Patient centered or provider centered? The inclusion of social determinants of health in emergency department billing and coding

The 2023 updates to emergency medicine evaluation and management coding are a significant change in policy that may have unintended consequences. Importantly, these changes, which place greater emphasis on provider documentation of the complexity of medical decision making, recognize the complex intersection between an individual's health and their social environment. Patients are categorized into a higher level of complexity, and potentially higher level of billing, if their diagnosis or treatment is significantly limited by a social determinant of health. This is notable, as higher reimbursement may have the downstream effect of increasing revenue for hospitals that serve populations with high social risk. However, lack of standardized, objective screening for social risk has the potential to add to stigmatization in the medical record. These changes are provider centered, and careful attention is needed to maintain a patient-centered focus as these new coding guidelines are enacted.

As providers of safety net health care, emergency medicine providers are intimately aware of the important role that social risk plays in patients' lives and, thus, in the medical decision-making process. Social risks (e.g., housing and food insecurity, inadequate access to preventative health care) are prevalent among emergency department (ED) patients. Such social determinants of health are associated with poor health outcomes, including higher rates of ED utilization, hospitalization, and mortality. By including social determinants of health in the assessment of medical complexity and risk, the new coding guidelines take an important step in recognizing the multifaceted care provided in the ED.