SDoH Assessments, Z-code Capture, and Principal Illness Navigation

EDITOR’S NOTE: This article marks the second installment in a two-part series centering on the CMS Physician Fee Schedule proposed ruling, as it pertains to SDoH assessments and Z-code capture in the outpatient setting.

The Centers for Medicare & Medicaid Services (CMS) is proposing the addition of a standalone G code furnished in conjunction with an evaluation and management (E&M) visit for the collection of a social determinants of health (SDoH) risk assessment. GXXX5 could be added on to the visit for an estimation of 5-15 minutes when SDoH factors based off the risk assessment are included and considered in the medical care of the patient, no more than every six months.

From an audit standpoint, compliant billing of this must ensure that healthcare practices are using evidence-based tools such as the Health-Related Social Needs (HRSN) Screening Tool, which covers the minimum five domains: food, housing, transportation, utilities, and personal safety. CMS is also requesting comments on the incorporation of requirements that providers and practices are not just using these tools, but also including the linkages to supportive services, such as community health integration (CHI) or other case management services.  

The SDoH assessment must be part of the medical record (documented) and should be considered as part of the broader ICD-10-CM Z-code (Z55-Z65) capture. Additionally, this code is going to be added to the Medicare Telehealth Services List, to allow for virtual visits. The CMS proposed guidelines start on page 251 of the new proposed rule.

CMS is also considering that there may be gaps in care delivery for patients who require additional care delivery, but do not have SDoH factors that impede the provision of medically necessary care. They are proposing codes for Principal Illness Navigation (PIN) – these services are focused on the navigator care delivery services for serious illnesses, called out specifically by CMS to include cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure, dementia, HIV/AIDS, severe mental illness, and substance abuse disorder. The proposed framework for PIN services is similar to chronic care management services and billing, which is a monthly reimbursement rate for services provided under the general supervision of the physician. However, CMS ironically ended the proposal for PIN to say that addressing the SDoH would be a requirement as a portion of the PIN services. The title for who provides these services falls under the care management/navigator category; my personal favorite from the inclusive category of titles was “social worker navigator.” These CMS proposed guidelines start on page 259 of the proposed rule.

Each of these proposed components demonstrates CMS’s continued commitment to health equity, and is a step in the right direction towards reimbursement for the time spent supporting patients’ social factors to ensure medical necessary care.

Programming note: Listen to live SDoH reports by Tiffany Ferguson, every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.