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Utilizing SDOH
By James E. Grue, OD,
Ronald P. Snyder, OD, FAAO
May 7, 2025
Medicare and other payors are increasingly scrutinizing documentation to ensure billing aligns with the complexity and comprehensiveness of care provided.
Integrating Social Determinants of Health (SDOH) effectively can demonstrate the medical necessity for higher-level services. Encouraging practices to integrate SDOH is part of a larger health care reform effort.
SDOH Options
Before incorporating SDOH in your practice, you must understand that there are multiple SDOH options available. Once you aware of these options, it will be easier for you to justify your billing level against future downgrading by payors.
It is relatively new and important that providers become aware that payors are downgrading billing levels.
For example, in Pennsylvania, BCBS routinely downgrades billing levels of a submitted claim if the level cannot be justified. You are permitted to challenge the downgrade, which can be reversed if you are successful with your challenge.
Incorporating SDOH into your documentation can be a key factor in justifying higher billing levels. Since SDOH factors significantly impact patient outcomes, documenting them thoroughly aligns with value-based care initiatives and strengthens your case when payors attempt to downgrade claims.
To improve your chances of successfully meeting challenges:
- Document Clearly: Identify SDOH factors like housing instability, food insecurity or lack of transportation that directly influence patient care.
- Link to Care Plan: Demonstrate how these factors impact your medical decision-making, treatment complexity and time spent.
- Use Z-codes: Including relevant ICD-10 Z-codes for SDOH can improve claim accuracy and support billing levels.
- Track Trends: Pay attention to payor patterns in claim downgrades to better prepare your documentation strategies.
Three Overall Approaches to the Use of SDOH for Eye Care
Option 1: No SDOH Focus:
Continue as you always have and strictly focus on clinical care (e.g., diabetic retinopathy detection) without additional SDOH data entry. There is no requirement that you consider SDOH if you aren’t going to use it to increase billing levels and if you don’t think that it improves patient outcomes.
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Option 2: Population-Level Approach:
This option involves utilizing SDOH at the population level. The rationale is that if we take a broad-brush approach to correcting SDOH issues, for example with food insecurities, the overall patient outcomes will improve.
Some eye care EHRs provide a general questionnaire that can be used in conjunction with a patient history that supports this approach. It doesn’t matter if the patient personally completes the question or if a staff member asks the questions. Either way, this shows payors that you are aware of the significance of these issues.
If you use the questionnaire results to refer the patient for some type of SDOH services, it shows that you are willing to contribute to the overall approach of helping patients overcome these needs.
Option 3: Individualized Care Integration:
The ultimate use of SDOH is at the individual patient level to improve a specific health outcome. Most practitioners are transitioning to align with health care reform, which calls for a new role in eye care for diabetes management.
Under health care reform it is essential that we continue to detect and manage diabetic retinopathy. Now we have a new, and possibly more important role, to work with the patients’ care team to help the patient reduce their risk of developing retinopathy.
Addressing SDOH issues is important in this new role in empowering the patient to be able to make good decisions.
Decide Which of these Options are Best for Your Practice
Option #1 doesn’t require any effort on your part. You simply continue to provide your customary care.
Option #2 requires that you simply add the SDOH survey to your patient history that your EHR has provided.
If you increase your billing level, at this point in time, we do not know if the payors will downgrade your claim. Payors want providers to use SDOH in a way that improves outcomes. If overall outcomes improve, then there likely will not downgrades. If the overall approach doesn’t create measurable improvements, then downgrades could be possible.
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Option #3 almost certainly insulates you from downgrades as you will be easily able to demonstrate how the care you are delivering is different from average care. This difference in care is so dramatic that you can use this approach to build diabetic referrals from primary care physicians.
This will contribute to your practice growth and sustainability goals. Provider burn out is becoming a big issue in optometry. This approach to diabetes management tends to be more professionally rewarding for those providers who have made the transition. That professional satisfaction may lessen provider burnout.
Using SDOH at the individual patient care level is part of a bigger decision of taking on the broader best practice role of actively working with the patient care team to help patients reduce their risk of developing retinopathy.
Detecting diabetic retinopathy and properly managing it has traditionally been in the scope of optometry and will continue to be critically important.
Future Success of Optometric Practices Hinges on Adopting the Measures of Health Care Reform
- Measuring clinical outcomes
- Empowering the patient
- Coordinating the care of the patient with the rest of the patient care team
Much of health care reform targets the ability for providers to be able to communicate more effectively with other providers on the patient care team.
Being able to do so facilitates coordinating the care of the patient. For those eye care practitioners that haven’t made the transition to meet the goals of healthcare reform, the three measures outlined are probably mystifying.
In our next article, we will demystify the process by describing how a leading optometry practice made the transition. This practitioner has made referrals for SDOH a major component of their diabetes management.
Read another article by Drs. Grue and Snyder and their colleague, Dr. Jessica Heinke
James E. Grue, OD, is a health-care reform speaker and consultant. To contact him: JimGrue@HealthCareRegistries.com
Ronald P. Snyder, OD, FAAO, is the president and CEO of HealthCare Registries, LLC. To contact him: RonSnyder@HealthCareRegistries.com
