Social Determinates of Health, Diagnosis Accuracy, and CPT II Coding Tip Sheet
Social Determinates of Health
Social Determinates of Health (SDOH) are environmental factors that can influence health outcomes. SDOH are conditions where people are born, live and work, these factors can include housing, transportation, discrimination, education, literacy, and access to food.
Screening members for SDOH helps providers understand the complexity of the members they serve. It also helps members improve their relationship and trust with their healthcare team. Additional benefits include the creation of a realistic care plan once the clinician understands the member’s available resources and current stressors.
Measure Description
The addition of SDOH Z-codes will support the development of Alliance health equity and population health programs. The SDOH codes will aid in the coordination of services based on member health and social needs, as well as close gaps in reporting.
Each quarter will have a $250 fee-for-service payment available for claims submissions showing Department of Health Care Services high priority Z-Codes, with a total of $1000 for four quarterly submissions.
Diagnosis Accuracy
ICD-10-CM is used to report the diagnosis and mortality data of patients. Diagnosis accuracy is crucial for improving patient care, claims payment, audit outcomes, healthcare financial predictions and data collection.
Coding specificity is coding to the most specific code that the medical record documentation supports. Utilizing diagnosis that are unspecified should be reserved for when clinical information is not known or available.
Common conditions that have over utilized unspecified codes include:
- Alcohol and drug use, abuse, and dependence
- Anemia
- Anxiety
- Arthritis
- Asthma
- Back pain
- Depression
- Disorders of the endocrine system (Hyper/hypotension, Diabetes, Hyper/Hypolipidemia, Vitamin-D deficiency)
- Epilepsy
- Generalized Pain
- Injuries
- Migraines
- Neoplasms
- Pneumonia
- Respiratory failure and infection
CPT Category II Codes
CPT category II codes are used to measure performance on quality metrics in the Healthcare Effectiveness Data and Information Set (HEDIS) and the Care-Based Incentive (CBI) program The Alliance uses them to track and fulfill your CBIs.
CPT II Category Codes always consists of…
CPT current procedural terminology II codes were developed by the American Medical Association (AMA) as a supplemental performance tracking set of procedural codes in addition to the Category I and III coding sets. Category II codes are optional, and cannot be used to replace Category I codes for billing purposes.
The Alliance highly encourages clinical office and billing staff to use CPT Category II codes for performance measurement in order to decrease the need for provider data submission, record abstraction and chart review - your payments, faster!