April showers bring social determinants of health flowers
The showers of April have brought a burst of blooms in the Social Determinants of Health (SDoH) reimbursement garden. First, the Centers of Medicare and Medicaid Services (CMS) released its 2020 rate sheet. As expected by the industry, Medicare Advantage and Part D plan supplemental benefits are set to expand in several areas. The emphasis on care moving outside of hospitals translates to a necessary increase in reimbursement for non-clinical resources and programs that help to minimize readmissions, as well as enhance the wellness of populations.
In 2016 CMS amended the Medicaid Managed care rule so Medicaid MCOs could support patients with nonmedical expenses. There has been talk since by CMS about the need to further expand coverage of non-clinical services that directly impact population health (e.g. air filter systems, fans). Yet, it was insurance companies, especially the Managed Medicaid and Medicare Advantage providers that stepped up first to bridge the needs gap. The majority provide robust funding for gaps in transportation, nutrition, GED prep classes and tests, employment, linkage to fitness programs, plus.
Fast forward to 2020 and CMS will begin to pay for services that promote healthy home environments, expanding coverage to two main SDoH: food insecurity and access to care (AKA: transportation). Traditionally where CMS goes the other payers follow, but in the scope of the SDoH it presents the reverse is true. The reimbursement expansion by CMS is set to include the following:
The opioid crisis will also receive greater fiscal emphasis, with supplemental benefits for patients with opioid use disorders. In addition, cost-sharing reductions for those persons who live with chronic pain will also be added. Medicare Part D plans will add at least one overdose reversal drug to the low cost-sharing tier. It is hoped this action will improve access to medications for those persons who need them.
Telehealth reimbursement will see expansion for remote patient monitoring under certain circumstances. Social cohesion and isolation are major SDoH, particularly for children and adults who live with disabilities, and adults receiving services under Long Term Services and Support programming. Telehealth services help directly address this determinant through an array of virtual programs and care processes.
The American Medical Association and UnitedHealth Care
The other hearty April blossom came with the American Medical Association announcing their alignment with United Healthcare to advance 23 new ICD-10 codes that address social barriers to care (AKA: the SDoH). Keep in mind that UnitedHealthcare already joined with NCQA and the National Association of Community Health Centers to advocate with CMS for code expansion of the most popular SDoH of food insecurity and access to care in the form of transportation. The expanded ICD-10 code recommendations encompass six key areas. These include the following:
The pressure is on for payers to empower new means of reimbursement for the SDoH, particularly with compelling recent evidence how the determinants impact 80 percent of health outcomes, and cause over 50 percent of readmissions. Now, expansion of the ICD-10 codes is a big plus for all, but only a small part of how to boost revenue. If the organization’s processes aren’t in place to make the best use of the codes, then they are for naught. It is just over a year that the American Hospital Association (AHA) approved non-clinical documentation from the interprofessional team to validate the use of the ICD10 Z codes; the psychosocial and socioeconomic stressor that impact health and behavioral healthcare outcomes and speak to the SDoH.
Providers must still hone their documentation skill and the efforts to assure they are garnering their share of appropriate reimbursement. Collaborative coalitions and communication are a must for all professionals involved in the documentation and coding effort. It will be quite interesting to see just how many organizations have been able to successfully use the Z codes, plus how much money they have captured. In the meantime, if CMS adopts the expanded ICD-10 codes, they may begin as early as 2020. My gut says it is a pretty good guess that we will see one mega roster of ICD-10 codes to be used for the SDoH come October.
Stay tuned for further updates on this exciting topic!
EDITOR’S NOTE: The author of this article used artificial intelligence- (AI)-assisted tools in its composition, but all content, analysis, and conclusions were based on the
One of the greatest challenges facing case management today is not a lack of clinical expertise; it is a lack of time. Case managers are
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
