E/M 2021 Guidelines and the Importance of SDOH

E/M 2021 Guidelines and the Importance of SDOH

By Cheryl A. Cyrus, RHIT, CPMA, CDEO, CRC

As of January 1, 2021, there are new Evaluation and Management (E/M) Services Guidelines for outpatient and ambulatory services that encompass specific areas of risk defined in the social determinants of health (SDOH). Professional fee coding auditors often review records with templates that have no data, as shown below in a chart captured from an Epic template. Electronic health record (EHR) analysts sometimes proactively add these items; however, in order to convey the full picture of the patient’s circumstances, the data must be complete.

SDOH elements are specifically utilized in accordance with a Level 4 service, as defined in the risk section of the 2021 American Medical Association (AMA) guidelines from the organization’s rollout presentation. An example from that AMA presentation is shown below.

With the 2021 E/M Guidelines, we only need two of three elements to meet our level of service. SDOH would tip the scales for coding either 99204 or 99214, such as in the following example.

Coding Example Scenario

A patient comes in for follow-up to laboratory testing. After a review of laboratory testing and a discussion with the patient, the provider confirms that the patient now has borderline hyperlipidemia in addition to hypertension. The provider states the patient should start taking Omega 3/fish oil to try to lower their cholesterol, along with diet and exercise. If the condition does not improve, Lipitor or another medication may be needed. An appropriate review of symptoms; past history, family history, and social history; and examination are performed relevant to this visit and diagnoses. The patient also indicates that they recently lost their transportation due to an accident, and their car is being repaired. A friend brought them to their appointment. The patient also indicates that they live in an area where there are few local pharmacies in close proximity and do not know if they can afford additional cost of nonprescription medication and need help with dietary requirements. The provider refers the patient to nutrition counseling and indicates they may be able to have a local drug store deliver supplements.

Reviewing the AMA’s table for medical decision-making (MDM) elements, this visit would be coded as follows:

The Importance of Capturing SDOH

Auditors want to be sure that healthcare providers and facilities are provided with the education to capture these elements. This not only impacts the provider’s overall MDM but may impact the associated healthcare facility and, ultimately, reimbursement.

For patients living in underserved and poverty-challenged areas of our country, the SDOH elements are significant. They will, in many cases, seriously impact a patient’s treatment, morbidity, and mortality. There are many examples of the impact of items related to SDOH. However, this data is usually not readily available. It takes detective skills to uncover the data, as it lies in a random telephone call or nurse follow-up note.

For example, if a patient lost their job, they may have no insurance and will not want treatment due to lack of the ability to pay for those services. If they lack transportation, they cannot receive their weekly injections for a condition that may ultimately be cured or have a long-term impact on their overall condition and healthcare status. The lack of family support could impact a patient with mental illness and prevent them the overall treatment they need to gain coping mechanisms, counseling, or other services. This, in turn, causes their condition to deteriorate further. We know the costs to the patient’s health, but this may lead to hospitalizations and extended treatment, and thus more costs passed on to our already overwhelmed healthcare system.

The 2021 E/M Services Guidelines do not specify that this information must be captured by the healthcare provider (i.e., physician, nurse practitioner, or physician’s assistant). The ICD-10-CM Official Guidelines for Coding and Reporting, B.14 on page 16, states: “Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off and incorporated into the health record by either a clinician or provider.”

This can be easily captured by the nurse who rooms the patient. This would be done at the same time as they are allowed to capture, since 2019, the patient’s chief complaint; objective elements such as vital signs, including weight and body mass index; the patient’s current medications; and any other items the patient would like to ask the provider at the time of their visit.

While it’s true that people are often very private and do not want to readily disclose this information, it’s important to connect with patients in a way that makes them feel comfortable and know the provider is there to help and not pass judgment. It’s also true that providers are overwhelmed with documentation requirements. It’s been said that there are 300-plus clicks of the mouse to get an office visit completed and charge capture elements just to send it on to the billing system. There must be a balance—a way to make sure that these are being captured in a workflow that makes the most sense for the provider’s office, staff, and patients.

You may have heard the phrase, “not documented, not done.” As health information professionals, let’s be sure we capture important information that, when taken into consideration, leads to additional services available for the patient. Since the E/M Services Guidelines now do not require “counting elements,” we can use this data to properly capture the level of MDM more consistent with the patient’s current status. We can then provide or refer the patient for additional services that may be helpful in the overall condition of the patients being cared for by our office. Knowledge is power, and education is the key to success.


Cheryl A. Cyrus (cheryl.cyrus@comforcehealth.com) is a quality assurance auditor at Comforcehealth.

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