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0:32 Everyone, and welcome to Roundtable 149. Thank you for joining us today and taking time out of your day to join us. I don’t have my co-pilot today, so I just wanted to take a minute and just see if everyone can see my screen and can also hear me. if you can just let me know in the question box. That would be great.
0:58 Awesome. Thank you so much.
1:07 Great everyone, thank you. Alright.
1:17 My name is Janice Tar Lucky. Psi X is Health Director of Education. And today, as I mentioned, we’ll be discussing social determinants of health. As per usual, some housekeeping items. There are no call in numbers. The format is streaming only. If you’re having any issues, you can reload your page and maybe your Internet, a little bit slow, et cetera. So just try that if you have any issues with sound or anything like that. Today’s webinar will be available on demand after the live session and will be accessible through a link that will provide in our follow-up e-mail, which will be sent out this afternoon, Please make sure that you opt into our e-mails, the e-mail will be coming from … coding roundtables at …
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3:21 We do, you know, we do update those quarterly.
3:27 Also, we do have a survey at the end of the webinar, If you could please take a minute to answer those. They’re very easy questions. And so, I guess we’ll just get started. So, thank you so much for, you know.
3:40 attending today, and, as I mentioned, we’re going to be talking about social determinants of health, and there’s different positions I can take on this presentation.
3:49 I’m trying to force, since this is a coding roundtable, I tried to focus on thing, you know, things as oops, As as coders, what we would like to discuss from that perspective, how is it impactful, the code? You know, how are the codes impactful? What are the coding guidelines, things like that?
4:08 So, let me just get myself situated here.
4:12 All right.
4:18 So, what are social determinants of health? That’s where we’re going to start with this presentation. And, I, some of these, some of these pictures.
4:26 I did borrow from CMS on some of their, some of their information. I do put all the links to the references I used at the end of the presentation, as well, if you want more information from the sources.
4:41 So, social determinants of health are …, as we commonly seen them abbreviate, I’ve also see them abbreviate as S D H, but as we all know, for, as coders SDA can also mean subdural hemorrhage or some. You know, it could probably have other meetings as well. But typically, we see that abbreviate as S T O, H. Their conditions in the environment, where people are born, live, learn, work, play, worship, and age, that affect a wide range of health functioning, and quality of life, outcomes, and risks, and we’ll go through some examples.
5:11 And from an AHIMA perspective, know, they have their mission statement, or what, why they’re, why they consider these to be impactful.
5:25 And the reason why they consider these important is that a growing number of evidence suggests that these upstream factors impact the health of individuals and communities to improve outcomes in health quality, quality, quality, more attention. Or equity. I should say, more attention must be given to social determinants, and you probably have seen this in the policies, you know, policymakers, in different, in different segments of healthcare, right? Not just, you know, not, we’re not just not just talking about coding.
5:56 We’re talking about, we’ve seen this. You know, we’ve seen this in terms of other fat and research, things like that.
6:03 So this isn’t just coding, but that’s kind of my focus today. And we’ll touch base on some of those other factors, as well. But to improve outcomes in health equity, more attention must be given to social determinants. The recent shift in health care towards value based care models that incentivize prevention and promote increased improved outcomes for individuals and population offers. An opportunity consider approaches, and partnerships that address health care factors upstream from the clinical encounter.
6:35 So, hospitals and health care systems do work to address their patient’s social needs and the broader social determinants of health and the communities they serve, and we’ll talk a little bit, we’ll dive a little bit deeper into that, as well. So, things that, you know, and impact society and environment, or food, housing, transportation, education.
6:54 So, if a patient can’t get to their appointment because of transportation issue, transportation issues that may be that may be a determinant of health because the patient can’t get to their appointments. They can’t see their doctor. They can’t get their prescribed medications, and so forth. So, those are upstream, upstream from the care that they are. They’re actually being provider or can’t be provided, because they can’t get to, you know, get those resources they need. And some of this data can be used to create those programs that allow these patients to get there, the programs they need in order to get to their appointments and things like that. That was just one basic example.
7:36 So, we want to be able to use this data, right. We have our codes now. They were created last year. We have some new codes for fiscal year 20, 23, as well.
7:46 But they want to be able to aggregate this data, and use this, and identify different populations and health trends. That guide, community partnerships, and every community is going to be different. If you think about, I mean, there’s some things, I always ask this question. I’ve presented this a couple of times now, But what, what are some, some, some things that you can think about in your community, And you could put this in the comments, and I’ll kind of read through them. What are some things that you can think of in your community?
8:13 That maybe recently, the one that I can think of, that we’ve discussed that actually, someone brought up in every presentation, was the whole shortage of formula, for babies, right? That mean, that impacted probably had an impact across our whole entire country in the United States. But what are some things in your community, things that may, you know, that’s, in terms that’s something that, you know, formula not being are available. That’s kind of more, and, you know, the food aspect.
8:40 But that can impact a baby’s health, right.
8:42 So what are some things in the comments that you guys can think of in your communities that you would like to share that can kind of meet in these, you know, social determinants of health? Whether it’s economic, whether it’s education, neighborhood, social, and community, or health care, And more as we go through this, you may think of things that you may have seen in the news. Maybe it’s, you know, a state level, maybe it’s a regional, maybe it’s, you know, even, you know, just your town itself.
9:15 Um, and we do have, you know, we have the veil of ability and the utility of ICD 10 codes at this point. The other question I have for everyone is: are you, is everyone adopting the use of DZ codes that we have available? And we’ll talk about for those that may not be that familiar with the zip codes that we have available. We will be touching base on those, but those that do are your, is your facility adopting the use of Z codes, are they being implemented, or they, are you asked to code them, or you asked not to code them, you know. Is there any confusion with you know the lack of clarity? And who can document them? We’ll talk about the coding guidance guidance on that. What about processing? or documenting? Do we see, you know, different clinicians documenting these social determinants of health?
10:06 Are your clinicians familiar with these? I mean, familiar with these social determinants of health, and I’m assuming that, and we’ll talk about this, too, that some of them probably do, because it can impact of reimbursement right for if you’re, if they’re using E and M codes.
10:25 And, also, in terms of, you know, know, is it something that, as coders, are you even looking at? Are you getting support from your leaders to collect their codes, or is it just, is it a low priority at this point?
10:42 So, let me know in the comments, and I’ll address those things as we go through the presentation.
10:53 OK, let’s move on to that each, so I do have some references. Oops.
11:00 Oh, God.
11:01 Sorry.
11:02 My slides are skipping everywhere.
11:05 This is from the CMS website, as well.
11:07 We have, if you’re looking to see what, what’s in what’s available in each of the social determinants of health, We have economic.
11:16 So, we probably think of this, but, I mean, do we really think of this? One in ten people in the US live in poverty.
11:24 They can’t afford food, health care, and housing, I think, at this point. I mean, we’re as we’re probably all kind of struggling a bit, because of, you know, the cost of things. But this is, this, was, this was out before, all of that even occurred, but it’s probably higher than that, at this point, This data.
11:43 But you don’t know, you think of, no, Western, Western countries, you don’t really think of poverty. But there are a ton of people living in poverty. Um, depending on where you live, you may or may not see it.
11:55 No, I definitely have seen an increase in, in homeless homelessness, and I think someone made a comment that their facility does require them to pick up the homeless homelessness.
12:07 No input, Is it really about employment? Is it about, you know, maybe the patient patient is disabled, or people are disabled and maybe they can’t find a job that they can do, maybe they have conditions that impact their ability to work. Maybe it’s not steady work. So, looking at programs for employment, career, counseling, high quality childcare, maybe you know, a patient patient can’t get to work because they have children that they need to watch, Maybe it’s not affordable. The cost of health, you know, childcare is more than it costs to, you know, their job is paying them just, for an example. Education. Accessing quality quality, so people, people with higher educations are likely to be healthier and live longer. And, why is that?
12:58 You know, low-income families. Maybe they can’t afford health insurance, or they struggle.
13:06 Maybe they have children with disabilities, and they face social discrimination, or they don’t have access to quality health care, I mean, quality, education, I should say, I keep saying health care.
13:20 Et cetera. So, I’m not going to read word for word on the slide. But this is just here if you need to refer to what each of these means, neighborhood and environment.
13:30 So, maybe people that live in neighborhoods with high risk of violence. You know, you feel unsafe.
13:36 You have greater risk of other of unsafe, maybe pollution in the air or water, Other safety factors. You know, the stress of living in in these areas may impact your health.
13:51 So, these all are taken, too, into account and why we need to start tracking these, so that programs and things can be be applied to these different types of communities. And every community is different, right?
14:05 So, how access to health care, coverage rates, cancer screenings. Maybe in one community, they have high cancer screening in another community, don’t. And why is that? Maybe they’re too far away. Maybe there’s some transportation issues, social and community. Is there a community, a positive place to live?
14:29 Do they have discrimination? Is it, you know, is it unaffordable to live there?
14:36 So, these are all things that these are our social determinants of health will look at.
14:43 So let’s take a look at an example. We have patient, A is non compliant with medication and nutritional requirements and follow up and is re-admitted monthly for medical into a medical condition exacerbation. After meeting with the case manager, the reason the patient is not taking their medication on a regular basis is because the patient can not afford the medication to the financial hardship and fixed income, and chooses between buying medication, groceries, and paying bills every month. So the need to allocate resources here, right?
15:11 So we can know this is probably pricey for the patient to be admit re-admitted monthly, not only for them, but also for the resources of the hospital, or the whatever, wherever the patients being admitted, or whatever setting the patients being seen in.
15:28 So the patient is referred to community outreach programs in the area of the outcomes can be measured and follow using coded data. So, again, I’m taking this from a coded coding perspective, utilizing our zip codes will allow hospitals and healthcare systems to better track patients’ needs and identify solutions to improve the health of their communities. So, we run a report.
15:46 We see, you know, these codes, you know, the patient, or re-admission, maybe, re-admission rates, and in, in an associate, an association with some of these zip codes, and they can use that data to make decisions, right?
16:03 That’s just a very basic example.
16:07 There may be community partners, you know, that are many, we have high demand, but limited funding, They may be able to re-allocate some funding to the, to the air, to the part, to the Asia should say, the programs that are in high need, maybe we have other programs that aren’t being utilized. So, they can re-allocate resources in that way.
16:29 They can optimally manage the pot, the population utilization.
16:33 They can no challenge to have more effective based systems between providers, government, and payers.
16:47 Yes.
16:49 And here is our, this is from CMS, kind of a simple way to understand, I like this, this picture. So, step one, from a coding perspective, we want to collect the social determinants of health data. So, any member of the person’s care team can collect social determinant of health data. And what I’ve seen, that’s why I asked this question earlier.
17:11 I’ve seen, you know, for example, within the record, I see, you know, social determinants of health listed in, it says not collected, not collected, not collected.
17:20 So, does that mean that we’re just ignoring that, you know, did the patients providers actually have time to collect that data? Do. They actually know, I know there’s a lot of shortages in nursing and things like that. Do they actually have the time to collect that information?
17:39 Are they close? Are they discussing it but not documenting it?
17:45 And, then we have, I’m just, that’s just a thought that came in my head after, after, You know, some of the things that I’m seeing in the field.
17:53 So, we can, we have provider, social workers, community health workers, case managers, patient navigators, and nurses that potentially could be collecting this information.
18:05 So, they can be collected at intake, through health risk assessments, screening tools, per person provider interaction, and individual self reporting. Remember, our coding guidelines, which we’ll get to?
18:16 We can, as long as the patient is licensed, or can be, can document in the patient’s record, we can, we can take that information, it doesn’t necessarily have to be a physician.
18:31 So, next are Step two. We have data recorded in the patient’s record. What do we do with that data?
18:40 Of course, we need it documented first, right?
18:43 Maybe document in the problem or diagnosis list, patient, or client history, or providers notes, care. Teams may collect more detailed social determinant of health data than current zip codes allow Right, So, over time, we’re going to probably see more zip codes.
18:59 And, of course, efforts are always ongoing to close these gaps.
19:05 Even before we had these E codes, probably, most of us have seen some of these, like, homeless patients, homeless and things like that. Step three maps, social determinants of health data to zip codes assistance, is available from ICD 10 coding guidelines for coding and reporting.
19:20 We have coding, billing, an EHR, systems, help coders assign standardized codes, and that’s another good point, is that in our we have guidance that tells us when we can assign them.
19:30 We also have some coding clinics that also provide definitions.
19:37 For us, for, for example, homelessness are sheltered and unsheltered, what does that mean? So, we can always look, use those references.
19:47 Coders can assign social determinants of health to zip codes based on self reported data and or information documented in individuals’ health record by any member of the care team. Obviously, they have to be able to document in the record for us to be able to code it.
20:00 Next, step four, we use social determinants of health code data. The data analysis can improve quality care co-ordination, experience of care, And we talked about these in that in the previous slide. So individuals’ social risk factors are unmet needs. So in that example, the patient, you know, was choosing between medications and, know, that they’re on a fixed income medication and food, for example.
20:27 They can inform health care and services, follow-up and discharge planning. So do they need to be referred to some community social work, etcetera. Trigger referrals to social services that meet individualist needs, track referrals between providers and social service organizations. Now step five we can report social determinants of health as eco data findings that can be added to key reports for executive leadership and board of directors to inform value based care opportunities. So, this is where I see the most impact, isn’t value based care. Instead of fee for service, we’re seeing this. This integrated into value based care.
21:04 Um, for example, I just recently read an article.
21:08 I’m not, I’m not two, I mean, I’m a two into, I don’t spend a lot of time in pro fee, for example, But I know that I just read that article and AHIMA, that discusses E and M codes how social determinants of health can play a part in your assignment for E and M codes. As of 2021, they built that into the into the E and M codes there.
21:41 All right.
21:43 Next, so using Z codes, do they really enhance your quality improvement initiatives, And I think that’s the plan, or the hope that they do.
21:53 So understanding how social determinants of health can be gathered. So I see someone commenting that we have a questionnaire that’s answered by the patient and online registration.
22:07 For example, so maybe that’s one option, we can select an online screening tool. Or maybe your facility has slept in a screening tool, workflows that minimize staff burden. So I mentioned, did it?
22:18 Did the providers actually have time to fill that in to spend that extra couple of seconds when they’re already burdened?
22:27 Just thinking from that point of view, they have so much documentation they already have to document. How do we minimize that for, for the staff members that are actually collecting this information? Of course. They have to be trained. We have to invest in an E R E R E HR that facilitates that data, decide what zip code data to use and monitor. So, every, again, every facility is going to be interested in different zip Codes. Are we going to capture, is it feasible to capture every single zip code that we have a code for, Probably not, but there may be some that may be more impactful than others, to certain to, you know, a region, or state, a city, etcetera, where you want to that. You find important.
23:10 Or the facility will find important. Your management finds important.
23:15 It’s an issue within your communities.
23:22 Of course, there should be a plan in place on how to utilize the data, right? You want to enhance patient care, improve care, co-ordination and referrals. So, we have these great programs. But if no one’s utilizing them, why, or why do we have them?
23:38 Support quality measures. Identify community population needs. So maybe we didn’t know there was a need for something.
23:44 And these, these helped identify that need and re-allocated resources to a program that’s actually needed versus, you know, program that’s not being, that’s being under utilized.
23:55 Support planning and implementation of social need, interventions, monitor, social determinants, health intervention, effectiveness. Of course, once we have this in place, we want to make sure that they’re being effectively used. Then, we have our health care team, We want to make sure they’re actually using it, right.
24:12 The data is sensitive. It’s HIPAA compliant. It’s standardized in the EHR.
24:18 Again, I’ve been seeing, you know, seeing this in the EHR, but I actually, it says not. It says, not collected, not collected.
24:24 That’s usually what I see in the record, or at least the records that I’ve, I’ve seen looked at.
24:31 So, I don’t know, That’s why, Again, that’s why I asked that earlier, if it’s actually a priority at your facility, and I’ll get to those answers in just a minute.
24:40 Refer individuals in social service organizations and appropriate support services through local, state, and national resources. And then we have coding professionals. So, taking this, you know, just very high level.
24:53 We have our Coding team managers, review codes for consistency, it’s part of our quality reviews, assign all relevant Z codes.
25:02 Um, there is a browser tool on the CDC National Center for Health Statistics to search for codes and information on code usage.
25:10 I think that was probably prior to the codes actually coming out. Obviously, we can use our codebooks or coding clinics and things like that.
25:20 So our current current code categories, we have proud problems related to education and literacy, problems related to employment and unemployment, occupational exposure problems related to housing.
25:31 And I think that became an issue more of an issue or something that we we, I saw, at least when coven hit.
25:40 And this was actually in the works before Covert.
25:42 But I think with Kovac coming out, all the issues we saw with …, um, know, the housing issues, people losing their houses, people losing their jobs. I think this, they really push this through, that’s when kind of the, you know, the lack of food, you know, going to the grocery store and not being able to get food.
26:01 Know, that’s kind of push this to the forefront a little faster than I think it would have. What would these codes would have been adopted? I think they’re kind of in the planning phase for these, and then we have problems related to upbringing.
26:14 You know, other problems related to primary support, and we’ll go into a little bit more detail about these on the next upcoming slides.
26:26 OK, so just taking a look at some of the comments here.
26:38 Sorry, there’s quite a few answers. So, so good. So, some of the comments. So, I ask the one question about what you’re seeing in your facility, or what you see in the records that you review, or just things that you see in the news in your area. So, patients can’t afford men’s leading to re-admissions, so great. So we talked about that one.
27:00 So homelessness and not having appropriate access to follow up care. That’s also a good one, so, you know, this is something that’s probably more in the recent, recent memories, right. Food prices. Gas prices. So, even if the patient has, you know, a car, maybe they can’t afford gas prices, right? So, transportation issues, they can’t afford food, which has always been an issue, but I think it’s become unemployment.
27:27 So another person just mentioning homelessness and unemployment as an issue where they are language barriers barrier Lack of doctors available.
27:35 So that’s a good one actually Depending on where you live, Maybe there’s a lack of specialty doctors Or or maybe there’s a there’s a there’s a lack of available appointments So even if you do want to follow up with your doctor, you can’t because there’s not enough appointments. So, good, so food shortage, social economics, patients living in cars, lack of public transportation, that’s actually a good lack of public transportation. I know where I live.
28:01 We don’t really have a lot of public transportation, Um, Especially in the area, like between one on the other side of town, we have public transportation on the but in-between Those two towns where I live there is no public. It’s really strange. I don’t know why, but that’s a That’s another good one. So, if I lived in in My Town, how would I get to the next town if I didn’t have a car, If I couldn’t drive or if I had health issues that didn’t allow me to drive. Maybe I have, you know epilepsy or something. And it doesn’t allow me to drive how am I going to get. And I know we have Uber but that’s, you know, public transportation is a little is more is less expensive, right? A little more affordable than you know taking Uber’s. Everywhere.
28:44 So yeah, a lot of people are saying financial is a big one.
28:47 Homelessness, that’s a good one too. So you may live in a rural area.
28:52 Maybe you don’t have a lot of grocery store, so, if they’re still with …, we are able to go, you know, if you live in a more metropolitan area, you may have had access to multiple grocery stores, and you can go from two different ones to get different options. But when you live in an area, maybe, I’m just taking a guess here, more rural area. You only have access to one grocery store, and if they’re out of groceries, what do you do, you have to drive hours, maybe you don’t have access to, you know, gas, et cetera to drive that far.
29:21 Another one, mental health availability, is one, another one that someone’s mentioning.
29:32 OK, so another one is small town hospitals with limited access to specialties, unable to afford medication drug shortages. That’s a good one. Drug shortages is definitely one I’ve seen.
29:48 OK, so this is another good one. So shelter from the Sun, so, you know, if you’re living in Las Vegas, for example, this, if it’s, very, you know, strong sun very hot in the summer.
30:00 So they’re going to be seeing more issues with with those types of maybe severe, sunburn, maybe heatstroke maybe you know so how do we help those people?
30:18 OK, so, getting on to our next question about social determinants of health, I asked the question about how is your facility approaching this. Mandatory one person saying mandatory at our facility. We asked the coders to code them. We capture all social determinants of health as per our policy.
30:41 So another, for another person saying, there’s a whole north section of our city that has no grocery store, so people without adequate transportation don’t have access to fresh, fresh produce, and foods in that area.
30:58 We absolutely code them.
31:02 OK.
31:06 Another person is just saying, Care management does a great job of documenting these and many doctors as well. That’s great.
31:15 In our facility, we want, if the patient, is, the patient is marked as homeless by registration. So, we’re required to pick up the zip code for homelessness.
31:27 So, that might be another thing. So, the wording by providers may not always be clear. It might not match up, specifically, so that’s another item that, that, you know, we have to cover or consider, is they don’t always match up with the specific zip codes. So, education, you know, having that clear, clear documentation, I’m using the same kind of terminology is another another issue that we see.
31:56 Not just with ours, These codes are social determinants of health, but all of our codes, right? Sometimes we need to to ask questions.
32:08 Oh, this is interesting, so someone’s just making a note that Medicaid kicks a lot of their codes off.
32:15 Um, yeah.
32:17 And the thing with Medicaid I noticed is that they’re using, you know, older groupers, A, that some of the codes aren’t, aren’t, you know, they’re not, they might be using groupers from five years ago.
32:28 So those codes probably get kicked out because they’re not coat current codes in the Cooper that they’re using. Of course, that depends on the State.
32:37 But they should still be in your, your system, right? If you’re running reports. They make up, they get, might get kicked off on the billing side of things. But they should, you know, from your office, your specific facility side, if you’re running reports in your, in your system, you should be able to still capture that data.
32:56 Yeah, so someone’s mentioning we have a section in the HMP. They have a lot of the social determinants of health questions. That’s where I’m seeing it, But they’re actually not answer to. It, just says, no, nothing on file, nothing on file. So I’m assuming that the provider isn’t asking those questions, or I’m not sure what’s going on there. I don’t think they’re being utilized.
33:17 Other people are just saying we mostly just code homelessness.
33:26 And some other comments. We see themes of issues with transportation for medical appointments, food insecurity.
33:33 And our nursing staff do complete the social determinants of health questionnaire.
33:42 And we see a lot more documentation on the psych side versus the medical side. That’s a good point. They probably spend a lot more time on the psych side than it, than anything.
33:58 All right, so for now, a lot of great points here. I’m going to kind of move on. If, we have time, I’ll kind of get back to some of the other comments.
34:06 OK, so here are code categories. Thank you for everyone that did respond. I think those are all great. So, these are our different code categories are Z, 55 problems related to education and literacy.
34:18 So what falls into that code description? So, maybe they don’t have a GED. They don’t have.
34:28 And you could see why some of these might fall more into Sike, You know, do we really spend a lot of time asking the patient their education level, when they’re coming in, you know? And when they’re severely ill to the hospital, do you have a GED? Do, did you graduate high school?
34:44 So, I can see why some of these probably aren’t, know, probably answered problems related to unemployment In An employment and unemployment, This probably has a question case, case managers price, probably ask about, Can you afford your medications? Do you have a job?
35:00 This is probably where we’re gonna see, you know, the patients unemployed, maybe even registration, know, maybe the patients, you know, having some mental health issues because they are being sexually harassed. That may be something we see in psych. I’m not saying that we will never see it on the medical side of things, but definitely some of these I can definitely see seeing more on the safe side of things and I, someone didn’t make that comment.
35:26 Um, occupy occupational exposure. We have problems related to physical environment, so inaccurate, inadequate, drinking, water supply. So this might be something, someone mentioned this on another presentation that I did in Michigan where they had the drinking issue, the drinking water. I don’t really know that the specifics. But I know kind of recall reading that in the in the new or listening to that in the news.
35:52 That might be an example of, you know, problems related to physical environment, lot and lack of safe drinking water example problems related to housing and economic circumstances. So this is where we, you know what is sheltered homelessness and homelessness mean, unsheltered homelessness mean? and we do have definitions that we’ll get to in just a second? I mean, you can kind of figure it out, right?
36:17 Um, do they reside in the street inadequate housing?
36:23 You know, do they have inadequate food supply? Lack of adequate food, will fall into that Z 59 category?
36:30 Then we have Z 60, adjustment to life cycle, transition’s, living alone, social exclusion or rejection, target of adverse discrimination and persecution.
36:45 I mean, hopefully not, I mean, but there may be some areas of the country, maybe this is an issue.
36:50 Yes, which we see it, you know, we do see that on the news as well.
36:59 We have problems related to upbringing, parental supervision, and control, child welfare custody. So that would be in that C 62 category, personal history of abuse.
37:12 Um, Z 63, we have other problems related to primarily support group, including family circumstances, So absence of a family member. And I see this I mean, I do see this with child sike, you know, if maybe there’s a disruption of the family, by separation divorce.
37:30 We have problems related to a certain psychosocial circumstance, so unwanted pregnancy, multi paradigm, The 65 problems related to other, so psychosocial circumstances, so, sir, conviction and civil and criminal proceedings without imprisonment. We have imprisonment and, of course, if someone’s going through this, it can be very expensive.
37:49 Maybe the reason they’re, you know, there, you know, maybe it’s, you know, maybe they normally wouldn’t be in prison, but they didn’t pay their, you know, pay whatever they didn’t pay there.
38:01 They’re tickets or something?
38:07 Maybe they can’t afford to.
38:10 So, next, we have our specific guidelines. Now, this was added fiscal year 20, 22, 21.
38:20 Where are they, they took out the whole social determinants of health and made it to its own subcategory. So, for social determinants of health, such as information found in Category C 55, is the 65, persons with potential health header hazards related to socio socioeconomic and psychosocial circumstances code, assignment, maybe based on the medical record, documentation from clinicians involved in the care of the patient, or not the patients providers, Since this information represents social information rather than a medical diagnosis.
38:49 So remember, we can take this from other coding Profesh or from other coding professionals from other … information.
38:59 That’s document and medical records. So for example, we can utilize social workers, community health workers, case managers, nurses, if their documentation is included in the official medical record, and I mentioned that earlier.
39:13 Patient self reported information can be used for social determinants of health, as well as long as the patient self report, it information is signed off by and incorporate it into the medical record by either a clinician or a provider.
39:31 So we have, not in this context. Clinicians are the patients provider. We talked about that.
39:37 And we see social determinants of health is in this list where we can take, know, normally we’d need, so the Provider to document the condition, but the exclusions, we know BMI, pressure ulcers, X You know, … is a new one Coma Scale is we can take that from other providers documentation.
40:02 Then we have our Coding Clinic, XE code update for fiscal year. It’s actually fiscal year 20 22 and they do provide some additional definitions about.
40:14 About, specifically, I mean, there’s different definitions here but homelessness and unsheltered homelessness, we had, we always had a code for homelessness. Now, we have to distinguish between sheltered and unsheltered. We also have a code for unspecified.
40:31 We also have lack of safe drinking water. They what they syrupy separated this into food insecurity.
40:37 Again, we’ve always had had this in, our, in our and our country in the US, but I think with covert, I think that really became a in the four it became an issue that became more aware, you know, brought more awareness to the issue of food insecurity.
40:54 At least from my perspective, you know, you always knew there was, but you started seeing more stories and stuff about it.
41:03 In that sense, but the one I wanted to talk about was kind of the next part of this Coding Clinic. It’s the same coding clinic.
41:11 They talk about if you need definitions, about homelessness, shelter, so defined as currently living in a shelter, motel, temporary trans, transitional living situation are not having a consistent place to sleep that’s considered sheltered versus unsheltered defined as residing in a place, not meant for human habitation, such as a car park sidewalk or abandoned building on the street, and then they define housing instability, so, and also, housing instability housed with risk of homelessness. So, if you need definitions, are there all are all outlined in this Coding Clinic from Fourth, Quarter 2020, 21.
42:02 And before this became in the guidelines for fiscal year 20, 22, I should say, we did have coding clinics that told us that it was acceptable to define, or they define clinicians, and they are one of the co-operating parties. And I know I always say this, so some of you may get sick of me saying this.
42:19 But even in the Federal Register, they refer to Coding Clinic that they kind of provide us, which with education, regarding the coding guidelines and help to help provide some guidance and, and things like that. So that we have some context when it’s not 100% clear. And then at times, we do have some coding clinics that come out, and then they add that information to the actual coding official coding guidelines. So, this was an advance of that coding clinic, or, you know, in advance of that, being in our coding guidelines.
42:54 They said, Please define clinicians in the context of ICD 10 official coding guidelines, Which allow COTA Summit for social determinants of health based on medical record documentation.
43:05 From clinicians involved in the care of the patient who are not, the patients, providers, and systems information, represents social information rather than medical diagnosis. For example, may coding professionals utilize documentation of social information from social workers or community health workers in order to assign codes for social determinants of health? And the answer is that the guidelines do not have a unique definition for the term clinician. In the context of code assignment, for social determinants, of health documentation, team meeting, the requirements for inclusion, and the patient’s official medical record based on regulatory accreditation requirements, or internal hospital policies, could be utilized since the information pertains to social, rather than medical information. So, that’s another good point. It meets the requirements for inclusion in the patient’s official medical record, and I have discussed this before, but, you know, if someone’s living alone, we have a zip code for that.
43:54 Know, for example, if it’s a normal, healthy patient, they, they drive, they, they, they are getting a basic procedure. They don’t need any wound care. The fact that they live alone doesn’t really impact their care, probably not. So, you want to make sure that it’s, it’s meets inclusion or meets. It’s pertinent to the patient’s stay and they go, they do add that to the, We’ll get to that in a second. They do add that to the guidelines for fiscal year 20 23.
44:21 And then they, they also have another coding clinic for self reported information.
44:25 This is from fourth quarter, 2019. This is before the, they added it to the official coding guidelines. That, yes, if the patient self reported information is signed off on and incorporated into the health record that we can assign codes describing social determinants of health.
44:45 And we do have proposed new social determinant of health codes for fiscal 2008, fiscal year 20, 23. None of them are C, C, so I know some of you have asked before, or any of these codes, social determinants of health impactful. So in the inpatient side, I did play around with APR, risk of mortality, Severity of illness, and none of these impacted. They’re all SOI, rho M of one. I played around with them. I couldn’t get a, Dick couldn’t couldn’t get anything to impact it.
45:15 And let me know in the comments if you do know of anything that impacts, I, couldn’t, I float, basically, plugin every single code and I didn’t see any impact with any of these social determinants of health, and just does that mean that they’re never going to be, no, they could impact, you know, as they collect more data, they can potentially impact reimbursement in the future, and, or severity of illness, risk of mortality. I would think that someone being homeless would be, you know, risk of mortality, would increase risk of mortality, but who am I to say that?
45:48 No, you really need data to support, to support that. So, we have new codes for transportation, insecurity, financial insecurity, mature material hardship.
46:03 And we also have some additional codes for greater specificity for non compliance.
46:09 So, Dietary Regiment, you’d have financial hardship so they’ve kind of broken it down.
46:15 Other medical management due to financial hardship, other reason, unspecified, reason. a lot of times, we have it documented.
46:22 But we don’t have a specific graders, specific code to, to capture.
46:27 And then we also have caregivers, the expansion of caregivers, non compliance with medical management, due to financial hardship, and so forth.
46:36 Caregivers, intentional under dosing a patient’s medication due to financial heart, to maybe they’re giving the medication every other day, instead of every day, because they can’t afford it. Maybe, you know, a child has asthma. Maybe they’re only giving it, you know, to time today, sort of three times a day, whatever the case may be, because they can’t afford the medication. So they’re trying to spread it out.
46:59 And what is material hardship?
47:03 So, inability to pay bills, this could, no.
47:09 Certain types of material hardship are more or less likely to impact socioeconomic emotional adjustment in young children.
47:16 So, not having the ability to pay your bills, maybe food insecurity, housing insecurity, medical hardship, having your utilities cut off, for example, not having those materials can cause Material hardship.
47:37 And for fiscal year 20, 23, we also have some updates to the socio determine if this isn’t the whole guideline. This is, of course, continues on the next page, but the part they update it is codes describing problems, or risk factors related to social determinants of health should be assigned when this information is documented. Assign as many social determinants of health codes as necessary to describe all the problems are risk factors, these codes should only be assigned, or should be assigned, only when the documentation specifies the patient has an associated problem or risk factor. For example, not every individual living alone would be assigned Z 60.2, problems related to living alone. So there has to be a problem or risk factor, right? So if you use a healthy patient, it will just use myself as an example. I don’t know. Let’s say I go in for an I use this example before appendectomy! You know, I’m totally fine living alone.
48:26 It’s a, you know, kind of a, you know, laparoscopic appendectomy, they say I live alone? Does it really? Is that a problem? No, I just go home and I heal and I come back from my follow-up visit and I’m fine.
48:37 Know, if a patient is living alone and it is a associated problem because they need help with wound maybe they need help with wound care. Maybe they need help. You know, ambulating to, you know the toilet.
48:50 Maybe they need help with, no, you know, with meals, et cetera. That might be an example where that would be appropriate to add C 60.2, so they did, they did add that. It’s just, we’re not just coding that when there is no issue, problem or risk factor.
49:10 We should be coding it when there is an issue arising from from that social determinant of health.
49:18 So, a summary of the guidelines. So we can code, and a clinician can document a patient’s social needs. We can code social determines of health from other clinicians documentation, and they define what that means in the guidelines. Patient self report it. Social needs can be also be coded when signed off in the medical records.
49:34 So, just wanted to kind of provide a summary there.
49:40 Um, and I have a ton of different references here, regarding social determinants of health.
49:46 Some of them are from CMS, some of them are from AHIMA, some of them are from the HA, etcetera.
49:53 So if you need more information about social determinants of health, um, those are a good place to start and some of these, these documents, do you have, Let me bring them up, actually, Ooops, Hmm, hmm, hmm.
50:13 I thought I had one of these pages up, so.
50:19 They have some great documents. I think that summarize, for example, Let me bring this to Healthy People.
50:27 Um, it’s a great document that kind of goes over and outlines, you know, health is more than health care.
50:38 You know, how is the policy impactful? How is it impacting our, you know, federal spending? You know, that we talked about value based care?
50:49 How can we improve health outcomes for all Americans?
50:53 No, I think this is a, these are great pictures. And this is kind of what I wanted to talk about.
51:01 Understanding the value proposition, Why is it important, you know, for a physician, why do they care about social determinants of health?
51:11 How do you create that value proposition for other providers?
51:16 How do you create that value proposition for employers, for public health leaders, for venture capitalists, for thought leaders, and being able to prioritize the social determinants of health?
51:36 That promotes inclusion of traditional non traditional stakeholders, including the business community, and highlights the opportunity cost of inaction.
51:45 So, and, you know, I think the data that comes out of this will be impactful, you know, for those that are collecting it, will be helpful for those that aren’t, you know, that don’t find it impactful.
52:00 No, right now, it’s, we think there is a lot of buy in, but, for those that aren’t buying in, I think the data will show, be very enlightening to those people.
52:09 Maybe not. I mean, I don’t know.
52:16 Any thoughts on that? Are there any issues with buy in at your facility?
52:25 So, kind of some of the comments are talking about, we’re collecting them, but not are off from the all providers are familiar with them and or documenting them. So we do need that buy in. It’s important that we we get those providers to document that information. You know, if we can cut down, you know, re-admission rates, getting those patients the medications they need, it will actually allow other patients to be seen for the, you know, for example, in those areas where We have a lot We don’t have a we have a lack of doctors are lack of appointments and patients can’t be seen.
53:02 You know, for those for those patients that, You know, it could free up some time, right?
53:15 So, another person’s commenting. I work at a universal university Level hospital. We are coding them. The nurses document it in the flow sheet, and we take it from there.
53:28 OK, so another person interested in to know what what kind of care facility you’re Erat We see a lot of illiteracy and low-level literacy document it.
53:44 OK, so, in terms of and at this person’s facility, in terms of coding, they’re updating it in their … system to auto suggest non provider documentation for both inpatient and outpatient, of course, auditing to confirm that decoders are capturing it, if it’s documented.
54:11 At our facility, I think we’re past the point of discussion of the importance, the need to capture, how to capture, we need, more conversations around how facilities are moving forward with engaging clinical areas, who serve these patients on the templates to drive documentation.
54:26 Good point.
54:33 We use the codes for what is documented? We don’t clarify any social determinants with physicians such as sheltered homelessness.
54:46 Um, another comment in their area, it’s a lack of food, we have a food desert, we have a dollar general store and two gas stations.
55:01 In our areas, we have a concern for lack of affordable housing, big real estate, boom, but not for low income.
55:10 At our rehab facility, we’ve always documented these, but, we didn’t it wasn’t a corporate issue regard to coding data capture, but coders do have the way to include these codes based on a professional training.
55:28 Where we? Where we are, we, we have houses too close together.
55:31 We have too much Noise, high crime area And too many stray animals so, you could see how different these different issues are different for different areas of the country.
55:48 Need, New York Cares and New Jersey charity care or insurance type programs that are geared for unemployment, who can’t afford insurance in the zip codes are essential to be coded.
55:59 I did this for two different hospitals and now, and also in New York, for two New Jersey hospitals, and now in New York Hospital.
56:17 Interesting, so we are a small town. We have people families. Surrendering are bending their pets due to lack of funds. This tends to be very stressful, especially when the pet is their only source of companionship. We try to help when feasible.
56:31 So some places, some people are saying that their doctors actually collect the information, and they’ve been asked questions.
56:40 Another comment, Is these codes risk adjusted in the ACO arena?
56:52 Locally, so this is, this is going to be dependent on your area of the country. So we do code the exposures For work related injury exposure for 911 survivors’. That’s a good point.
57:05 I’m kind of what I was looking for in terms of specific to your region.
57:16 All great points that you guys are making.
57:21 All right.
57:26 So, another point that someone’s making is and where they are, that there’s a lot of old houses with lead paint, old water systems, with poor water quality.
57:36 Yes.
57:41 OK, let me scroll to the bottom mirror.
57:58 So I think I answered this. So if it’s not impacting care in any way that, you know, per the coding guidelines, and maybe it’s not always obvious, they say that we shouldn’t, If it’s not a risk factor, for a specific issue that’s being addressed, that we’re not going to code it, like the patient living alone.
58:16 Other examples, ameen, it’s going to be kind of, yeah, I can see that being a little bit of an issue with interpretation, but you can always submit that question, if you have a specific scenario, and see what their advice is going to be. Coding clinic.
58:44 Yes, so another example of so a patient’s living alone, if but they need to leave to care for their pets so that would be an example of something that’s impacting their care, right? Maybe they don’t want to go for to sniff placement, for example, because I don’t want to leave their pet alone.
58:59 That might be something that’s impacting their care, right?
59:05 So those are just the So maternal material hardship is just the code category, so not being able to pay bills may fall under that. It’s not a gender, like a specific code.
59:17 It’s a, it’s a General Code category.
59:31 OK, so, if a patient needs a driver to drive them home after a procedure, and they live alone, Yep, that can impact their care, right? So those are all good examples.
59:51 Yeah. So, those are good points, too. We do have codes for bullying.
59:56 You know, if you’re if you work for a pediatrician, you might see maybe parent family, member issues, or a family member dies or divorce issues or bullying, or even school shootings stuff. That’s a good a good good point.
60:13 So, depending if you work for, you know, a pediatrician versus, you know, a plastic surgeon, you know, they may all have different things that they they focus on, depending on the population that they’re seeing at there at there, Offices.
60:34 Thank you. Flint, Michigan is what I was thinking of. Thank you.
60:37 In terms of the water, the water issue, all right, I think we’re out of time. But I think those are all great points, kind of a high level overview.
60:49 And, I think as, as we collect more data, we’ll see more impact, or the lack of, and I think there will be some impact.
60:57 We’ll be able to definitely see some changes, hopefully, for the positive on, some of these are coding, You know, the fact that we can now collect this information. Um, it’s a tool that we can use to create reports.
61:16 I think it’s, it’s going to be positive. So, anyway, I’ll let everyone go. Thank you so much for attending today’s presentation.
61:24 And, have a great day.