Health plans and providers need to ensure they understand their role in supporting the Centers for Medicare & Medicaid Services’ (CMS) Strategic Plan related to the Quintuple Aim and the advancement of health equity, with an emphasis on data collection and reporting.
Introduction
Health plans and providers need to ensure they understand their role in supporting the Centers for Medicare & Medicaid Services’ (CMS) Strategic Plan related to the Quintuple Aim and the advancement of health equity, with an emphasis on data collection and reporting.
The literature related to health equity frequently states that lack of data related to social determinants of health (SDoH) inhibits the development of partnerships with the community and other stakeholders that are critical to the development of effective health equity advancement strategies specific to the population that providers and health plans serve. This data must also tie product and service utilization that is related to SDoH and health equity directly to health outcomes, and CMS has already begun doing this with the development of the Health Equity Index (HEI) as an enhancement to the Star ratings for Medicare Advantage beginning in 2024. Also, for Medicare Advantage, CMS has begun requiring health plans to submit supplemental benefits data to the Encounter Data Processing System (EDPS), and this data will help ensure that these benefits support beneficiary access to care consistent with CMS’ overarching health equity goals.
Providers will have a greater responsibility to collect complete and accurate SDoH data, since they are often the first point of contact for health plan members; hence, tools and systems such as the EMR/EHR will need to be able to accommodate the capturing, documenting, storing, and billing of this data.
ICD-10 diagnosis capture and documentation: Z codes
CMS and other private payers require documentation of the needs identified in the SDoH screening or other assessment in the medical record through complete and accurate ICD-10 Z-code diagnosis capture and reporting. All Z-code categories (Z55-Z65) should be assigned as many times as documented by the provider during the assessments.
Coding guidelines state that for SDoH, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider, since this information represents social information rather than medical diagnoses. These clinicians include, but are not limited to, non-physician providers such as social workers, community health workers, case managers, or nurses. Coding guidelines also state that patient self-reported documentation may be used to assign codes for SDoH if the patient self-reported information is signed off by and incorporated into the medical record by either a clinician or a provider. Also, these codes are not acceptable as primary diagnoses on a claim, so it is important for coders and billers to know this and for EMR/EHR systems to have rules that do not allow this.
ICD-10 capturing, storing, and billing
Many provider EMR/EHR systems might not be configured to store all the diagnosis codes captured during the screening much less to bill them on a claim. However, the inability or unwillingness to make the necessary technical modifications to store and bill the codes is not an excuse to leave off the codes that do not fit on the claim. An 5010 X12 837 electronic claim can capture up to 12 diagnoses for a professional claim and up to 25 diagnoses for an institutional claim. If the current EMR/EHR and/or claims system cannot accommodate at least as many as the X12 837 allows, it is time to discuss with the vendor(s) the need to expand the number that can be stored and submitted. Consider surveying providers to determine the number of diagnosis codes their EMR/EHR can capture and to identify how many systems need remediation. Profiling the provider population to determine the average number of codes submitted can also help pinpoint who might not be leveraging the full number of allowable codes when compared to the average. An example would be providers who consistently submit only one diagnosis code per claim, and/or who consistently submit no more than four for a population with higher chronic illness prevalence. A paper claim captures even fewer diagnosis codes, and providers submitting on paper will require special attention.
Furthermore, most payers, including Medicare, state that a claim requiring more than 25 diagnoses for institutional and 12 diagnoses for professional must be split into two (or more) claims. CMS has recently established HCPCS code G0136 in 2024 for SDoH screening. An EMR could be modified to do this splitting automatically via a rule that detects the screening HCPCS and Z codes and drops the screening and associated diagnosis codes to its own claim. If the Z codes are billed with E&M codes, the second claim could be a 99499 CPT as the only code with a zero-dollar charge; check with the payer for specific requirements and check with the EMR/EHR vendor to ensure that they are able to perform the splitting as required.
Conclusion
CMS reported that from 2017 to 2019, there was a 21.4 percent positive change in coding for Z codes, and a 12.6 percent increase in the number of Medicare beneficiaries with Z-code claims. New and emerging technologies are available to assist with clinical documentation workflow for SDoH and with promoting interoperability to support the partnerships necessary for the advancement of health equity as envisioned by CMS.
Most assuredly, CMS and other entities will continue to monitor and report changes in coding and billing of Z codes so that appropriate benchmarks for data collection can be set. It is critical that this data is complete and accurate because it informs health equity and SDoH strategies specific to the population served by the health plan and its providers, which promotes a positive return on investment for these strategies related to health care outcomes and cost in accordance with the Quintuple Aim.
About the author
Dawn Carter is a director of product strategy at Centauri Health Solutions. Her career in health care spans 25 years, which most recently includes extensive experience in developing revenue integrity and quality software solutions, with a focus on encounter management and risk adjustment solutions for Medicare Advantage, Medicaid and Commercial health plans.
She also provides strategic advisory solutions and consulting services for revenue cycle operations. Prior to that, her experience spans all domains of health care including health plan claims and provider systems administration, and healthcare applications development. Her experience also includes multiple teaching engagements in medical administration, billing and coding.
Carter holds a Bachelor’s degree in Business Administration. She is a passionate and prolific industry speaker, author, blogger and subject matter expert in claims, EDI management, and risk adjustment.