New SDOH Reporting Requirements Expected to Impact HI Workflow, Staffing

With the start of the new year, health information (HI) teams are integrating the government’s new requirements for reporting social determinants of health (SDOH) data.

As of Jan. 1, 2024, the Centers for Medicare and Medicaid Services (CMS) began requiring healthcare organizations to screen for five social risk drivers, a task that was voluntary in 2023. The required five SDOH domains are: food insecurity, interpersonal safety, housing insecurity, transportation insecurity, and utilities.

The SDOH reporting requirements apply to hospitals and health systems that admit patients. The collection period will run through 2024, and healthcare organizations will have until May 15, 2025, to submit the data.

Healthcare teams are expected to ask patients questions pertaining to the five domains at any point during their hospital inpatient stay, putting in place a mechanism to pull data with yes/no answers and a field to note if patients were unable or declined to answer. When choosing an assessment process, CMS suggests healthcare teams review and consider the most widely-used, health-related social needs (HRSNs) screening tools, such as those on the Social Interventions Research and Evaluation Network (SIREN) website.

The SDOH reporting mandate is part of a larger initiative by CMS to advance health equity, expand coverage, and improve care for underserved and disadvantaged communities. 

“Demographic, SDOH, and social risk factor information can help drive quality improvement and dramatically improve CMS’s ability to evaluate changes in the prevalence of SDOH and social risk factors, and their influence on health outcomes,” the agency said in its CMS Framework for Health Equity 2022-2032.

CMS is also introducing two new inpatient quality reporting measures in 2024: screening for SDOH and positive rate for SDOH. Screening for SDOH will assess how many patients age 18 and older were screened for the required domains. Positive rate for SDOH will track how many patients screened positive for the required domains.

For healthcare organizations that started voluntary reporting of SDOH data in 2023, the changes in 2024 will likely be minimal, says Lynn A. Wall, MBA, RHIT, CCS, CDIP, an AHIMA-approved ICD-10-CM/PCS trainer and manager of coding quality and education for Lifepoint Health in Brentwood, TN.

“It will be health care organizations that did not voluntarily collect this data in 2023 that I see experiencing the most amount of change,” she says. “Multiple processes will need to be put into place to meet the mandate.”

How Requirements May Affect HI Professionals

The new SDOH reporting requirements will impact the work of HI teams in a number of ways, Wall says.  

Workflows, for instance, may need to be adjusted to allow time to collect data, extra time may be needed for patient inquiries, and staffing challenges may arise, depending on the department responsible for collecting the SDOH data, she says.

For organizations just starting the process, the first step is to determine who will document the SDOH information, says Tammy Combs, RN, MSN, CDIP, CCS, CNE, an AHIMA-approved ICD-10-CM/PCS/CDI trainer and AHIMA director of clinical documentation integrity (CDI) services. Next, is making sure HI teams know where the information is documented and who will be reviewing and assessing the screenings, she says.

Training and education of CDI professionals and coding professionals is essential to ensure they’re reviewing for the screening data and know what to do if information is missing, Combs says.

“If a CDI professional identifies a gap, who are they sending that query to?” she says. “Traditionally, CDI [professionals] have always sent queries to physicians. With SDOH, it may not be the physician who is documenting it. It may be social workers. It may be nurses. They may need to look at a process that is a little different than what they’ve done before.”

How much time the requirements add to workflows will depend on the organization and structures in place, Combs says. As with any major change, effective communication from leadership is key, she adds.

“There are a lot of ‘what if’s’ and questions that typically will arise whenever you’re doing something new,” she says. “Especially if organizations have not been preparing for this, they need to have effective lines of communication in place among team members.”

Once processes are in place, HI professionals shouldn’t wait until the submission deadline to view the data or run reports, Wall says.  

“Look at the data now,” she says. “Does it make sense? Is the information flowing correctly from the chosen data source? Perform random sample audits of the facility’s data to ensure its accuracy and quality, and based on the audits, further refine and/or develop documentation standards for consistent data capture and reporting of the data.”

If coded data is being used, Wall also suggests conducting coding audits to ensure hospital coding professionals are capturing SDOH diagnosis codes. Patients may be screened, but if it is not coded/captured, it will not be reported, she says.

“Review the data source utilized for reporting measures to ensure data is flowing appropriately,” she says. “Lastly, run comparative reports frequently to ensure accuracy of data capture. Quality data in equals quality data out.”

Wall also recommends that HI teams plan ahead for future SDOH measures. Although the current mandate involves only five SDOH measures, HI professionals should consider expanding their review of inpatient accounts to include other SDOH areas for possible inclusion in future CMS quality measures, Wall?? says. 

SDOH Reporting Obstacles 

HI professionals should expect some challenges as the requirements get underway, HI leaders warn.  

“[Official] guidance of how to actually use the social determinants of health codes is pretty thin,” says William C. Fiala, BS, MA, CCS-P, CPC, RMA, an AHIMA-approved ICD-10-CM instructor and principal at Fiala Analytical Services in Akron, OH.

For example, one of the five required SDOH domains for 2024 is utilities, says Fiala, who also serves as professor of practice in the College of Health and Human Sciences at the University of Akron. A new code in the 2024 ICD-10-CM code set is: Z58.81: basic services unavailable in physical environment. The inclusion terms include “unable to obtain telephone service, due to unavailability in geographic area.”  

However, what this means is vague, Fiala says.

“Is this limited to landlines?” he asks. “Cellular service? Either or both? Cellular service of a particular level or quality—4G, 5G? Review of the American Hospital Association’s Coding Clinic and the ICD-10 Coordination and Maintenance Committee Meeting materials do not provide any real clarity. There is concern as to how useful the resultant data — the frequency of the code being reported — will be.”

Fiala encourages HI professionals to work within their health systems and with professional organizations like AHIMA to bring clarity and objectivity to the circumstances under which the underlying SDOH ICD-10-CM codes should be reported.    

“At the system level, it’s asking questions like, ‘How do we answer the telephone question?’ ‘What is our standard for applying these codes?’ ” Fiala says. “The systems [should] work with the cooperating parties to develop standards where they're lacking. We want to get to where the reporting standard is similar, such that the data is useful.”

Additional challenges to the reporting requirements include the potential for inaccurate or poor-quality information, Wall says. For instance, if patients misunderstand the questions asked or fail to answer honestly, some responses may be altered out of embarrassment, lack of understanding, or fear, she says. Another concern are language barriers that could prevent appropriate responses.

While the new requirements will involve some obstacles, Combs emphasizes they are a starting point and that the wrinkles will iron out as the process evolves.

“We need to remember this is important information that has the potential to have a very big, positive impact on the future of healthcare,” she says. “There is some vagueness in capturing this information. It’s hard to dive into that level of detail until you really start getting into it and reporting that out. That’s why it’s important to share concerns, have dialogue, and ask questions so that as we move forward, CMS can provide the clarity needed.”

Alicia Gallegos is a freelance healthcare writer based in the Midwest.