- UnitedHealthcare and the American Medical Association are working together to create 23 ICD-10 codes that the two entities say will help address social determinants of health by directly connecting patients to services and resources in their communities.
- This new set of codes would identify food, housing and financial insecurity, transportation access and caregiver needs, among others, expanding on the 11 codes that already exist to help address social determinants of health.
- UnitedHealthcare began working on growing the existing set of codes last year and the initiative was backed by AMA during a CMS ICD-10 Steering and Maintenance Committee meeting last month. The proposed codes would apply beginning Oct. 1, 2020.
Payers and providers continue to seek new ways to address social determinants of health without adding administrative burden for clinicians and cost of care for patients. Billing codes, however, are a primary fee-for-service function and an administrative headache for providers.
The 11 codes that exist are already scarcely used, according to a guideline document published by the American Hospital Association last April, and are but a small fragment of a 68,000-code database. According to AMA, UnitedHealthcare "does not seek to add to physicians' administrative burdens" with the new codes. The new codes would add specificity, allowing providers to identify when patients are unable to pay to fill prescriptions or don't have access to transportation for appointments.
Billing codes have been a touchy subject for decades. CMS, for example, included a change in its 2019 Physician Fee Schedule last year that would consolidate some billing codes for office visits in an effort to reduce documentation and reporting requirements. That proposal was shot down by groups across the industry, most notably in a letter signed by 170 organizations led by AMA.
Still, UnitedHealthcare's Medicare Advantage plans have seen some success in using existing codes to address SDOH. The company says its SDOH data model has resulted in more than 700,000 social service referrals for MA enrollees since 2017.
MA is becoming something of a laboratory for payers interested in experimenting with new ways to tackle population health issues, especially for people with chronic conditions. CMS finalized a rule this week enabling MA plans to provide new supplementary benefits that address social determinants in 2020. Those benefits include covering the cost of fresh produce for beneficiaries with heart disease and carpet cleaning for asthma patients.
Administrator Seema Verma said CMS is not planning on offering those benefits to people enrolled in traditional Medicare, arguing it would be too costly.
A study published in December found that one in every five patients struggles with a high-risk health problem related to their socioeconomic status. More than half suffer from a moderate- to high-risk issue. Medicare and Medicaid beneficiaries made up 40% of those with socioeconomic issues, and they had the most complex problems.