The IPPS Proposed Rule Demonstrates the Importance of SDoH

The Centers for Medicare & Medicaid Services (CMS) has issued its 2025 Inpatient Prospective Payment System (IPPS) Proposed Rule, through which it proposes to change the severity designation for several Social Determinants of Health (SDoH) ICD-10-CM codes. The SDoH generally continues to prove to be very important data element across healthcare. SDoH are social problems, conditions, or risk factors that influence or affect a patient’s health and quality-of-life outcomes.

CMS recently conducted a data analysis of the impact on resource use, generated utilizing claims data, and they are suggesting for 2025 the introduction of seven ICD-10-CM diagnosis codes describing inadequate housing and housing instability from non-complication or comorbidity (Non-CC) pr complication or comorbidity (CC), based on the higher average resource costs of cases with these diagnosis codes, compared to similar cases without them.

If the proposed policy change is finalized, it is believed that it would more accurately reflect each healthcare encounter for hospitals that take care of individuals with inadequate housing or housing instability, and also improve the reliability and validity of the coded data, in support of efforts to advance health equity.

In addition, the 2025 Proposed Rule suggests the addition of SDoH data elements into the Long-Term Care Hospital (LTCH) Quality Reporting Program, requiring such facilities to report data elements on housing, food and utility stability, and access to transportation.

I think we can all agree that housing issues typically impact health, requiring more resources, so the change being made to the SDoH for housing is a positive step. This will also provide additional data to better understand the overall impact on hospitalizations by having this coded data and financial details.

There are specific ICD-10-CM coding guidelines for the assignment of SDoH codes. So as a reminder, in Guideline 14, Documentation by Clinicians Other than the Patient’s Provider, “there are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., a physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). In this context, ‘clinicians’ other than the patient’s provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record.” Within this list of exceptions are the SDoH.

This is a very important coding exception to understand and apply. In addition, body mass index (BMI), coma scale, National Institutes of Health Stroke Scale (NIHSS), blood-alcohol level codes, codes for SDoH, and underimmunization status should only be reported as secondary diagnoses.  There are more details and more information on the SDoH in the Official Guidelines, Section I.C.21.c.17.

It is imperative for providers to be documenting the SDoH elements in the health record. In the hospital, the emergency room provider documentation should include a section for SDoH, and another good location is in the history and physical (H&P) document. Be sure to take a look at these two health record documents and determine if they are capturing the SDoH in their documentation; now would be the time to conduct a small review or audit on 50 inpatient encounters admitted via the emergency room to assess.