Social Determinants of Health, Diagnosis Accuracy and CPT II Coding Tip Sheet

Social Determinants of Health

Social Determinants 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 supports the development of Alliance health equity and population health programs. The Z codes aid in the coordination of services based on member health and social needs, and close gaps in reporting.

Each quarter has a $250 fee-for-service payment available for claims submissions showing Department of Health Care Services high-priority Z codes, with a total of $1,000 for four quarterly submissions.

Coding Requirements

Data is collected using appropriate diagnoses from claim submissions.

ICD-10 Code	Code Description
Z55.0	Illiteracy and low-level literacy
Z58.6	Inadequate drinking-water supply
Z59.00	Homelessness
Z59.01	Sheltered homelessness
Z59.02	Unsheltered homelessness
Z59.1	Inadequate housing (lack of heating/space, unsatisfactory surroundings)
Z59.3	Problems related to living in residential institution
Z59.41	Lack of adequate food and safe drinking water
Z59.7	Insufficient social insurance and welfare support
Z59.811	Housing instability, housed, with risk of homelessness
Z59.812	Housing instability, housed, homelessness in past 12 months
Z59.819	Housing instability, housed unspecified
Z59.89	Other problems related to housing and economic circumstances (foreclosure, isolated dwelling, problems with creditors)
Z60.2	Problems related to living alone
Z60.4	Social exclusion and rejection (physical appearance, illness or behavior)
Z62.819	Personal history of unspecified abuse in childhood
Z63.0	Problems in relationship with spouse or partner
Z63.4	Disappearance & death of family member (assumed death, bereavement)
Z63.5	Disruption of family by separation and divorce (marital estrangement)
Z63.6	Dependent relative needing care at home
Z63.72	Alcoholism and drug addiction in family
Z65.1	Imprisonment and other incarceration
Z65.2	Problems related to release from prison
Z65.8	Other specified problems related to psychosocial circumstances (religious or spiritual problem)

Best Practices

Resources

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. Using diagnoses that are unspecified should be reserved for when clinical information is not known or available.

Common conditions that have overused unspecified codes include:

Alcohol and drug use, abuse, and dependence
Anemia
Anxiety
Arthritis
Asthma
Back pain
Depression
Diabetes
Epilepsy
Generalized pain
Hyper/hypotension
Hyper/hypolipidemia
Injuries
Migraines
Neoplasms
Pneumonia
Respiratory failure and infection
Vitamin D deficiency

Measure Description

Best Practices

Resources

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 CBI.

CPT Category II codes always consist of: CPT Coding Example

CPT Category 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 measurements to decrease the need for provider data submission, record abstraction and chart review.

CPT Code Functions

Category I Codes	E&M, ANES, SURG, RAD, LAB
Category II Codes	TRACKING QUALITY OF CARE
Category III Codes	EMERGING TECHNOLOGY

CPT II Codes

Diabetic Poor Control >9%
HbA1c test result
HbA1c level <7%	3044F
HbA1c level ≥7 and <8%	3051F
HbA1c level ≥8 and ≤9%	3052F
HbA1c level >9%	3046F

Controlling Blood Pressure
Systolic <130 mm Hg	3074F
Systolic 130-139 mm Hg	3075F
Systolic ≥140 mm Hg	3077F
Diastolic <80 mm Hg	3078F
Diastolic 80-89 mm Hg	3079F
Diastolic ≥90 mm Hg	3080F

When reporting the appropriate CPT II code for the A1c result value, bill with the date of the test, not the date of the office visit when the test was reviewed.

Manage Care

Social Determinants of Health, Diagnosis Accuracy and CPT II Coding Tip Sheet