UnitedHealthcare and the American Medical Association said Tuesday they want to expand the set of ICD-10 diagnostic codes to include more specific diagnoses related to a person's social determinants of health.
The hope is that these codes would allow clinicians to document patients' social determinants in a standardized way, which would allow them to better tailor care plans or refer patients to community organizations that could meet those social needs.
"If someone has a transportation barrier and they are unable to get to their doctor's appointment or to pick up their prescription, today in the ICD-10 codes, there isn't a way to diagnose that," said Sheila Shapiro, senior vice president for national strategic partnerships in UnitedHealthcare's clinical services team. "There is no common way for the system to communicate around not only that barrier, but the solutions that can be brought to assist that individual."
Today, a clinician may use medical code that identifies a patient as low-income, but that's as granular as it gets. UnitedHealthcare's proposed set of codes would more specifically identify the person as unable to pay for transportation for medical appointments of prescriptions, for instance.
That would then tell the healthcare provider they should order prescriptions mailed to the home or possibly provide some form of transportation, explained Dr. Tom Giannulli, chief medical officer at the AMA's Integrated Health Model Initiative, which is supporting UnitedHealthcare's proposal.
Expanding diagnostic codes related to social determinants of health is another step in the healthcare industry's journey to address those factors outside of the doctor's office that often have a greater impact on outcomes than clinical care. In recent years, social determinants have become a buzzword in the healthcare industry as insurers and providers have looked for new ways to control health spending. Now insurers and health systems are moving beyond initial pilot projects to address those factors in a sustainable, scalable way.
The existing ICD-10 family of diagnostic and procedural codes includes 11 codes that identify social and environmental barriers to a patient's care, but they are broad categories. UnitedHealthcare's proposal would add 23 more codes to that list. Some of those codes would indicate a patient's inability to pay for prescriptions, inadequate social interaction, or fears about losing housing.
Trenor Williams, the founder of Socially Determined, a company that uses data to help organizations build programs to address their patients' social needs, said expanding the codes to include more specific diagnoses is a good start and an opportunity to better document social risk factors among a population.
It also could prompt more discussion among stakeholders about providing reimbursement that is risk-adjusted based on a patient's social determinants, Williams said. Some groups, including the National Academy of Medicine and the Medicare Payment Advisory Commission, have explored the feasibility of adjusting Medicare payments for socioeconomic status. Congress has also commissioned reports on the subject. But so far Medicare payments remain unadjusted for social factors.
UnitedHealthcare presented its recommendation to expand the codes at the ICD-10 Coordination and Maintenance Committee meeting in March. Following a 60-day comment period, the committee will determine whether to act on UnitedHealthcare's recommendation in the early summer. The new codes would be available to use as early as 2020, if the committee approves them, Shapiro said.