical therapist, or care manager.

Why This Coding Could Be Important to Your Healthcare Organization

Many practices and healthcare organizations enter into risk-adjusted contracts or contracts with incentives for certain quality metrics to accurately and completely report diagnosis codes. Years ago, a general surgeon told me that he always put the patient's underlying medical conditions on the claim form in addition to the surgical diagnosis because he "wanted the payer to know just how sick the patient was."

The ICD-10 diagnosis rule about reporting underlying conditions is to report all conditions that are treated or that affect the care of the treatment. Reporting comorbid conditions gives the payer an accurate assessment of the disease burden of the individual patient and of the panel of patients the practice cares for.

Risk adjustments in contracts is another factor. Groups whose revenue is 100% fee-for-service, without any linking to quality measures or value-based care, have the least incentive to take the extra time to add diagnosis codes that describe a patient's social determinants of health conditions. If there is a contract that includes quality measures or value-based care, there may be an end-of-year adjustment, based partially on the acuity of the panel of patients.

Other models where the practice shares more risk with the payer, such as alternative payment models (APMs) and population-based models such as ACOs, adjust end-of-year payments on the basis of cost, quality, and the disease burden of the population of patients in the panel.

Many physicians find it very time-consuming to document services. Often, their documentation shows that they treated conditions that they did not add to the assessment, or that a social problem or comorbidity affected the treatment they prescribed at the encounter. It can be a hard sell to ask our physician who is treating the complex patient with a foot ulcer to take the time to look up three more codes. The benefits are being able to easily identify patients in the practice with psychosocial needs and conveying to the insurer just how sick this patient is.

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