New 2021 Medical Decision-Making Factor

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New 2021 Medical Decision-Making Factor

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CPT EM 2021 Medical Decision Making

QUESTION: Our clinic is seeing more and more people who lack adequate food and housing. Sometimes this impacts the physician’s plan and assessments. The physicians are concerned that there is high risk for the patient not being able to carry out the needed health requirements. Is there any way for us to give the physicians additional credit for this work?

Question from Fresno, CA subscriber

ANSWER: The Evaluation and Management (E/M) changes for new 2021 office visit coding guidelines will allow you to factor Social Determinants of Health (SDH) in medical decision-making effective January 1. Potential health hazards such as inadequate housing (Z59.1) and food and safe drinking water (Z59.4) that are related to socioeconomic and psychosocial circumstances can be coded from the treating physician’s documentation. You can also count documentation from a physician who is not treating the patient for the factor but is considering it in the provider’s treatment and assessment.

There are a list of ICD-10-CM Z codes that describe SDH. Never report these as primary diagnoses and instead as secondary or additional diagnoses. Some additional codes for hazards your physician may be weighing in an encounter;s medical decision making are:

  • Z55.0Illiteracy and low-level literacy
  • Z59.0Homelessness
  • Z59.5Extreme poverty
  • Z59.7Insufficient social insurance and welfare support
  • Z62.0Inadequate parental supervision and control.

For more 2021 E/M coding changes tactics, nationally recognized coding and training expert, Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, can help. During her upcoming online training “Master Massive E/M Coding Changes (99201-99215) by Jan. 1 Deadline,” Kim will walk you through EXACTLY how you can ethically and optimally apply every 2021 office visit code change by the January 1st deadline.


E/M Coding Online Training Resources

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Meet Your Writer

Kim Huey
MJ, CHC, CPC, CCS-P, PCS, CPCO

KGG Coding and Reimbursement Consulting, LLC

Kim is an independent coding and reimbursement consultant, providing audit, training and oversight of coding and reimbursement functions for physicians. Kim completed three years of pre-medical education at the University of Alabama before she decided that she preferred the business side of medicine. She completed a Bachelor’s degree in Health Care Management and went on to obtain certification through the American Academy of Professional Coders and the American Health Information Management Association. Recognizing the important position of compliance in today’s world, she has also obtained certification as a Certified Healthcare Compliance Consultant and a Certified Healthcare Audit Professional. Kim is also an AHIMA-approved ICD-10-CM trainer and has recently earned a Master of Jurisprudence in Health Law. For over twenty-five years, Kim has worked with providers in virtually all specialties, from General Surgery to Obstetrics/Gynecology to Oncology to Internal Medicine and beyond. She has spoken at the national conference for numerous organizations.

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